Transcatheter perforation of atretic pulmonary valve by the stiff end of a coronary wire in neonates with pulmonary atresia with intact ventricular septum: A solution in developing countries

Objectives: To evaluate the safety of using the stiff end of a coronary wire to perforate an atretic pulmonary valve (PV) in patients with pulmonary atresia with intact ventricular septum (PAIVS). Background: Radiofrequency perforation is an accepted modality to perforate the PV in patients PAIVS. However, the high cost precludes its widespread use. Patients and methods: This is a single-center experience that spanned from March 2013 to January 2016 and involved 13 neonates who were severely cyanotic with PAIVS and with ductal-dependent pulmonary circulation. The stiff end of a coronary wire was used to perforate the atretic PV anterogradely, followed by balloon pulmonary valvuloplasty. Results: The mean age of patients was 3.9 b 2.7 days and their mean weight was 2.8 b 0.19 kg. The mean oxygen saturation was 77.1 b 3.2%. All had membranous pulmonary atresia, with patent infundibulum and tripartite right ventricle. The valve was successfully perforated in 11 out of 13 patients. Death occurred in two patients (15.4%) owing to heart failure and sepsis. Patent ductus arteriosus stenting was performed 2 days after the procedure in one patient because of cyanosis followed by one and half ventricle repair at of age 5 months. Two patients (15.4%) had one and a half ventricle repair at age of 5 months and 6 months owing to insufficient anterograde pulmonary flow. Two patients (15.4%) underwent second intervention with balloon dilatation of the valve. The remaining seven patients (53.8%) had no further intervention. Two cases (15.4%) had femoral artery thrombosis treated with streptokinase. The mean duration of follow-up was 13.17 b 7 months. There was significant improvement in the degree of tricuspid incompetence. There was a significant growth in the tricuspid valve annulus during the follow-up (the mean Z score increased from -0.8 b 0.9 to 0.1 b 0.9) (p = 0.003). There was also a significant increase in the tricuspid valve annulus/mitral valve annulus ratio as its mean increased from 0.73 b 0.10 to 0.86 b 0.11 during follow-up (p < 0.001). Conclusion: Perforation of the atretic PV in selected cases with membranous atresia and patent infundibulum using the stiff end of a coronary wire is an effective alternative to using radiofrequency perforation. (C) 2018 Production and hosting by Elsevier B.V. on behalf of King Saud University. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).