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CASE IN POINT - CLINICS IN PEDIATRIC CARDIOLOGY AND OTORHINOLARYNGOLOGY
Year : 2017  |  Volume : 4  |  Issue : 3  |  Page : 198-200

Simultaneous balloon dilatation of subglottic stenosis and device closure of a large patent ductus arteriosus in infancy


1 Department of Pediatric Cardiology, Medica Superspeciality Hopsital, Mukundapur, Kolkata, West Bengal, India
2 Department of Otorhionolaryngology, Medica Superspeciality Hopsital, Mukundapur, Kolkata, West Bengal, India
3 Department of Pediatrics, Medica Superspeciality Hopsital, Mukundapur, Kolkata, West Bengal, India
4 Department of Anaesthesiology, Medica Superspeciality Hopsital, Mukundapur, Kolkata, West Bengal, India

Date of Web Publication30-Jan-2018

Correspondence Address:
Anil K Singhi
Department of Pediatric Cardiology, Medica Superspeciality Hopsital, Mukundapur, Kolkata - 700 099, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/astrocyte.astrocyte_22_17

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  Abstract 


Anatomic obstruction of the tracheobronchial tree in a patient with large posttricuspid shunt is rare and causes significant respiratory symptoms. The treatment of such patients is challenging. Here, we discuss and highlight the importance of detailed evaluation, planning, and teamwork for minimally invasive treatment of two major causes of respiratory distress. Hospital record analysis of a young infant who underwent simultaneous minimally invasive therapy for both cardiac and tracheal lesions. A 7-month-old infant weighing 4.4 kg had very large patent ductus arteriosus (PDA), along with heart failure and severe subglottic stenosis. She underwent successful minimally invasive balloon dilatation of subglottic stenosis followed by transcatheter device closure of PDA. Minimally invasive therapy for subglottic stenosis and device closure of PDA in a small infant is a safe and effective treatment in a well-planned and coordinated team approach.

Keywords: Balloon dilatation, device closure, patent ductus arteriosus, subglottic stenosis


How to cite this article:
Singhi AK, Mohan N V, Dutta C, Satpathy AS, Mittal A, Mishra A. Simultaneous balloon dilatation of subglottic stenosis and device closure of a large patent ductus arteriosus in infancy. Astrocyte 2017;4:198-200

How to cite this URL:
Singhi AK, Mohan N V, Dutta C, Satpathy AS, Mittal A, Mishra A. Simultaneous balloon dilatation of subglottic stenosis and device closure of a large patent ductus arteriosus in infancy. Astrocyte [serial online] 2017 [cited 2020 Mar 28];4:198-200. Available from: http://www.astrocyte.in/text.asp?2017/4/3/198/224191




  Introduction Top


Congenital heart disease with large left-to-right shunt such as large patent ductus arteriosus (PDA) in a small infant presents with symptoms of heart failure and poor weight gain. At times, the large left-to-right shunt lesions are complicated by additional comorbidities making the treatment challenging. We describe a case of severe subglottic stenosis in an infant with a very large PDA and severe pulmonary hypertension who was managed in a minimally invasive manner.


  Case Report Top


A 7-month-old infant weighing 4.4 kg had a history of breathing and feeding difficulty since neonatal period. She was diagnosed to have a very large PDA and was kept on medical follow-up and observation with decongestive medications. She required mechanical ventilation during an episode of pneumonia. Flexible laryngoscopy performed to evaluate difficult extubation revealed subglottic stenosis. She was discharged from the hospital with symptoms of stridor and respiratory distress, which were contributed both by very large PDA and significant subglottic stenosis. She was admitted in our hospital for minimally invasive care of her two major lesions. The plan was to relieve the subglottic stenosis by balloon dilation with or without tracheal stenting followed by PDA device closure. On evaluation, the baby had stridor and tachypnea. Her oxygen saturation in all limbs was 98%. The second heart sound was normally split with the aortic component equal to the pulmonic component. There was 2/6 ejection systolic murmur at the left second intercostal space. The liver was palpable 2 cm below the right costal margin. The echocardiogram showed 5 mm PDA with left-to-right shunt, dilated left atrium and left ventricle, and severe hyperkinetic pulmonary hypertension with good left ventricular systolic function. On microlaryngoscopy, a membranous stenotic segment was found in the subglottic region [Figure 1]a. It was managed with cold dissection and dilated with Acclarent 5 × 25 mm balloon (Johnson and Johnson, New Brunswick, New Jersey) in two sittings for 2 min each [Video 1a]. The stenotic segment opened well and the whole length was visible up to the carina [Figure 1]b; [Video 1]. In addition, mitomycin C was topically applied. The baby was extubated the same evening. Next day, she was taken for PDA device closure. The procedure was done under sedation and local anesthesia. Basal hemodynamics showed aortic pressure of 84/44 mmHg (mean of 64 mmHg) and pulmonary artery pressure of 84/35 mmHg (mean of 52 mmHg). Descending aortic angiogram showed 5 mm PDA with long ampulla and good aortic arch [Figure 2]a; [Video 2]a. The PDA was crossed with 4F JR 3.5 catheter and 0.035 Terumo wire combination. A 6-F delivery system was taken across the PDA and through it a 10/8 Amplatzer duct occluder–I device (St Jude Medical, Minnesota) was deployed under fluoroscopic guidance. The aortic pressure post procedure was 108/65 mmHg (mean of 75 mmHg) with no arch gradient and the pulmonary artery pressure reduced to 35/20 mmHg (mean of 25 mmHg). Final aortic angiogram showed no significant residual PDA flow and good arch flow [Figure 2]b; [Video 2]b. The respiratory distress and stridor both disappeared after the procedure and the baby was shifted to the ward. The baby was discharged on the next day. At 3 months follow-up she was doing well with no features of residual PDA and airway obstruction.
Figure 1: (a) Fibrooptic laryngoscopy showing severe subglottic stenosis. [Video 1a] (b) Post balloon dilatation well opened the trachea till carina [Video 1b].

