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Mejia E, McLennan D, Zablah J, Soszyn N, Shibbani K, Morgan GJ. Establishing Carotid Seldinger as Routine Access in Infants; Planning, Performance, and Follow-Up Protocols. Pediatr Cardiol 2023; 44:1815-1820. [PMID: 37603081 DOI: 10.1007/s00246-023-03267-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 08/07/2023] [Indexed: 08/22/2023]
Abstract
Percutaneous carotid access (PCA) in infants has been reported in small multicenter cohorts, case reports and wider studies over the last 20 years. Compare outcomes after implementation of a systematic approach to PCA in a single center including an imaging follow-up protocol. Retrospective case-control study of PCA at Children's Hospital Colorado was performed from January 2013 to December 2022. Seventy-four patients underwent 82 PCAs for cardiac catheterization. The median age (range) was 14 days (1-359), and weight was 3.25-kg (1.9-7.9). Median sheath size was 4-Fr (3.3-6). Seventy-seven interventions performed included PDA stenting, aortic valvoplasty, BTT shunt stenting, and coarctation stenting. Vascular access was performed using a modified 21 g butterfly needle. A protocolized approach was implemented in 2020 reversing the patient head-to-toe orientation on the catheterization table, maintaining intubation and sedation for 4-h during recovery and routine use of a specific vascular ultrasound protocol. Following these changes, time to access significantly improved with no major complications. Before 2020, two access related complications occurred. One requiring surgical vascular repair and one occlusive thrombus. A significant increase in sheath time in post-era was associated with increased case complexity. Longer sheath times were not associated with increased risk of vessel injury or thrombus. No neurological insults were reported. Our experience confirms that PCA is safe and achievable with preserved vessel patency regardless of patient weight or sheath size. A protocolized planning, recovery, and follow-up regimen is recommended to establish safe practice and identify and treat complications as necessary.
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Affiliation(s)
- Ernesto Mejia
- Department of Pediatric Cardiology, University of Colorado, Children's Hospital Colorado, The Heart Center, 13123 E 16th Ave, B100, Aurora, CO, 80045, USA
| | - Daniel McLennan
- Department of Pediatric Cardiology, Children's Wisconsin, Milwaukee, WI, USA
- Department of Pediatric Cardiology, University of Iowa, Stead Family Children's Hospital, Iowa City, IA, USA
| | - Jenny Zablah
- Department of Pediatric Cardiology, University of Colorado, Children's Hospital Colorado, The Heart Center, 13123 E 16th Ave, B100, Aurora, CO, 80045, USA
| | - Natalie Soszyn
- Department of Pediatric Cardiology, University of Colorado, Children's Hospital Colorado, The Heart Center, 13123 E 16th Ave, B100, Aurora, CO, 80045, USA
| | - Kamel Shibbani
- Department of Pediatric Cardiology, University of Iowa, Stead Family Children's Hospital, Iowa City, IA, USA
| | - Gareth J Morgan
- Department of Pediatric Cardiology, University of Colorado, Children's Hospital Colorado, The Heart Center, 13123 E 16th Ave, B100, Aurora, CO, 80045, USA.
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Hybrid stenting of the arterial duct with carotid cutdown and flip technique: immediate and early results. Cardiol Young 2022; 32:1254-1260. [PMID: 34629130 DOI: 10.1017/s1047951121004017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
UNLABELLED Stenting of the arterial duct (PDA) has become a standard palliation for ductal-dependent pulmonary circulation. Carotid arterial access provides a direct route for stenting vertical ducts. We evaluated our early results of hybrid ductal stenting via surgical carotid cutdown. METHODS AND RESULTS In this retrospective single centre cohort study, hybrid PDA stenting was attempted in 11 patients with "flip technique", between January 2020 and February 2021, and was successful in 10. Median age was 29 days (interquartile range 17.5-87) and mean weight 3.37 ± 1.23 kg. Mean fluoroscopy time was 13.58 ± 5.35 minutes, mean procedure time was 48.50 ± 22.5 minutes, and mean radiation dose was 1719.5 ± 1217.6 mGycm2. Mean time for cutdown was 9.9 ± 2.4 minutes and for haemostasis and suturing was 25.3 ± 11.0 minutes. Median duration of ventilation post-stenting was 26 hours (interquartile range 21-43.75). The median ICU stay post-procedure was 5 days (interquartile range 4-7.25) and mean hospital stay was 12 ± 6.3 days. On early follow-up, carotid patency was confirmed in all patients with colour Doppler, with no intravascular thrombi, narrowing, haematomas, or aneurysms noted. There were no complications secondary to vascular access. There was one early mortality, 27 days post-stenting, which was unrelated to the procedure. CONCLUSION This study adds to the limited literature on ductal stenting with carotid access and the flip technique. In our early experience, the hybrid carotid approach is an attractive alternative to percutaneous carotid puncture and has simplified a complex and challenging intervention, with good outcomes.
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Al-Saloos H, Yassin H. Diagnosis and therapeutic cardiac catheterization of symptomatic bicuspid aortic stenosis in the pediatric population. Heart Views 2022; 23:47-54. [PMID: 35757452 PMCID: PMC9231541 DOI: 10.4103/heartviews.heartviews_39_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 04/10/2022] [Indexed: 11/05/2022] Open
Abstract
Bicuspid aortic valve (BAV) is the most common congenital heart disease with a prevalence of 0.5%–1.3% of the population. Many children with BAV are asymptomatic. Clinically relevant abnormal valve function usually occurs in adulthood. However, in rare cases, children can fail to thrive which requires valvular intervention. In this review, we will explore in more detail the anatomy of the BAV, clinical presentation of BAV, diagnosis of BAV, and its function by echocardiography, and indications for transcatheter intervention in the pediatric population.
