Percutaneus pulmonary artery banding

History and physicalexamination :
A 3-month-old boy, weighing 5.2 kg, was hospitalized with a history of a runny nose, cough, and shortness of breath for 2 days. Upon admission, the patient was, presenting with sinus tachycardia at 170 bpm, a respiratory rate of 45 breaths per minute, SpO2 at 98%. The patient’s condition deteriorated due to Haemophilus influenzae pneumonia. He was intubated, started on inotropic support, and antibacterial therapy. Subsequent days showed an improvement in the infection.
Imaging:

An X-ray indicated lung congestion, and cardiomegaly. The patient was admitted to the PICU. The initial ECHO revealed RV and LV dilation, severe TR with a maximum PG of 74 mmHg, and TAPSE of 9 mm. The LVEF was 30%, indicating reduced LV function with an FS of 15% and an EF of 29-30%. Moderate MRV was measured at 0.5 cm². Dilatation cardiomyopathy was suspected. A nasopharyngeal swab tested positive for Respiratory Syncytial Virus. Troponin levels were at 1174 ng/ml, and NT-ProBNP was 99544 ng/ml. Therapy for suspected acute myocarditis was initiated. An echocardiogram revealed an apical mVSD with a bilateral shunt, and an MRI showed an apical VSD of 10 mm, myocardial edema, and dyskinesis in the left ventricular basal, inferolateral, and apical segments, consistent with acute myocarditis. Percutaneous PA banding was planned, and a cardiac CT revealed multiple mVSDs.
Indication for intervention:

Multiply mVSDs
Intervention:

At 16 days of hospitalization, the patient underwent percutaneous pulmonary flow restriction device implantation. Under general anaesthesia, a 4F sheath was inserted into the left and right femoral veins. Pulmonary angiography showed an RPA measuring 6.6 x 15 mm and an LPA measuring 5.9 x 14.4 mm. The Medtronic MVP-7Q self-expanding device was chosen, prepared on the table by making a cut in the polytetrafluoroethylene coating for one of the apical stent cells for the right LPA device, and for the RPA device, the polytetrafluoroethylene coating was cut off so the entire one device cell. The devices were inserted simultaneously. The right-side device was implanted distal to the upper lobe artery, and the left-side device was implanted proximal to the upper lobe artery. On day 7 post-procedure, the patient was extubated and stabilized. Five days later, percutaneous apical mVSD closure was performed via the jugular vein using a Conar (LT-MFO-10-8) device and an Amplatzer PDA device (9-PDA-006). The flow restrictors were grasped and removed. The patient was extubated after the procedure, but on the second day, a muscular VSD appeared in the mid-portion of the septum, and the patient began to decompensate. Five days later, the patient was resuscitated, intubated again, and the following day, an Amplatzer (PDA 9-PDA-006) device was implanted from the femoral approach. Finally, the patient’s condition began to improve, and he was extubated and transferred to the normal ward.
Learning points of the procedure:

Reduction of transcutaneous pulmonary artery flow using bilateral pulmonary artery restrictors is possible. The procedure is particularly useful in situations where the patient's general condition is very unstable, and also when pulmonary artery narrowing is required temporarily. In this particular case, the removal of the restrictors was successful without technical difficulties.