CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 1, January/February 2013
AFRICA
75
mycin (for 2 weeks) for
Streptococcus viridans
. MRA revealed a long
segment coarctation distal to the left subclavian with multiple aneu-
rysms in the post stenotic area. Conventional aortogram confirmed
the above findings. The pressure gradient across the coarctation
was 100 mmHg. Two overlapping covered CP stents (Nu-Med, New
York, USA) were placed to dilate the coarcted segment as well as
completely cover the aneurysms, reducing the pressure gradient to 5
mmHg. The recovery was unremarkable.
Discussion and conclusion:
Osler introduced the term mycotic
aneurysm in 1885 to describe any aneurysm that develops in context
with bacterial endocarditis irrespective of the pathogen. Mycotic
aneurysm has a high risk of rupture in coarctation of aorta with up to
50–100% mortality. Treatment of adult coarctation with covered stent
is a standard practice in several centres. The PTFE covering is useful
in treating aneurysms complicating bare metal stent implantation or
coexisting patent ductus arteriosus. This report highlights the safety
of endovascular covered stents in managing mycotic aneurysms of
coarctation of the aorta not reported to date.
538: UNUSUAL SYSTEMICVENOUS COLLATERALS CHAN-
NEL TO LEFT ATRIUM CAUSING DESATURATION AFTER
FONTAN OPERATION CLOSED PERCUTANEOUSLY
Savitri Shrivastava, AMarwah, S Khatri, KS Iyer
Fortis Escorts Heart Institute, Okhla Road, New Delhi, India
Abstract:
We present an unusual cause of progressive cyanosis in a
child 2 years after successful Fontan surgery. One large venous chan-
nel and two small venous channels were draining into the left atrium
(LA) directly; the larger channel was closed by Amplatzer vascular
plug and small venous collaterals were closed by coils, resulting in
improvement of oxygen saturation.
Case report:
A 7-year-old girl with tetralogy of Fallot (TOF), with
hypoplastic right ventricle and adequate branch pulmonary arteries,
had undergone modified right BT shunt in infancy followed by BD
Glenn, ligation of pulmonary artery and takedown of BT shunt at
16 months, followed by an extracardiac Fontan at 5 ½ years. She
had a smooth postoperative course with saturation of 95 %. She had
gradual return of cyanosis, exertional dyspnoea and easy fatigabil-
ity over 6 months. Her saturation was 85% at rest and 78% after 10
minutes walking. Transoesophageal echocardiogram (TEE) revealed
normally functioning Fontan circuit, normal ventricular function, and
no atrioventricular (AV) valve incompetence, pericardial or pleural
effusions. One venous channel was seen arising from the brachio-
cephalic vein. On cardiac catheterisation, intracardiac and Fontan
pressures were normal. Inferior vena cava (IVC) angiogram revealed
a large tortuous venous channel arising at T8-T9 level and draining
into the LA of 12 mm diameter, an additional small vein was seen
connecting the larger venous channel to the LA. Innominate vein
angiogram revealed a small venous channel communicating with the
LA. These channels were occluded with 8 mm Amplatzer plug and
two coils. Post-deployment angiograms revealed complete occlusion
of all the venous channels, with 94% saturation. The patient remains
well at 6-month follow-up. We could not find a similar case report in
the English literature.
Conclusion:
Large venous channels draining directly into LA can be
closed percutaneously. Long-term follow-up is necessary.
545: PRENATALLY BORDERLINE LEFT HEART A PROB-
LEMAT ALL?
Monika Kaldararova
1
, Peter Tittel
1
, Andrea Kantorova
1
, Martin
Culen
1
, Michal Holan
2
, Martin Zahorec
1
1
National Institute for Cardiovascular Diseases, Children’s Cardiac
Center, Slovakia
2
Medifera Medical Center, Slovakia
Background:
Borderline left heart (Border-LH) raises the question of
two- versus single-ventricle circulation. Aim of the study was detailed
analysis of prenatal Border-LH and further postnatal outcome.
Patients and methods:
We analysed 14 patients (9 female) with
Border-LH identified prenatally between 2008 and 2012. 1. Prenatal
echocardiographical measurements included: mitral/tricuspid valve
(MV/TV) annulus, aortic/pulmonary valve (AOV/APV), left/right
ventricular (LV/RV) width and length; these were compared to 35
healthy matched controls (NORMAL) and to 17 patients with hypo-
plastic left heart syndrome (HLH). 2. Postnatal anatomy and outcome
were evaluated, with median follow-up 15 months.
