Structural Heart Disease > Cases

Percutaneous Closure of Blalock-Taussig Shunt with Remnant Left to Right Shunt in Patient with Tetralogy of Fallot
- Operator: Seung-Whan Lee, MD
Case Presentation
A 38 year-old male presented with dyspnea on exertion. He has a past medical history of tetralogy of Fallot with pulmonary atresia and underwent right (Rt) modified Blalock-Taussig (BT) shunt with azygos vein and staged RVOT reconstruction (Rastelli procedure) with BT shunt take down operation and VSD patch closure. He also received ASD device closure.
Echocardiographic Findings
  1. There was no remnant shunt flow through previous VSD patch closure and ASD device closure sites.
  2. D-shaped LV, enlarged RV and thickened RV walls suggesting pressure overloading of RV.
  3. Moderate TR and increased peak TR velocity was also noted.
Right Heart Catheterization and Angiography
  1. The mean pulmonary arterial (PA) pressure was mildly elevated (25~29 mmHg).
  2. Sequential step-up of oxygen saturation at the Rt pulmonary artery (RV; 56%, main PA; 66%, Rt. PA; 84%) with increased Qp/Qs (1.35) was checked.
  3. On aniography, it revealed dilated previous azygos vein BT shunt and shunt flow from Rt subclavian artery (SCA) to Rt PA through BT shunt ( Movie 1).
  4. On the CT angiography, the diameter of entry site to BT shunt sac was 6-7 mm (Figure 1).
We performed right femoral puncture and inserted 6F sheath. A 6F JR 4 catheter was placed to the right SCA using 0.032 inch terumo wire and right SCA angiogram was performed to evaluate the size, position and the shape of the entry of BT shunt ( Movie 2). We exchanged the wire to 0.035 inch terumo stiff wire and advanced the wire into dilated BT shunt sac using 3.8F Rubicon 35 microcatheter. And then the catheter was exchanged to 6F internal mammary catheter to deliver the vascular plug. After removing the terumo stiff wire, 9 x 12 mm Amplatzer vascular plug II device (ususally 30-50% larger than the vessel diameter at the occlusion site) was deployed at the entry site of BT shunt sac from Rt SCA ( Movie 3). A repeat Rt. SCA angiography was performed 5 minutes after the device implantation showed no remnant shunt flow ( Movie 4).
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