TOTAL LEFT PULMONARY ARTERY OCCLUSION AFTER PERCUTANEUS PDA CLOSURE IN 700 G PRETERM NEONATE

History:
At 23 rd. day of life 700 g preterm neonate has hemodynamically significant PDA with history of unsuccessful pharmacological treatment with nonsteroid anti-inflammatory agents. Decision was made to offer percutaneous closure of the PDA. During intervention was successfully closed PDA with Piccolo device with no signs of obstruction in descending aorta or left pulmonary artery on ECHO. After 3 months during follow up complete occlusion of the left pulmonary artery was suspected on ECHO examination, During angiography complete left pulmonary artery occlusion was confirmed. Retrograde pulmonary venogram showed 2 mm in diameter extremely hypoplastic left pulmonary artery with complete obstruction of the lumen with the Piccolo device pulmonary disc . Percutaneous accesses of the left pulmonary artery was not possible. Hybrid procedure was scheduled. Before planned intervention patient was urgently sent back to the hospital because of the acute right ventricle failure, pulmonary hypertension with critical clinical deterioration. After partial recovery another episode of acute heart failure was observed. We suspect left pulmonary artery complete occlusion, broncho-pulmonal dysplasia due to prematurity and secondary pulmonal hypertension as cause of failure. At the age of 8 month and body weight 2500 g hybrid procedure was performed. After longitudinal sternotomy, pericardium was opened and direct puncture of the main pulmonary trunk followed. Additionally x-ray positive left PA band was created to advance targeting during perforation. 4 Fr short sheet was used to advance ''chiba'' needle with coronary wire inside. Left pulmonary artery was reached true the body of the Piccolo device and confirmed with coronary wire configuration and contrast injection. After cannulation of the pulmonary artery with short sheet 4,5 mm coronary stent was implanted. After left pulmonary artery reopening right ventricle failure disappeared and patient has good somatic growth, At the age of 1 year diagnostic angiography with 3D rotation was performed with preventive ballooning for neointima proliferation with 5 mm coronary balloon. At the age of 2 years another percutaneous intervention on coronary stent was successful with post-dilatations and re-stenting and second postdilatation with ultra high pressure balloon and 6.2 mm diameter of the lumen was achieved. Unfortunately, left pulmonary upper lobe artery became obstructed during coronary stent fracture. Patient was discharged in good clinical condition.

Imaging:
ECHO, angiography, 3-D rotational angiography.

Indication for intervention:
Hemodynamically significant PDA, left pulmonary artery complete obstruction, right ventricle failure

Intervention:
Percutaneous PDA Closure in preterm neonate, diagnostic angiography, hybrid procedure; sternotomy, left pulmonary artery opening and stenting, Angiography and stent postdilatation, angiography and re- stenting, postdilatation with ultrahigh pressure ballon

Learning points of the procedure:
1. During PDA closure in preterm neonates device should be implanted strictly intraductally 2. The length of the duct in preterm neonate is one of the critical measurements for Piccolo device selection 3. Completely obstructed pulmonary artery could be visualized with the pulmonary venous retrograde injection 4. Completely obstructed left main pulmonary artery as a complication of percutaneous PDA closure could be reopened during hybrid procedure 5. Coronary stent could be postdilatated with re-stenting and postdilatation with ultra high pressure balloon 5. Coronary stent could be crashed