Management algorithm in pulmonary atresia with intact ventricular septum

Borderline Ventricles: From Evaluation to Treatment

A heart with a borderline ventricle refers to a situation where there is uncertainty about whether the left or right underdeveloped ventricle can effectively support the systemic or pulmonary circulation with appropriate filling pressures and sufficient physiological reserve. Pediatric cardiologists often deal with congenital heart diseases (CHDs) associated with various degrees of hypoplasia of the left or right ventricles. To date, no specific guidelines exist, and surgical management may be extremely variable in different centers and sometimes even in the same center at different times. Thus, the choice between the single-ventricle or biventricular approach is always controversial. The aim of this review is to better define when "small is too small and large is large enough" in order to help clinicians make the decision that could potentially affect the patient's entire life.

Current status of transcatheter intervention for complex right ventricular outflow tract abnormalities

Various transcatheter interventions for the right ventricular outflow tract (RVOT) have been introduced and developed in recent decades. Transcatheter pulmonary valve perforation was first introduced in the 1990s. Radiofrequency wire perforation has been the approach of choice for membranous pulmonary atresia in newborns, with high success rates, although complication rates remain relatively common. Stenting of the RVOT is a novel palliative treatment that may improve hemodynamics in neonatal patients with reduced pulmonary blood flow and RVOT obstruction. Whether this option is superior to other surgical palliative strategies or early primary repair of tetralogy of Fallot remains unclear. Transcatheter pulmonary valve replacement has been one of the biggest innovations in the last two decades. With the success of the Melody and SAPIEN valves, this technique has evolved into the gold standard therapy for RVOT abnormalities with excellent procedural safety and efficacy. Challenges remain in managing the wide heterogeneity of postoperative lesions seen in RVOT, and various technical modifications, such as pre-stenting, valve ring modification, or development of self-expanding systems, have been made. Recent large studies have revealed outcomes comparable to those of surgery, with less morbidity. Further experience and multicenter studies and registries to compare the outcomes of various strategies are necessary, with the ultimate goal of a single-step, minimally invasive approach offering the best longer-term anatomical and physiological results.

Transcatheter Interventions for Neonates with Congenital Heart Disease: A Review

Newborns with congenital heart disease often require interventions linked to high morbidity and mortality rates. In the last few decades, many transcatheter interventions have become the first-line treatments for some critical conditions in the neonatal period. A catheter-based approach provides several advantages in terms of procedural time, length of hospitalization, repeatability and neurodevelopmental issues (usually related to cardiopulmonary bypass). The main transcatheter procedures will be reviewed, as they are now valid alternatives to conventional surgical management.

Optimal management of pulmonary atresia with intact ventricular septum in a developing country: the art of pulmonary valve mechanical perforation in the era of CTO hardware

BACKGROUND

Transcatheter valve mechanical perforation (TVMP) in pulmonary atresia with intact ventricular septum (PAIVS) is an acceptable yet challenging alternative to radiofrequency.

AIMS

To evaluate and compare safety, feasibility, and efficiency of two TVMP techniques.

METHODS

Clinical data of neonates with PAIVS who underwent an attempt for TVMP between 2009 and 2019 were retrospectively reviewed. Patients were divided into two groups according to perforation technique: using the stiff end of a percutaneous transluminal coronary angioplasty (PTCA) ordinary 0.014" wire (group A) and subsequently with the floppy tip of a chronic total occlusion (CTO) guidewire (group B). The technical aspects, procedural and discharge outcomes of both groups were compared.

RESULTS

A total of 19 antegrade TVMP procedures (Group A, n=10, and Group B, n=9) were attempted in 18 neonates with an overall success rate of 73.7% and no procedure-related mortality. Groups' analysis showed that the introduction of CTO hardware maximized procedure success rates (P=0.002) with zero failure and misperforations (P=0.022). The significant drop in perforation time (P < 0.001) and irradiation exposure (P=0.006) allowed additional ductal stenting during the same procedure, optimizing patients' clinical outcomes and shortening overall hospital stay. Discharged patients had room air mean oxygen saturation of 91.4% (± 5.5) with no evidence of heart failure.

CONCLUSIONS

In selected cases of PAIVS, TVMP using CTO wires is a safer, highly efficient, and simplified alternative to other mechanical perforation techniques. It substantially revolutionized the management of PAIVS in our center optimizing short-term prognosis.

Predictors of death after receiving a modified Blalock-Taussig shunt in cyanotic heart children: A competing risk analysis

Objective

To determine risk factors affecting time-to-death ≤90 and >90 days in children who underwent a modified Blalock-Taussig shunt (MBTS).

Methods

Data from a retrospective cohort study were obtained from children aged 0–3 years who experienced MBTS between 2005 and 2016. Time-to-death (prior to Glenn/repair), time-to-alive up until December 2017 without repair, and time-to-progression to Glenn/repair following MBTS were presented using competing risks survival analysis. Demographic, surgical and anesthesia-related factors were recorded. Time-to-death ≤90 days and >90 days was analyzed using multivariate time-dependent Cox regression models to identify independent predictors and presented by adjusted hazard ratios (HR) and 95% confidence intervals (CI).