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Polat TB. Use of percutaneous carotid artery access for performing pediatric cardiac interventions: Single-center study. Ann Pediatr Cardiol 2019; 13:16-24. [PMID: 32030031 PMCID: PMC6979034 DOI: 10.4103/apc.apc_26_19] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 06/05/2019] [Accepted: 07/23/2019] [Indexed: 11/15/2022] Open
Abstract
Background: Carotid artery (CA) access allows a more straight route for many left heart lesions. This has previously been achieved via a surgical cut-down approach in certain pediatric cardiac interventions. However, there are little data considering CA access in pediatric cases, percutaneously. Aim: We hypothesized that there would be notable improvements in efficiency as well as overall success when using the CA for access in selected cases. Methods: Between November 2016 and January 2019, records of patients undergoing attempted percutaneous CA access under ultrasound guidance for cardiac catheterization were reviewed. Results: Thirty patients underwent 36 catheterizations; median age 17 days (range, 6 days–9 months) and median weight 3.2 kg (1.2–7.8). Procedures performed were stenting or stent redilatation of the patent ductus arteriosus in 23, stenting or angioplasty of modified Blalock–Taussig shunts in four, aortic valvuloplasty in three, angioplasty for coarctation of the aorta in four, renal angioplasty in one, and diagnostic catheterization in one case. The intended intervention was unsuccessful in two patients despite successful CA access. Follow-up imaging showed a normal carotid in 28 of 30 (94%), with mild luminal narrowing with normal Doppler velocities in two instances. No patient had clinically apparent neurological sequelae attributable to CA access. Conclusions: Our data indicate that CA access should be employed when dealing with a select group of infants requiring vertical approach for left-sided cardiac lesions. Percutaneous CA access, even in very small preterm infants, is safe and feasible with negligible vascular injury and no neurological adverse events.
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Affiliation(s)
- Tugcin Bora Polat
- Department of Pediatric Cardiology, Altinbas University School of Medicine, Istanbul, Turkey
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Meliota G, Lombardi M, Zaza P, Tagliente MR, Vairo U. Balloon angioplasty of aortic coarctation in critically ill newborns using axillary artery access. Ann Pediatr Cardiol 2019; 13:67-71. [PMID: 32030037 PMCID: PMC6979016 DOI: 10.4103/apc.apc_2_19] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 03/30/2019] [Accepted: 08/12/2019] [Indexed: 12/03/2022] Open
Abstract
Balloon angioplasty may be performed as the first treatment of aortic coarctation to stabilize newborns too sick for immediate surgery. The issue of vascular access is the key to the successful treatment of critical newborns. In our study, we argue that the lesser-known axillary access route is the safest and most effective route of vascular access for balloon angioplasty in infants with aortic coarctation. To support this argument, we present the case of eight unstable newborns with complex heart diseases, who were successfully treated with percutaneous intervention through the axillary artery. This case series is followed by an analysis of the greater efficacy of this technique compared to the more conventional femoral and carotid routes. We conclude by acknowledging the substantial advantages of this lesser-known vascular access and advocate its more widespread clinical implementation in the treatment of critical newborns.
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Affiliation(s)
- Giovanni Meliota
- Department of Paediatric Cardiology, Giovanni XXIII Paediatric Hospital, Bari, Italy
| | - Maristella Lombardi
- Department of Paediatric Cardiology, Giovanni XXIII Paediatric Hospital, Bari, Italy
| | - Pierluigi Zaza
- Department of Paediatric Cardiology, Giovanni XXIII Paediatric Hospital, Bari, Italy
| | | | - Ugo Vairo
- Department of Paediatric Cardiology, Giovanni XXIII Paediatric Hospital, Bari, Italy
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The results of interventional catheterization in infants weighing under 2,000 g. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2019; 27:304-313. [PMID: 32082877 DOI: 10.5606/tgkdc.dergisi.2019.17229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 03/10/2019] [Indexed: 11/21/2022]
Abstract
Background The aim of this study was to evaluate the early and mid-term results of interventional cardiac catheterization and procedure-related complications in infants weighing <2,000 g. Methods Between May 1998 and April 2017, 22 patients (14 males, 8 females; mean age 14±8.4 days; range, 1 to 30 days) weighing <2,000 g who underwent a total of 23 interventional cardiac catheterization were retrospectively analyzed. Procedures were balloon coarctation angioplasty in 14, balloon atrial septostomy in five, balloon aortic valvuloplasty in one, balloon pulmonary valvuloplasty in one, patent ductus arteriosus closure in one, and stent placement in the ductus in one patient. Another patient underwent balloon coarctation angioplasty and balloon aortic valvuloplasty in the same session. Results The overall success rate of the interventional procedures was 95.6%. The mean follow-up was 3.2±1.6 years (range, 1 to 5.5) for 18 patients with available records. The rate of serious complications was 18%. The most frequent complications in the early period were low hemoglobin levels requiring erythrocyte suspension transfusion (54.5%) and vascular injury (54.5%). Two patients required reintervention, one patient required surgery after the second intervention, and three patients required only surgery. Six patients underwent palliative interventional procedures, and interventional procedures led to definitive treatment in five patients. Conclusion The mortality and morbidity rate of surgery is high in premature under 2,000 g infants and interventional heart catheterization can be life-saving in this patient group, although it is associated with significant complications in low birth weight newborns.
