Percutaneous closure of nonrestrictive aortopulmonary window in three infants

Operative Repair of Aortopulmonary Window: A 25-Year Experience

Background: Aortopulmonary window (APW) is a rare anomaly with variable morphology and associated cardiac anomalies. We evaluated impact of patient and operative factors on mid-term outcomes following APW repair. Methods: Twenty-nine patients underwent surgical APW repair at our institution from 1996 to 2022. Eight (28%) had simple APW, accompanied by only atrial septal defect or patent ductus arteriosus; 21 (72%) had complex APW with additional cardiovascular lesions, including nine with interrupted aortic arch. Median operative age was 19 days (range 2 days-1.5 years) via single-patch (n = 12, 41%), double-patch (n = 15, 52%), or ligation and division (n = 2, 7%). Results: The only mortality occurred in-hospital 1.4 years postoperatively following remote myocardial infarction. Factors associated with longer postoperative length of stay were complex APW (P = .003), genetic syndrome (P = .003), noncardiovascular comorbidities (P = .002), lower birth weight (P = .03), and lower operative weight (P = .03). Six patients (21%) with complex APW underwent unplanned cardiothoracic reintervention(s), including two with arch reintervention following arch advancement for interruption. Reintervention-free survival was similar for simple versus complex APW, operative age categories, and repair techniques. At median follow-up 5.5 years postoperatively, no patients had residual APW or persistent pulmonary hypertension, 1 (3%) had greater than mild ventricular dysfunction, and 25 (89% survivors) had NYHA class I functional status. Conclusions: Operative APW repair has excellent mid-term survival, durability, and functional status, regardless of operative age, cardiovascular comorbidities, or repair technique. Cardiac and noncardiac comorbidities may be associated with prolonged length of stay.

Surgical management of aortopulmonary window with pulmonary artery dilatation causing left main coronary compression

Aortopulmonary window is a rare congenital heart defect. Left main coronary artery extrinsic compression by an enlarged pulmonary artery is a rare complication and a potential cause for chest pain and sudden cardiac death in patients with pulmonary hypertension. Here, we present the case of a 14-year-old boy with a large aortopulmonary window who was planned for a device closure, but during the procedure, he developed ST-T segment changes while the device was being deployed, and hence the procedure was abandoned. The boy subsequently underwent a successful surgical closure thereafter.

Transcatheter closure of the aortopulmonary window in a three-month-old infant with a symmetric membranous ventricular septal defect occluder device

Although most of aortopulmonary window cases are closed surgically, percutaneous closure can be also used in suitable patients. Defects which are far from the pulmonary and aortic valves, coronary artery, and pulmonary artery bifurcation, with adequate septal rims are considered suitable for percutaneous closure. A three-month-old male infant weighing 4 kg was referred to our pediatric cardiology department with the complaints of fatigue while breastfeeding, difficulty in weight gain, heart murmur, and respiratory distress. A large aortopulmonary window (5.3 mm) and left heart chamber dilatation were detected on echocardiography. The large aortopulmonary window was closed using a symmetric membranous ventricular septal defect occluder device. The closure procedure was performed via the antegrade route without forming an arteriovenous loop. In conclusion, the use of a symmetric membranous ventricular septal defect device for closure of large aortopulmonary window seems to be a safe and effective alternative to surgery in selected infants.

Large Unrepaired Aortopulmonary Window Presenting in Adulthood

Background

Aortopulmonary window is an uncommon congenital heart disease, with untreated cases not surviving beyond childhood. However, very rarely it can present in adult patients with features of pulmonary hypertension. Clinically these patients cannot be differentiated from other more common conditions with left to right shunt. Transthoracic echocardiography if performed meticulously, can depict the defect in aortopulmonary septum.

Results

We report a case of large unrepaired aortopulmonary window in a 23 years old patient, diagnosed on transthoracic echocardiography.

The prenatal diagnosis of aortopulmonary window by fetal echocardiography

OBJECTIVE

The purpose of this study was to analyze the fetal echocardiographic features and the associated anomalies of prenatal aortopulmonary window (APW).

METHODS

We retrospectively reviewed the fetal echocardiographic database (n = 24 000) in our hospital between May 2012 and December 2017. The general clinical information, fetal echocardiographic features, and the associated anomalies in patients with APW were analyzed. Four patients had undergone whole genome sequencing using fetal tissues.

RESULTS

Six cases of APW confirmed by autopsy were identified in our fetal echocardiographic database. On the three-vessel view, a communication between the pulmonary artery trunk and ascending aorta was noted above the two semilunar valves in all cases. The most frequent type of APW among the cases was type II, and all cases were associated with other cardiac anomalies. No pathogenic or suspected pathogenic copy number variation or insertion-deletions were detected in this series.