Results

Of 380 children, 119 died, 122 survived and 139 progressed to Glenn/repair. Time-to-death probability (95% CI) within 90 days was 0.18 (0.14–0.22). Predictors of time-to-death ≤90 days (n = 63) were low weight (<3 kg) (HR 7.6, 95% CI:2.8–20.4), preoperative ventilator support (HR 2.7, 95% CI:1.3–5.6), postoperative shunt thrombosis (HR 5.0, 95% CI:2.4–10.4), bleeding (HR 4.5, 95% CI:2.1–9.4) and renal failure (HR 4.1, 95% CI:1.5–10.9). Predictors of time-to-death >90 days (n = 56) were children diagnosed with pulmonary atresia with ventricular septal defect and single ventricle (compared to tetralogy of fallot) (HR 3.2, 95% CI:1.2–7.7 and HR 3.1, 95% CI:1.3–7.6, respectively), shunt size/weight ratio >1.1 vs <0.65 (HR 6.8, 95% CI:1.4–32.6) and longer duration of mechanical ventilator (HR 1.002, 95% CI:1.001–1.004). Shunt size/weight ratio ≥1.0 (vs <1.0) and ≥0.65 (vs <0.65) were predictors for overall time-to-death in neonates and toddlers, respectively (HR 13.1, 95% CI:2.8–61.4 and HR 7.8, 95% CI:1.7–34.8, respectively).

Conclusions

Perioperative factors were associated with time-to-death ≤90 days, whereas particular cardiac defect, larger shunt size/weight ratio, and longer mechanical ventilation were associated with time-to-death >90 days after receiving MBTS. Larger shunt size/weight ratio should be reevaluated within 90 days to minimize the risk of shunt over flow.

Transcatheter radiofrequency pulmonary valve perforation in newborns with pulmonary atresia/intact ventricular septum: Echocardiographic predictors of biventricular circulation

OBJECTIVE

We report a single-institute experience of neonatal transvenous radiofrequency pulmonary valve perforation for pulmonary atresia/intact ventricular septum, with echocardiographic predictors of biventricular circulation.

METHODS

Data were reviewed retrospectively for all neonates who underwent primary transvenous pulmonary valve perforation for pulmonary atresia/intact ventricular septum between January 2008 and November 2018 at our institution. We compared patients who need systemic-to-pulmonary shunt or ductal stenting with patients who did not need.

RESULTS

During the study period, 31 patients with pulmonary atresia/intact ventricular septum underwent successful radiofrequency pulmonary valve perforation and balloon dilation of the pulmonary valve. There was no procedure-related mortality. Sixteen patients (52%) needed systemic-to-pulmonary shunt or ductal stenting after initial procedure. Among the survivors (follow-up time of 1 to 11.5 years), 15 patients had a biventricular circulation and 6 patients had 1 and 1⁄2 ventricular circulation. Two patients are awaiting for Fontan operation. Both the TV/MV annulus ratio (>0.85) and tricuspid valve z-score (>-1) were found to be a good predictor of a biventricular outcome in our cohort.

CONCLUSIONS

Percutaneous radiofrequency pulmonary valve perforation and balloon valvotomy is an effective and safe primary treatment strategy for neonates with pulmonary atresia/intact ventricular septum. Ductal stenting or systemic-to-pulmonary shunt may be required in the majority of patients who had smaller right heart components. Preselection of patients according to tricuspid valve z-score and TV/MV annulus ratio allows predicting biventricular circulation.

Fetal Cardiac Intervention for Pulmonary Atresia with Intact Ventricular Septum: International Fetal Cardiac Intervention Registry

INTRODUCTION

Invasive fetal cardiac intervention (FCI) for pulmonary atresia with intact ventricular septum (PAIVS) and critical pulmonary stenosis (PS) has been performed with small single-institution series reporting technical and physiological success. We present the first multicenter experience.

OBJECTIVES

Describe fetal and maternal characteristics of those being evaluated for FCI, including pregnancy/neonatal outcome data using the International Fetal Cardiac Intervention Registry (IFCIR).

METHODS

We queried the IFCIR for PAIVS/PS cases evaluated from January 2001 to April 2018 and reviewed maternal/fetal characteristics, procedural details, pregnancy and neonatal outcomes. Data were analyzed using standard descriptive statistics.

RESULTS

Of the 84 maternal/fetal dyads in the registry, 58 underwent pulmonary valvuloplasty at a median gestational age of 26.1 (21.9-31.0) weeks. Characteristics of fetuses undergoing FCI varied in terms of tricuspid valve (TV) size, TV regurgitation, and pulmonary valve patency. There were fetal complications in 55% of cases, including 7 deaths and 2 delayed fetal losses. Among those who underwent successful FCI, the absolute measurement of the TV increased by 0.32 (±0.17) mm/week from intervention to birth. Among 60 liveborn with known outcome, there was a higher percentage having a biventricular circulation following successful FCI (87 vs. 43%).