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Ligon RA, Kim DW, Vincent RN, Bauser-Heaton HD, Ooi YK, Petit CJ. Angiographic follow-up of infants and children undergoing percutaneous carotid artery interventions. Catheter Cardiovasc Interv 2018; 91:1301-1306. [DOI: 10.1002/ccd.27481] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 12/07/2017] [Accepted: 12/10/2017] [Indexed: 11/12/2022]
Affiliation(s)
- R. Allen Ligon
- Children's Healthcare of Atlanta, Department of Pediatrics; Emory University School of Medicine; Atlanta Georgia
| | - Dennis W. Kim
- Children's Healthcare of Atlanta, Department of Pediatrics; Emory University School of Medicine; Atlanta Georgia
| | - Robert N. Vincent
- Children's Healthcare of Atlanta, Department of Pediatrics; Emory University School of Medicine; Atlanta Georgia
| | - Holly D. Bauser-Heaton
- Children's Healthcare of Atlanta, Department of Pediatrics; Emory University School of Medicine; Atlanta Georgia
| | - Yinn K. Ooi
- Children's Healthcare of Atlanta, Department of Pediatrics; Emory University School of Medicine; Atlanta Georgia
| | - Christopher J. Petit
- Children's Healthcare of Atlanta, Department of Pediatrics; Emory University School of Medicine; Atlanta Georgia
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Ligon RA, Ooi YK, Kim DW, Vincent RN, Petit CJ. Intervention on Surgical Systemic-to-Pulmonary Artery Shunts: Carotid Versus Femoral Access. JACC Cardiovasc Interv 2017; 10:1738-1744. [PMID: 28823774 DOI: 10.1016/j.jcin.2017.05.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 05/03/2017] [Accepted: 05/04/2017] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The purpose of this study was to compare results between the femoral arterial (FA) and carotid arterial (CA) approaches in catheter-based interventions on Blalock-Taussig shunts (BTS). BACKGROUND Transcatheter intervention on BTS is often performed in shunt-dependent, hypoxemic infants. The approach to BTS intervention likely has an impact on timeliness and overall success. METHODS The authors reviewed all cases of catheter intervention for BTS obstruction between 2012 and 2017 for their institution. They sought to compare procedural success rates and time, sheath time, time to arterial access, and time from access to stent implantation between FA and CA approaches. RESULTS There were 42 BTS interventions between 34 patients. BTS intervention was more successful from the CA approach (p = 0.035). Among the FA cohort, BTS intervention was unsuccessful in 8 cases (25%), 5 of which were converted to CA with subsequent success. The CA cohort had lower procedure time (62 min vs. 104 min; p = 0.01) and anesthesia time (119 min vs. 151 min; p = 0.01). Additionally, CA access was associated with shorter time to arterial access (4.0 min vs. 9.3 min; p < 0.01), time to placement of the guidewire through the BTS (6.5 min vs. 13 min; p < 0.01), and time from the final sheath to BTS stent implantation (9 min vs. 20 min; p < 0.01). CONCLUSIONS Operators should consider the route of access to the BTS deliberately. The authors' approach has been the carotid artery as an alternative access site-associated with greater procedural success, shorter procedural time, and shorter time to stent implantation.
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Affiliation(s)
- R Allen Ligon
- Children's Healthcare of Atlanta, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Yinn K Ooi
- Children's Healthcare of Atlanta, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Dennis W Kim
- Children's Healthcare of Atlanta, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Robert N Vincent
- Children's Healthcare of Atlanta, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Christopher J Petit
- Children's Healthcare of Atlanta, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia.
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Uslu B, Cakmak YO, Sehirli Ü, Keskinoz EN, Cosgun E, Arbak S, Yalin A. Early Onset of Atherosclerosis of The Carotid Bifurcation in Newborn Cadavers. J Clin Diagn Res 2016; 10:AC01-5. [PMID: 27437199 DOI: 10.7860/jcdr/2016/19827.7706] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Accepted: 04/18/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The anatomy of arterial bifurcations affects blood flow and has a significant role in the development of vascular disease. Therefore, it is important to know the structural characteristics of the Common Carotid Artery (CCA) and its branches for early onset of atherosclerosis in newborns. AIM The present study was conducted to evaluate the characteristics of CCA in newborn cadavers. MATERIALS AND METHODS Eight carotid arteries obtained from newborn cadavers were used. The outflow to inflow area ratios was calculated to evaluate vessel diameters. Additionally, scanning electron and light microscopic investigations were conducted with tissue samples. The brachial artery of each cadaver was used as controls. Correlation between area ratios and atherosclerotic endothelial damage was determined. RESULTS Light microscopic investigations demonstrated that control group sections showed no positivity for Oil red O staining, while carotid bifurcation regions depicted widespread occurrence of intimal lipid accumulations. Scanning electron microscopic examination of control group sections presented regular endothelial topography, while carotid bifurcation region topography exhibited numerous blood cells and separated endothelial cells. Fibrin accumulation on endothelial surface in low area ratios was another important finding in the examination of its endothelial surface degeneration. The above-mentioned morphological findings seemed to be quite parallel to outflow to inflow area ratio data favouring low area and degeneration. CONCLUSION The correlation between area ratios and the histological characteristic of cerebral vessels of newborn cadavers indicate that early stages of atherosclerosis began in early embryologic life.
