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Stanley HM, Callahan R. Novel application of the Diabolo technique to restrict pulmonary blood flow in a single ventricle patient with a right ventricle to pulmonary artery conduit. Catheter Cardiovasc Interv 2024; 103:736-740. [PMID: 38488184 DOI: 10.1002/ccd.31008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/10/2024] [Accepted: 03/01/2024] [Indexed: 04/14/2024]
Abstract
Balancing pulmonary and systemic circulations in single ventricle patients with a conduit after Stage 1 palliation is challenging. A transcatheter intervention for excessive pulmonary blood flow would provide benefit. We report a case of a critically ill single ventricle patient with symptoms of excessive pulmonary blood flow after Stage 1 despite maximal medical therapy. The patient underwent percutaneous intraluminal downsizing of the right ventricle to pulmonary artery conduit using a novel application of the Diabolo-covered stent technique, with subsequent clinical improvement. A second catheterization was performed during the interstage period with successful dilation of the stent to achieve appropriate saturations. The Diabolo technique can be successfully employed in this population to restrict pulmonary blood flow and has the advantage of being adjusted during placement and in subsequent interventions.
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Affiliation(s)
- Helen M Stanley
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ryan Callahan
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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2
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Khan A, Qureshi AM, Bansal M, Stapleton G, Webb MK, Lam W, Eilers L, Singh HR, Gowda ST. Extra-cardiac and complex Fontan baffle fenestration using radio frequency current via surgical electrocautery. Cardiol Young 2023; 33:2621-2627. [PMID: 37092668 DOI: 10.1017/s1047951123000380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
BACKGROUND Fontan baffle punctures and creation of Fontan fenestration for cardiac catheterisation procedures remain challenging especially due to the heavy calcification of prosthetic material and complex anatomy. OBJECTIVES We sought to evaluate our experience using radiofrequency current via surgical electrocautery needle for Fontan baffle puncture to facilitate diagnostic, electrophysiology, and interventional procedures. METHODS A retrospective chart review of all Fontan patients (pts) who underwent Fontan baffle puncture using radiofrequency energy via surgical electrocautery from three centres were performed from January 2011 to July 2021. RESULTS A total of 19 pts underwent 22 successful Fontan baffle puncture. The median age and weight were 17 (3-36 years) and 55 (14-88) kg, respectively. The procedural indications for Fontan fenestration creation included: diagnostic study (n = 1), atrial septostomy and stenting (n = 1), electrophysiology study and ablation procedures (n = 8), Fontan baffle stenting for Fontan failure including protein-losing enteropathy (n = 7), and occlusion of veno-venous collaterals (n = 2) for cyanosis. The type of Fontan baffles included: extra-cardiac conduits (n = 12), lateral tunnel (n = 5), classic atrio-pulmonary connection (n = 1), and intra-cardiac baffle (n = 1). A Fontan baffle puncture was initially attempted using traditional method in 6 pts and Baylis radiofrequency trans-septal system in 2 pts unsuccessfully. In all pts, Fontan baffle puncture using radiofrequency energy via electrocautery needle was successful. The radiofrequency energy utilised was (10-50 W) and required 1-5 attempts for 2-5 seconds. There were no vascular or neurological complications. CONCLUSIONS Radiofrequency current delivery using surgical electrocautery facilitates Fontan baffle puncture in patients with complex and calcified Fontan baffles for diagnostic, interventional, and electrophysiology procedures.
