Hybrid intraoperative pulmonary artery stent placement for congenital heart disease

Hybrid Interventions in Congenital Heart Disease: A Review of Current Practice and Rationale for Use

BACKGROUND

Hybrid interventions have become a common option in the management for a variety of patients with congenital heart disease. In this review, we discuss the data that have driven decision making about hybrid interventions to date.

METHODS

The existing literature on various hybrid approaches was reviewed and summarized. In addition, the key tenants to creating a successful hybrid program within a congenital heart center are elucidated.

RESULTS

Hybrid strategies for single-ventricle patients, pulmonary atresia with intact ventricular septum, branch pulmonary artery stenosis, and muscular ventricular septal defect closure have important benefits and limitations compared with traditional approaches.

CONCLUSION

A growing body of evidence supports the use of hybrid interventions in congenital heart disease. But important questions remain regarding improved survival and other long-term outcomes, such as neurocognition, that might impact widespread adoption as a primary treatment strategy.

Pulmonary Artery Stenosis in Tetralogy of Fallot

Tetralogy of Fallot (TOF) is the most common cyanotic congenital cardiac defect. The survival rate after primary complete repair is high (98-100%); however, pulmonary artery stenosis (PAS) is not uncommon after TOF repair, and severe PAS aggravates pulmonary regurgitation, resulting in right ventricle dilation, ventricular arrhythmia, and possibly death. PAS in TOF can be congenital due to hypoplasia or coarctation or can be acquired secondary to a surgical procedure. The latter may be caused by an exogenous conduit implant, compression from the adjacent enlarged ascending aorta, or outflow tract dilation after transannular patch repair. PAS can also be caused by the pulmonary artery plasty strategy itself. Here, the intrinsic mechanisms underlying PAS and pulmonary artery plasty techniques and strategies are reviewed to provide guidance for surgeons.

Hybrid Procedures. Opening Doors for Surgeon and Cardiologist Close Collaboration

Background: Collaboration between cardiac surgeons and cardiologists can offer interventions that each specialist may not be able to offer on their own. This type of collaboration has been demonstrated with the hybrid Stage I in patients with hypoplastic heart syndrome. Since that time, a hybrid approach to cardiac interventions has been expanded to an incredible variety of potential indications. Methods: Seventy-one patients were scheduled for a hybrid procedure along 8 years. This was defined as close collaboration between surgeon and cardiologist working together in the same room, either cath-lab (27 patients) or theater (44 patients). Results: Six groups were arbitrarily defined. A: vascular cut-down in the cath-lab (27 neonates); B: bilateral banding (plus ductal stent) in hypoplastic left heart syndrome or alike (15 children); C: perventricular closure of muscular ventricular septal defect (10 cases); D: balloon/stenting of pulmonary branches along with major surgical procedure (12 kids); E: surgical implantation of Melody valve (six patients) and others (F, one case). Two complications were recorded: left ventricular free wall puncture and previous conduit tearing. Both drawbacks were successfully sort out under cardiopulmonary by-pass. Conclusion: Surgeon and cardiologist partnership can succeed where their isolated endeavors are not enough. Hybrid procedures keep on spreading, overcoming initial expectations. As a bridge to biventricular repair or transplant, bilateral banding plus ductal stent sounds interesting. Novel indications can be classified into different groups. Hybrid procedures are not complication-free.

Treatment approach to unilateral branch pulmonary artery stenosis

Unilateral proximal pulmonary artery stenosis is often seen in the setting of postoperative congenital heart disease. Accurate assessment of the hemodynamic significance of such a lesion is important so as to determine "When to intervene?" A thorough evaluation should include symptom assessment, anatomical assessment through detailed imaging, functional assessment using differential pulmonary blood flow measurement and cardiopulmonary exercise testing. Symptoms of exertional dyspnea or intolerance, decreased pulmonary blood flow to stenosed lung, and abnormal exertional performance would be factors to pursue therapy in the setting of significant anatomical narrowing. Safe and effective therapy can be offered through transcatheter or surgical techniques and has been shown to improve exertional performance.