CONCLUSIONS

Our data suggest a possible benefit to fetal therapy for PAIVS/PS, though rates of technically unsuccessful procedures and procedure-related complications, including fetal loss were substantial. FCI criteria are extremely variable, making direct comparison to nonintervention patients challenging and potentially biased. More uniform FCI criteria for fetuses with PAIVS/PS are needed to avoid unnecessary procedures, expose only fetuses most likely to sustain a benefit, and to enable comparisons to be made with nonintervention patients.

Transcatheter Approach for Critical Pulmonary Stenosis or Pulmonary Atresia with Intact Ventricular Septum in Young Infants Using the Simmons Catheter

Methods and Results

We retrospectively reviewed 52 young infants, 41 of whom had CPS and 11 had PA/IVS, in a single center from June 2009 to October 2017. Patients were divided into three groups according to the type of catheter used to enter through the RVOT. The unique structure of the Simmons catheter allowed it to be maneuvered directly into the RVOT within a few minutes. Compared with the other two groups, the Simmons catheter group had a significantly shorter fluoroscopy time entering through the RVOT (P < 0.001) and a shorter total X-ray exposure time (P < 0.001). Furthermore, compared with the floating catheter group, the success rate of surgery was much higher in the Simmons catheter group (P < 0.001).

Conclusions

The Simmons catheter is a safe and effective method to enter through the RVOT in infants with CPS or PA/IVS. Therefore, the Simmons catheter could be an alternative catheter when entering through the RVOT in young infants, especially neonates with low birth weight.

A low threshold for neonatal intervention yields a high rate of biventricular outcomes in pulmonary atresia with intact ventricular septum

AIMS

Management strategies for pulmonary atresia with intact ventricular septum are variable and are based on right ventricular morphology and associated abnormalities. Catheter perforation of the pulmonary valve provides an alternative strategy to surgery in the neonatal period. We sought to assess the long-term outcome in terms of survival, re-intervention, and functional ventricular outcome in the setting of a 26-year single-centre experience of low threshold inclusion criteria for percutaneous valvotomy.

METHODS AND RESULTS

Retrospective analysis of patients diagnosed with pulmonary atresia with intact ventricular septum from 1990 to 2016 at a tertiary referral centre, was performed. Of 71 patients, 48 were brought to the catheterisation laboratory for intervention. Catheter valvotomy was successful in 45 patients (94%). Twenty-three patients (51%) also underwent ductus arteriosus stenting. The length of intensive care and hospital stay was significantly shorter, and early re-interventions were significantly reduced in the catheterisation group. There were eight deaths (17%); all within 35 days of the procedure. Of the survivors, only one has required a Fontan circulation. Twenty-eight patients (74%) have undergone biventricular repair and nine patients (24%) have one-and-a-half ventricle circulation. Following successful valvotomy, 80% of patients required further catheter-based or surgical interventions.

CONCLUSIONS

A low threshold for initial interventional management yielded a high rate of successful biventricular circulations. Although mortality was low in patients who survived the peri-procedural period, the rate of re-intervention remained high in all groups.

Prediction of biventricular repair by echocardiography in borderline ventricle

Objective:

In recent years, attempting the biventricular pathway or biventricular conversions in patients with borderline ventricle has become a hot topic. However, inappropriate pursuit of biventricular repair in borderline candidates will lead to adverse clinical outcomes. Therefore, it is important to accurately assess the degree of ventricular development before operation and whether it can tolerate biventricular repair. This review evaluated ventricular development using echocardiography for a better prediction of biventricular repair in borderline ventricle.

Data sources:

Articles from January 1, 1990 to April 1, 2019 on biventricular repair in borderline ventricle were accessed from PubMed, using keywords including “borderline ventricle,” “congenital heart disease,” “CHD,” “echocardiography,” and “biventricular repair.”

Study selection:

Original articles and critical reviews relevant to the review's theme were selected.

Results:

Borderline left ventricle (LV): (1) Critical aortic stenosis: the Rhodes score, Congenital Heart Surgeons Society regression equation and another new scoring system was proposed to predict the feasibility of biventricular repair. (2) Aortic arch hypoplasia: the LV size and the diameter of aortic and mitral valve (MV) annulus should be taken into considerations for biventricular repair. (3) Right-dominant unbalanced atrioventricular septal defect (AVSD): atrioventricular valve index (AVVI), left ventricular inflow index (LVII), and right ventricle (RV)/LV inflow angle were the echocardiographic indices for biventricular repair. Borderline RV: (1) pulmonary atresia/intact ventricular septum (PA/IVS): the diameter z-score of tricuspid valve (TV) annulus, ratio of TV to MV diameter, RV inlet length z-score, RV area z-score, RV development index, and RV-TV index, etc. Less objective but more practical description is to classify the RV as tripartite, bipartite, and unipartite. The presence or absence of RV sinusoids, RV dependent coronary circulation, and the degree of tricuspid regurgitation should also be noted. (2) Left-dominant unbalanced AVSD: AVVI, LV, and RV volumes, whether apex forming ventricles were the echocardiographic indices for biventricular repair.