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Affiliation(s)
- Asra Khan
- Pediatric Interventional Cardiology, Baylor College of Medicine, Texas Children's Hospital, 6651 Main Street, Suite E1920, Houston, TX 77030, USA
| | - Athar M Qureshi
- Pediatric Interventional Cardiology, Baylor College of Medicine, Texas Children's Hospital, 6651 Main Street, Suite E1920, Houston, TX 77030, USA
| | - Manish Bansal
- Pediatric Interventional Cardiology, Baylor College of Medicine, Texas Children's Hospital, 6651 Main Street, Suite E1920, Houston, TX 77030, USA
| | - Gary Stapleton
- Pediatric Interventional Cardiology, Baylor College of Medicine, Texas Children's Hospital, 6651 Main Street, Suite E1920, Houston, TX 77030, USA
| | - Melissa K Webb
- Pediatric Interventional Cardiology, Baylor College of Medicine, Texas Children's Hospital, 6651 Main Street, Suite E1920, Houston, TX 77030, USA
| | - Wilson Lam
- Pediatric Interventional Cardiology, Baylor College of Medicine, Texas Children's Hospital, 6651 Main Street, Suite E1920, Houston, TX 77030, USA
| | - Lindsay Eilers
- Pediatric Interventional Cardiology, Baylor College of Medicine, Texas Children's Hospital, 6651 Main Street, Suite E1920, Houston, TX 77030, USA
| | - Harinder R Singh
- The Children's Hospital of San Antonio, 333 N. Santa Rosa Street, San Antonio, TX 78207, USA
| | - Srinath T Gowda
- Pediatric Interventional Cardiology, Baylor College of Medicine, Texas Children's Hospital, 6651 Main Street, Suite E1920, Houston, TX 77030, USA
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Youssef DE, Averin K, Richards S, Sheppard C, Seaman C, Pietrosanu M, Bates A. A North American, single-center experience implanting fenestrated atrial devices and atrial flow regulators into a heterogeneous group of pediatric pulmonary hypertension patients. Front Pediatr 2023; 11:1073336. [PMID: 36762281 PMCID: PMC9905673 DOI: 10.3389/fped.2023.1073336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 01/09/2023] [Indexed: 01/26/2023] Open
Abstract
INTRODUCTION The clinical deterioration commonly experienced by pediatric patients with pulmonary arterial hypertension (PAH) has motivated a shift in the treatment of pulmonary hypertension (PH) through innovations in surgical salvage interventions. The Occlutech fenestrated atrial septal defect (FASD) Occluder and the atrial flow regulator (AFR), which provides a protective, atrial-level shunt during hypertensive crises, have found an important role in treating pediatric patients with PAH. Other groups of pediatric patients with PH may also benefit from a similar protective physiology. The primary aim of this work is to present a single center's experience with AFR and FASD devices for managing a heterogeneous group of pediatric PH patients. A secondary goal is to identify hemodynamic changes and complications following device implantation. MATERIALS AND METHODS We performed a retrospective review of all pediatric PH patients who, after being found suitable, either successfully or unsuccessfully received an FASD or AFR device between January 2015 and December 2021 at the Stollery Children's Hospital in Edmonton, Canada. RESULTS Fourteen patients (eight female) with a median age of 4.6 (range 0.3-17.9) years and a median body mass index of 15.1 (Q1 = 13.8, Q3 = 16.8) kg/m2 underwent device implantation: five received FASDs, eight received AFRs, and one was ultimately unable to receive an implant due to thrombosed iliac vessels and required surgical intervention. Of the fourteen patients, seven were in group 1 (PAH), one was in group 3 (lung disease), and six were in group 5 (primarily pulmonary hypertension vascular disease) under the World Symposium PH classification. All patients were on mono-, dual-, or triple-drug PH therapy. Device stabilization was not possible for two patients, who then required a repeat catheterization. Of the group 1 patients, three AFR and three FASD implants were successful, while one FASD implant was unsuccessful due to thrombosed vessels. At a six-month clinical assessment, all group 1 patients had patent devices and improved WHO FCs. CONCLUSION This work presents a single center's experience with AFR and FASD implants in a heterogeneous group of fourteen pediatric patients with severe PH. This treatment strategy is novel in the pediatric population and so this work provides momentum for future studies of interventional cardiac catheterization procedures for pediatric patients with PH. Further collaborations are required to develop criteria to identify ideal pediatric candidates and optimally time interventions in order to maximize the benefits of this treatment.