CONCLUSION

Prenatal diagnosis of APW is feasible, which is helpful during prenatal consultations, so that parents can make better decisions regarding postpartum treatment options and pregnancy outcomes.

Diagnosis and surgical treatment of aortopulmonary window: Our single-center experience

Background

In this study, we aimed to report our single-center experience in aortopulmonary window and review clinical signs, symptoms, surgical correction techniques, and long-term outcomes.

Methods

We retrospectively reviewed the medical records of a total of 30 patients who were followed with the diagnosis of aortopulmonary window in our hospital between May 1998 and June 2016. The clinical characteristics of the patients, echocardiographic and angiographic findings, surgical treatment outcomes, and medical problems during follow-up were reviewed.

Results

The most common signs and symptoms were murmur, dyspnea, tachypnea, growth retardation, and signs of congestive heart failure. The mean age at the time of surgery was 8.2±14.4 months (7 days to 60 months). Eighteen patients (60%) had additional congenital cardiac anomalies. Eleven patients had simple congenital heart diseases, and seven patients had complex congenital heart diseases. Four patients were unable to be operated due to Eisenmenger syndrome (n=3) and complex congenital heart disease (n=1). No early or late postoperative death was observed. The mean follow-up was 6.4±4.8 years (range, 5 months to 16 years). In addition to aortopulmonary window repair, an additional cardiac anomaly modifying surgical intervention was corrected in nine patients (34.6%). One patient was reoperated for residual aortopulmonary window and another patient for pulmonary stenosis (valvular, supravalvar) after three years. One of these patients underwent pulmonary balloon valvuloplasty after two years. The reoperation rate was 7.7% (n=2) during follow-up.

Conclusion

Aortopulmonary window is a rare cardiac anomaly which may be overlooked by echocardiographic study, and which is amenable for repair with low-surgical risk. It is, therefore, imperative to diagnose and treat this condition, before pulmonary vascular disease develops.

Percutaneous closure of an aortopulmonary window using Amplatzer Duct Occluder II: Additional Sizes: the first reported case

To date, there are no reported cases of the Amplatzer Duct Occluder II: Additional Sizes' use in percutaneous closure of an aortopulmonary window. We report a case of percutaneous closure of an aortopulmonary window in a 4.5-month-old, 6 kg child. Owing to the patient's low weight, high risk of damage to the pulmonary valve, as well as the possibility of aortic and pulmonary artery obstruction, classic implants were deemed unsuitable and a decision was made to use the Amplatzer Duct Occluder II: Additional Sizes. The implant performed very well - the soft waist filled the aortopulmonary connection and both retention discs were properly shaped and pressed against vessel walls. Echocardiogram performed 12 hours after the procedure confirmed a correct occluder position. Low-profile retention discs had no impact on pulmonary valve function, despite the defect's proximity to the valve. No obstruction of the aortic or pulmonary artery lumen was noted. The Amplatzer Duct Occluder II: Additional Size implant is a safe and useful device for percutaneous closure of an aortopulmonary window in a carefully selected group of patients.

Closure of aortopulmonary window using Nit-Occlud® PDA-R device in a 3-month-old infant

Aortopulmonary window (APW) is a rare abnormality in which a pulmonary defect exists between the ascending aorta and the main pulmonary artery. Given that it may result in cardiac failure and pulmonary vascular disease in the early period, treatment needs to be performed without delay. In addition to surgical treatment, transcatheter closure may also be performed for selected patients. This study describes the case of an infant diagnosed with APW and who underwent successful transcatheter closure using a Nit-Occlud® PDA-R device.

Percutaneous closure of complex paravalvular aortic root pseudoaneurysm and aorta-cavitary fistulas

Native aortic valve or its prosthetic valve endocarditis can extend to the adjacent periannular areas and erode into nearby cardiac chambers, leading to pseudoaneurysm and aorta-cavitary fistulas respectively. The later usually leads to acute cardiac failure and hemodynamic instability requiring an urgent surgical intervention. However rarely this might pass unnoticed and the patient might present later with cardiac murmur. Percutaneous device closure of aortic pseudoaneurysm, ruptured sinus of Valsalva aneurysm, aorta-pulmonary window, paravalvular leaks, and aorta-cavitary fistula have been reported. We present a 59-year-old female who developed a large aortic root pseudoaneurysm with biventricular communication aorta-cavitary fistulas presenting late following aortic prosthetic valve endocarditis. She underwent successful percutaneous device closure of her pseudoaneurysm and aorta-cavitary fistulas using two Amplatzer Duct Occluders. This case illustrates a challenging combination of aortic root pseudoaneurysm and biventricular aorta-cavitary fistulas that was successfully treated with percutaneous procedure.