Hybrid Pulmonary Vein Stenting in Infants with Refractory to Surgical Pulmonary Vein Stenosis Repair

Pulmonary vein stenosis (PVS) is still a frustrating disease with extremely high mortality, especially in children with multiple severe PVS. Hybrid pulmonary vein stenting (HPVS) is a rescue treatment for recurrent and malignant PVS. The aim of this study is to share our successful experience with intraoperative HPVS for recurrent PVS after total anomalous pulmonary venous connection (TAPVC) repair in infant. Six patients were identified between 2013 and January 2018, who were diagnosed with recurrent PVS and underwent HPVS in the operating room. The mean age at the time of the HPVS was 10.3 ± 2.7 months (range 7-14 months) and the mean body weight was 7.9 ± 2.6 kg (range 4.1-10.5 kg). Prior pulmonary vein surgery had been performed on average 2.7 times (range 2-3) in all patients. We used a bare-metal stent (BMS) of 6-8 mm diameter in 15 veins of five patients and a drug-eluting coronary stent (DES) in two veins of one patient. All patients had undergone several elective further pulmonary vein in-stent balloon dilatations or another stent insertion after HPVS. Over a mean follow-up of 17.3 ± 13.7 months (range 6-44 months), all patients maintained patency of stents although two patients died due to respiratory failure not associated with PVS. HPVS is a useful treatment modality for recurrent PVS patient that could save the life and achieve longer freedom from restenosis than repetitive surgical pulmonary vein widening only. Even though the prognosis of severe multiple PVS is very poor, planned HPVS could be a good palliation in this patients group.

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

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

Utilizing Hybrid Techniques to Maximize Clinical Outcomes in Congenital Heart Disease

PURPOSE OF REVIEW

The past couple of decades have brought tremendous advances to the field of pediatric and adult congenital cardiology. Recent collaborations between interventional cardiologists and cardiac surgeons have sparked novel innovative hybrid procedures that provide potentially safer, faster, and less invasive alternatives to the management of many diseases. This paper will review the most recent advances in hybrid interventions in the field of pediatric and adult congenital cardiology.

RECENT FINDINGS

The earliest experiences with hybrid interventions included intraoperative stenting of pulmonary arteries and perventricular device closure of ventricular septal defects. Newer hybrid interventions have focused on a hybrid approach to stage 1 palliation for infants with hypoplastic left heart syndrome and hybrid approaches to transcatheter pulmonary valve replacement in patients of all ages. Hybrid approaches to complex congenital heart disease are important in the management of congenital heart disease offering a less invasive approach, and novel hybrid procedures will likely be a focus of future research in this field.

Protective effect of diethylcarbamazine inhibits NF-κB activation in isoproterenol-induced acute myocardial infarction rat model through the PARP pathway

The present study investigated the protective effect of diethylcarbamazine in inhibiting nuclear factor (NF)-κB activation in isoproterenol‑induced acute myocardial infarction (AMI) rats through the poly ADP ribose polymerase (PARP) pathway. Male albino Wistar rats were injected subcutaneously with isoproterenol (100 mg/kg/day) for 2 days to induce an AMI model. Diethylcarbamazine (50 mg/kg) was administered by gavage for 12 days prior to the isoproterenol-induced AMI. It was noted that diethylcarbamazine significantly inhibited AMI‑induced casein kinase and lactate dehydrogenase levels, and reduced the AMI‑induced wet heart weight to body weight ratio in AMI rats. Diethylcarbamazine treatment significantly weakened reactive oxygen species production and reduced the levels of tumor necrosis factor (TNF)‑α, interleukin‑6 and NF‑κB/p65 in AMI rats. Western blotting demonstrated that diethylcarbamazine significantly suppressed the AMI‑induced inducible nitric oxide synthase (iNOS), transforming growth factor (TGF)‑β1, cyclooxygenase‑2 (COX‑2) and PARP protein expression in AMI rats. The results demonstrated that the protective effect of diethylcarbamazine inhibited isoproterenol‑induced AMI through the suppression of inflammation, iNOS, TGF‑β1, COX‑2 and the PARP pathway, and revealed the clinical potential of diethylcarbamazine for therapeutic and clinical applications.

