Author + information
- Received November 13, 2013
- Revision received December 16, 2013
- Accepted December 19, 2013
- Published online August 1, 2014.
- Justin Z. Lee, MD∗,
- Kwan S. Lee, MD†∗ (, )
- Aiden Abidov, MD†,
- Ricardo A. Samson, MD‡ and
- Kapildeo Lotun, MD†
- ∗Department of Internal Medicine, University of Arizona, Tucson, Arizona
- †Department of Cardiovascular Diseases, University of Arizona, Tucson, Arizona
- ‡Cardiology Section, Department of Pediatrics, University of Arizona, Tucson, Arizona
- ↵∗Reprint requests and correspondence:
Dr. Kwan S. Lee, Division of Cardiovascular Diseases, University of Arizona, 3950 South Country Club Road, Suite 200, Tucson, Arizona 85714.
A 61-year-old woman, 6 months after orthotopic heart transplantation (OHT), presented with gradual-onset class III dyspnea and fatigue for 4 months. Her transplantation procedure was significant for right ventricular sternal adhesions after left ventricular assist device placement and significant size mismatch between the donor and recipient aortas, requiring fashioning of the donor aorta to correct the mismatch. A computed tomography angiogram (Fig. 1) showed an eccentric anastomotic line supravalvular stenosis 1.5-cm distal to the pulmonic valve, 1.4 × 2.0 cm at the narrowest portion with post-stenotic dilation of 4.0 cm. Right ventricular systolic pressure (RVSP) was 60 mm Hg + central venous pressure with supravalvular flow acceleration.
The close proximity of the stenosis to the pulmonary valve led to an unsuccessful initial angioplasty attempt as there was persistent distal migration of the balloon during inflation and an inability to maintain a stable balloon position. The procedure was reattempted with angioplasty and stenting using a Palmaz 39 × 10-mm balloon-expendable stent (Cordis, Miami, Florida) mounted on a balloon-in-balloon 20 × 40-mm balloon (NuMed, Hopkington, New York) using a rapid pacing stabilization technique with transesophageal echocardiographic guidance (Figs. 2, 3). Post-dilation was then performed with a Tyshak II 25 × 40-mm balloon (B. Braun, Bethlehem, Pennsylvania) (Fig. 4). The procedure was successful with reduction of the peak gradient from 22 mm Hg to 3 mm Hg and resulting peak RVSP reduction from 70 mm Hg to 51 mm Hg with minimal pulmonary artery diameter increase from 1.4 cm to 2.2 cm. The patient’s fatigue and dyspnea resolved.
This is the first described case of suture line supravalvular pulmonic stenosis post- OHT and highlights the possibility of successful endovascular therapy using rapid pacing as a stabilization technique for device deployment. Intraprocedural transesophageal echocardiographic imaging was instrumental in positioning the stent secondary to the close proximity of the pulmonary valve.
Dr. Lee receives honoraria from St. Jude Medical and Maquet Medical Systems. Dr. Abidov receives grant support from Astellas Pharma and National Institutes of Healthhttp://dx.doi.org/10.13039/100000002 and serves on the Advisory Board of the Advanced Cardiovascular Imaging Consortium (ACIC). All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received November 13, 2013.
- Revision received December 16, 2013.
- Accepted December 19, 2013.
- American College of Cardiology Foundation