Results:
1. Prenatally, in Border-LH significantly smaller struc-
tures were found compared to NORMAL but bigger compared to
HLH. Border-LH/NORMAL/HLH: median MV/TV 0.60/0.92/0.42
(
p
<
0.0001), AO/AP 0.54/0.91/0.32 (
p
<
0.0001), LV/RV width
0.59/0.93/0.42 (
p
<
0.0001), LV/RV length 0.92/0.99/0.41 (
p
<
0.0001).
2. Postnatal z-scores: median MV -1.2, AOV -1.05; smaller (z-score
≤
2) MV and/or AOV in 3 patients (21.4%). Additional findings were:
ventricular septal defect (VSD) in 7 (50%), bicuspid aortic valve in 6
(42.9%), and persistent left superior vena cava to coronary sinus in 3
(21.4%) patients. 3. All patients were able to maintain a biventricular
circulation postnatally, 1 (7.1%) without (w/o) intervention. Thirteen
(92.9%) developed pathology, 10 (71.4%) underwent coarctation of
aorta (CoA) repair, and 1 VSD closure. Three (21.4%) early deaths
occurred: 2 prior to surgery, 1 after CoA repair. 4. No late deaths
were registered. By 2 months MV and AOV were all within normal
range. In 2 (14.3%) balloon angioplasty for re-CoA was performed,
in 2 (14.3%) mild mitral stenosis developed, w/o intervention needed.
Summary:
Border-LH means a thinner LV with almost normal length
and smaller MV and/or AOV prenatally; but with normal postnatal
growth potential. Despite the positive consequence of biventricular
circulation, these patients are not free of interventions. CoA can be
expected with arterial duct closure. Frequently associated pathology
indicates that this is not just prenatally ‘lower-flow’ circulation but
probably represents a more complex morphological problem.
563: FOETAL PULMONARY VALVULOPLASTY BY PERCU-
TANEOUS TRANSHEPATIC ACCESS IN A LAMB MODEL
Andrew Edwards
1, 2, 3
, Alex Veldman
4
, Ilias Nitsos
1
, Yuen Chan
5
,
Nadine Brew
1
, Samuel Menahem
3,6
, Dietmar Schranz
,4
, Flora Wong
1,6,7
1
The Ritchie Centre, MIMR, Monash University, Melbourne, Australia
2
Perinatal Services, Monash Medical Centre, Melbourne, Australia
3
Foetal Cardiac Unit, Monash Medical Centre, Melbourne, Australia
4
Pediatric Heart Center, Justus-Liebig University, Giessen, Germany
5
Department of Pathology, Monash Medical Centre, Melbourne,
Australia
6
Department of Paediatrics, Monash University, Melbourne, Australia
7
Monash Newborn, Monash Medical Centre, Melbourne, Australia
Background/hypothesis:
Foetal pulmonary valvuloplasty may
ameliorate hypoplastic right heart syndrome and mitigate postnatal
disease. Foetal heart access by direct foetal heart puncture is well-
described. We have recently developed a percutaneous transhepatic
foetal cardiac catheterisation technique, which may be safer and
offer technical advantages. We hypothesised that foetal pulmonary
valvuloplasty could be performed by a percutaneous transhepatic
approach at mid-gestation.
Materials and methods:
Nine foetal lambs at 97-100 (term 147)
days’ gestation (average weight: 1 215 g) were studied under mater-
nal general anaesthesia. Under ultrasound guidance, the foetal
hepatic vein was percutaneously punctured using a 16 GA IV-cannula
with needle
in situ
. A 2.4/1.9Fr coronary catheter was inserted over a
0.014 inch floppy-guidewire, and the inferior vena cava (IVC), right
atrium (RA), right ventricle (RV), pulmonary artery, ductus arte-
riosus and descending aorta were catheterised. After removing the
guiding catheter, but with the guidewire in place, a coronary PTCA
dilatation catheter was positioned across the pulmonary valve, and
several inflations of the balloon were performed simulating a valvu-
loplasty. Seven foetuses were euthanised post-procedure, and 2 were
euthanised after term-delivery, for postmortem examination.
Results:
Percutaneous cannulation of the foetal hepatic vein followed
by RA and RV catheterisation was successful in all cases. One foetus