Conclusions:

Although the evaluation of echocardiography cannot guarantee the success of biventricular repair surgery, echocardiography can still provide relatively valuable basis for surgical decision making.

[Percutaneous management of pulmonary atresia with intact ventricular septum and critical pulmonary stenosis]

INTRODUCTION

Pulmonary atresia with intact ventricular septum and critical pulmonary stenosis in newborns encompasses a wide spectrum of disease, including cases with significant right ventricular hypoplasia and coronary artery to right ventricle fistulae, which may be considered a contraindication for decompression of the right ventricle. The aim of this study was to review the middle- and long-term outcomes of these patients over 20 years and identify differential factors between both groups, including patients with coronary artery fistulae.

PATIENTS AND METHODS

We performed a descriptive retrospective study by identifying all patients that received a diagnosis of pulmonary atresia with intact ventricular septum and critical pulmonary stenosis between January 1996 and January 2018. We collected and analysed data regarding right ventricular morphology, surgical management, percutaneous intervention and medium- and long-term outcomes.

RESULTS

51 patients were admitted. A total of 9 patients (17.6%) died during the followup. None of the deceased patients had coronary artery to right ventricle fistulae. The median length of follow up in the 42 survivors was 8.9 years (1-16). The functional class based on the latest revision of the New York Heart Association classification was 1.2 for the overall sample. Survivors of critical pulmonary stenosis had a functional class of 1.1, and survivors of pulmonary atresia with intact ventricular septum a functional class of 1.6. There were no differences based on the presence or absence of coronary artery to right ventricle fistulae.

CONCLUSIONS

Coronary artery to right ventricle fistulae may not be a contraindication for biventricular strategy. Patients with critical pulmonary stenosis had better outcomes compared to patients with pulmonary atresia with intact ventricular septum. The aggressive strategy of opening the pulmonary valve early on was associated with a good overall survival and correlated to a good functional class.

Transcatheter pulmonary valvuloplasty in neonates with pulmonary atresia and intact ventricular septum

BACKGROUND

Transcatheter pulmonary valvuloplasty in neonates with pulmonary atresia and intact ventricular septum (PA-IVS) or duct-dependent pulmonary valve stenosis (DD-PVS) has become a reasonable alternative to surgical right ventricle decompression.

AIM

To investigate mid-term outcomes following pulmonary valvuloplasty.

METHODS

Sixty-five neonates with PA-IVS (n=29) or DD-PVS (n=36) (median age 4 days; mean weight 3.0kg) undergoing pulmonary valvuloplasty were reviewed retrospectively. Procedural data and clinical outcomes were assessed.

RESULTS

Pulmonary valvuloplasty was successful in 59 patients (90.8%). Preterm birth, larger tricuspid valve annulus diameter and PA-IVS correlated with procedural failure. Eleven patients (18.6%) required a Blalock-Taussig shunt during early follow-up, despite valvuloplasty. These neonates had smaller tricuspid and pulmonary valve annulus Z-scores (-1.9 vs. -0.8 [p=0.04] and -2.5 vs. -0.9 [P=0.005], respectively) and a higher incidence of "bipartite" right ventricle (P=0.02). Mean follow-up was 5.4±3.3 years. Mortality after successful valvuloplasty was 8.5% (n=5). Among the 54 survivors, biventricular repair was achieved in 52 patients (96.3%), including nine with a previous Blalock-Taussig shunt. The cumulative rate of subsequent surgery (excluding Blalock-Taussig shunt) was 13.7% (95% confidence interval 6.8-26.7%) and 16.4% (95% confidence interval 8.5-30.4%) at 2 and 4 years, respectively. Secondary surgery was significantly more frequent in PA-IVS compared with DD-PVS, and in neonates with a Blalock-Taussig shunt (P=0.003 and 0.01, respectively).

CONCLUSIONS

Selected neonates with DD-PVS or PA-IVS managed by transcatheter pulmonary valvuloplasty had a good mid-term outcome. In neonates with a borderline small right ventricle, a hybrid strategy with a supplementary source of pulmonary blood flow can be efficient to achieve biventricular repair.

Atrial septal defect (ASD) device trans-catheter closure: limitations

Transcatheter closure is a widespread technique used to treat secundum atrial septal defects (ASDs). When compared to surgery, it provides a less invasive approach with quicker recovery and reduced physical and psychological impact. Nowadays, almost 85-90% of all secundum ASD can be closed by using a transcatheter approach. However, several limitations may have a significant impact on the feasibility and success of percutaneous ASD closure. Limitations can be grouped as: (I) anatomical; (II) device-related; (III) associated defects and natural history associated issues; (IV) physiological; (V) complications. Physician should be aware of potential limits of percutaneous ASD closure.

