Successful transcatheter closure with the buttoned device of aortopulmonary window in an adult

The Journey of an Indian Pediatric Cardiologist : Dr. K. C. Chaudhuri Lifetime Achievement Award/Oration at AIIMS, New Delhi, September 2017

The life journey of an Indian pediatric cardiologist, who bestowed considerable attention to the development of new knowledge and train/teach physicians around the world while providing care of patients with heart disease over a 45-y period, is reviewed. This appraisal focuses particular attention on the scientific contributions to the literature. These include spontaneous closure of physiologically advantageous ventricular septal defects, various issues related to a congenital heart defect namely, tricuspid atresia and transcatheter and, interventional pediatric cardiac procedures.

Transesophageal Echocardiography in a Distal Aortopulmonary Window

Aortopulmonary window (APW) is a relatively rare cardiac lesion representing approximately 0.2%–0.4% of all cardiac malformation. It is a cardiac abnormality that results from abnormal communication between the proximal aorta and the main pulmonary artery in the presence of two normally separated aortic and pulmonary valves. In the past, the diagnostic and surgical approach to APW was almost always preceded by cardiac catheterization. With recent advances in noninvasive approach and techniques of two-dimensional echocardiography diagnosis of the defect and associated anomalies are facilitated without a cath study. We report a 4-month-old infant with a distal APW who was referred to our center for surgical repair. We emphasize the usage of transesophageal echocardiography as a valuable intraoperative tool which not only confirms the preoperative diagnosis but also helps in assessing the surgical repair of an APW.

Unconventional uses of septal occluder devices: Our experience reviewed

Device closure is now an accepted modality of treatment for cardiac septal defects such as fossa ovalis Atrial Septal Defect (ASD), Ventricular Septal Defect (VSD) and Patent Ductus Arteriosus (PDA) and have well-accepted indication and long term results. Devices used for these defects have been specifically designed for use in closing these defects. In this manuscript, we are reporting the efficacy of closure of nonseptal defects with devices conventionally used for septal cardiac defects although they have not been prototyped for use in such conditions.

AIM

To study use of occluder devices in nonseptal defects/malformation.

MATERIAL & METHODS

39 patients, in the age group 2-67 yrs, were treated percutaneously with occluder devices for various conditions. These included: coronary arteriovenous (CAV) fistula (n = 6), pulmonary AV fistula (n = 4), systemic AV fistula (vascular plug; n = 1), closure of AP window (duct occluder; n = 3), closure of ascending aorta perforation (septal occluder; n = 2), ruptured sinus of Valsalva (RSOV) (duct occluder; n = 13), Fontan fenestration closure (ASD septal occluder, patent foramen ovale device, vascular plug n = 3,1 each), splenic artery (duct occluder; n = 1), Balock Taussig shunt (duct occlude; n = 1)and closure of mitral paravalvular leak (n = 3; duct occlude devices = 2, VSD device: n = 1) and aortic paravalvular leak n = 2 (duct occluder; n = 2 additional vascular plug = 2).

RESULTS

Procedural success: Successful closure as signified by no residual shunt was achieved in all coronary AV fistula (immediately n = 2, at 3 months in all), ruptured sinus of Valsalva (immediate in all), fenestrated Fontan (immediately in all), and ascending aorta perforations (immediate), mitral paravalvular leak (immediate in none, and late in 2/3). The aortic paravalvular leak closed at 3 months follow-up in one and small residual persisted after 1 month in another.

COMPLICATIONS

Local site Hematoma was observed in 4 patients. 2 of them required post procedure transfusion for the same. Hematuria was observed in 2 of the 4 patients of mitral paravalvular leak and 2 patients of RSOV device closure. Hematuria subsided with conservative management before discharge from hospital in all the 4 cases. One patient with residual mitral regurgitation required surgical management for continuing hematuria, anemia and hyperbilirubenemia. There was one mortality observed on table during the attempted closure of a very large RSOV who presented to us in severe congestive heart failure and shock. On follow up ranging from 2 months to 6 years, all the patients are asymptomatic. There was no late complication related to device in any patient.

CONCLUSION

It is feasible in selected nonseptal defects, which traditionally have been subjected to surgical interventions, to treat successfully, non surgically with the use of non prototype occluder devices without significant complications. Conventionally these devices have not been recommended for closure of nonseptal defects but show good early outcome. Adequate sample size with good follow up data is necessary before concluding that it can be safe alternative to surgery on long term.

Aortopulmonary window in infants

One of the rarest congenital heart diseases that results from a defect between the main pulmonary artery and the proximal aorta is named aortopulmonary window (APW). Such abnormality could be isolated, but in fifty percent of patients may be associated with other cardiac abnormalities, including arch abnormalities, specifically coarctation of the aorta, interrupted aortic arch, tetralogy of fallot, and atrial septal defect (ASD). Surgical closure or catheter-delivered devices is recommended in all patients with APW and should be performed after diagnosis as soon as possible to prevent irreversible pulmonary vascular disease. In the current era, early mortality following repair of simple APW is low and depends on the presence of associated lesions, especially interrupted aortic arch. We report an 8-month-old boy with APW who was referred to our center by respiratory symptoms and heart murmurs.

