Left pulmonary artery stent restenosis in a patient with repaired tetralogy of fallot

Logeshwari1*, Sripreethi2, Umarani3, Jayamenon4

1Staff Nurse, Kauvery Hospital, Heartcity , Trichy, Tamil Nadu

2Nurse Educator, Kauvery Hospital, Heartcity , Trichy, Tamil Nadu

3Assistant Nursing Superintendent, Kauvery Hospital, Heartcity , Trichy, Tamil Nadu

4Nursing Superintendent, Kauvery Hospital, Heartcity , Trichy, Tamil Nadu

*Correspondence

Abstract

A 20-year-old female with a history of surgically corrected Tetralogy of Fallot (2008) and prior left pulmonary artery (LPA) stenting (2018) presented with exertional breathlessness. Evaluation revealed severe stenosis of the previously placed LPA stent. She underwent successful catheter-based balloon dilatation of the LPA stent. Post-procedure recovery was stable with improvement in pulmonary blood flow. This case highlights the importance of long-term follow-up and timely interventional management in congenital heart disease patients.

Keywords: Tetralogy of Fallot; Left Pulmonary Artery; Stenosis; Stent Restenosis; Balloon Angioplasty; Cardiac Catheterization; Congenital Heart Disease; Post-operative Complications; Pulmonary Artery; Stenting.

Introduction

Tetralogy of Fallot is one of the most common congenital cyanotic heart diseases, characterized by four anatomical defects: ventricular septal defect, right ventricular outflow tract obstruction, overriding aorta, and right ventricular hypertrophy. Surgical correction in childhood significantly improves survival; however, long-term complications such as pulmonary artery stenosis may occur. Interventions like Pulmonary artery stenting are often required, but restenosis of the stent is a known complication, requiring repeat intervention.

Patient Profile

Name  : Ms.Y

Age/Sex: 20 years/Female

History of Present Illness

  • The patient presented with complaints of exertional dyspnea.
  • No history of chest pain (angina)
  • No history of syncope

Past History

Status post intracardiac repair for Tetralogy of Fallot in 2008

Status post LPA stenting in 2018.

Relevant Clinical Findings

General Examination

  • Conscious, oriented
  • No cyanosis
  • No pedal edema

Vital Signs

Pulse70/min
BP110/60 mmHg
Respiratory Rate20/min
SpO₂98%

Systemic Examination

CVSS1, S2 present with ejection systolic murmur
RSNormal vesicular breath sounds
AbdomenSoft
CNSNo focal neurological deficit

Laboratory Investigation

Alkaline Phosphatase126 U/L
Total Protein7.7 g/dl
Indirect Bilirubin.0.8 mg/dL
Aspartate Aminotransferase (AST/SGOT)31 U/L
Albumin, Serum4.4 g/dl
Urea Serum23 mg/dL
Potassium4.3 mmol/L
CHO/HDL Ratio4
Glucose In Glucometer POCT227 mg/dL
Alanine Aminotransferase (ALT/SGPT)30 U/L
LDL Cholesterol117.43 mg/dL
A/G Ratio1.3.
Total Bilirubin1.1 mg/dL
Direct Bilirubin0.3 mg/dL

Complete Blood Count

Packed Cell Volume (PCV)41.5 %
Neutrophil75.6 %
Monocyte7.2 %
Basophil0.3 %
Total WBC Count11450 Cells/Cumm
Total RBC Count4.91 ML/10^9
Lymphocyte16.9 %
Absolute Neutrophil Count (ANC)8650 cells/µl
Haemoglobin14.1 g/dl

Clinical Chemistry

  • S/p: TOF (2008)
  • LPA stenting (2018)
  • Fc II
  • Good LV systolic function
  • RA/RV dilated
  • Moderate TR
  • Mild RV dysfunction
  • No aortic stenosis
  • Free PR (pulmonary Regurgitation)
  • Clinical correlation advised

ECHO

Management

Medical Management

  • Anticoagulation (Heparin during procedure)
  • Monitoring of vitals and oxygen saturation
  • Post-procedure medications (as prescribed)
  • Surgical / Interventional Management
  • Cardiac catheterization performed
  • Balloon dilatation of LPA stent
  • Successful restoration of blood flow with reduced gradient

Nursing Management

  • Pre-procedure Care
  • Patient preparation and consent
  • Baseline vitals monitoring
  • IV access secured
  • Intra-procedure Care
  • Monitoring ECG, BP, oxygen saturation
  • Assisting in maintaining sterile field
  • Post-procedure Care
  • Monitor puncture site for bleeding
  • Assess distal pulses
  • Monitor vitals and oxygenation
  • Bed rest as advised
  • Pain assessment and management

Discharge Advice

  • Continue prescribed medications
  • Avoid strenuous activity initially
  • Maintain follow-up with cardiologist. To be enrolled in the GUCH Registry
  • Monitor for symptoms:
  • Breathlessness
  • Chest pain
  • Palpitations
  • Maintain good hydration and nutrition
  • Immediate hospital visits if symptoms worsen

Discussion

Patients with repaired Tetralogy of Fallot require lifelong follow-up due to risks of residual or progressive lesions. Pulmonary artery stenosis is a known complication that may arise due to surgical scarring or stent restenosis.

Balloon dilatation via catheterization is a minimally invasive and effective treatment for stent stenosis. Early detection and intervention help prevent right ventricular overload and long-term cardiac dysfunction.

Conclusion

This case emphasizes the importance of regular follow-up in congenital heart disease patients. Timely diagnosis and interventional management such as balloon dilatation can significantly improve patient outcomes and quality of life. Multidisciplinary care, including medical, surgical, and nursing management, plays a crucial role in successful recovery.

References

  • Khambadkone, S., Coats, L., Taylor, A., Boudjemline, Y., Derrick, G., Tsang, V., & Bonhoeffer, Philipp (2005). Percutaneous pulmonary valve implantation in humans: Results in 59 consecutive patients. Circulation, 112(8), 1189–1197.
  • McElhinney, David B., Hellenbrand, W. E., Zahn, E. M., & Jones, T. K. (2010). Short- and medium-term outcomes after transcatheter pulmonary valve placement in the US Melody Valve Trial. Circulation, 122(5), 507–516.
  • Feltes, Thomas F., Bacha, E., Beekman, R. H., Cheatham, J. P., Feinstein, J. A., Gomes, A. S., Hijazi, Z. Zahn, E. M. (2011). Indications for cardiac catheterization and intervention in pediatric cardiac disease: A scientific statement. Circulation, 123(22), 2607–2652.
  • Warnes, Carole A., Williams, R. G., Bashore, T. M., Child, J. S., Connolly, H. M., Dearani, J. Webb, G. D. (2008). ACC/AHA guidelines for the management of adults with congenital heart disease. Journal of the American College of Cardiology, 52(23), e143–e263.
  • Baumgartner, Helmut, Bonhoeffer, P., De Groot, N. M., de Haan, F., Deanfield, J. E., Galie, Walma, E. (2010). ESC guidelines for the management of grown-up congenital heart disease. European Heart Journal, 31(23), 2915–2957.
  • O’Laughlin, Michael P., Perry, S. B., Lock, J. E., & Mullins, C. E. (1991). Use of endovascular stents in congenital heart disease. Circulation, 83(6), 1923–1939.

 

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