Emergency transcatheter closure of a stented PDA in a patient with pulmonary atresia and intact ventricular septum: be ready for the unexpected!

Patients with congenital heart disease and duct‐dependent pulmonary circulation can undergo stenting of the patent ductus arteriosus (PDA). This case shows that, due to the physiological changes occurring after stent implantation, sometimes it is necessary to close the stented PDA rather than to redilate it.

Stenting the complex patent ductus arteriosus in tetralogy of Fallot with pulmonary atresia: challenges and outcomes

Patent ductus arteriosus (PDA) stenting has gained acceptance for palliation in cyanotic congenital heart disease. The PDA in tetralogy of Fallot with pulmonary atresia (ToF-PA) arises, in the left aortic arch, from underneath the arch and connects to the proximal left pulmonary artery, often resulting in stenosis. The PDA is usually elongated and tortuous, making stent implantation challenging. Shorter duration of palliation, aggravation of branch pulmonary artery stenosis resulting in poor growth and difficulty at surgery makes ductal stenting controversial. Access via the carotid and axillary artery reduces complexity of the procedure and improves success, with recent data demonstrating good pulmonary artery growth. Advances in bioresorbable stents offer future promise and will likely resolve some controversies surrounding PDA stenting in ToF-PA.

Predictors of Mortality in Children with Pulmonary Atresia with Intact Ventricular Septum

Pulmonary atresia with intact ventricular septum (PA/IVS) is a rare cardiac congenital lesion characterized by imperforate pulmonary valve, intact ventricular septum, and atrial level shunt. Although different management strategies to establish a source of non-ductal dependent pulmonary blood flow have been described, studies have not assessed the relationship between the therapeutic approach, patient characteristics, and outcomes. The purpose of this study was to identify predictors of mortality for patients with PA/IVS. Neonates and children with PA/IVS were identified through analysis of the 2012 Kids' Inpatient Database of the Healthcare Cost and Utilization Project. Hospital admissions that included a cardiac catheterization and/or surgical procedure were analyzed to identify demographics, co-morbidities, and outcomes. We identified 508 patients with PA/IVS with hospital admissions that included cardiac catheterization (n = 165), surgical procedures (n = 273), or both (n = 70). The incidence of mortality in this cohort was 6.69% (34/508). Univariable analysis demonstrated that age less than 12 months (p < 0.001), non-elective admission (p < 0.001), AKI (p = 0.001), sepsis (p = 0.002), and the use of ECMO (p < 0.001) were associated with an increased risk of mortality, while no difference was observed for the type of therapeutic approach (p = 0.498). These variables were used in a multivariable logistic regression analysis to develop the predictive model for mortality. Age less than 12 months, non-elective admission, and the use of ECMO in children with PA/IVS were predictors for mortality. Interestingly, the type of therapeutic approach did not influence mortality, which suggests that patient characteristics other than the method chosen to provide pulmonary blood flow determine mortality.

Perioperative and Anesthetic Considerations in Pulmonary Atresia With Intact Ventricular Septum

Pulmonary atresia with intact ventricular septum (PA/IVS) is a rare right-heart obstructive lesion with a wide anatomic and physiologic spectrum of disease, ranging from simple membranous pulmonary valve atresia with a fully developed right ventricle (RV) to a severely hypoplastic RV and ventriculocoronary (RV-coronary) fistulas. Affected neonates are dependent on prostaglandin for adequate pulmonary blood flow. Depending on the severity of disease, treatment options range from transcatheter pulmonary valve perforation and ultimate biventricular repair to staged single-ventricle palliation. Cardiac transplantation is recommended in the most severe cases. This review will discuss the perioperative and anesthetic management of patients with PA/IVS and highlight the challenges in management.

Transcatheter pulmonary valve perforation using chronic total occlusion wire in pulmonary atresia with intact ventricular septum

Background:

Perforation of pulmonary valve using radiofrequency ablation in pulmonary atresia with intact ventricular septum (PA IVS) is a treatment of choice. However, significant cost of the equipment limits its utility, especially in the developing economies.

Objective:

To assess the feasibility, safety, and efficacy of perforation of pulmonary valve using chronic total occlusion (CTO) wires in patients with PA IVS as an alternative to radiofrequency ablation.

Methods:

This is a single-center, nonrandomized, retrospective study conducted during June 2008 to September 2015. Twenty-four patients with PA IVS were selected for the procedure during the study period. The median age and weight of the study population were 8. days and 2.65 kg, respectively. Four patients were excluded after right ventricular angiogram as they showed right ventricular-dependent coronary circulation. The pulmonary valve perforation was attempted using various types of CTO wires based on the tip load with variable penetrating characteristics.