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Affiliation(s)
- David Edward Youssef
- Division of Pediatrics, Department of Pediatric Pulmonary Hypertension, Stollery Children's Hospital, Edmonton, AB, Canada
| | - Konstantin Averin
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.,Cohen Children's Heart Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, United States
| | - Susan Richards
- Division of Pediatrics, Department of Pediatric Pulmonary Hypertension, Stollery Children's Hospital, Edmonton, AB, Canada
| | - Catherine Sheppard
- Division of Pediatrics, Department of Pediatric Pulmonary Hypertension, Stollery Children's Hospital, Edmonton, AB, Canada
| | - Cameron Seaman
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Matthew Pietrosanu
- Department of Mathematical and Statistical Sciences, University of Alberta, Edmonton, AB, Canada
| | - Angela Bates
- Division of Pediatrics, Department of Pediatric Pulmonary Hypertension, Stollery Children's Hospital, Edmonton, AB, Canada.,Division of Pediatric Critical Care, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
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Matsuo K, Hirose M, Aoki H, Kayatani F. Transconduit approach for pulmonary vein stenting in an extracardiac Fontan and plastic bronchitis case. BMJ Case Rep 2022; 15:e250565. [PMID: 35985750 PMCID: PMC9396155 DOI: 10.1136/bcr-2022-250565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Plastic bronchitis (PB) is a rare but severe complication in patients following the Fontan operation, the final palliative procedure for single ventricle heart disease. PB is characterised by the formation of rubbery casts of the tracheobronchial tree that may cause cough, wheezing, dyspnoea and hypoxia. Progressive airway obstruction may lead to asphyxia and death, and the overall mortality rate is 15.2%. Most patients receive a combination therapy from three different treatment strategies, that is, therapy for relief of airway obstruction, anti-inflammatory treatment and treatment to improve haemodynamics of the Fontan physiology. Therapy improving haemodynamics consists of optimising the Fontan circulation or cardiac function, antiarrhythmic therapy, inhibition of lymph leakage/production, decompression of the Fontan circulation and heart transplantation.We present the case of a child with PB after extracardiac Fontan operation, who was refractory to balloon angioplasty and surgical release for pulmonary vein (PV) stenosis. We decided to perform stent implantation for the right PVs through transconduit puncture instead of fenestration because the position of fenestration was too high to access the PVs. After PV stenting via the transconduit approach, she experienced improvement in cough, wheezing and breathlessness, and a significant reduction in airway cast formation.
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Affiliation(s)
- Kumiyo Matsuo
- Pediatric Cardiology, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Masaki Hirose
- Pediatric Cardiology, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Hisaaki Aoki
- Pediatric Cardiology, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Futoshi Kayatani
- Pediatric Cardiology, Osaka Women's and Children's Hospital, Izumi, Japan
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Greenleaf CE, Lim ZN, Li W, LaPar DJ, Salazar JD, Corno AF. Impact on clinical outcomes from transcatheter closure of the Fontan fenestration: A systematic review and meta-analysis. Front Pediatr 2022; 10:915045. [PMID: 36268038 PMCID: PMC9576841 DOI: 10.3389/fped.2022.915045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 08/26/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Meta-analysis of the impact on clinical outcome from transcatheter closure of Fontan fenestration. METHODS Cochrane, Embase, MEDLINE, and Open-Gray were searched. Parameters such as changes in oxygen saturation, cavo-pulmonary pressure, maximum heart rate during exercise, exercise duration, and oxygen saturation after fenestration closure were pooled and statistical analysis performed. RESULTS Among 922 publications, 12 retrospective observational studies were included. The included studies involved 610 patients, of which 552 patients (90.5%) had a fenestration. Of those patients, 505 patients (91.5%) underwent attempt at trans-catheter closure. When it could be estimated, the pooled overall mean age at trans-catheter fenestration closure was 6.6 ± 7.4 years, and the mean follow-up time was 34.4 ± 10.7 months. There were 32 minor (6.3%) and 20 major (4.0%) complications during or after trans-catheter Fontan fenestration closure. The forest plots demonstrate that following fenestration closure, there was a significant increase in the mean arterial oxygen saturation of 7.9% (95% CI 6.4-9.4%, p < 0.01). There was also a significant increase in the mean cavo-pulmonary pressure of 1.4 mmHg (95% CI 1.0-1.8 mmHg, p < 0.01) following fenestration closure. The exercise parameters reported in 3 studies also favored closing the fenestration as well, yet the exercise duration increase of 1.7 min (95% CI 0.7-2.8 min, p < 0.01) after fenestration closure is probably clinically insignificant. CONCLUSION Late closure of a Fontan fenestration has the impact of improving resting oxygen saturation, exercise oxygen saturation, and a modest improvement of exercise duration. These clinical benefits, however, may be at the expense of tolerating slightly higher cavo-pulmonary mean pressures.