Twenty years of experience with intraoperative pulmonary artery stenting

OBJECTIVES

To describe our 20-year experience with intraoperative pulmonary artery (PA) stent placement and evaluate long-term patient outcomes, specifically the need and risk factors for reintervention.

BACKGROUND

Intraoperative PA stent placement is an alternative to surgical patch arterioplasty and percutaneous angioplasty or stent placement to treat branch PA stenosis.

METHODS

We performed a retrospective review of all intraoperative PA stents placed at our institution from 1994-2013. Patient and stent characteristics and outcome data were collected. Risk factors associated with reintervention were identified using univariate cox regression analysis.

RESULTS

Eighty-one PA stents were placed in 68 patients. The procedural complication rate was 4.4%. During a median follow-up period of 6 years (interquartile range [IQR] 0.9-12.7), 30 patients (44%) underwent reintervention on the stented PA with a median time to first reintervention of 2.6 years (IQR 0.7-4.4 years). The first reintervention was surgical in 30% and catheter-based in 70%. Risk factors for reintervention included age < 18 months (Hazard ratio [HR] 2.97, P = 0.005) and body surface area < 0.47 m² (HR 3.20, P = 0.003) at the time of stent implantation, and the presence of multiple aortopulmonary collaterals in patients with tetralogy of Fallot (HR 4.61, P = 0.003).

CONCLUSIONS

Intraoperative PA stent implantation is a safe and effective alternative to percutaneous stent implantation and offers several advantages, including the ability to implant adult-size stents in small patients while avoiding injury to peripheral vessels, to position stents to facilitate future percutaneous stent redilation, and to access the PAs directly, which eliminates radiation exposure. © 2017 Wiley Periodicals, Inc.

Hybrid Pulmonary Artery Stenting at the Bidirectional Glenn or Fontan Operation in Patients With Single Ventricle Congenital Heart Disease

BACKGROUND

Stenosis of the retroaortic pulmonary artery is common in patients with single ventricle heart disease. Intraoperative hybrid stenting at the bidirectional Glenn or Fontan operation can treat this lesion and avoid a complex surgical arterioplasty.

METHODS

Patients who underwent intraoperative stent implantation to the retroaortic pulmonary artery during the bidirectional Glenn or Fontan operation at our center between January 2005 and July 2014 were retrospectively identified.

RESULTS

Thirteen patients were included with a median weight of 8 kg (5.6-14.4 kg) and age of 6 months (4 months-3.8 years). All had undergone Norwood operation, and eight (62%) had hypoplastic left heart syndrome. Eight (62%) underwent stent placement during bidirectional Glenn and five (38%) during Fontan operation. Ten patients had one stent placed, and three had two overlapping stents. The median diameter of the stenotic vessel was 3 mm (2.0-5.5 mm) and diameter of the balloon used for stent expansion was 7 mm (5-10 mm). Two complications occurred including pulmonary hemorrhage from presumed wire perforation and left main stem bronchus compression requiring stent removal. No patient required stent intervention in the postoperative period, and all were discharged from the hospital. At a median follow-up of 1.3 years (2 months-7.1 years), six patients underwent interval dilation to account for somatic growth.

CONCLUSIONS

Hybrid stenting of the retroaortic pulmonary artery at the bidirectional Glenn or Fontan operation is an effective treatment of pulmonary artery stenosis and prevents the need for a complex surgical arterioplasty.

Sutureless Patch Angioplasty for Postoperative Pulmonary Artery Stenosis in Congenital Cardiac Surgeries

BACKGROUND

Reconstruction of branch pulmonary arteries (PAs) can be demanding in redo congenital cardiac surgeries. Sutureless patch angioplasty could be a useful method to solve this problem, and we evaluated the feasibility of sutureless patch angioplasty for postoperative PA stenosis in patients who underwent congenital cardiac surgery.