Results:

The procedure was successful in 16 of twenty patients using CTO wires: Shinobi in nine, Miracle in four, CROSS-IT in two, and Conquest Pro in one. Two patients had perforation of right ventricular outflow tract (RVOT). Pericardiocentesis was required in one patient to relieve cardiac tamponade. Later, the same patient underwent successful hybrid pulmonary valvotomy. The other patient underwent ductus arteriosus (DA) stenting. Balloon atrial septostomy was needed in three cases with systemic venous congestion. Desaturation was persistent in five cases necessitating DA or RVOT stenting to augment pulmonary blood flow. There were two early and two late deaths. The mean follow-up was 22.66 ± 16 months. Three patients underwent one and half ventricle repair and one Blalock–Taussig shunt during follow-up.

Conclusion:

Perforation of the pulmonary valve can be done successfully using CTO wires in selected cases of pulmonary atresia with intact ventricular septum.

Intervention in Patients with Critical Pulmonary Stenosis in the Ductal Stenting Era

We aimed to assess early and midterm outcomes of balloon valvuloplasty (BVP) procedure in patients with critical pulmonary stenosis (CPS) and to describe the predictors of the need for additional pulmonary flow and reintervention in this subgroup of patients. From 2005 to 2014, 56 neonates were diagnosed with CPS and were included in this study. All echocardiographic, catheterization and angiographic data obtained prior to the initial BVP and at follow-up were reviewed. BVP was successful in 55 neonates (98 %). Twenty-one neonates needed pulmonary blood flow augmentation after BVP (38 %). Ductal stenting (DS) was performed in 20. The patients' mean tricuspid valve (TV) annulus diameter was 10.4 ± 2 mm, and the Z score was -1.29 ± 1 (-3.7 to 0.78). The mean pulmonary valve (PV) annulus diameter was 6 ± 0.9 mm, and the Z score was -1.74 ± 1 (-4.34 to 0.05). A transcatheter or surgical reintervention was performed in 11 patients. A TV Z score < -1.93 SD predicted the need for pulmonary blood flow augmentation after a successful BVP, with a sensitivity of 63.2% and a specificity of 84.4%. A PV Z score < -1.69 SD predicted the need for pulmonary flow augmentation, with a sensitivity of 74 %. The presence of bipartite RV was found to be a significant predictor of the need for reintervention (odds ratio 9.6). Our study showed the excellent immediate outcomes of BPV and DS in a pure cohort of patients with CPS. Prophylactic DS in selected cases seems reasonable and safe.

Pulmonary atresia with intact ventricular septum and coronary cameral fistulae: an unusual finding of a subsystemic right ventricle

We report the case of a neonate with pulmonary atresia with intact ventricular septum and coronary cameral fistulae despite having a subsystemic right ventricle. We review the literature on coronary cameral fistulae in this disease and right ventricle-dependent coronary circulation. We discuss the potential consequences of this physiology, including risk of adverse cardiovascular events that may impact risk stratification and surgical palliation.

Outcomes and predictors of reintervention in patients with pulmonary atresia and intact ventricular septum treated with radiofrequency perforation and balloon pulmonary valvuloplasty

Radiofrequency perforation and valvuloplasty (RFV) is an effective initial treatment in patients with pulmonary atresia and intact ventricular septum (PA-IVS) and mild to moderate right ventricle and tricuspid valve hypoplasia. Outcomes and risk factors for the need for additional interventions in these patients are poorly defined. All patients with PA-IVS who underwent RFV at our center between January 2000 and July 2011 were reviewed. Twenty-three patients met the inclusion criteria. All patients underwent successful valvuloplasty with no procedural deaths and one major complication. Excluding two patients with limited follow-up, 6 (29 %) patients underwent no subsequent interventions, whereas 9 (42 %) patients underwent surgical right-ventricular outflow tract augmentation. All except one patient with adequate follow-up have a biventricular circulation with saturation >92 %. Patients who did not undergo any right-ventricular outflow tract intervention after valvuloplasty had a significantly lower gradient across the pulmonary valve after valvuloplasty (9.9 mmHg ± 8.4 vs. 19.1 mmHg ± 10.4, p = 0.05). Significantly more patients who received a supplemental source of pulmonary blood flow had a tricuspid valve z-score <-0.7 compared with patients who did not receive supplemental blood flow [2 (15 %) vs. 7 (70 %), p = 0.008]. In our cohort of patients with PA-IVS, radiofrequency perforation with valvuloplasty was an effective and safe first step in establishing a biventricular circulation. Postvalvuloplasty pulmonary valve gradient may be predictive of subsequent outflow tract intervention, and tricuspid hypoplasia may be predictive of the need for a supplemental source of pulmonary blood flow.