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Affiliation(s)
- Bahar Uslu
- PhD, Department of Obstetrics and Gynaecology, Yale School of Medicine , New Haven, CT, USA
| | - Yusuf Ozgur Cakmak
- Department of Anatomy, School of Medicine, Koc University , Istanbul, Turkey
| | - Ümit Sehirli
- Department of Anatomy, School of Medicine, Marmara University , Istanbul, Turkey
| | - Elif Nedret Keskinoz
- Department of Anatomy, School of Medicine, Acibadem University , Istanbul, Turkey
| | - Erdal Cosgun
- PhD, Department of Biostatistics and Medical Informatics, School of Medicine, Acibadem University , Istanbul, Turkey
| | - Serap Arbak
- PhD, Department of Histology & Embryology, School of Medicine, Acibadem University , Istanbul, Turkey
| | - Aymelek Yalin
- PhD, Department of Anatomy, School of Medicine, Eastern Mediterranean University , Famagusta, Northern Cyprus
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Justino H, Petit CJ. Percutaneous Common Carotid Artery Access for Pediatric Interventional Cardiac Catheterization. Circ Cardiovasc Interv 2016; 9:e003003. [DOI: 10.1161/circinterventions.115.003003] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Surgical cutdown for access to the common carotid artery provides a more direct route for certain pediatric cardiac interventions and avoids femoral artery injury in small infants. The safety of percutaneous carotid access (PCA) in children is unknown.
Methods and Results—
Retrospective review of PCA at Texas Children’s Hospital and Children’s Healthcare of Atlanta. From July 2006 to November 2014, 42 patients underwent 47 attempts at catheterization via PCA. Median (range) age was 20 days (0 days–2.9 years) and weight was 3.2 kg (1.1–12.2). Two patients had failed PCA with no sequelae. Of the 45 catheterizations with successful PCA and sheath placement, 44 interventions were performed, the most common being stenting or stent redilation of the ductus arteriosus, balloon aortic valvuloplasty, and stenting or angioplasty of Blalock–Taussig shunts. After sheath withdrawal, hemostasis was achieved with manual compression, with no need for surgical control of bleeding. Follow-up carotid imaging was performed in all. Acutely, 3 patients developed carotid thrombosis with resolution in 1 and mild residual narrowing in 2 after anticoagulation therapy. At follow-up, 40 of 42 patients (95%) had a normal carotid artery, with 2 instances of mild stenosis. There were no neurological sequelae attributable to PCA.
Conclusions—
PCA is safe even in small infants, and hemostasis can be achieved without surgical repair, with a carotid patency rate superior to published data after surgical cutdown. Surgical cutdown is not routinely required for pediatric cardiac catheterization via the carotid artery.
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Affiliation(s)
- Henri Justino
- From the C.E. Mullins Cardiac Catheterization Laboratories, Texas Children’s Hospital (H.J.); Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, TX (H.J.); and Division of Cardiology, Children’s Healthcare of Atlanta, Emory University School of Medicine, GA (C.J.P.)
| | - Christopher J. Petit
- From the C.E. Mullins Cardiac Catheterization Laboratories, Texas Children’s Hospital (H.J.); Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, TX (H.J.); and Division of Cardiology, Children’s Healthcare of Atlanta, Emory University School of Medicine, GA (C.J.P.)
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Choudhry S, Balzer D, Murphy J, Nicolas R, Shahanavaz S. Percutaneous carotid artery access in infants < 3 months of age. Catheter Cardiovasc Interv 2015; 87:757-61. [DOI: 10.1002/ccd.26310] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 09/07/2015] [Accepted: 10/09/2015] [Indexed: 11/10/2022]
Affiliation(s)
- Swati Choudhry
- Division of Pediatric Cardiology, Department of Pediatrics; St. Louis Children's Hospital, Washington University School of Medicine; St. Louis Missouri
| | - David Balzer
- Division of Pediatric Cardiology, Department of Pediatrics; St. Louis Children's Hospital, Washington University School of Medicine; St. Louis Missouri
| | - Joshua Murphy
- Division of Pediatric Cardiology, Department of Pediatrics; St. Louis Children's Hospital, Washington University School of Medicine; St. Louis Missouri
| | - Ramzi Nicolas
- Division of Pediatric Cardiology, Department of Pediatrics; St. Louis Children's Hospital, Washington University School of Medicine; St. Louis Missouri
| | - Shabana Shahanavaz
- Division of Pediatric Cardiology, Department of Pediatrics; St. Louis Children's Hospital, Washington University School of Medicine; St. Louis Missouri
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Abstract
Neonatal aortic stenosis is a complex and heterogeneous condition, defined as left ventricular outflow tract obstruction at valvular level, presenting and often requiring treatment in the first month of life. Initial presentation may be catastrophic, necessitating hemodynamic, respiratory and metabolic resuscitation. Subsequent management is focused on maintaining systemic blood flow, either via a univentricular Norwood palliation or a biventricular route, in which the effective aortic valve area is increased by balloon dilation or surgical valvotomy. In infants with aortic annular hypoplasia but adequately sized left ventricle, the Ross-Konno procedure is also an attractive option. Outcomes after biventricular management have improved in recent years as a consequence of better patient selection, perioperative management and advances in catheter technology. Exciting new developments are likely to significantly modify the natural history of this disorder, including fetal intervention for the salvage of the hypoplastic left ventricle; 3D echocardiography providing better definition of valve morphology and aiding patient selection for a surgical or catheter-based intervention; and new transcutaneous approaches, such as duel beam echo, to perforate the valve.
