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Efficient Approach to Superior Vena Cava Baffle Stenosis Following the Mustard Procedure: Expanding Role of a Mechanical Rotating Dilator Sheath for Lead Extraction
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  • Chi Chi Do-Nguyen,
  • Alexander Ochman,
  • Maxwell Kilcoyne,
  • Richard Kovach,
  • Boban Abraham,
  • Pedram Kazemian,
  • Lynn McGrath,
  • Randy Stevens
Chi Chi Do-Nguyen
Philadelphia College of Osteopathic Medicine
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Alexander Ochman
Deborah Heart and Lung Center
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Maxwell Kilcoyne
Philadelphia College of Osteopathic Medicine
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Richard Kovach
Deborah Heart and Lung Center
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Boban Abraham
Saint Christopher's Hospital for Children
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Pedram Kazemian
Deborah Heart and Lung Center
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Lynn McGrath
Deborah Heart and Lung Center
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Randy Stevens
Saint Christopher's Hospital for Children
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Peer review status:ACCEPTED

20 Apr 2020Submitted to Journal of Cardiac Surgery
22 Apr 2020Assigned to Editor
22 Apr 2020Submission Checks Completed
22 Apr 2020Reviewer(s) Assigned
26 Apr 2020Review(s) Completed, Editorial Evaluation Pending
26 Apr 2020Editorial Decision: Accept

Abstract

Introduction: In adult congenital patients with transposition of the great arteries originally treated with the Mustard (atrial switch) procedure, the most common reason for re-intervention is baffle stenosis. This may be exacerbated by permanent transvenous pacemaker lead placement across the baffle. Case Report: A 47-year-old female status post Mustard procedure performed at 15 months old presented with a high-grade stenosis of the superior vena cava (SVC) baffle from the SVC to the left atrium, with a nonfunctional permanent pacemaker lead passing through the baffle. A mechanical rotating dilator sheath was used for attempted lead extraction, relieving the baffle stenosis almost completely as a secondary effect, prior to the placement of a 10 x 27 mm Visipro balloon expandable stent in the SVC baffle. Conclusions: Use of the mechanical rotating dilator sheath is an evolving treatment strategy in adult congenital heart disease to minimize the risk of bleeding, trauma to surrounding structures, and death. Its ability to fully alleviate baffle stenosis even when full lead extraction is not feasible or is associated with significant procedural risk further demonstrates its expanded role in this patient population. A multidisciplinary approach and great diligence must be employed to avoid potential complications.