METHODS

We retrospectively reviewed 28 patients (19 males and 9 females) who underwent sutureless patch angioplasty for postoperative PA stenosis between November 2004 and April 2015. The median age was 7.3 months (range, 4.3 to 54.7), and the median weight was 7.2 kg (range, 5.3 to 12.2 kg). Right PA angioplasty was performed in 5, left PA angioplasty in 10, and both sides in 13 patients. The most common original diagnosis was hypoplastic left heart syndrome (n = 18 of 28, 64.3%). Concomitant surgeries were the bidirectional cavopulmonary shunt in 24 patients, the Fontan operation in 3, and the Rastelli operation in 1 patient.

RESULTS

No operative death occurred. However, 2 late deaths were recorded, and both were unrelated to PA angioplasty. Mean follow-up duration was 60.9 ± 33.1 months. None of the patients had postoperative bleeding or thrombotic occlusion. No reoperation for PA restenosis was performed, and only 1 patient (3.6%) had a PA balloon angioplasty with a good result 12.9 months after the operation. Echocardiography or computed tomography angiography at the recent follow-up showed good branch PAs in all patients.

CONCLUSIONS

Sutureless patch angioplasty for postoperative PA stenosis could simplify PA angioplasty, and be a safe and effective method for PA reconstruction in patients who undergo congenital cardiac surgery.

Alternative hybrid and staged interventional treatment of congenital heart defects in critically ill children with complex and non-cardiac problems

INTRODUCTION

An individually designed strategy of comprehensive alternative hybrid and staged interventional treatment (AHASIT) can be a reasonable alternative to conventional treatment of congenital heart defects, reduce the risk of cardiac surgery or interventions performed separately, and give an additional chance for critically ill children.

AIM

To present our experience and the results of AHASIT of severely ill or borderline children referred for surgery with the diagnosis of congenital heart defects.

MATERIAL AND METHODS

A group of 22 patients with complex cardiac and non-cardiac pathologies was retrospectively selected and analyzed. An individual preoperative severity scale was established for AHASIT patients, with one point for each of the following preoperative complications: prematurity, low body weight, cyanosis, intolerance to drug therapy, failed interventional treatment prior to admission, mechanical ventilation prior to the procedure, chronic respiratory failure and non-cardiac, mainly congenital malformations (congenital diaphragmatic hernia, lower extremity agenesia, duodenal atresia) and acquired problems (newborn edema, necrotic enterocolitis, intracranial hemorrhage, liver and renal failure, anemia and thrombocytopenia, infections or colonization with drug-resistant pathogens).

RESULTS

The analysis of the postoperative course showed that the patients with 5 AHASIT points or more had a more complicated postoperative course than the patients with 1 to 4 AHASIT points.

CONCLUSIONS

The AHASIT of pediatric congenital heart defects with complex and non-cardiac problems appeared to be an attractive option for selected severely ill patients. The strategy was found to be effective in selected neonates suffering from complex and accompanying non-cardiac pathologies, with positive final results of both cardiological intervention and planned surgery.

Hybrid stent implantation to the pulmonary artery from peripheral access via recruited systemic-pulmonary shunt

The implantation of vascular stents in patients with low body weight and difficult anatomy of the stenosis needs individual cannulation strategy or a hybrid approach. We present a successful balloon angioplasty with direct stent implantation to severe ostial stenosis of the left pulmonary artery to xenograft anastomosis (LPA) in a 6-year-old boy late after surgical correction of pulmonary atresia with ventricular septal defect. Peripheral approach to LPA was possible after surgical rethoracotomy and the recruitment of a left Blalock-Taussig (BT) shunt stump. The cooperation of cardiovascular intervention with surgical approach appears a safe strategy for borderline patients referred for staged treatment of complex congenital heart defects.

