Heart Center: Pulmonary Balloon Angioplasty

Branch pulmonary artery stenosis is a narrowing of the vessels that leave the heart and go to the lungs. This narrowing can be isolated to a particular area, can involve a long segment of the vessel, or can involve narrowings in multiple vessels. Branch pulmonary artery stenosis occurs in 2-3 percent of all patients with congenital heart disease or 0.016 percent of the general population. It can occur as an isolated finding (with or without other heart disease), in association with an inherited syndrome or chromosomal abnormality, or following surgery that involves the pulmonary arteries. The stenosis can result in increased right heart pressures, decreased pressure in the affected pulmonary artery, and decreased blood flow to the involved lung. The severity of the stenosis is based on the pressure difference, or gradient, before and after the narrowing. The higher the difference, the more severe the stenosis. Intervention is often recommended if the right heart pressures are greater than half of the left heart pressures, if the pressure difference across the stenosis is more than 20mmHg, or if the blood flow to the involved lung is reduced by more than 25 percent.

In the past, surgeons were asked to enlarge the pulmonary arteries by cutting them open and placing patches onto the vessels. This procedure was not very successful, however, unless the stenosis was very close to the main pulmonary artery and the stenosis was isolated. Today there is a nonsurgical option to open up the narrow pulmonary arteries called pulmonary balloon angioplasty. During the procedure, fluoroscopy (X-ray) is used to guide a catheter with a balloon on the end into the narrowed area through a blood vessel in the leg. Once the catheter is in the correct place, the balloon is rapidly inflated and deflated to dilate, or open, the artery. This technique can be performed successfully on patients who have, and patients who have not, had prior surgery. After the procedure the patient will be admitted to the hospital for overnight observation and released the next day.

The results for pulmonary balloon angioplasty vary. Success depends on the type and location of the narrowing, the size of the balloon used, the inflation pressure used to inflate the balloon, and whether the stenosis is associated with a syndrome or chromosomal abnormality. Angioplasty to treat stenosis associated with genetic syndromes or caused by previous shunts has a somewhat lower success rate. The immediate success rate, as determined by a 75 percent increase in the narrowed area, a 50 percent decrease in the pressure gradient, or a 25 percent increase in blood flow to the affected lung, is approximately 80 percent for patients without a genetic syndrome and 30-50 percent for those with a genetic syndrome as the cause of their pulmonary artery stenosis.

The long-term results for this procedure are unknown, but it appears that the stenosis, in general, does not recur. However, the initial result, although improved, may not be adequate. Sometimes multiple and/or graded (stepwise increase in size) angioplasty procedures may be necessary before the maximal benefit is obtained.

A few complications can occur with this procedure. They all are less than 2 percent and include femoral vein damage, pulmonary artery damage, pulmonary artery aneurysm (bulging in a weak spot), lung edema or fluid accumulation, bleeding, increased X-ray exposure time, and death. To combat these complications, the balloon size is carefully matched to the pulmonary vessel size, and heparin, a blood thinner, is given to prevent blood clot formation. Blood is ordered and is available for immediate use in case of bleeding.

Your cardiologist and Dr. Zellers will inform you more fully about this procedure on the morning of your child's catheterization. You will be able to ask questions and will be asked to sign a consent form. Cardiac catheterization may also be required at a later date. Often an echocardiogram is ordered the day after the procedure and again within the year after the procedure.

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