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Case Report
Right Ventricular Outflow Tract Stenting in Tetrology of Fallot with Restrictive Ventricular Septal Defect
January 2006
Case Report. A 6-month-old child was admitted with cyanosis noted from birth with failure to thrive, cyanotic spells and worsening cyanosis. The child weighed 4.5 kg, had severe systemic desaturation (
Catheterization revealed the following data:
RV: 124/0–12 mmHg
Systemic saturation = 54%
PA: 12/8, mean = 11 mmHg; PS gradient = 112 mmHg
LV: 70/0–8 mmHg;
Aorta: 66/49 mmHg
The RVOT was crossed with a 0.018-inch Roadrunner® wire (Cook, Inc., Bloomington, Indiana) and the RVOT was stented with a 8 x 17 mm Express™ peripheral stent (Boston Scientific, Natick, Massachusetts) (Figures 3 and 4). The stent was postdilated with 10 x 20 mm Stricker balloon.
Post-stenting catheterization data were as follows:
RV: 24/0–8 mmHg
Systemic saturation = 98%
PA: 20/8; mean = 13 mmHg
PS gradient = nil
LV: 90/0–8 mmHg
Aorta: 90/42 mmHg
The left ventricle, which was under filled prior to the procedure, was well filled post-stenting (Figures 2 and 5).
Discussion. The indications for RVOT stenting are RV-to-PA conduit stenosis, residual infundibular stenosis after intracardiac repair, tetrology of Fallot with hypoplastic branch pulmonary arteries after palliative shunt surgery, pulmonary atresia after perforation of atretic segment, and RV hypertrophic cardiomyopathy.1,2 RVOT stenting is superior to plain balloon dilatation alone due to incomplete abolition of gradients, a high incidence of restenosis and precipitation of hypoxicspells.3 Treatment of choice in native infundibular stenosis is surgery, as it carries a very low risk and rarely requires reoperation.
RVOT stenting provides an effective alternative to palliative surgical enlargement of the RVOT. Restenosis causes recurrence of gradients in some cases, but responds to redilatation.2 Complications of RVOT stenting are stent migration, ventricular arrhythmias, collapse or fracture of the stent and recurrent stenosis.2 In properly selected cases, RVOT stenting can be used as a palliative procedure with gratifying results, as occurred in our case. RVOT stenting is usually indicated in cases where total intracardiac repair is not possible. In our case, due to the underweight child having severe desaturation and the parents’ unwillingness to allow open heart surgery, we carried out the percutaneous intervention.
During the 6-month follow-up period, repeat angiography was performed, showing no stent migration, restenosis or fracture. The child is scheduled for total intracardiac repair soon, and the surgeons do not anticipate problems in cutting across the stent to widen the RVOT.
1 Hausdorf G, Schulze-Neick I, Lange PE. Radiofrequency-assisted “reconstruction” of the right ventricular outflow tract in muscular pulmonary atresia with ventricular septal defect. Br Heart J 1993;69:343–346.
2 Gibbs JL, Uzun O, Blackburn MEC, et al. Right ventricular outflow stent implantation: an alternative to palliative surgical relief of infundibular pulmonary stenosis. Heart 1997;77:176–179.
3 Nakanishi T. Intavascular stents for management of pulmonary artery and right ventricular outflow obstruction. Heart Vessels 1994;9:40–48.