The future of transcatheter pulmonary valvulation

Percutaneous pulmonary valve implantation now has a key role in the setting of dysfunctional right ventricle-to-pulmonary artery conduits or failing bioprosthetic pulmonary valves. However, despite the excellent results obtained with the two devices available currently (the Melody(®) valve [Medtronic Inc., Minneapolis, MN, USA] and the Edwards SAPIEN(®) valve [Edwards Lifesciences, Irvine, CA, USA]), many patients eligible for pulmonary valve replacement remain unsuitable for percutaneous pulmonary valve implantation, mainly because of large native outflow tracts. Accordingly, one of the major challenges for the future is to expand percutaneous pulmonary valve implantation to a broader population of patients. Moving forward, there is important ongoing research that is intended to improve patient outcomes, expand percutaneous pulmonary valve implantation therapy and continue to reduce the number of open-heart surgeries in this population. In this review, we underline the limitations and issues associated with the devices available currently, and we focus on the development of new strategies (such as hybrid approaches or magnetic resonance-guided procedures), new devices (such as right ventricular outflow tract reducers or the novel Native Outflow Tract valved stent from Medtronic) and new technologies (such as tissue-engineered valves), which may help to take up these challenges and represent the future of transcatheter valve implantation.

Hybrid intraoperative pulmonary artery stenting in redo congenital cardiac surgeries

Objective

Reconstruction of branch pulmonary arteries (PAs) can be challenging in redo congenital heart surgeries. Treatment options like percutaneous stent implantation and surgical patch angioplasty may yield suboptimal results. We present our experience with hybrid intraoperative stenting which may be an effective alternative option.

Methods

We retrospectively analyzed data of all patients with PA stenosis who underwent intraoperative PA branch stenting in our institution between January 2011 and December 2012.

Results

Ten patients [6 females, median age 10 (1.4 to 37) years], underwent hybrid stenting of the PA. Primary cardiac diagnoses were pulmonary atresia with ventricular septal defect (VSD) in three patients, pulmonary atresia with intact ventricular septum in two, Tetralogy of Fallot (TOF) in one, Double outlet right ventricle (DORV) with pulmonary stenosis (PS) in one, complex single ventricle in two and VSD with bilateral branch PA stenosis in one patient. Concomitant surgeries were revision/reconstruction of RV-PA conduit in 4, Fontan completion in 4, repair of TOF with conduit placement in 1 and VSD closure in 1 patient. The left PA was stented in 7, the right in 2 and both in 1, with a total of 11 stents. There were no complications related to stent implantation. Two early postoperative deaths were unrelated to stent implantation. At mean follow-up period of 14.8 (12–26) months, stent position and patency were satisfactory in all survivors. None of them needed repeat dilatation or surgical reintervention.

Conclusion

Hybrid stenting of branch PA is a safe and effective option for PA reconstruction in redo cardiac surgeries. With meticulous planning, it can be safely performed without fluoroscopy.

Strategies for high-risk reoperations in congenital heart disease

Adults with congenital heart disease (CHD) is a rapidly growing group of patients, and part of this is owing to the improvement in survival for the vast majority of infants with CHD who have undergone successful surgery and live well into adult years. Residual or recurrent lesions may precipitate the need for reoperation and some patients require numerous surgical procedures or interventions over a lifetime. This article will review the surgical issues associated with reoperation in patients with CHD and discuss the different perioperative strategies that serve to decrease the risk of reoperation.

Surgical repair of pulmonary artery branches

Surgical repair of pulmonary artery (PA) branches encompasses many different clinical scenarios and technical challenges. The most common, such as bifurcation and central PA reconstruction, are described, as well as the challenges of complex and peripheral reconstruction.

Anti-platelet agents in pediatric cardiac practice

Pediatric patients with a variety of congenital and acquired cardiac conditions receive antithrombotic therapy. Many of the indications are empirical, and have either not been proven in controlled studies or are extrapolated from adult studies. This article reviews the current available literature regarding the use of anti-platelet drugs in the pediatric cardiac population.

