Angiography and Intervention in TGV
Angiography and Intervention in TGV
Angiography and Intervention in TGV
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11/5/2009<br />
<strong>Angiography</strong> <strong>and</strong><br />
<strong>Intervention</strong> <strong>in</strong> <strong>TGV</strong><br />
David Balzer MD<br />
Wash<strong>in</strong>gton University School of Medic<strong>in</strong>e<br />
St. Louis Children’s Hospital<br />
Transposition of the Great Vessels<br />
Pre-operative<br />
<strong>Angiography</strong><br />
Coronary anatomy<br />
<strong>Intervention</strong><br />
BAS & Park blade<br />
Post-operative<br />
<strong>Angiography</strong><br />
Coronary<br />
<strong>Intervention</strong>al<br />
<strong>Intervention</strong><br />
Pulmonary<br />
Coronary<br />
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11/5/2009<br />
Pre-operative Evaluation<br />
<strong>Angiography</strong><br />
Rarely needed any longer because of<br />
echocardiography but may be used if echo<br />
f<strong>in</strong>d<strong>in</strong>gs are <strong>in</strong>conclusive<br />
Best used to def<strong>in</strong>e coronary artery anatomy<br />
us<strong>in</strong>g laid back aortogram<br />
Pre-operative Evaluation: laid back<br />
aortogram<br />
Am J Cardiol 1990;65:1379-1383<br />
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11/5/2009<br />
Pre-operative Evaluation<br />
<strong>TGV</strong>/<strong>in</strong>tact septum<br />
Transvenous left ventriculogram<br />
Straight AP/Lat projections<br />
Pre-operative Evaluation<br />
Left ventriculogram demonstrat<strong>in</strong>g subPS secondary<br />
to bulg<strong>in</strong>g of <strong>in</strong>terventricular septum <strong>in</strong>to LV cavity<br />
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11/5/2009<br />
Pre-operative Evaluation<br />
Spectrum of outflow tract morphology from Taussig-<br />
B<strong>in</strong>g DORV (A-C) through <strong>TGV</strong>/VSD (D)<br />
Pre-operative evaluation<br />
Taussig-B<strong>in</strong>g DORV with restrictive VSD<br />
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11/5/2009<br />
Pre-operative Evaluation<br />
Taussig-B<strong>in</strong>g DORV<br />
LAO view<br />
Pre-operative Evaluation<br />
<strong>TGV</strong>/VSD<br />
Leftward <strong>and</strong> posterior malalignment of conal septum<br />
(A) creat<strong>in</strong>g LVOTO<br />
Rightward <strong>and</strong> anterior malalignment of conal septum<br />
(B) creat<strong>in</strong>g RVOTO<br />
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11/5/2009<br />
Pre-operative Evaluation<br />
<strong>TGV</strong>/VSD<br />
Left ventriculogram (LAO) view<br />
Subpulmonary obstruction<br />
Leftward posterior deviation of conal septum<br />
Pre-operative Evaluation<br />
Left ventriculogram (hepatoclavicular view)<br />
2 muscular VSDs<br />
LVOTO secondary to post/left deviation of outlet<br />
septum <strong>and</strong> fibromuscular ridge<br />
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11/5/2009<br />
Pre-operative <strong>in</strong>tervention: Rashk<strong>in</strong>d<br />
septostomy<br />
First <strong>in</strong>troduced <strong>in</strong> 1966<br />
Improves oxygenation by<br />
improv<strong>in</strong>g mix<strong>in</strong>g of<br />
oxygenated <strong>and</strong><br />
deoxygenated blood<br />
May be used for any pt with<br />
transposition physiology<br />
May be performed <strong>in</strong> the<br />
NICU with echo guidance or<br />
the cardiac cath lab with<br />
fluoroscopic guidance<br />
Works for pts < 1 mo of age<br />
Rashk<strong>in</strong>d septostomy<br />
McQuillen (Circ 2006;113:280-5) reported<br />
MRI bra<strong>in</strong> abnormalities that were strongly<br />
associated with BAS<br />
Beca (J Am Coll Cardiol 2009;53:1807-11)<br />
<strong>and</strong> Petit (Circ 2009;119(5):706-16) both<br />
demonstrated no association between BAS<br />
<strong>and</strong> preoperative bra<strong>in</strong> <strong>in</strong>jury<br />