Diagnosis, treatment and outcomes of patients with aortopulmonary window

BACKGROUND

Aortopulmonary window (APW) is a communication between the ascending aorta and the pulmonary artery in the presence of two separate semilunar valves and is the rarest of septal defects.

AIMS

To present our experience with the diagnosis and outcome of APW cases.

STUDY DESIGN

Retrospective cohort study.

METHODS

Between June 2003 and October 2011, thirteen patients were diagnosed with APW. Clinical features of patients, findings of echocardiographic and angiographic examination, results of surgical intervention and follow-up were reviewed retrospectively.

RESULTS

Eleven children (10 days to 16 years), underwent surgical correction of APW. In a 12-month-old boy, the defect was repaired by the transcatheter approach. In addition to APW repair, closure of VSD was performed in 2 patients. APW were associated with interruption in two patients; one also had a complex pathology. None of the patients died due to complications of surgical or transcatheter procedures. After a median follow-up period of 40 months, the patients were asymptomatic and none of them required additional medication, except for the patient with complex pathology including an interrupted aortic arch, who underwent balloon angioplasty for recoarctation.

CONCLUSION

In any infant with the findings of congestive heart failure and failure to thrive, APW must be kept in mind as a differential diagnosis. In isolated APW cases before 6 months of age, echocardiography is often sufficient for diagnosis. In complex cases, cardiac catheterisation is performed for the comprehensive evaluation of associated defects. After 6 months, cardiac catheterisation could be utilised to perform vasoreactivity testing and, if possible, to close the defect.

Closure of an aortopulmonary window using the Amplatzer Duct Occluder II

We report two cases of transcatheter-device closure of aortopulmonary windows, a residual defect occurring after previous surgical closure, and a native lesion. The postsurgical defect was closed with an Amplatzer Duct Occluder II (AGA Medical Corporation, MN). The native lesion was not suitable for an Amplatzer Duct Occluder II device; thus, it was closed using an Amplatzer Duct Occluder (AGA Medical Corporation, MN). The Amplatzer Duct Occluder II provides an additional device for aortopulmonary window closure, but anatomy and defect characteristics dictate the most appropriate device.

Transcatheter closure in two rare cases of left-to-right shunt with Cardio-O-Fix occluders

We present two procedures of transcatheter closure: that of an aorto-pulmonary window in a 12-month-old infant with a body weight of 7 kilograms, and that of ruptured sinus of Valsalva aneurysm into the right atrium in an adult patient. In the first case, we applied the muscular ventricular septal defect Cardio-O-Fix, while in the other we applied the patent ductus arteriosus Cardio-O-Fix occluder. The procedures were successful in both patients, and we achieved complete closure of the unwanted shunts.

Transcatheter closure of an iatrogenic aorto-right ventricular fistula

Aortocardiac fistulas are rare, especially if they develop after an aortic valve replacement surgery. We report the case of a 54-year-old male submitted to aortic valve replacement and implantation of an ascending aortic prosthetic graft, complaining of exertional dyspnea, who was found to have significant shunt between the aortic root and right ventricle (RV), and de novo moderate pulmonary hypertension. At the catheterization laboratory, the left-to-right shunt was confirmed (Qp:Qs = 1.9:1). Contrast angiography of the ascending aorta showed a significant flow into the right ventricular cavity, and the fistulous tract was then measured, inflating a Tyshak II balloon of 10 × 20 mm (NuMED, Hopkinton, New York), until achieving a complete interruption of flow. Minimal diameter of the defect was 4.9 mm. Percutaneous closure of the aorto-RV shunt was performed under general anesthesia and transesophageal echocardiogram and fluoroscopic guidance. Using a venous and an arterial femoral access, a 0.035″ hydrophilic guide-wire crossed the defect between the aorta and RV, creating an arteriovenous loop. Then, using a 7F Delivery System 45° (AGA medical corporation, Golden Valley, MN) an Amplatzer Duct Occluder(®) (AGA Medical Corporation) 8/6 mm was advanced and released within the defect, achieving an almost complete closure of the fistulous tract.

Current treatment of aortopulmonary window

Aortopulmonary window is a rare abnormal congenital communication between the pulmonary artery and the ascending aorta with intact aortic and pulmonary valves. Because pulmonary hypertension and premature death are the natural history of the uncorrected left-to-right shunt physiology that occurs with aortopulmonary window, surgical correction, which is the gold standard of treatment, should be offered to patients at the time of diagnosis, before the development of lung injury and irreversible pulmonary hypertension.