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Affiliation(s)
- Nigel E Drury
- Wessex Cardiothoracic Centre, Southampton University Hospitals NHS Trust, Southampton General Hospital, Southampton, Hampshire, UK.
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Catheter Intervention for Congenital Heart Disease at Risk of Circulatory Failure. Can J Cardiol 2013; 29:786-95. [DOI: 10.1016/j.cjca.2013.04.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Revised: 04/17/2013] [Accepted: 04/17/2013] [Indexed: 11/24/2022] Open
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Neonatal Interventions for Left-Sided Obstructive Lesions: Alternatives to Surgery. Interv Cardiol Clin 2013; 2:11-22. [PMID: 28581977 DOI: 10.1016/j.iccl.2012.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Percutaneous neonatal cardiac interventions are effective in management strategies. Aortic valve dilation has become a first line therapy with excellent outcomes and low morbidity equivalent to surgery. Percutaneous intervention for coarctation of the aorta can safely postpone surgical intervention in small unwell neonates, allowing stabilization and growth. Stent implantation can provide a stable and predictable relief of obstruction; however, care should be taken to implant stents so that they can be removed subsequently. As experience increases, the role of percutaneous techniques in the management of high-risk neonates with coarctation of the aorta will become better defined and improve the outcomes.
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Al Marshafawy H, Al Sawah GA, Hafez M, Matter M, El Gamal A, Sheishaa AG, El Kair MA. Balloon Valvuloplasty of Aortic Valve Stenosis in Childhood: Midterm Results in a Children's Hospital, Mansoura University, Egypt. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2012; 6:57-64. [PMID: 22412302 PMCID: PMC3296496 DOI: 10.4137/cmc.s8602] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background: Balloon valvuloplasty was established as an alternative to surgery for treatment of aortic valve stenosis in childhood. Acute complications after balloon dilatation including aortic insufficiency or early death were described. Aim of Work: To analyze early outcome and midterm results of balloon aortic valvuloplasty (BAV) in Children’s Hospital, Mansoura University, Egypt. Subjects and Methods: Between April 2005–June 2008, all consecutive patients of age <18 years treated for aortic valve stenosis (AVS) with BAV were analyzed retrospectively. The study included 21 patients; 17 males, and 4 females. Their age ranged from the neonatal period to 10 years (mean age 5.6 ± 3.7 years). Patients with gradient ≥50 mmHg and aortic valve insufficiency (AI) up to grade I were included. All patients had isolated aortic valve stenosis except 3 patients (14.3%) had associated aortic coarctation. Six patients (28.6%) had bicuspid aortic valve. All patients had normal myocardial function except one (4.8%) had FS 15%. The duration of follow up was (mean ± SD: 18.5 ± 11.7 months). Results: Femoral artery approach was used in 20 patients (95.2%) and carotid artery in one neonate (4.8%). Balloon/annulus ratio was 0.83 ± 0.04. Significant reduction in pressure gradient was achieved (mean 66.7 ± 9.8 mmHg to 20.65 ± 2.99 mmHg) (P < 0.001). Nine patients (42.8%) developed grade I AI, 2 patients (9.5%) developed grade II AI and 1 patient (4.8%) developed grade III AI. Two early deaths (9.5%); one died due to heart failure caused by grade IV AI and a neonate died because of severely compromised LV function. One patient (4.8%) had femoral artery occlusion necessitating anticoagulation. Patients remained free from re-intervention during follow up. Conclusion: Balloon valvuloplasty of aortic valve stenosis significantly reduces gradient with low morbidity and mortality in children.
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Affiliation(s)
- Dietmar Schranz
- Pediatric Heart Center Justus Liebig University, Giessen, Germany
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Rossi RI, Manica JLL, Petraco R, Scott M, Piazza L, Machado PM. Balloon aortic valvuloplasty for congenital aortic stenosis using the femoral and the carotid artery approach: a 16-year experience from a single center. Catheter Cardiovasc Interv 2011; 78:84-90. [PMID: 21234922 DOI: 10.1002/ccd.22938] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Accepted: 12/11/2010] [Indexed: 11/09/2022]
Abstract
OBJECTIVES The aim of this article is to report a 16-year experience with percutaneous balloon aortic valvuloplasty (BAVP) in newborns and young infants up to 3 months of age in a tertiary care cardiac reference center in a developing country and to determine its value in postponing open heart surgery. BACKGROUND Congenital aortic stenosis (AS) is a potentially life threatening disorder. BAVP and surgical procedures have similar short and medium-term efficacy. METHODS Thirty-one consecutive newborns and young infants with critical AS underwent BAVP in our department from 1991 to 2007. Mean patient age at time of the procedure was 22 days (range 2-92 days) and mean weight was 3,310 g (1,840-4,400 g). RESULTS There was a significant reduction in mean Doppler-derived peak gradient across the aortic valve immediately after the procedure (75.1 ± 22 versus 32.2 ± 13.02, P < 0.001), and this finding was maintained throughout follow-up. Since 2003, when the carotid approach became routine practice, no major vascular complications were observed. Mean time of follow-up was 81 months (5 days-196 months) with only two deaths (7.4%). Only 24% patients required surgical reintervention on the aortic valve during follow-up. Survival free from aortic valve surgery was 80% at 24 months, 66% at 63 months, and 50% at 80 months. CONCLUSION Percutaneous intervention for relief of critical aortic stenosis in newborns in a tertiary center of a developing country is safe and has excellent short and long-term results comparable to other centers throughout the world.
