The Cardiovascular Center of premier health institution The Medical City (TMC) has successfully performed the country’s first covered stent implantation as an alternative to open heart surgery on a 13-year-old boy with a congenital heart defect. 

Pocholo Malabanan was rushed to TMC’s emergency room in October 12, 2012 due to severe headache and vomiting.  His blood pressure was noted to be dangerously elevated for which emergency measures were started.  He was diagnosed with severe hypertension, which was secondary to a congenital heart condition called Coarctation of the Aorta (CoA). 

Children with CoA have an abnormal narrowing of the aorta, which is the major artery that leaves the heart and delivers oxygenated blood to the rest of the body. Aside from high blood pressure, other symptoms include shortness of breath, fainting, dizziness, headaches, leg cramps, leg weakness, and cold legs and feet.

Due to financial constraints, the procedure was performed on May 9, 2013. TMC interventional cardiologists Drs. Dexter Cheng, Olympia Q. Malanyaon, and Jose Jonas del Rosario performed the stenting at the TMC Cardiac and Vascular Catheterization Laboratory (TMC Cath Lab).  Pocholo was discharged two days later, feeling better and eager to resume his normal activities and varsity sports. His blood pressure immediately normalized and his maintenance anti-hypertensive medications were discontinued.

Interventional repair of the Coarctation of the aorta results in a markedly shorter hospital stay, which in turn translates to a less expensive hospitalization as compared to open heart surgery.  The procedure is relatively painless and recovery is immediate without need of intensive care unit stay.  Blood loss is so minimal that transfusions are also likewise avoided, thus minimizing the associated risks for the patient.

The non-surgical procedure done to repair CoA signifies a new frontier in the use of non-surgical technology for the treatment of complex congenital heart defects in the Philippines.  “This is the first in the country. The technology that has been available in countries in Europe and Asia for the past 10 years or so has arrived at The Medical City,” said Dr. Cheng.

The treatment of CoA consists of enlarging the narrowed aortic segment and implanting a covered stent to keep it well dilated and to help avoid the formation of aneurysms. In the past, CoA repair involved either closed heart surgery or open heart surgery followed by five to seven days in the hospital for recovery. Over the past decade, literature from Europe has been shown that covered stents have better long-term outcomes and negligible complications in the treatment of newly diagnosed CoA or recurrences after an initial surgical operation.

A stent is a small mesh metal alloy tube used to treat narrowed arteries. A covered stent has the  added advantage of being covered with a special Gortex tube that expands with the stent and thus affords added strength and protection to the newly dilated arterial tissue.  The use of covered stent is recommended for the treatment of CoA in patients because bare stents cannot completely prevent complications such as aneurysms (an abnormal widening or ballooning of a portion of an artery) or aortic rupture.

The procedure itself took less than an hour. The child was anesthetized via general anesthesia by Dr. Abelardo Alan Prodigalidad, Jr.  A small 1.5 inch surgical cut near the left groin was made to isolate the femoral artery, the main artery of the thigh.   It was through this artery, which was exposed by thoracovascular surgeon, Dr. Karl G. Reyes, that the entire procedure was done. A covered stent placed over a deflated balloon and the catheter's tip was inserted into the femoral artery. Under X-ray guidance, this was expertly positioned across the narrowing of the aortic arch. The balloon then inflated to widen the narrowed segment, leaving the covered stent behind to scaffold the newly widened aorta.  After the stent was deployed, all materials were removed from the patient and the small cut at the groin sewn up.

The procedure is safe and effective.  Complications during the procedure are rare and all can be treated immediately. These include blood loss requiring a transfusion, allergic reaction to X-ray dye requiring medication, and improper stent position requiring retrieval by catheter or surgery. There is a small risk of blockage of the groin vessels used for catheterization procedure, but these ordinarily respond immediately to medication therapy and resolve with time.

 “This is a definitive procedure which resolved the child’s Coarctation of the aorta and thus, his hypertension,” said Dr. Cheng. If needed in the future, the covered stent may be redilated as the child grows taller and heavier as an adult. Dr. Cheng however said this may not be necessary because the stent diameter achieved in this patient should be adequate for most adults. An annual follow-up check with his interventional cardiologist is recommended.

Pocholo’s congenital heart defect was first disclosed to his family when he was barely three months old. Maria Sergia Malabanan, Pocholo’s mother, said a doctor from another hospital made them to choose between miracle and heart transplant in the United States. She however said it would be quite difficult for them to raise the amount needed for the procedure. Maria Sergia also claimed Pocholo did not manifest symptoms until the night of October 11, 2012 when he vomited and had a terrible headache.

He was brought to the Emergency Room of TMC the next day because his headache persisted and was becoming unbearable. Dr. Cheng ordered an echocardiography and CT angiogram of the aorta which confirmed Pocholo’s CoA. He explained the boy’s condition to his family and presented two options, an open heart surgery or stenting of the narrowed blood vessel.  The advantages and disadvantages of either procedure were discussed thoroughly.  Making the patient and his family understand the illness and the treatments available is of paramount importance for the physicians of TMC, where patient partnership is a service philosophy.

Maria Sergia said given all its advantages, stenting was their choice. Although the procedure has never been done in the country in a pediatric patient, she completely trusted Pocholo’s doctors led by Dr. Cheng and the Cardiovascular Center of The Medical City.

While the family was raising funds for the procedure, Pocholo was maintained on anti-hypertensive medications. Through the help of Maria Sergia’s employer and a charitable organization in Dubai, she was able to raise funds for the stenting.

Maria Sergia has gone back to Dubai feeling more secure about his son’s health condition. “He is no longer hypertensive and his heart ailment was cured without doing major surgery and leaving a large scar on his chest,” she said. The boy’s aunt, Mariel Bautista, takes care of him and his siblings whenever their mom is away. Pocholo, who will be in eighth grade this June, is ready for school as he looks forward to happier and healthier days ahead.