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Affiliation(s)
- Christopher E Greenleaf
- Pediatric and Congenital Cardiac Surgery, Children's Heart Institute, Memorial Hermann Children's Hospital, UTHealth, McGovern Medical School, Houston, TX, United States
| | - Zhia Ning Lim
- University College of London (UCL) Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Wen Li
- Division of Clinical and Translational Sciences, Department of Internal Medicine, UTHealth, McGovern Medical School, Houston, TX, United States
| | - Damien J LaPar
- Pediatric and Congenital Cardiac Surgery, Children's Heart Institute, Memorial Hermann Children's Hospital, UTHealth, McGovern Medical School, Houston, TX, United States
| | - Jorge D Salazar
- Pediatric and Congenital Cardiac Surgery, Children's Heart Institute, Memorial Hermann Children's Hospital, UTHealth, McGovern Medical School, Houston, TX, United States
| | - Antonio F Corno
- Pediatric and Congenital Cardiac Surgery, Children's Heart Institute, Memorial Hermann Children's Hospital, UTHealth, McGovern Medical School, Houston, TX, United States
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6
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Abstract
Fontan fenestration allows right-to-left shunting increasing cardiac output and oxygen delivery. Increased shunting occurs as cardiac function and ventricular end-diastolic pressures improve, potentially decreasing oxygen saturation. Complete closure may result in impaired Fontan haemodynamics and low cardiac output; however, there are no dedicated devices to reduce fenestration size. We describe Fontan fenestration size reduction using the Atrial Flow Regulator.
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Transcatheter creation of a pulmonary artery to left atrial fenestration in a failing Fontan circulation using the Atrial Flow Regulator (AFR). Cardiol Young 2021; 31:1376-1379. [PMID: 33766177 DOI: 10.1017/s1047951121000731] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Transcatheter creation of an interatrial communication using the Occlutech Atrial Flow Regulator Device for pulmonary hypertension or heart failure is well described. We report a case of an 8-year-old boy with a failing Fontan circulation, in whom the Atrial Flow Regulator was used to successfully create a fenestration between the pulmonary artery and left atrium, improving his clinical condition.
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8
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Sugiyama H, Taniguchi K, Asagai S, Toyohara K, Inai K. A novel procedure of puncture to access the pulmonary venous atrium in complex congenital heart disease with surgical correction. J Cardiol 2021; 77:660-668. [PMID: 33455847 DOI: 10.1016/j.jjcc.2020.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 11/04/2020] [Accepted: 12/09/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND In complex congenital heart disease, supraventricular arrhythmia develops long term after surgical repair. The arrhythmia could have pharmacological tolerance and sometimes be fatal. We report our experiences with puncturing tough or calcified surgical repair material to access the pulmonary venous atrium for the purpose of the management of arrhythmia in complex congenital heart disease with surgical correction. METHODS From June 2016, subsequent 9 patients underwent the procedure. Their age at the procedure ranged from 11 to 43 years old (median 26.4 years old). Surgical procedures were Mustard procedure (XenomedicaⓇ) in 6, lateral tunnel total cavo-pulmonary connection with autologous pericardium in 2, and extra-cardiac total cavo-pulmonary connection with expanded polytetrafluoroethylene (ePTFE) tube in 1. RESULTS Multi-planar reconstruction imaging by cardiac computed tomography was done for making plans before the procedures. Under intracardiac echocardiography guidance, an 8 French steerable sheath was perpendicularly adjusted to target objects. The sharpened edge of 0.014 inch guide wire penetrated with gentle forward force. Subsequently, the puncture site was dilated from a small balloon to a large one step by step. In all patients, penetration was successfully completed. Catheter ablation was achieved in 8 patients and a pacemaker was implanted through the re-canalized superior caval vein in 1 patient. No complications were recorded. CONCLUSION The trans-catheter puncture of the synthetic or calcified material is safe and feasible, although careful planning is required with imaging. A steerable sheath could easily be controlled to the make appropriate angle to the target object for preventing slippage and conveying effective force.