Advances in interventional and hybrid therapy in neonatal congenital heart disease

In addition to the considerable surgical advances in treating congenital heart diseases, hybrid and transcatheter therapies have become a cornerstone of neonatal cardiology within the last decade. Approaches to the care of cyanotic newborns with congenital heart disease focused on manipulations of the inter-atrial septum, right ventricular outflow tract obstructions, and on the arterial duct as the source for pulmonary blood flow. Currently, fewer interventional procedures are used in newborns and small infants to treat excessive pulmonary blood flow caused by shunt lesions, but transcatheter techniques and hybrid strategies have been developed to treat newborns suffering from inadequate systemic perfusion. However, transcatheter techniques are still not available to treat failing systemic ventricles without obvious structural disorders of the myocardium or dilated cardiomyopathies in newborns and infancy, despite new surgical-interventional strategies are already developed to avoid or to delay early heart transplantation. In conclusion, material and technical improvements have enabled transcatheter techniques to replace medical-based therapies to solve structurally dependent cardiovascular diseases. However, evidence-based and long-term follow-up data are required.

Transcatheter management of neonates with pulmonary atresia with intact ventricular septum: a single center experience from Turkey

Pulmonary atresia with intact ventricular septum (PAIVS) is characterized by a broad spectrum of heterogeneous morphologies. Perforation of the atretic valve, balloon dilatation, and stenting of the patent ductus arteriosus are the percutaneous techniques that are used with increasing frequency in our clinic as well. They have some advantages over surgery, including short hospital stay and short intensive care unit stay. The main goal of the primary interventional approach is to avoid surgery. However, a group of patients with PAIVS still need surgery due to poor right ventricular growth. Therefore, the final achievement of the initial percutaneous treatment strategies is still debatable. In this article, we present the early- and mid-term results of the percutaneous approach utilized at our clinic in order to investigate the final effects of interventional therapy according to initial morphology. Between May 2010 and May 2012, 15 neonates diagnosed with PAIVS underwent transcatheter intervention. Detailed echocardiographic examination focused on right ventricle size, and tricuspid valve morphology and coronary sinusoids were performed in all the patients before the intervention. Nine of the patients were boys and six were girls. The mean age was 11.40 ± 12.87 days and mean weight was 3.34 ± 0.46 kg. Only one procedure-related mortality occurred. The mean follow-up period was 10.05 ± 3.42 months (1-26 months). The mean duration of intensive care was 7.19 ± 5.14 days. The mean follow-up time was 10.05 ± 3.42 months. After this period, survival rate was 66% (10/15). Two of the patients achieved biventricular physiology after pulmonary valve perforation. Two patients still have univentricular physiology. Six patients have been followed as a one and half ventricle repair candidate. Five out of 15 patients had stent patency during 6 months of follow-up, while restenosis developed in one patient (1/5, 20%), who had undergone the Glenn operation at 5 months of age. Transcatheter management for PAIVS is a feasible, safe, and effective primary palliative treatment in newborns. Shunt surgery may be considered in cases where cyanosis occurs despite transcatheter intervention. Right ventricular size determines the type of intervention. The early outcomes can be comparable with surgical palliation. However, a group of PAIVS, particularly with severe right ventricular hypoplasia, needs surgery even after a successful primary percutaneous intervention.

Catheter-based treatment in patients with critical pulmonary stenosis or pulmonary atresia with intact ventricular septum: a single institute experience with comparison between patients with and without additional procedure for pulmonary flow

OBJECTIVES

We report a single institute experience of transcatheter pulmonary valvotomy using the soft end of a guidewire followed or not by a systemic-pulmonary shunt in patients with pulmonary atresia with intact ventricular septum (PAIVS) or critical pulmonary stenosis (CPS). In addition, we compare patients with or without an additional source of flow to support the pulmonary circulation after successful pulmonary valvotomy.

METHODS

All neonates with PAIVS or CPS who underwent primary transcatheter pulmonary valvotomy between January 2004 and December 2010 were reviewed retrospectively. Some of them needed an additional source of flow to support the pulmonary circulation. We performed a comparison between those who required an additional source of pulmonary flow and those who did not.

RESULTS

The initial procedure was successful in 20 out of 22 patients (seven of nine with PAIVS; all of 13 with CPS), but 10 of them needed an additional source of flow to support the pulmonary circulation: nine had arterial duct stenting and one had surgical Blalock-Taussig shunt. There were no deaths or major acute complications, except for femoral artery occlusion in three patients. The bipartite right ventricular morphology, the tricuspid z-score of ≤-0.74, the tricuspid to mitral valve ratio of ≤ 0.9, and the z-score of the diastolic interventricular septal thickness ≥ 2.37 in preprocedural examination showed more tendency of needing shunt placement.

CONCLUSION

Transcatheter pulmonary valvotomy using the soft end of a guidewire followed or not by the arterial duct stent implantation was an effective approach in those patients. The angiographic distinction between CPS and PAIVS did not affect anything in this study including the procedural method, success, and odds for reintervention. The degree of right ventricle cavity hypoplasia provided the main restriction to forward flow after pulmonary valvotomy.

