Successful Hybrid Rescue of Occluded Pulmonary Artery in Pulmonary Atresia

ybrid cardiac procedures are a result of synergisticcooperation between the cardiologist and surgeon. Theyare a combination of surgical repair and intraoperativecatheter-based interventions, and may provide an effectiveoption for the repair of complex congenital heart lesions.We present a 30-year-old man with pulmonary atresia anda ventricular septal defect. He previously had a Waterstonshunt placed at 10 days of age and a right pulmonary arteryshunt at 4 years of age. He had ventricular septal defectclosure with a 23-mm homograft conduit connecting the rightventricular outflow tract to the main pulmonary artery con-fluence at 9 years of age. The patient presented to us 21 yearslater with pulmonary conduit obstruction, right pulmonaryartery stenosis, and an occluded left pulmonary artery (LPA;Figures 1, 2A, and 2B). The catheterization demonstratedright ventricular pressure (70% of systemic arterial pressure)at 89/14 mm Hg. There was a 28-mm Hg gradient to the rightpulmonary artery, and the LPA was occluded. A 7-mm distalLPA was demonstrated by left pulmonary vein wedge angio-gram. Given the long occlusion between the conduit and thelower LPA, we were concerned that the LPA would not beaccessible for direct patch augmentation, and hence decidedtoperformahybridprocedure;however,withnodirectaccessto the distal LPA, this would require a covered stent tosuccessfully connect the distal LPA to a proximal conduit.A redo median sternotomy was performed, and bypasscannulas were inserted into the ascending aorta and bothvenae cavae. The conduit was opened, and the incision wasextended along the anterior aspect of the LPA as distally aspossible. A calcified thrombus was present in the LPA thatextended into the lower branch of the LPA. The thrombuswas gently removed piecemeal from the LPA with a bonerongeur and a Fogarty catheter. The presence of back bleedfrom the pulmonary artery was an indication that continuityhad been reestablished. On palpation in the hilar area, theLPA felt soft and pliable. Under an emergent/compassionaterequest, two 28-mm-long Numed (Numed Inc) covered stentsmounted on a balloon-in-balloon catheter with a 9-mmdiameter internal balloon were inserted into the LPA over aguidewire. Only the internal 9-mm balloon was used todeploy the covered stent, which was subsequently redilated to10 mm with a 10-mm Z-Med II balloon (B. Braun MedicalInc). Two stents were deployed in the same manner in tandemto reconstruct approximately a 35-mm segment of the LPA. Abovine pericardial patch was sutured onto the artery proxi-mally to augment it. Finally, two 3110 Palmaz stents (PalmazScientific) were introduced on a 10-mm Z-Med II balloon andplaced in tandem proximally (Figure 3). The right pulmonaryartery ostial stenosis was also stented with a 3110 Palmazstent and dilated to 18 mm. Pulmonary valve replacement(27-mm pericardial tissue valve) and augmentation of theright ventricular outflow tract with a ribbed reinforced Gore-Tex patch were performed to complete the procedure. Post-operative recovery was uneventful, and the patient wasdischarged 6 days later on aspirin and clopidogrel. Computedtomographic imaging with 3-dimensional reconstructiondemonstrated satisfactory blood flow to the entire lower lobeoftheleftlung,butwithashortgapbetweentheproximaland