Safe surgical strategy for extracardiac conduit replacement in common arterial trunk

Repair of common arterial trunk using an extracardiac right ventricular to pulmonary arterial conduit is the preferred method in most cardiac surgical centres. Reoperation is a fact of life for survivors of common arterial trunk and related cardiac lesions who have undergone such repairs. Long-term survivors may require periodic conduit revisions, with a potentially escalating technical difficulty and risk. Herein we present an analysis of the currently available choices for extracardiac conduits, and outline what we consider to be a safe and reliable surgical strategy for conduit revision.

Per-operative stent placement in the right pulmonary artery; a hybrid technique for the management of pulmonary artery branch stenosis at the time of pulmonary valve replacement in adult Fallot patients

After having undergone surgical correction at an early age, many patients with tetralogy of Fallot develop long-term complications including progressive pulmonary regurgitation and peripheral pulmonary stenosis. A high percentage of these patients need to undergo a second operation in their adolescence or early adulthood. If simultaneous treatment of both pulmonary regurgitation and peripheral pulmonary stenosis is warranted, a complete surgical approach has several disadvantages. We describe four cases of Fallot patients with severe pulmonary regurgitation and peripheral pulmonary stenosis who were treated using a hybrid approach involving surgical implantation of a pulmonary homograft and peroperative stenting of the pulmonary artery.

Transcatheter rehabilitation of pulmonary arteries

Pulmonary arterial stenoses commonly occur in patients with congenital heart disease. Indications for treatment are based around reduction of right ventricular hypertension and equalization of flow to each lung and its constituent segments. There are many treatment approaches for these lesions depending on the anatomy, location and the age of the patient. Although surgical reconstruction remains an option, it is technically challenging and in many cases, the results are disappointing. In the modern era, the majority of these patients are treated with transcatheter therapy, including balloon angioplasty, and increasingly, the use of intravascular stents. In this article, we discuss these issues and deal with both the technical approach to transcatheter therapy and up-to-date results.

Treatment of congenital heart disease: risk-reducing measures in young adults

Adults with congenital heart disease form a new and relatively young population, since surgical treatment of heart defects became available three to four decades ago. Owing to improved survival this population is steadily growing in number and age. Little is known regarding long-term survival; however, late complications occur frequently. During adulthood, almost half of the patients have one or more complication, such as endocarditis, stroke, systemic or pulmonary hypertension, aortic aneurysm or dissection and arrhythmias. Heart failure and sudden cardiac death are the main causes of death. Treatment of adults with congenital heart disease is aimed at the reduction of symptoms, but also at minimizing the risk and severity of late complications. In this article the most recent advances in the treatment of congenital heart disease will be discussed. The main focus of the article will be on pharmacological, interventional and surgical interventions that reduce the risk of heart failure, arrhythmias, vascular complications, pulmonary hypertension and endocarditis.

[Modern therapy of congenital heart defects]

Modern therapy of congenital heart defects consists of interventional and surgical procedures. The following report provides information about the most common congenital heart defects and the corresponding therapeutic options. Furthermore, the combined application of interventional and surgical procedures, so-called hybrid procedures, is described in detail as well as the latest developments in percutaneous valve replacement therapy.

Antiplatelet therapy in pediatric cardiovascular patients

Platelets play a critical role in normal physiologic processes such as hemostasis, wound healing, inflammation, and innate immunity. However, they also play a role in the pathologic process of thrombosis. Although antiplatelet therapy is most commonly used to prevent thrombotic events for adults with atherosclerotic vascular disease, children with certain types of congenital heart disease, stroke, and Kawasaki disease also are at risk for thrombosis and may benefit from antiplatelet therapy. Unfortunately, very little data on the efficacy and safety of antiplatelet therapy for pediatric patients are available. As a consequence, consistent clinical practice among pediatric practitioners is lacking. Furthermore, much of what is practiced results from extrapolation from adult studies, which may be problematic because many aspects of platelet biology differ between children and adults. This review discusses aspects of antiplatelet therapy for pediatric patients.