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Affiliation(s)
- Raul I Rossi
- Hemodynamic Service, Instituto de Cardiologia do Rio Grande do Sul, Fundação Universitária de Cardiologia, Brasil.
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Koestenberger M, Beitzke A, Knez I, Raith W, Nagel B. Transcarotid balloon valvuloplasty for critical aortic stenosis in a premature neonate weighing 1100 g. Pediatr Int 2010; 52:e158-60. [PMID: 20723117 DOI: 10.1111/j.1442-200x.2010.03065.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Davenport JJ, Lam L, Whalen-Glass R, Nykanen DG, Burke RP, Hannan R, Zahn EM. The successful use of alternative routes of vascular access for performing pediatric interventional cardiac catheterization. Catheter Cardiovasc Interv 2008; 72:392-398. [DOI: 10.1002/ccd.21621] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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20
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Kim DW, Raviele AA, Vincent RN. Use of a 3 French system for balloon aortic valvuloplasty in infants. Catheter Cardiovasc Interv 2006; 66:254-7. [PMID: 16127701 DOI: 10.1002/ccd.20424] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
For infants with valvar aortic stenosis, balloon aortic valvuloplasty has supplanted surgical valvotomy as the initial treatment of choice at most institutions. Technological innovations have resulted in further miniaturization of balloon dilation catheters, allowing this procedure to be performed through smaller sheath sizes. Currently, the Tyshak-Mini balloon dilation catheter (B. Braun Medical) allows passage of up to an 8 mm dilation balloon catheter through a 3 Fr hemostatic sheath. The efficacy of this system for the treatment of valvar aortic stenosis in infants less than 6 months of age was evaluated in 20 patients undergoing 22 procedures. Mean age at the time of intervention was 26 +/- 46 days. Mean transvalvar gradient was 76 +/- 22 mm Hg prior to balloon dilation. Following balloon valvuloplasty, residual gradient was 26 +/- 12 mm Hg, reflecting a mean change in peak-to-peak gradient of 49 +/- 19 mm Hg. Postintervention increase in aortic insufficiency was one grade or less in 19/22 procedures, two grades in 2 procedures, and three grades in 1 procedure. There were no significant vascular complications reported immediately following the procedure. Repeat valvuloplasty was performed in three patients in which the 3 Fr system was used in two patients. The 3 Fr system for balloon aortic valvuloplasty in infants less than 6 months of age is effective and safe.
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Affiliation(s)
- Dennis W Kim
- Department of Pediatrics, Emory University Medical School, Sibley Heart Center Cardiology, Children's Healthcare of Atlanta, Atlanta, Georgia 30329, USA.
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Abstract
Therapy for severe aortic valve stenosis in infants and children has shifted from the operating suite to the catheterization laboratory and even to the bedside as a direct result of improved catheter technology, evolving techniques, and comparable results to conventional surgical intervention. This review summarizes the brief history pertaining to the various techniques and outcomes of transcatheter balloon valvuloplasty in infants and children with critical or severe aortic valve stenosis.
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Affiliation(s)
- Howard S Weber
- Division of Pediatric Cardiology, Penn State University Children's Hospital, Hershey, Pennsylvania, USA.
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Sehirli US, Yalin A, Tulay CM, Cakmak YO, Gürdal E. The diameters of common carotid artery and its branches in newborns. Surg Radiol Anat 2005; 27:292-6. [PMID: 16237488 DOI: 10.1007/s00276-005-0322-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2004] [Accepted: 01/13/2005] [Indexed: 11/29/2022]
Abstract
The common carotid artery (CCA) bifurcation is of clinical importance due to its vascular access site for intravascular intervention. Additionally, it is also one of the most common sites of atherosclerotic plaque formation. There are numerous studies on the diameters of CCA, internal carotid artery (ICA), and external carotid artery (ECA) in adults, but few studies on newborns. Cadaver and angiographic studies have shown dimensional variations in the carotid arteries within/between individuals and also between different sexes. It is well known that the initial lesions of atherosclerosis begin very early in fetal life. Therefore, it is important to know the anatomical details of the CCA and its branches. In the present study, the neck regions of 20 (11 males and 9 females) fixed newborn cadavers were dissected. The CCAs were cut below the bulb of the carotid bifurcation further; ICA and ECA were cut above the bulb of the carotid bifurcation. The internal diameters of the CCA, ICA, and ECA were measured using a light microscopy. ECA/CCA, ICA/CCA, ICA/ECA ratios, and outflow to inflow area ratio were calculated. The mean outflow to inflow area ratio was 1.14+/-0.28. Our results highly correlated with the defined optimal ratio (1.15). The ECA/CCA, ICA/CCA, and ICA/ECA ratios were 0.78+/-0.12, 0.71+/-0.13, and 0.93+/-0.16, respectively. There were no statistically significant differences between male and female and also between right and left sides. These findings are of importance in understanding the anatomy of carotid artery during newborn period.
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Affiliation(s)
- Umit S Sehirli
- Department of Anatomy, Marmara University School of Medicine, 34668 Haydarpasa, Istanbul, Turkey.
