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Alnoor M, Ing FF. Use of Flow Restrictors in Congenital Heart Disease. Interv Cardiol Clin 2024; 13:333-341. [PMID: 38839167 DOI: 10.1016/j.iccl.2024.02.004] [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: 06/07/2024]
Abstract
The surgical pulmonary artery band was first introduced in 1952 and, to this day, can produce challenges in regard to the ideal amount of restriction and the need for reoperations. A transcatheter option may be the ideal solution as it allows for a less-invasive approach for a better hemodynamic assessment and easier re-intervention. To date, multiple approaches have been developed with device modifications to create restrictions to flow, each with advantages and limitations. Continued experience is still necessary to determine the ideal device to use to create an adequate and modifiable level of restriction.
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Affiliation(s)
- Mohammad Alnoor
- Department of Pediatrics, Division of Pediatric Cardiology, University of California-Davis, 2521 Stockton Boulevard, Sacramento, CA 95817, USA.
| | - Frank F Ing
- Department of Pediatrics, Division of Pediatric Cardiology, University of California-Davis, 2521 Stockton Boulevard, Sacramento, CA 95817, USA
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Warren M, Vasquez Choy A, Khan M, Brown M, LaPar D, Salazar J, Mallula K. Percutaneous Pulmonary Flow Restriction in Infants With Congenital Heart Disease. JACC. ADVANCES 2024; 3:101031. [PMID: 39129995 PMCID: PMC11312791 DOI: 10.1016/j.jacadv.2024.101031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 03/17/2024] [Accepted: 04/24/2024] [Indexed: 08/13/2024]
Abstract
Background Restriction of PBF in infants born with CHD is often required to avoid pulmonary over-circulation prior to definitive intervention. The current standard is to surgically place pulmonary artery bands, but these have limitations and are associated with complications. Objectives The purpose of this study was to a single-center experience with a relatively novel technique to percutaneously restrict pulmonary blood flow (PBF) in select infants with congenital heart disease (CHD). Methods Patients were selected to undergo this procedure either due to low birth weight or prematurity. All of them had CHD that would result in over-circulation without control of PBF. By a percutaneous method, modified vascular plug devices were placed in the bilateral branch pulmonary arteries. Results Seven neonates with CHD resulting in left-sided obstruction underwent this procedure. All patients demonstrated evidence of restricted PBF with a decrease in mean oxygen saturation from 95% to 84%. One patient required pulmonary artery band placement due to over-circulation 5 days after the procedure. All patients proceeded to full surgical intervention without device embolization or need for pulmonary arterioplasty. Hemodynamics demonstrated adequate limitation of PBF in 5 patients who underwent presurgical cardiac catheterization with a mean pulmonary vascular resistance of 1.52 WU × m2 and a mean transpulmonary gradient of 5.9 mm Hg. Conclusions Percutaneous PBF restriction appears to be safe and a less invasive option to delay surgical intervention in a select population to allow for somatic growth and gestational maturation. It results in a decrease in the total number of sternotomies.
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Affiliation(s)
- Matthew Warren
- Children’s Heart Institute, Children’s Memorial Hermann Hospital, UTHealth, Houston, Texas, USA
| | - Ana Vasquez Choy
- Children’s Heart Institute, Children’s Memorial Hermann Hospital, UTHealth, Houston, Texas, USA
| | - Mohammed Khan
- Children’s Heart Institute, Children’s Memorial Hermann Hospital, UTHealth, Houston, Texas, USA
| | - Matthew Brown
- Children’s Heart Institute, Children’s Memorial Hermann Hospital, UTHealth, Houston, Texas, USA
| | - Damien LaPar
- Children’s Heart Institute, Children’s Memorial Hermann Hospital, UTHealth, Houston, Texas, USA
| | - Jorge Salazar
- Children’s Heart Institute, Children’s Memorial Hermann Hospital, UTHealth, Houston, Texas, USA
| | - Kiran Mallula
- Children’s Heart Institute, Children’s Memorial Hermann Hospital, UTHealth, Houston, Texas, USA
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Reddy RK, Buckley JR. Trimming the Fat: Is Postoperative Chylothorax Preventable? Pediatr Crit Care Med 2024; 25:278-280. [PMID: 38451800 DOI: 10.1097/pcc.0000000000003434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Affiliation(s)
- Reshma K Reddy
- Both authors: Department of Pediatrics, Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, SC
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McCay N, Roberts P, Walsh K. Use of a modified microvascular plug to modify fenestration flow in a rapidly failing Fontan. Cardiol Young 2024; 34:698-700. [PMID: 38224016 DOI: 10.1017/s1047951123004523] [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: 01/16/2024]
Abstract
We report a case of an alternative transcatheter use of the modified Medtronic microvascular plug to modify fenestration stent flow in a patient with a rapidly deteriorating clinical condition. This four-year-old boy developed severe cyanosis following fenestration stent insertion, initially placed due to prolonged drainage post-Fontan with extra-cardiac conduit. In April 2023, he underwent urgent cardiac catheterisation and had partial occlusion of fenestration stent with a modified 9Q microvascular plug. His oxygen saturations improved from 50 to 89% in room air with no re-emergence of raised cavopulmonary pressures.
