Left Pulmonary Artery Stenting with Glenn Shunt: Introducing a Hybrid Procedure
The patient was a 24-year-old male who presented with dyspnea. He was cyanotic, and the oxygen saturation in the room air was 65%. The patient had clubbing in his toes and fingers. No procedure had been performed for this patient until then.\nEchocardiography revealed moderate enlargement and normal function of a predominant morphologic right ventricle (RV). Both of the atrioventricular (AV) valves opened to the RV with mild regurgitation, and both great arteries arose from the RV with severe subvalvular and valvular pulmonary stenosis. The position of the great arteries was D-malposed; i.e. the aorta was anterior and right-sided.\nThe patient’s ventricular function rendered him amenable to the Fontan surgery. Catheterization measured the mean pulmonary artery pressure (PAP) and left ventricular end diastolic pressure (LVEDP) as 10 mm Hg and 12 mm Hg, respectively. During RV injection, it was observed that the left pulmonary artery (LPA) was not opacified; decision was, therefore, made to conduct magnetic resonance imaging (MRI) so as to better evaluate the pulmonary artery branches. The procedure showed a long, significant stenosis of the LPA, which was 25 mm in length and 4 mm in diameter ( and ).\nGiven the posterior position of the LPA and the relative distant location of the stenosis from the bifurcation and the desire to reduce surgery time, a hybrid LPA stenting procedure was opted for. After median sternotomy and routine cannulation, cardiopulmonary bypass was performed, the heart was arrested, and the Glenn Shunt was conducted on the beating heart with low-grade hypothermia and without an aortic clamp. Next, the main of the pulmonary artery (PA) was incised before the bifurcation, and a 3- mm Bare Stent (Genesis, Cordis Co.) was mounted on a 12 × 40-mm balloon (Opta Pro, Cordis Co.), which was passed through the LPA. The course of the catheter and stent as well as the covering of the lesion with the stent was monitored via transesophageal echocardiography (TEE). The acceptable position of the stent having been ascertained, the balloon was inflated up to 5 Atm and the final diameter of the stent reached 12 mm. TEE confirmed the correct position of the stent and the diameter of the LPA after stenting (). After the procedure, oxygen saturation rose to 83%.\nAt six months’ follow-up of the patient, exercise capacity and cyanosis had improved significantly, with O2 saturation having reached near 85% by pulse oximetry. Furthermore, no restenosis was seen in the follow-up imaging by transthoracic echocardiography ().