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Circulation: Cardiovascular Imaging
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Circulation: Cardiovascular Imaging. 2008;1:e17-e18
doi: 10.1161/CIRCIMAGING.108.792143
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Cardiovascular Images

Coil Occlusion of Aortopulmonary Collateral Arteries Before Arterial Switch Procedure in an Infant With Transposition of the Great Arteries

Victoria Jowett, MBBS, BSc, MRCPCH; Graham Derrick, BMedSci, BM, BS; Victor Tsang, MD and Jan Marek, MD, PhD

From the Great Ormond Street Hospital for Children, London, United Kingdom.

Correspondence to Jan Marek, MD, PhD, Director of Echocardiography, Consultant Paediatric Cardiologist, Great Ormond Street Hospital for Children, Great Ormond Street, London WC1N 3JH, United Kingdom. E-mail Marekj{at}gosh.nhs.uk

A 1-day-old infant with a prenatal diagnosis of transposition of the great arteries was admitted to our unit. He was born at term, weighing 3.2 kg. He arrived in a stable condition, with saturations of 88%, on a prostaglandin infusion at a rate of 5 ng/kg per min in accordance with the prenatal plan. Echocardiogram demonstrated transposition of the great arteries with intact ventricular septum and usual coronary arrangement. There was adequate mixing via a moderate-sized atrial communication measuring 6 mm. In addition, there was a large persistent arterial duct with left-to-right shunting.

Over the next 24 hours, the infant developed tachypnoea, poor systemic perfusion, and progressive metabolic acidosis. He was electively intubated and ventilated and commenced on ionotropes and antibiotics. Abdominal distension was noted without x-ray changes, and he was, therefore, started on prophylactic treatment for necrotizing enterocolitis. Repeat echocardiogram demonstrated the presence of major aortopulmonary collateral arteries in addition to a large persistent arterial duct and moderate atrial communication (Figure 1).


Figure 1792143
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Figure 1. Serial echocardiogram demonstrated large arterial duct (A), aortic origin of collateral vessel (B), and its tortuous course toward tight lung (C). Systolic-diastolic flow was documented on pulsed Doppler tracing (D).

 
A cardiac catheter was performed to further elucidate the nature of the collateral vessels and perform an atrial septostomy. At the time of catheter, 2 major aortopulmonary collaterals were identified. These were successfully occluded with 2 and 1 detachable Cook patent ductus arteriosus coils (3 mmx3 loop), respectively (Figure 2).


Figure 2792143
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Figure 2. Serial angiogram indicated 2 major collateral vessels on aortogram (A) and on selective injections into right (B) and left (C) collateral vessels. After successful embolization, there was no antegrade flow seen on aortogram (D), and only 1 very small collateral remained patent (E).

 
His condition improved, and an arterial switch procedure was performed on day 7 of life. He was extubated after 5 days and had no significant complications in the postoperative course.

Major aortopulmonary collateral arteries or enlarged bronchial arteries are well described in transposition of the great arteries1 and can present problems on cardiopulmonary bypass with flow from the collaterals returning to the left atrium, resulting in blood in the surgical field and the potential for poor organ perfusion. The additional flow can also present problems in the postoperative period, with high pulmonary blood flow and cardiac volume overload requiring closure of collaterals.2

These images illustrate the detection of these vessels by echocardiography before corrective surgery, allowing interventional catheter embolization of these vessels in advance of arterial switch procedure. Thus, the risk of complications during cardiopulmonary bypass and the risk of high postoperative pulmonary blood flow were avoided. Although postoperative embolization of major aortopulmonary collateral arteries has been described, this is the first report of embolization before a corrective surgical intervention in a patient with transposition of the great arteries.


    Disclosures
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None.


    References
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1. Wernovsky G, Bridges ND, Mandell VS, Castaneda AR, Perry SB. Enlarged bronchial arteries after early repair of transposition of the great arteries. J Am Coll Cardiol. 1993; 21: 465–470.[Abstract]

2. Santoro G, Carrozza M, Russo MG, Calabro R. Symptomatic aorto-pulmonary collaterals early after arterial switch operation. Paediat Cardiol. 2008;Epub ahead of print.





This Article
Right arrow Extract Freely available
Right arrow Full Text (PDF)
Right arrow Data Supplement
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrowRequest Permissions
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Jowett, V.
Right arrow Articles by Marek, J.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Jowett, V.
Right arrow Articles by Marek, J.
Related Collections
Right arrow Catheter-based coronary and valvular interventions: other
Right arrow Echocardiography
Right arrow Pediatric and congenital heart disease, including cardiovascular surgery