Pulmonary atresia with intact septum: the use of Conquest Pro coronary guidewire for perforation of atretic valve and subsequent interventions

OBJECTIVE

To determine the feasibility and safety of the Conquest Pro wire as an alternative to radiofrequency wire for perforation of atretic pulmonary valve and subsequent balloon dilatation and patent ductus arteriosus stenting in patients with pulmonary atresia with intact ventricular septum.

BACKGROUND

Radiofrequency valvotomy and balloon dilatation has become the standard of care for pulmonary atresia with intact ventricular septum in many institutions today.

METHODS

We report eight consecutive patients in whom we used the Conquest Pro coronary guidewire, a stiff wire normally reserved for revascularisation of coronary lesions with chronic total occlusion, for perforation of atretic pulmonary valve and subsequent balloon dilatation, and stenting of the patent ductus arteriosus.

RESULTS

Perforation of atretic pulmonary valve was successful in seven out of eight cases. Radiofrequency valvotomy was employed after failure of perforation by the Conquest Pro wire in one case where the right ventricular outflow tract was broad based and tapered towards the pulmonary valve, and was heavily trabeculated. Failure of the Conquest Pro wire to perforate the pulmonary valve plate was mainly attributed by the failure to engage the wire at the correct position.

CONCLUSION

The Conquest Pro wire for perforation and subsequent interventions in the more straightforward cases of pulmonary atresia with intact ventricular septum is effective and safe, simplifying the entire procedure. However, the radiofrequency generator and wires remain essential tools in the paediatric interventional catheter laboratory.

Impact of prenatal diagnosis on outcome of pulmonary atresia and intact ventricular septum

OBJECTIVES

To determine the impact of fetal echocardiography on the management of pregnancy and of newborns affected by pulmonary atresia and intact ventricular septum (PAIVS) and to evaluate the outcome of infants with and without prenatal diagnosis of PAIVS.

METHODS

We searched our database for cases of PAIVS prenatally and postnatally diagnosed during the period January 1993-December 2009. Postnatal follow-up was available in all cases included in the study. Karyotyping and fluorescent in situ hybridization analysis for the DiGeorge critical region (22q11.2) were performed in all but one case.

RESULTS

The study comprised 60 cases of PAIVS: 36 with (Group A) and 24 without (Group B) prenatal diagnosis. In Group A, there were two intrauterine deaths, six postnatal deaths (five early after birth) and one termination of pregnancy. In this group, radiofrequency (RF) perforation was successfully performed in 25 cases; 20/25 infants had a biventricular (BV) repair, without further operation in 13 of them. No patient of Group B died. In this group, RF perforation was successfully performed in 22 cases; 20/22 had a BV repair without further procedure in 15 of them.

CONCLUSIONS

Prenatal diagnosis of PAIVS allows a reliable prognosis of severity and planning of proper surgical repair strategies. Fetuses that are prenatally diagnosed present a more severe spectrum of the disease; for the cases capable of getting through the neonatal period, the mortality rate and the need for further intervention were not significantly different when compared with babies with only postnatal diagnosis.

Preoperative evaluation of pulmonary artery morphology and pulmonary circulation in neonates with pulmonary atresia--usefulness of MR angiography in clinical routine

BACKGROUND

To explore the role of contrast-enhanced magnetic resonance angiography (CE-MRA) in clinical routine for evaluating neonates with pulmonary atresia (PA) and to describe their pulmonary artery morphology and blood supply.CE-MRA studies of 15 neonates with PA (12 female; median weight: 2900 g) were retrospectively evaluated by two radiologists in consensus. Each study was judged to be either diagnostic or non-diagnostic depending on the potential to evaluate pulmonary artery morphology and pulmonary blood supply. In those cases where surgery or conventional angiocardiography was performed results were compared.

RESULTS

CE-MRA was considered diagnostic in 87%. Pulmonary artery morphology was classified as "confluent with (n = 1) and without (n = 1) main pulmonary artery", "non-confluent" (n = 6) or "absent" (n = 7). Source of pulmonary blood supply was "a persistent arterial duct" (n = 12), "a direct" (n = 22) or "indirect (n = 9) aortopulmonary collateral artery (APCA)" or "an APCA from the ascending aorta" (n = 2). In no patient were there any additional findings at surgery or conventional angiocardiography which would have changed the therapeutic or surgical approach.

CONCLUSIONS

CE-MRA is a useful diagnostic tool for the preoperative evaluation of the morphology of pulmonary arteries and blood supply in neonates with PA. In most cases diagnostic cardiac catheterization can be avoided.

Regression of a coronary arterial fistula in an infant with pulmonary atresia and an intact ventricular septum

This report describes a premature newborn with pulmonary atresia and an intact ventricular septum who presented with a significant fistula between the right ventricle and the left anterior descending coronary artery (LAD). The right ventricle was not decompressed to prevent myocardial damage. After 2 months, the fistula had closed spontaneously. The pulmonary valve was opened, and biventricular circulation was achieved.