Author + information
- Received March 10, 2014
- Revision received March 13, 2014
- Accepted March 13, 2014
- Published online October 1, 2014.
- Federica Sidoti, MD∗ (, )
- John Hibbeln, MD,
- Michel Ilbawi, MD and
- Damien Kenny, MD
- Rush Center for Congenital & Structural Heart Disease, Rush University Medical Center, Chicago, Illinois
- ↵∗Reprint requests and correspondence:
Dr. Federica Sidoti, Rush Center for Congenital & Structural Heart Disease, Rush University Medical Center, Suite 776 Jones, 1653 West Congress Parkway, Chicago, Illinois 60612.
The hybrid approach has evolved into a viable alternative to Norwood stage I procedure for hypoplastic left heart syndrome. A 4-month-old girl with DiGeorge syndrome and an unbalanced atrioventricular canal with hypoplastic left ventricle and aortic valve underwent a hybrid procedure with bilateral branch pulmonary artery banding and placement of a 7 × 20-mm Formula 418 stent (Cook Medical, Bloomington, Indiana) in the patent ductus arteriosus (PDA). Two months later, following an upper respiratory infection, she developed ventricular dysfunction thought to be secondary to ductal stent narrowing and consequently underwent further stenting of the proximal and distal PDA segments with 7 × 16-mm and 7 × 12-mm Formula stents (Cook Medical), respectively. Despite this procedure, she had 3 short-term failed extubation attempts, and bronchoscopy revealed a short segment of severe tracheal compression below the vocal cords, with 80% to 90% collapse of the airway, as well as strong pulsation of the anterior wall, concerning for vascular compression. A subsequent computed tomography angiogram confirmed marked compression of the trachea by the PDA stent and the aorta anteriorly, and by a right aberrant subclavian artery posteriorly (Figure 1). Specifically, the stentedPDA was having a mass effect on the aortic arch, which was compressing the trachea (Figures 2A to 2C). Consequently, the baby underwent comprehensive stage II Norwood repair with arch reconstruction and bilateral bidirectional Glenn procedure, PDA stent and PA banding takedown, and relief of tracheal compression. She was extubated 8 days later and has had no further airway issues.
Vascular stent mass effect has been described but may be under-recognized in complex congenital heart lesions. As less invasive options to palliate these conditions become more common, evaluation of potential airway compression with advanced imaging should be considered.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received March 10, 2014.
- Revision received March 13, 2014.
- Accepted March 13, 2014.
- American College of Cardiology Foundation