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Affiliation(s)
- Hisashi Sugiyama
- Pediatric Cardiology, Seirei Hamamatsu General Hospital, Tokyo Women's Medical University, 2-12-12, Sumiyoshi, Naka Ward, Hamamatsu, Shizuoka 430-8553, Japan.
| | - Kouta Taniguchi
- Pediatric Cardiology, Seirei Hamamatsu General Hospital, Tokyo Women's Medical University, 2-12-12, Sumiyoshi, Naka Ward, Hamamatsu, Shizuoka 430-8553, Japan
| | - Seiji Asagai
- Pediatric Cardiology, Seirei Hamamatsu General Hospital, Tokyo Women's Medical University, 2-12-12, Sumiyoshi, Naka Ward, Hamamatsu, Shizuoka 430-8553, Japan
| | - Keiko Toyohara
- Pediatric Cardiology, Seirei Hamamatsu General Hospital, Tokyo Women's Medical University, 2-12-12, Sumiyoshi, Naka Ward, Hamamatsu, Shizuoka 430-8553, Japan
| | - Kei Inai
- Pediatric Cardiology, Seirei Hamamatsu General Hospital, Tokyo Women's Medical University, 2-12-12, Sumiyoshi, Naka Ward, Hamamatsu, Shizuoka 430-8553, Japan
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9
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Choi RS, DiNardo JA, Brown ML. Superior Cavopulmonary Connection: Its Physiology, Limitations, and Anesthetic Implications. Semin Cardiothorac Vasc Anesth 2020; 24:337-348. [PMID: 32646291 DOI: 10.1177/1089253220939361] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The superior cavopulmonary connection (SCPC) or "bidirectional Glenn" is an integral, intermediate stage in palliation of single ventricle patients to the Fontan procedure. The procedure, normally performed at 3 to 6 months of life, increases effective pulmonary blood flow and reduces the ventricular volume load in patients with single ventricle (parallel circulation) physiology. While the SCPC, with or without additional sources of pulmonary blood flow, cannot be considered a long-term palliation strategy, there are a subset of patients who require SCPC palliation for a longer interval than the typical patient. In this article, we will review the physiology of SCPC, the consequences of prolonged SCPC palliation, and modes of failure. We will also discuss strategies to augment pulmonary blood flow in the presence of an SCPC. The anesthetic considerations in SCPC patients will also be discussed, as these patients may present for noncardiac surgery from infancy to adulthood.
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Affiliation(s)
- Ray S Choi
- Children's Hospital Colorado, Denver, CO, USA.,Boston Children's Hospital, Boston, MA, USA
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10
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Kumar TKS. The failing Fontan. Indian J Thorac Cardiovasc Surg 2020; 37:82-90. [PMID: 33603286 DOI: 10.1007/s12055-020-00931-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 01/13/2020] [Accepted: 01/28/2020] [Indexed: 11/30/2022] Open
Abstract
Nearly 50 years back, Francis Fontan pioneered an operation for tricuspid atresia that bears his name today. The operation has since undergone numerous modifications and continues to be widely applied to an array of single ventricles. Despite restoring normal oxygen levels in the body, the operation creates a neoportal system where adequate cardiac output can be generated only at the expense of increased systemic venous congestion. This results in slow but relentless damage to the end organ systems especially the liver. Continuous surveillance of the patient to monitor this circulation, that will ultimately fail, is of paramount importance. Timely medical and cardiac catheterization and surgical intervention can extend the life span of Fontan patients. Ultimately a change of the hemodynamic circuit in the form of heart transplantation or ventricular assist device will be required to salvage the failing Fontan circuit.