Retrograde use of the Cardioseal/Starflex occluder device

The Cardioseal/Starflex septal occluder is usually deployed through a long transvenous sheath for closure of atrial septal defects, persistent foramen ovale, and, less commonly, ventricular septal defects. We describe two patients with residual left-to-right shunting after surgical palliation of congenital heart defects and illustrate the successful use of the double-umbrella device in these situations using a retrograde transarterial approach. This is exemplified by two previously not described interventions: retrograde closure of a large muscular ventricular septal defect in a patient after a palliative Mustard operation and a transcatheter closure of a Waterston-Cooley anastomosis. Effective and safe closure of left-to-right shunting can be achieved by retrograde use of the Cardioseal/Starflex device in selected adolescents and grown-ups with congenital heart disease.

Transcatheter closure of aortopulmonary window using Amplatzer device

Two cases of transcatheter closure of aortopulmonary window (APW) using an Amplatzer duct occluder in one and a septal occluder device in the second are described. Transcatheter device closure of APW should be considered when anatomy is favorable in terms of location and size of the defect with absence of associated anomalies.

Transcatheter occlusion of ruptured sinus of valsalva aneurysm: innovative use of available technology

A 9-year-old boy was found to have ruptured sinus of Valsalva aneurysm (RSVA) and aortic coarctation. Following relief of aortic coarctation by balloon angioplasty, transcatheter coil occlusion of the RSVA was performed successfully under transesophageal echocardiographic and fluoroscopic monitoring; bioptome-assisted delivery of 0.052" Gianturco coil was undertaken via a 7 Fr sheath stabilized by an 0.035" guidewire passing through the RSVA and the sheath. This report details the technique of occlusion.

[Aortopulmonary window: clinical assessment and surgical results]

INTRODUCTION AND OBJECTIVES

Aortopulmonary septal defect is an uncommon congenital cardiac anomaly. To date, approximately 300 cases have been reported. We present our experience, emphasizing the importance of early correction to avoid irreversible pulmonary hypertension.

PATIENTS AND METHOD

Between 1979 and 2000, seven patients underwent surgical repair of this heart defect in our hospital. Two had type I (proximal), 4 had type II (distal) and 1 had type III (complete). Complex associated cardiac anomalies were present in 4 cases: type A interruption of the aortic arch in 2 cases, hypoplastic aortic arch in 1 and transposition of great arteries with ventricular septal defect in 1. Four cases (57%) were diagnosed by echocardiography. In all patients diagnoses were confirmed by cardiac catheterization. Patient records were reviewed retrospectively, with special attention to clinical, echocardiographic and hemodynamic data as well as surgical characteristics.

RESULTS

No intraoperative deaths occurred. The patient with associated transposition of great arteries died 22 days after surgery as a result of severe pulmonary hypertension. The remaining patients are asymptomatic without treatment after a mean follow-up period of 69 months.

CONCLUSIONS

Even though aortopulmonary septal defect is a rare anomaly, it should be considered whenever the course of complex congenital heart disease includes early cardiac failure and pulmonary hypertension. Repair before 6 months will prevent irreversible damage of pulmonary vessels.

Centering-on-demand buttoned device: its role in transcatheter occlusion of atrial septal defects

Since the initial design and description of the buttoned device, it has undergone a number of design changes. Introduction of radiopacity in the knot (button) made it easier to visualize and document that buttoning has indeed occurred. Introduction of two buttons has markedly decreased the unbuttoning rate with potential for eliminating it. A centering mechanism was then incorporated into the device, which allowed closure of larger defects and use of smaller-sized devices. For some unknown reason, unbuttoning rate no longer occurs since the introduction of this device. The centering-on-demand (COD) device also appears to have increased the effective occlusion rates. At the present time, however, no long-term follow-up data are available to assess the long-term efficacy of the new device. Experience in a larger number of patients and evaluation of follow-up data are necessary to confirm the safety and efficacy observed in the small cohort reported in this review.

Amplatzer device closure of a residual aortopulmonary window

Significant residual defects after surgical closure of aortopulmonary windows have previously required re-operation. In this paper, we describe the use of a custom made Amplatzer closure device to occlude a hemodynamically significant defect in a 5-year-old child. The device was successfully deployed without complication, and resulted in a major reduction in aorto-pulmonary flow.

Congenital Heart Surgery Nomenclature and Database Project: aortopulmonary window

The extant nomenclature for aortopulmonary window (AP window) and pulmonary artery origin from ascending aorta (hemitruncus) is reviewed for the purpose of establishing a unified reporting system. The subject was debated and reviewed by members of the STS-Congenital Heart Surgery Database Committee and representatives from the European Association for Cardiothoracic Surgery. All efforts were made to include all relevant nomenclature categories using synonyms where appropriate. A comprehensive database set is presented that is based on a hierarchical scheme. Data are entered at various levels of complexity and detail that can be determined by the clinician. These data can lay the foundation for comprehensive risk stratification analyses. A minimum database set is also presented that will allow for data sharing and would lend itself to basic interpretation of trends. Outcome tables relating diagnoses, procedures, and various risk factors are presented.

Transumbilical venous, anterograde, snare-assisted balloon aortic valvuloplasty in a neonate with critical aortic stenosis

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.