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Sperotto F, Lang N, Nathan M, Kaza A, Hoganson DM, Valencia E, Odegard K, Allan CK, da Cruz EM, Del Nido PJ, Emani SM, Baird C, Maschietto N. Transcatheter Palliation With Pulmonary Artery Flow Restrictors in Neonates With Congenital Heart Disease: Feasibility, Outcomes, and Comparison With a Historical Hybrid Stage 1 Cohort. Circ Cardiovasc Interv 2023; 16:e013383. [PMID: 38113289 DOI: 10.1161/circinterventions.123.013383] [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: 06/24/2023] [Accepted: 08/31/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Neonates with complex congenital heart disease and pulmonary overcirculation have been historically treated surgically. However, subcohorts may benefit from less invasive procedures. Data on transcatheter palliation are limited. METHODS We present our experience with pulmonary flow restrictors (PFRs) for palliation of neonates with congenital heart disease, including procedural feasibility, technical details, and outcomes. We then compared our subcohort of high-risk single ventricle neonates palliated with PFRs with a similar historical cohort who underwent a hybrid Stage 1. Cox regression was used to evaluate the association between palliation strategy and 6-month mortality. RESULTS From 2021 to 2023, 17 patients (median age, 4 days; interquartile range [IQR], 2-8; median weight, 2.5 kilograms [IQR, 2.1-3.3]) underwent a PFR procedure; 15 (88%) had single ventricle physiology; 15 (88%) were high-risk surgical candidates. All procedures were technically successful. At a median follow-up of 6.2 months (IQR, 4.0-10.8), 13 patients (76%) were successfully bridged to surgery (median time since PFR procedure, 2.6 months [IQR, 1.1-4.4]; median weight, 4.9 kilograms [IQR, 3.4-5.8]). Pulmonary arteries grew adequately for age, and devices were easily removed without complications. The all-cause mortality rate before target surgery was 24% (n=4). Compared with the historical hybrid stage 1 cohort (n=23), after adjustment for main confounding (age, weight, intact/severely restrictive atrial septum or left ventricle to coronary fistulae), the PFR procedure was associated with a significantly lower all-cause 6-month mortality risk (adjusted hazard ratio, 0.26 [95% CI, 0.08-0.82]). CONCLUSIONS Transcatheter palliation with PFR is feasible, safe, and represents an effective strategy for bridging high-risk neonates with congenital heart disease to surgical palliation, complete repair, or transplant while allowing for clinical stabilization and somatic growth.
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Affiliation(s)
- Francesca Sperotto
- Department of Cardiology (F.S., N.L., E.V., C.K.A., E.M.d.C., N.M.), Boston Children's Hospital, Harvard Medical School, MA
| | - Nora Lang
- Department of Cardiology (F.S., N.L., E.V., C.K.A., E.M.d.C., N.M.), Boston Children's Hospital, Harvard Medical School, MA
- Department of Pediatric Cardiology, University Heart & Vascular Center Hamburg, Germany (N.L.)