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Affiliation(s)
- T K Susheel Kumar
- Department of Cardiothoracic Surgery, New York University, 530 First Avenue, New York, NY 10016 USA
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Zentner D, Celermajer DS, Gentles T, d’Udekem Y, Ayer J, Blue GM, Bridgman C, Burchill L, Cheung M, Cordina R, Culnane E, Davis A, du Plessis K, Eagleson K, Finucane K, Frank B, Greenway S, Grigg L, Hardikar W, Hornung T, Hynson J, Iyengar AJ, James P, Justo R, Kalman J, Kasparian N, Le B, Marshall K, Mathew J, McGiffin D, McGuire M, Monagle P, Moore B, Neilsen J, O’Connor B, O’Donnell C, Pflaumer A, Rice K, Sholler G, Skinner JR, Sood S, Ward J, Weintraub R, Wilson T, Wilson W, Winlaw D, Wood A. Management of People With a Fontan Circulation: a Cardiac Society of Australia and New Zealand Position statement. Heart Lung Circ 2020; 29:5-39. [DOI: 10.1016/j.hlc.2019.09.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 09/16/2019] [Indexed: 02/07/2023]
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A word of caution: diabolic behaviour of AndraStents®: inflation of supporting balloon leads to "diabolo"-misconfiguration of the stent. Cardiol Young 2019; 29:972-976. [PMID: 31218985 DOI: 10.1017/s1047951119001264] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AIMS Transcatheter implantation of pulmonary balloon-expandable stent-valves requires pre-stenting of the right ventricular outflow tract with large calibre stents. To increase awareness of the associated risks of this part of transcatheter pulmonary valve replacement therapy, we report potential fatal complications during the implantation of AndraStents® in the right ventricular outflow tract in six cases from five different European institutions and their management. METHOD AND RESULT We present a retrospective case series analysis looking at the time period from 2013 to 2018. Of 127 AndraStents® implanted in the right ventricular outflow tract, in six patients, age from 13 to 71 years, a misconfiguration of the AndraStent® occurred forming a "diabolo"-configuration. During inflation of the balloon, the stent showed extreme "dog-boning", an expansion of the stent at both ends with the middle part remaining unexpanded. This led to rupture of the balloon and loss of manoeuvrability in four patients. Out of the total six cases, in four patients the stent was eventually expanded with high-pressure balloons, and in one case the stent was surgically retrieved. In one patient, in whom a percutaneous retrieval of the embolised stent was attempted, a fatal bleeding occurred. CONCLUSIONS Pre-stenting of the right ventricular outflow tract by AndraStents® can lead to misconfiguration of the stent with potentially fatal complications. Rescue strategies of misconfigured stents include stent inflation and placement with high pressure non-compliant balloons or surgical backup. Interventional retrieval measures of AndraStents® cannot be advised.
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13
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Bauer A, Esmaeili A, deRosa R, Voelkel NF, Schranz D. Restrictive atrial communication in right and left heart failure. Transl Pediatr 2019; 8:133-139. [PMID: 31161080 PMCID: PMC6514282 DOI: 10.21037/tp.2019.04.03] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Heart failure (HF) is usually defined by the dominantly affected heart chamber; therefore, termed right or left HF (RHF or LHF). Pulmonologists understand RHF as a complex syndrome characterized by insufficient delivery of blood from the right ventricle associated with elevated systemic venous pressure at rest or exercise. Cardiologists specify LHF by its clinical functional class and the relation to a reduced (HFrEF), preserved (HFpEF) or mid-range ejection fraction (HFmrEF). Pediatric cardiologist, dealing also with patients with a failing single ventricle, define HF as a condition of insufficient systemic oxygen delivery (DO2). Certainly, pediatricians do not think of the right and left heart, or even a single ventricle as an isolated, independently acting entity. Because of the importance of cardiac interactions, the creation of a restrictive atrial communication aims at a palliative approach with the goal to diminish the congestive consequences of a dysfunctional ventricle; further to serve as a pop-off valve in order to prevent syncope and cardiovascular collapse. This review covers the background, the particular indications, the techniques and preliminary results achieved following the creation of a restrictive atrial septum defect (rASD) in different pathophysiological settings. Based on the institutional experience, percutaneous trans-catheter perforation of the atrial septum, followed by gradual balloon dilatation can be performed at any age and location worldwide. Medical institutions in low resource countries can make use of such palliating procedures in the setting of right as well as LHF independent of their pharmacological facilities.
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Affiliation(s)
- Anna Bauer
- Pediatric Heart Center, Justus-Liebig University, Giessen, Germany
| | - Anoosh Esmaeili
- Department of Pediatric Cardiology, Johann-Wolfgang Goethe University, Frankfurt, Germany
| | - Roberta deRosa
- Cardiovascular Department, University of Salerno, Salerno, Italy
| | | | - Dietmar Schranz
- Pediatric Heart Center, Justus-Liebig University, Giessen, Germany
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14
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Abstract
This report describes the first clinical experience with the new Occlutech Atrial Flow Regulator (AFR®) device for implementation of a late Fontan fenestration. The AFR® device secured a defined diameter of the fenestration without spontaneous re-occlusion of this extra-anatomic perforation. This ensured a permanent clinical improvement of our failing Fontan patient.
