Tough Calls: Case 9

Inferior Baffle Stenosis

Imagine how you would work through each case. What equipment would you select and what would you do first? After having a go at it, see what our panel would do in the same situation. This exercise highlights the many possible approaches to a difficult problem. By seeing what others would do after thinking it through yourself, you will gain an understanding of the spectrum of approaches to a problem. 

History

 

42 year old male with a history of transposition of the great arteries with a small ventricular septal defect. Had Mustard procedure. Epicardial dual chamber pacemaker for sick sinus syndrome. Recently admitted due to right heart failure. Echo shows IVC baffle stenosis with turbulent flow and a peak velocity of 1.5m/s. Underwent right heart catheterization:

- IVC pressue: 22mmHg

- LV pressure: 41/5 (13) mmHg

 

Expert Approaches

Hover over an experts image to view their approach.

  • Wire out into LV (curve distal end of super stiff wire)

  • Balloon dilate IVC to ~14mm high pressure balloon

  • 30/40mm Palmaz XL on 20mmx4cm BIB depending on length purposely jailing ~50% of SVC

  • Post dilate to 18-20mm if needed

  • Double balloon distal stent with wire in SVC and LV to flare distal stent and unjail SVC

Dr. Ryan Callahan
MD, FSCAI
 

Boston Children's Hospital

Division of Invasive Cardiology

Assistant Professor of Pediatrics, Harvard Medical School 

  • With good wire position from femoral vein into the distalatrium/baffle or possibly the SVC. Compliant balloon (ie: sizingballoon) interrogation of the baffle to assess expansion and response.Balloon expandable (uncovered such as Genesis XD or Palmaz XL)stent implantation into the distal baffle so that the stenosis isexpanded and the stent is stabilized. Goal is to increase the size, butnot be matched to the dilated proximal baffle.

Dr. Matt Crystal
MD, FACC, FSCAI

New York-Presbyterian & Morgan Stanley Children's Hospital

Assistant Professor of Pediatrics, Columbia University Medical Centre
Associate Director, Pediatric Cardiac Catheterization Cardiology

  • Confida wire from IVC to subpulmonic LV

  • Palmaz XL on BiB sized to distal reference

  • May need two – inflate carefully to avoid watermelon seeding

Dr. Harsimran SIngh
MD, MSc
 

Director, Adult Congenital Heart Disease,

Director, Cardiovascular Disease Fellowship, Weill Cornell Medicine

  • Measure accurately! CTA may assist in pre-procedural planning

    • Need accurate Diameter of Stenosis and Length of segment

  • Femoral access, create a stable exchange length wire position in SVC (rail is probably not needed), long 14Fr sheath into systemic venous atrium/SVC past the stenosis

  • Mount bare metal open cell [i.e. eV3IntraStentMax LD 36 mm length]onto BIB–probably need 20-24 mm (need exact measurements as above)and deliver through sheath

  • Uncover, perform side arm sheath check angios for placement, again after inner balloon inflated, then outer balloon inflation to deliver into stenosis.Post-dilate as needed, or place add’l stent if recoil

  • Measure gradient, perform post implant angiography

Dr. Allison Calbalka
MD, FSCAI
 

Professor of Pediatrics, Mayo Clinic College of Medicine

Consultant, Pediatric Cardiology 

Director, Congenital Cardiac Laboratory

Mayo Clinic, Rochester, Minnesota

  •  I would stent the inferior baffle stenosis

Dr. Zahid Amin
MD, FSCAI, FAHA, FAAP

William B. Strong Chair and Professor and Section Chief

Division of Pediatric Cardiology 
Congenital and Structural Heart Disease
Children’s Hospital of Georgia, Augusta University