| | - Meena Nathan
- Department of Cardiac Surgery (M.N., A.K., D.M.H., P.J.D.N., S.M.E., C.B.), Boston Children's Hospital, Harvard Medical School, MA
| | - Aditya Kaza
- Department of Cardiac Surgery (M.N., A.K., D.M.H., P.J.D.N., S.M.E., C.B.), Boston Children's Hospital, Harvard Medical School, MA
| | - David M Hoganson
- Department of Cardiac Surgery (M.N., A.K., D.M.H., P.J.D.N., S.M.E., C.B.), Boston Children's Hospital, Harvard Medical School, MA
| | - Eleonore Valencia
- Department of Cardiology (F.S., N.L., E.V., C.K.A., E.M.d.C., N.M.), Boston Children's Hospital, Harvard Medical School, MA
| | - Kirsten Odegard
- Department of Cardiac Anesthesia (K.O.), Boston Children's Hospital, Harvard Medical School, MA
| | - Catherine K Allan
- Department of Cardiology (F.S., N.L., E.V., C.K.A., E.M.d.C., N.M.), Boston Children's Hospital, Harvard Medical School, MA
| | - Eduardo M da Cruz
- Department of Cardiology (F.S., N.L., E.V., C.K.A., E.M.d.C., N.M.), Boston Children's Hospital, Harvard Medical School, MA
| | - Pedro J Del Nido
- Department of Cardiac Surgery (M.N., A.K., D.M.H., P.J.D.N., S.M.E., C.B.), Boston Children's Hospital, Harvard Medical School, MA
| | - Sitaram M Emani
- Department of Cardiac Surgery (M.N., A.K., D.M.H., P.J.D.N., S.M.E., C.B.), Boston Children's Hospital, Harvard Medical School, MA
| | - Christopher Baird
- Department of Cardiac Surgery (M.N., A.K., D.M.H., P.J.D.N., S.M.E., C.B.), Boston Children's Hospital, Harvard Medical School, MA
| | - Nicola Maschietto
- Department of Cardiology (F.S., N.L., E.V., C.K.A., E.M.d.C., N.M.), Boston Children's Hospital, Harvard Medical School, MA
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Kizilski SB, Recco DP, Sperotto F, Lang N, Hammer PE, Baird CW, Maschietto N, Hoganson DM. Transcatheter Pulmonary Artery Banding in High-Risk Neonates: In-Vitro Study Provoked by Initial Clinical Experience. Cardiovasc Eng Technol 2023; 14:640-654. [PMID: 37580629 DOI: 10.1007/s13239-023-00674-2] [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: 04/25/2023] [Accepted: 07/17/2023] [Indexed: 08/16/2023]
Abstract
PURPOSE Very high-risk, ductal-dependent or complex two-ventricle patients with associated comorbidities often require pulmonary blood flow restriction as bridge to a more definitive procedure, but current surgical options may not be well-tolerated. An evolving alternative utilizes a fenestrated Micro Vascular Plug (MVP) as a transcatheter, internal pulmonary artery band. In this study, we report a case series and an in-vitro evaluation of the MVP to elicit understanding of the challenges faced with device implantation. METHODS Following single-center, retrospective review of eight patients who underwent device placement, an in-vitro flow study was conducted on MVP devices to assess impact of device and fenestration sizing on pulmonary blood flow. A mathematical model was developed to relate migration risk to vessel size. Results of the engineering analysis were compared to the clinical series for validation. RESULTS At median follow-up of 8 months (range 1-15), survival was 63% (5/8), and 6 (75%) patients underwent subsequent target surgical intervention with relatively low mortality (1/6). Occluder-related challenges included migration (63%) and peri-device flow, which were evaluated in-vitro. The device demonstrated durability over normal and supraphysiologic conditions with minimal change in fenestration size. Smaller vessel size significantly increased pressure gradient due to reduced peri-device flow and smaller effective fenestration size. CONCLUSION Device oversizing, with appropriate adjustment to fenestration size, may reduce migration risk and provide a clinically appropriate balance between resulting pressure gradient and Qp:Qs. Our results can guide the interventionalist in appropriately selecting the device and fenestrations based on patient-specific anatomy and desired post-implantation flow characteristics.
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Affiliation(s)
- Shannen B Kizilski
- Department of Cardiac Surgery, Harvard Medical School, Boston Children's Hospital, 300 Longwood Avenue, Bader, 2nd Floor, Boston, MA, 02215, USA
| | - Dominic P Recco
- Department of Cardiac Surgery, Harvard Medical School, Boston Children's Hospital, 300 Longwood Avenue, Bader, 2nd Floor, Boston, MA, 02215, USA
| | - Francesca Sperotto
- Department of Cardiology, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - Nora Lang
- Department of Cardiology, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatric Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter E Hammer
- Department of Cardiac Surgery, Harvard Medical School, Boston Children's Hospital, 300 Longwood Avenue, Bader, 2nd Floor, Boston, MA, 02215, USA
| | - Christopher W Baird
- Department of Cardiac Surgery, Harvard Medical School, Boston Children's Hospital, 300 Longwood Avenue, Bader, 2nd Floor, Boston, MA, 02215, USA
| | - Nicola Maschietto
- Department of Cardiology, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - David M Hoganson
- Department of Cardiac Surgery, Harvard Medical School, Boston Children's Hospital, 300 Longwood Avenue, Bader, 2nd Floor, Boston, MA, 02215, USA.