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Nykanen DG, Zahn EM. Transcatheter techniques in the management of perioperative vascular obstruction. Catheter Cardiovasc Interv 2005; 66:573-9. [PMID: 16270363 DOI: 10.1002/ccd.20554] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The role of transcatheter intervention for the treatment of vascular obstruction is well documented in the preoperative or remote postoperative settings. More recently, the roles of angioplasty and stent implantation have been advocated as intraoperative and immediate postoperative strategies. As one considers the inherent advantages in this cooperative approach to congenital heart disease, the development of a truly hybrid interventional suite seems imperative.
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Affiliation(s)
- David G Nykanen
- Congenital Heart Institute, Miami Children's Hospital, Miami, Florida, USA.
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Hussain A, al Faraidi Y, Abdulhamed J, Bacha EA, Hammer GB, Feinstein JB. Transesophageal echocardiography-guided transventricular balloon dilation of congenital critical aortic stenosis in the neonate and young infant. J Cardiothorac Vasc Anesth 2002; 16:766-72. [PMID: 12486662 DOI: 10.1053/jcan.2002.128435] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Arif Hussain
- Department of Cardiac Anesthesia, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia.
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Peuster M, Fink C, Schoof S, Von Schnakenburg C, Hausdorf G. Anterograde balloon valvuloplasty for the treatment of neonatal critical valvar aortic stenosis. Catheter Cardiovasc Interv 2002; 56:516-20; discussion 521. [PMID: 12124964 DOI: 10.1002/ccd.10259] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
We report our experience with anterograde balloon valvuloplasty in 17 neonates treated between November 1996 and June 2001 for critical aortic stenosis. Patients with hypoplastic left heart syndrome were excluded. Anterograde balloon valvoplasty of the aortic valve was possible in all 17 patients. The mean peak systolic gradient prior to cardiac catheterization was 73 mm Hg (range, 30-117 mm Hg) and decreased to 37 mm Hg (range, 21-60 mm Hg) after the dilation. Aortic regurgitation after balloon valvoplasty was absent or mild in 14/17 patients, moderate in 2 patients, and severe in 1 patient. There was no mortality or echocardiographic evidence for aortic cusp perforation or mitral regurgitation associated with the procedure. Redilation was necessary in 3/17 patients. Two patients are awaiting elective Ross operation. One patient with endocardial fibroelastosis died at 11 months of age. Anterograde balloon valvoplasty can be safely and effectively performed to palliate neonates with critical aortic valve stenosis.
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Affiliation(s)
- Matthias Peuster
- Department of Pediatric Cardiology and Pediatric Intensive Care, Georg-August University, Göttingen, Germany.
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Lofland GK, McCrindle BW, Williams WG, Blackstone EH, Tchervenkov CI, Sittiwangkul R, Jonas RA. Critical aortic stenosis in the neonate: a multi-institutional study of management, outcomes, and risk factors. Congenital Heart Surgeons Society. J Thorac Cardiovasc Surg 2001; 121:10-27. [PMID: 11135156 DOI: 10.1067/mtc.2001.111207] [Citation(s) in RCA: 157] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES We sought to determine factors that would predict whether a biventricular repair or Norwood procedure pathway would give the best survival in neonates with critical aortic stenosis. METHODS Survival and risk factors were determined with parametric time-dependent event analysis for patients undergoing either the Norwood procedure or biventricular repair, and predicted optimal pathway and survival benefit were derived from multivariable linear regression. RESULTS From 1994 to 2000, 320 neonates with critical left ventricular outflow obstruction were entered into a prospective multi-institutional study. Patients who died without intervention (n = 19) and those with primary cardiac transplantation (n = 6) were excluded. An initial intended biventricular repair pathway was indicated in 116 patients, with survival of 70% at 5 years. An initial Norwood procedure was performed in 179 patients, with survival of 60% at 5 years. Using predictions from separate multivariable hazard models for survival with each of the 2 pathways, we determined predicted optimal pathway and survival benefit for each patient. Significant independent factors associated with greater survival benefit for the Norwood procedure versus biventricular repair included younger age at entry, lower z-score of the aortic valve and left ventricular length, higher grade of endocardial fibroelastosis, absence of important tricuspid regurgitation, and larger ascending aorta. Predicted survival benefit favored the Norwood procedure in 50% of patients who had biventricular repair, and it favored biventricular repair in 20% of patients who had the Norwood procedure. CONCLUSIONS Morphologic and functional factors can be used to predict optimal pathway and survival benefit in neonates with critical left ventricular outflow obstruction.
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Affiliation(s)
- G K Lofland
- Section of Cardiac Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA.
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Abstract
We present a 1,600 g infant who underwent successful balloon aortic valvuloplasty from the right carotid artery approach. A simple technique to facilitate access to the left ventricle and expedite the procedure is described. Issues unique to performing balloon aortic valvuloplasty on such a small child are discussed.