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Figure 2: (a) Aortic angiogram in lateral view showing the large patent ductus arteriosus (PDA) – two arrows delineating the margin [Video 2a]. (b) Lateral view aortic angiogram post PDA device closure showing stable PDA device position and no residual flow (Bold arrow) [Video 2b].

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  Discussion Top


PDA is a common congenital heart disease. Large left-to-right shunt causes heart failure symptoms and the patients are prone to respiratory tract infection such as pneumonia which may need hospitalization. At times, these babies require ventilation for pneumonia and may develop iatrogenic airway obstruction such as subglottic stenosis, which may make extubation difficult. In fact, subglottic stenosis is the most common cause of airway obstruction in children, 90% of which is caused by endotracheal intubation. A child showing features of respiratory distress after extubation leads to the suspicion of subglottic stenosis and the same can be confirmed by flexible bronchoscopy.[1] The treatment of subglottic stenosis in children depends on the severity of airway narrowing and symptoms. The traditional treatment of anatomic airway narrowing involved surgical intervention. Recently, minimally invasive endoscopic balloon dilatation of the subglottic stenosis has gained popularity in the treatment of de novo or recurrent narrowing of the airway.[2],[3] The treatment plan becomes complex if the infant has associated significant heart disease causing heart failure such as a large PDA. In the current era, transcatheter intervention device closure of PDA has been well established. Large device in small babies can cause obstruction to the arch or branch pulmonary arteries and smaller device are prone to embolization. Meticulous assessment of the cardiac anatomy and planning of the procedure is required for successful device deployment. Though challenging, it is possible even in infants less than 6 kg with a large PDA to close by duct occluder.[4],[5] Two significant lesions affecting both the airway and circulatory system require a coordinated team approach involving multiple specialists. In our case, the team of doctors comprising otolaryngologist, pediatric cardiologist, anesthesiologist, and pediatric intensive care specialist planned and executed the procedure well. Sequentially, the subglottic stenosis was balloon dilated and extubated the same day followed by PDA device closure under conscious sedation. Two major causes of respiratory distress in a young infant dealt in a minimally invasive manner is relatively rare and highlights the importance of detailed evaluation, planning, and teamwork.


  Conclusion Top


Subglottic stenosis is the most common cause of airway obstruction in children, 90% of which is caused by endotracheal intubation. Large PDA can present with features of heart failure and respiratory tract infection such as pneumonia. Presence of two significant causes of respiratory distress such as subglottic stenosis and large PDA in a young infant makes therapy challenging. Minimally invasive therapy by balloon dilatation of the subglottic stenosis and transcatheter device closure of PDA is a safe an effective therapy in expert hands.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Botto HA, Pérez CG, Cocciaglia A, Nieto M, Rodríguez HA. Diagnosis and treatment of pediatric subglottic stenosis: Experience in a tertiary care center. Arch Argent Pediatr 2015;113:368-72.  Back to cited text no. 1
    
2.
Maeda K, Ono S, Baba K. Management of laryngotracheal stenosis in infants and children: The role of re-do surgery in cases of severe subglottic stenosis. Pediatr Surg Int 2013;29:1001-6.  Back to cited text no. 2
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3.
Wentzel JL, Ahmad SM, Discolo CM, Gillespie MB, Dobbie AM, White DR. Balloon laryngoplasty for pediatric laryngeal stenosis: Case series and systematic review. Laryngoscope 2014;124:1707-12.  Back to cited text no. 3
[PUBMED]    
4.
Park YA, Kim NK, Park SJ, Yun BS, Choi JY, Sul JH. Clinical outcome of transcatheter closure of patent ductus arteriosus in small children weighing 10 kg or less. Korean J Pediatr 2010;53:1012-7.  Back to cited text no. 4
[PUBMED]    
5.
Sivakumar K, Francis E, Krishnan P. Safety and feasibility of transcatheter closure of large patent ductus arteriosus measuring ≥4 mm in patients weighing ≤6 kg. J Interv Cardiol 2008;21:196-203.  Back to cited text no. 5
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