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Carlozzi LN, Johnston TA, Jones TK, Rubio AE, Morray BH. Modified Medtronic Microvascular Plug Implantation to Reduce Pulmonary Blood Flow in Patients With a Shunted Single Ventricle. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:101070. [PMID: 39132399 PMCID: PMC11308124 DOI: 10.1016/j.jscai.2023.101070] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 05/26/2023] [Accepted: 06/27/2023] [Indexed: 08/13/2024]
Affiliation(s)
- Lauren N. Carlozzi
- Division of Pediatric Cardiology, Department of Pediatrics, University of Washington/Seattle Children’s Hospital, Seattle, Washington
| | - Troy A. Johnston
- Division of Pediatric Cardiology, Department of Pediatrics, University of Washington/Seattle Children’s Hospital, Seattle, Washington
| | - Thomas K. Jones
- Division of Pediatric Cardiology, Department of Pediatrics, University of Washington/Seattle Children’s Hospital, Seattle, Washington
| | - Agustin E. Rubio
- Division of Pediatric Cardiology, Department of Pediatrics, University of Washington/Seattle Children’s Hospital, Seattle, Washington
| | - Brian H. Morray
- Division of Pediatric Cardiology, Department of Pediatrics, University of Washington/Seattle Children’s Hospital, Seattle, Washington
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Haddad RN, Bentham J, Adel Hassan A, Al Soufi M, Jaber O, El Rassi I, Kasem M. Outcomes of manually modified microvascular plugs to pulmonary flow restrictors in various congenital heart lesions. Front Cardiovasc Med 2023; 10:1150579. [PMID: 37492157 PMCID: PMC10363685 DOI: 10.3389/fcvm.2023.1150579] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 06/27/2023] [Indexed: 07/27/2023] Open
Abstract
Background The development of microvascular plugs (MVPs) has enabled novel transcatheter deliverable endoluminal pulmonary flow restrictors (PFRs) with the potential to treat newborns and infants with life-threatening congenital heart diseases (CHDs) in a minimally invasive manner. We present our experience to evaluate the efficacy of this concept in controlling pulmonary blood flow in various CHDs. Methods Retrospective clinical data review of patients with CHD and pulmonary over-circulation who received bilateral PFRs percutaneously. Results Twenty-eight PFRs (7 MVP-5Q, 12 MVP-7Q, and 9 MVP-9Q) were finally implanted in 14 patients with a median age of 1.6 months (IQR, 0.9-2.3) and a median weight of 3.1 Kg (IQR, 2.7-3.6). Nine patients had large intra-cardiac left-to-right shunts (including 3 with fatal trisomy and palliative programs), 2 had borderline left ventricles, 2 had Taussig-Bing anomaly, and one had a hypoplastic left heart. Four patients had concomitant ductal stenting. Two MVP-5Qs were snare-removed and upsized to MVP-7Q. Patients experienced a significant drop in oxygen saturation and Qp/Qs. All patients were discharged from the ICU after a median of 3.5 days (IQR, 2-5.8) postoperative. Five patients had routine inter-stage catheterization and no device embolization or pulmonary branch distortion was seen. Fourteen (50%) PFRs were surgically explanted uneventfully on a median of 4.3 months (IQR, 1.2-6) post-implantation during biventricular repair in 6 patients and stage-2 palliation in one patient. The latter died 1 month post-operative from severe sepsis. Four patients are scheduled for surgical PFR removal and biventricular repair. Two patients with trisomy 18 died at 1 and 6.8 months post-procedure from non-cardiac causes. One patient with trisomy 13 is alive at 2.7 months post-procedure. Conclusion It is feasible to bespoke MVPs and implant them as effective PFRs in various CHDs. This approach enables staged left ventricular recruitment, comprehensive stage-2 or biventricular repair with lower risk by postponing surgeries to later infancy. Device explantation is uneventful, and the outcomes afterward are promising.
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Affiliation(s)
- Raymond N. Haddad
- M3C-Necker, Hôpital Universitaire Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Jamie Bentham
- Department of Congenital Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Ahmed Adel Hassan
- Department of Pediatric Cardiology, Heart Centre of Excellence, Al Jalila Children’s Speciality Hospital, Dubai, United Arab Emirates
| | - Mahmoud Al Soufi
- Department of Pediatric Cardiology, Heart Centre of Excellence, Al Jalila Children’s Speciality Hospital, Dubai, United Arab Emirates
| | - Osama Jaber
- Department of Congenital Cardiac Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Issam El Rassi
- Department of Pediatric Cardiac Surgery, Heart Centre of Excellence, Al Jalila Children’s Speciality Hospital, Dubai, United Arab Emirates
| | - Mohamed Kasem
- Department of Pediatric Cardiology, Heart Centre of Excellence, Al Jalila Children’s Speciality Hospital, Dubai, United Arab Emirates
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Zaleski KL, Valencia E, Matte GS, Kaza AK, Nasr VG. How We Would Treat Our Own Hypoplastic Left Heart Syndrome Neonate for Stage 1 Surgery. J Cardiothorac Vasc Anesth 2023; 37:504-512. [PMID: 36717315 DOI: 10.1053/j.jvca.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/26/2022] [Accepted: 01/02/2023] [Indexed: 01/09/2023]
Affiliation(s)
- Katherine L Zaleski
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Eleonore Valencia
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Gregory S Matte
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Aditya K Kaza
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Viviane G Nasr
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA.
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