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Affiliation(s)
- T E Fagan
- Department of Pediatrics, Division of Cardiology, Children's Hospital of Iowa, University of Iowa Hospitals and Clinics, Iowa City 52242, USA
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Robinson BV, Brzezinska-Rajszys G, Weber HS, Ksiazyk J, Fricker FJ, Fischer DR, Ettedgui JA. Balloon aortic valvotomy through a carotid cutdown in infants with severe aortic stenosis: results of the multi-centric registry. Cardiol Young 2000; 10:225-32. [PMID: 10824903 DOI: 10.1017/s104795110000915x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES The purpose of this study was to evaluate the short and intermediate term results of infants who have undergone balloon aortic valvotomy from the carotid arterial approach, and to identify risk factors in those infants who had a poor outcome. METHODS Between 1988 and 1999, balloon aortic valvotomy was attempted at four centres in 95 infants with severe aortic stenosis. Echocardiographic and hemodynamic data, and outcome, were analysed retrospectively. RESULTS Valvotomy was accomplished in 92 of the 95 infants, with a median age of 5 days, a range from 0 to 191 days, and weighing 3.4 kg, with a range from 1.0 to 6.5 kg. Major procedural complications occurred in 10 infants. Post-procedural aortic regurgitation was severe in 5 patients. There were 13 early deaths, and 4 late deaths. The period of mean follow-up has been 2.1 years, with a range from 0 to 9.3 years. The actuarial survival at 3 years was 76 +/- 6%. Further interventions were needed in 19 patients, giving a 3-year freedom from reintervention of 67 +/- 6%. The 51 infants who were duct-dependent were further analyzed, and found to have a higher mortality (38%) compared to those infants not dependent on the arterial duct (5%). Risk factors for a poor outcome in the duct-dependent infants were mitral stenosis (p<0.005), a left ventricle which did not form the cardiac apex (p<0.005), and an aortic valve with a diameter of less than 6 mm (p<0.05). CONCLUSIONS This multi-centric registry shows good results in the intermediate term for treating infants with severe aortic valvar stenosis with balloon valvotomy through a carotid arterial cutdown. Infants dependent on prostaglandin had a worse outcome, especially if they had any of the identified risk factors.
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Strife JL, Sze RW. Radiographic evaluation of the neonate with congenital heart disease. Radiol Clin North Am 1999; 37:1093-107, vi. [PMID: 10546668 DOI: 10.1016/s0033-8389(05)70251-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Remarkable advances in pediatric cardiology have been spurred by the explosion of technologies both in interventional and surgical techniques and the ability to manipulate the genome of experimental animals. After a brief discussion concerning the striking advances in the molecular understanding of congenital heart disease, this article focuses on clues to the diagnosis of congenital heart disease and on chest radiography and common, specific lesions of the neonate such as hypoplastic left heart, transposition of the great vessels, and severe tetralogy of Fallot. The impact of treatment protocols involving interventional cardiology in the neonate also are discussed.
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Affiliation(s)
- J L Strife
- Department of Radiology, Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Abstract
Over the past decade, transcatheter interventions have become increasingly important in the treatment of patients with congenital heart lesions. These procedures may be broadly grouped as dilations (e.g., septostomy, valvuloplasty, angioplasty, and endovascular stenting) or as closures (e.g., vascular embolization and device closure of defects). Balloon valvuloplasty has become the treatment of choice for patients in all age groups with simple valvar pulmonic stenosis and, although not curative, seems at least comparable to surgery for congenital aortic stenosis in newborns to young adults. Balloon angioplasty is successfully applied to a wide range of aortic, pulmonary artery, and venous stenoses. Stents are useful in dilating lesions of which the intrinsic elasticity results in vessel recoil after balloon dilation alone. Catheter-delivered coils are used to embolize a wide range of arterial, venous, and prosthetic vascular connections. Although some devices remain investigational, they have been successfully used for closure of many arterial ducts and atrial and ventricular septal defects. In the therapy for patients with complex CHD, best results may be achieved by combining cardiac surgery with interventional catheterization. The cooperation among interventional cardiologists and cardiac surgeons was highlighted in a report of an algorithm to manage patients with tetralogy of Fallot or pulmonary atresia with diminutive pulmonary arteries, involving balloon dilation, coil embolization of collaterals, and intraoperative stent placement. In this setting, well-planned catheterization procedures have an important role in reducing the overall number of procedures that patients may require over a lifetime, with improved outcomes.
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Affiliation(s)
- J Pihkala
- Division of Cardiology, Hospital for Sick Children, University of Toronto School of Medicine, Ontario, Canada
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Rao PS, Jureidini SB. Transumbilical venous, anterograde, snare-assisted balloon aortic valvuloplasty in a neonate with critical aortic stenosis. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1998; 45:144-8. [PMID: 9786391 DOI: 10.1002/(sici)1097-0304(199810)45:2<144::aid-ccd8>3.0.co;2-c] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Balloon aortic valvuloplasty is an acceptable alternative to surgery in the treatment of critical aortic stenosis in the neonate. In this report, we describe a 1-day-old infant with critical aortic stenosis who was successfully treated with an anterograde, transumbilical venous, snare-assisted balloon aortic valvuloplasty. Based on this experience, it is suggested that the anterograde transumbilical venous approach is a feasible and effective alternative to retrograde femoral, carotid, or umbilical arterial and transfemoral venous anterograde routes for performing balloon aortic valvuloplasty in the neonate.
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Affiliation(s)
- P S Rao
- Department of Pediatrics, Saint Louis University School of Medicine/Cardinal Glennon Children's Hospital, Missouri 63104-1095, USA.
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Hijazi ZM. All roads lead to Rome: which is the easiest and safest? Critical aortic valve stenosis in the neonate. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1998; 45:149-50. [PMID: 9786392 DOI: 10.1002/(sici)1097-0304(199810)45:2<149::aid-ccd9>3.0.co;2-c] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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