We report our experience with a 23 year old man having tetralogy of Fallot with pulmonary atresia, who underwent radiofrequency perforationReference Walsh, Lee, Chaturvedi, Van Arsdell and Benson1 of his atretic pulmonary valve. His aorta arose exclusively from the morphologically right ventricle, with the smaller left ventricle, having moderately impaired function, emptying through a large interventricular communication. During his first week of life, he had undergone banding of a large right-sided systemic-to-pulmonary collateral artery arising from the descending aorta, and subsequently underwent construction of a left-sided modified Blalock Taussig shunt at the age of 6 years. He presented to us with wasting of the skeletal muscles, increasing cyanosis, and reduced exercise capacity. Cardiac magnetic resonance showed stenosis at the distal end of the Blalock Taussig shunt, so catheterization was considered, with a view to dilating the stenotic area so as to enhance the flow of blood to the lungs. It did not prove possible, however, to cannulate the shunt. An angiogram (Fig. 1) taken after an injection through the collateral arteries showed a pulmonary trunk of good size, separated by an imperforate pulmonary valve from the cavity of the right ventricle. In the light of these findings, we perforated the valve as a palliative procedure, using a Nykanen radiofrequency perforation catheter (Baylis Medical Company Inc, Montreal, Canada) along with a coaxial injectable catheter. Perforation was achieved after 2 applications of 5 watts for 2 seconds, maintaining gentle pressure on the radiofrequency perforation catheter. We then dilated the valve using a balloon of 8 millimetres diameter. The pulmonary angiogram (Fig. 2) following the intervention showed forward flow through the pulmonary valve to the lungs, with moderate pulmonary regurgitation. The resting saturations had improved to 85% when measured in room air at the end of the procedure.
Figure 1
Figure 2
At follow-up 3 months after the procedure, the patient showed significant improvement in his exercise capacity. Considering the effect of pulmonary regurgitation over the long term on right ventricular function, we plan to re-evaluate the patient in 6 to 12 months time with a view to proceeding to more definite repair, either surgically or by percutaneously implanting a pulmonary valve.
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