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Kerst G, Vázquez-Jiménez J, Gonzalez y Gonzalez MB, Maizza A, Ostermayer S. Tachykardien bei Kindern ohne und mit angeborenem Herzfehler. Monatsschr Kinderheilkd 2017. [DOI: 10.1007/s00112-017-0378-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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16
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Schranz D. Behandlungsstrategien bei Patienten mit univentrikulärem Herzen. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2016. [DOI: 10.1007/s00398-016-0109-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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17
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Singhi AK, Kothandum S. Unusual method of creation of a transcatheter fenestration in an extracardiac conduit Fontan circulation. Ann Pediatr Cardiol 2016; 9:258-62. [PMID: 27625527 PMCID: PMC5007938 DOI: 10.4103/0974-2069.189112] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Failing Fontan physiology in univentricular hearts manifest with protein-losing enteropathy, plastic bronchitis, low cardiac output, and recurrent effusions. Transcatheter creation of fenestration in a failing Fontan may be useful in alleviating the symptoms by improving the cardiac output. It is traditionally achieved by puncturing through the conduit from femoral or jugular venous access. In the absence of good venous path, transhepatic access provides a direct route for needle puncture of the conduit. If marked intimal ingrowth into the conduit results in increasing rigidity and makes the conduit nonyielding, alternative approaches may be needed. A successful creation of pulmonary artery to atrial roof communication through the potential space of transverse sinus using a covered stent is presented.
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Affiliation(s)
- Anil K Singhi
- Department of Cardiac Sciences, Medica Superspeciality Hospital, Mukundapur, Kolkata, India
| | - Sivakumar Kothandum
- Department of Pediatric Cardiology, Institute of Cardio Vascular Diseases, The Madras Medical Mission, Mogappair, Chennai, Tamil Nadu, India
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Aldoss O, Divekar A. Modified Technique to Create Diabolo Stent Configuration. Pediatr Cardiol 2016; 37:728-33. [PMID: 26739005 DOI: 10.1007/s00246-015-1339-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 12/22/2015] [Indexed: 10/22/2022]
Abstract
Diabolo stent configuration aids in stent positioning, stability, and creating a controlled defect with a predetermined size. A number of techniques to create the diabolo configuration have been previously described. The indications for creating a controlled "defect" are rapidly growing and include the Fontan circulation, patients with severe end-stage pulmonary hypertension, restrictive atrial communication in the setting of hypoplastic right or left heart syndrome, and diastolic left heart failure. We describe an alternative technique using a prefabricated readily available tool (gooseneck snare) to create a diabolo stent configuration. The chosen balloon expandable stent is mounted on a 5-mm gooseneck snare centered on an angioplasty catheter larger than 5 mm diameter. When deployed, the snare restricts the central waist to 5 mm and both ends expand to a larger diameter creating a dumbbell/diabolo configuration. A total of six diablo stent configurations were successfully implanted in four patients with failing Fontan physiology; five to create a transcatheter fenestration and one to relieve atrial septal restriction. Data expressed as median and IQR. Their weight was 24.8 kg (19.6-46.95), and age years was 9.2 (6.28-13.23). There were no complications and a consistent diabolo configuration with a 5-mm central waist was created in all patients. The snare serves as a sterile, preconfigured, radiopaque, readily available tool of adequate length and strength, to create consistent diabolo stent configuration without any modifications. This technique is a simple, reproducible, and easy to learn.
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Affiliation(s)
- Osamah Aldoss
- Stead Family Department of Pediatrics, Division of Pediatric Cardiology, University of Iowa Children's Hospital, 200 Hawkins Dr., Iowa City, IA, 52242, USA.
| | - Abhay Divekar
- Stead Family Department of Pediatrics, Division of Pediatric Cardiology, University of Iowa Children's Hospital, 200 Hawkins Dr., Iowa City, IA, 52242, USA
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