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11/5/2009<br />
Pre-operative <strong>in</strong>tervention: Park blade<br />
Used for older pts (~>1<br />
mo. old) or very thick<br />
septums<br />
Blades available <strong>in</strong> 9.4<br />
mm, 13.4 mm <strong>and</strong> 20<br />
mm sizes<br />
4-5 <strong>in</strong>cisions are made<br />
often followed by BAS<br />
Post Operative Complications<br />
RVOTO<br />
Reported <strong>in</strong>cidence of up to 20%<br />
Obstruction may be <strong>in</strong>fundibular, valvar,<br />
supravalvar, or branch pulmonary arteries<br />
Coronary artery stenosis or obstruction<br />
Occur <strong>in</strong> up to 7.8% of patients<br />
Many patients are asymptomatic<br />
LVOT/Aortic arch obstruction<br />
Most commonly associated with TGA/VSD or<br />
Taussig-B<strong>in</strong>g DORV<br />
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11/5/2009<br />
Post-operative Evaluation<br />
<strong>Angiography</strong><br />
Some centers cont<strong>in</strong>ue to advocate follow up<br />
selective coronary angiography <strong>in</strong> all pts s/p<br />
ASO<br />
Many labs however do not rout<strong>in</strong>ely perform<br />
coronary angiography unless residual lesions<br />
suspected by ekg <strong>and</strong> echo<br />
RVOT obstruction<br />
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11/5/2009<br />
RVOT obstruction<br />
Supravalvar PS<br />
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11/5/2009<br />
Supravalvar PS<br />
Angioplasty alone often not successful at reliev<strong>in</strong>g<br />
obstruction but with higher pressure balloons such<br />
(i.e. Atlas) may be successful<br />
Stent<strong>in</strong>g may be needed for complete relief of<br />
obstruction but be aware of coronary arteries<br />
Supravalvar PS<br />
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11/5/2009<br />
Supravalvar PS<br />
Proximal PA stenosis<br />
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11/5/2009<br />
Proximal PA stenosis<br />
Proximal PA stenosis<br />
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11/5/2009<br />
Coronary stenosis<br />
Occurs <strong>in</strong> 7.8% of pts<br />
after ASO*<br />
Selective coronary<br />
angiography is<br />
<strong>in</strong>dicated <strong>in</strong> all<br />
symptomatic pts or<br />
those with ekg or echo<br />
abnormalities<br />
May be <strong>in</strong>dicated <strong>in</strong> all<br />
pts regardless of<br />
symptoms<br />
*J Am Coll Cardiol 1997;29:202-6)<br />
Coronary stenosis: <strong>Intervention</strong><br />
Primary reported <strong>in</strong>tervention is surgical<br />
Hausdorf * reported PTCA <strong>in</strong> 4 pts follow<strong>in</strong>g<br />
arterial switch with acutely successful results<br />
<strong>in</strong> all pts <strong>and</strong> dur<strong>in</strong>g 2-12 months of follow up.<br />
*Am J Cardiol 1995;76:621-23<br />
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LVOTO<br />
Supravalvar AS rarely a problem follow<strong>in</strong>g<br />
arterial switch<br />
Coarctation of aorta is most commonly<br />
associated with Taussig-B<strong>in</strong>g DORV <strong>and</strong> is<br />
amenable to transcatheter <strong>in</strong>tervention<br />
(angioplasty or stent<strong>in</strong>g)<br />
Conclusions<br />
<strong>Angiography</strong> is rarely <strong>in</strong>dicated preoperatively<br />
because of echocardiography but<br />
may be useful for coronary anatomy<br />
BAS is safe <strong>and</strong> effective therapy to improve<br />
mix<strong>in</strong>g prior to def<strong>in</strong>itive surgical repair<br />
Various levels of RVOTO are frequently seen<br />
follow<strong>in</strong>g surgical repair <strong>and</strong> may be<br />
amenable to transcatheter <strong>in</strong>tervention<br />
Coronary artery stenosis/occlusions may<br />
occur <strong>and</strong> may be asymptomatic<br />
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