The use of catheter intervention procedures for congenital heart disease

Bioptome-assisted stent repositioning in the case of stent migration during balloon-expandable stenting for coarctation of the aorta

Coarctation of aorta is commonly treated with endovascular interventions such as coarctation stenting. Migration of stent is the most dreaded complication of coarctation stenting. A 60-year-old lady with severe malaligned coarctation underwent endovascular stent placement. The expanded stent migrated to proximal aorta, which could be stabilized with a bioptome, re-positioned with a balloon and postdilated to its optimal size, resulting in a good outcome.

Health-related quality of life in children and adolescents living in the north-east of China before and after cardiac catheter interventional treatment

BACKGROUND

The goal of the present prospective study was to assess health-related quality of life in children and adolescents with CHD before and after cardiac catheter treatment.

METHODS

The study enrolled 96 children/adolescents with CHD from the north-east of China who underwent cardiac catheter intervention treatment between March, 2013 and January, 2014. The health-related quality of life at 24 hours before treatment, 1 month after treatment, and 6 months after treatment was evaluated using Pediatric Quality of Life Inventory Measurement Models 4.0 (PedsQLTM 4.0) generic core scales, and the scores were further compared.

RESULTS

Before treatment, each HRQOL domain score and the total score were obviously decreased than the post-treatment scores (1 month and 6 months). The total score and the scores in physical functioning and psychological functioning components were further increased 6 months after treatment than the scores 1 month after treatment.

CONCLUSION

The present study suggests that cardiac catheter interventional treatment improves the life quality of children or adolescents with CHD as time increases after the intervention.

Univentricular Heart

As early as 1699, Chemineau described a heart composed of 2 auricles but only 1 ventricle. 1 The univentricular heart has since fascinated the medical community. Unique in its complexity and scope, the univentricular heart has sparked intense debates about embryology and nomenclature, challenged our understanding of cardiovascular physiology and hemodynamics, and inspired some of the most creative surgical and interventional approaches in human history. The present report provides an overview of the nomenclature and classification of the univentricular heart, epidemiology and pathological subtypes, genetic factors, physiology, clinical features, diagnostic assessment, therapy, and postoperative sequelae. Although the present report touches on issues applicable to neonates and children with univentricular hearts, the focus is on information of interest and relevance to the adult cardiologist.

Medical management of three asymptomatic infants with severe valvar aortic stenosis

We report on the clinical course and serial hemodynamic studies of three patients with severe valvar aortic stenosis diagnosed in the neonatal period. None of the children were symptomatic in the first year of life. In each case, a conservative initial management approach was adopted. Between the time of initial study (mean age, 1.8 months) and the follow-up at 12-27 months of age (mean, 14.3 months), mean left ventricular systolic pressure decreased from 151 to 125 mmHg, the mean peak systolic pressure gradient across the aortic valve decreased from 61 to 33 mmHg, and the mean calculated aortic valve area index increased from 0.24 to 0.60 cm2/m2. One patient was operated on for symptoms that appeared at 14 months of age. The patient followed longest is now 5 years old, is growing well, has a normal electrocardiogram and an echo-predicted left ventricular systolic pressure of 128 mmHg. This experience suggests that not all asymptomatic neonates with severe valvar aortic stenosis require surgical intervention early in life. In some, the aortic valve orifice may increase in size with somatic growth and obviate the need for surgery in infancy or early childhood.

Interventional cardiac catheterization

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.

Use of balloon-expandable stents for coarctation of the aorta: initial results and intermediate-term follow-up

OBJECTIVES

In this study we report our preliminary results and intermediate-term follow-up (up to 3.5 years) of stent implantation for coarctation of the aorta (COA).

BACKGROUND

Balloon angioplasty has gained acceptance as a modality of treatment for COA. Some patients do not respond optimally to balloon angioplasty alone. Balloon-expandable stents have been used in pulmonary arteries and large systemic arteries such as the femoroiliac vessels, with a significant improvement in vessel patency and a reduction in the pressure gradient compared with balloon angioplasty alone.

METHODS

Nine patients (>10 years old) with COA in whom balloon dilation alone was thought to be ineffective underwent stent implantation. Seven patients had a previous operation or balloon dilation, or both, to relieve their coarctation but had a significant residual/recurrent gradient.

RESULTS

At the time of stent implantation, the systolic and mean gradients decreased from a mean (+/-SEM) of 37 +/- 7 and 14 +/- 3 mm Hg to 4 +/- 1 and 2 +/- 0.6 mm Hg, respectively (p < or = 0.002). The coarctation diameter increased from a mean of 9 +/- 1 to 15 +/- 1 mm (p < 0.002). The patients have been followed for up to 42 months (mean 18, median 13) with no complications; the stents remain in position with no fracture. One patient underwent further successful dilation 3 years after stent implantation because of an exercise-induced gradient. No other intervention has been required. The systolic gradient at latest follow-up is 7 +/- 2 mm Hg. Only two (a 44-year old with diabetes and a 50-year old with long-standing hypertension) of five patients previously requiring antihypertensive treatment still remain on medications for blood pressure control.

CONCLUSIONS

The use of stents in COA is a feasible alternative to surgical repair or balloon angioplasty in selected patients with an effective gradient reduction. Intermediate-term follow-up shows excellent gradient relief, with no complications in this group of patients.

Transcatheter closure of oversized persistent ductus arteriosus by simultaneous delivery of two Rashkind umbrella devices

Transcatheter closure of persistent ductus arteriosus (PDA) with a diameter of > 9 mm is considered to be impossible or at least difficult with the occlusion systems that are currently available. We report a simple technique for occluding oversized PDAs with two diameter of 13 mm was successfully occluded in a 40-year-old man. Complete closure without residual shunt was documented by echocardiogram and angiogram.

Acute dissection of the right ventricular outflow tract after balloon dilatation in a patient with previously corrected tetralogy of Fallot

Percutaneous balloon dilatation has been used successfully to dilate various stenoses occurring after repair of congenital heart disease. Acute dissection of a stenotic right ventricular outflow tract occurred after attempted balloon dilatation in a patient with previously corrected tetralogy of Fallot.

Nonoperative closure of the patent ductus arteriosus: the Frankfurt experience

Nonoperative closure of patent ductus arteriosus (PDA) by means of Ivalon plugs (according to the technique of Porstmann) was performed in 101 patients. Sixty-five patients were symptomatic, the Q p/Q s ratio exceeded 1.5 in 56 patients, and pulmonary hypertension (mean pulmonary artery pressure greater than 20 mmHg) was present in 50 patients. In 100/101 patients the PDA could be closed successfully. Ninety-nine patients were without any evidence of residual left-to-right shunt. In one patient a hemodynamically insignificant left-to-right shunt was found with color Doppler echocardiography. Complications were pulmonary embolism due to plug dislocation in two patients (12th and 14th patient; 2 and 7 weeks after the procedure, respectively). One of these patients underwent elective surgery with patch closure of the ductus and removal of the embolized plug. In the other patient the ductus was successfully closed with a second larger plug while the first plug was left in a peripheral pulmonary artery. Surgical revision of the femoral artery was required in six and blood transfusion in two patients. Deep venous thrombosis developed in two patients. During follow-up (total follow-up time more than 200 patient years) no late complications were observed. In conclusion, transfemoral catheter closure of PDA by means of Ivalon plugs is an effective method. It is applicable to adolescents and adults with a low complication rate. The ductus can be closed without residual left-to-right shunt. Long-term results are excellent.

Immediate and follow-up results of balloon angioplasty of postoperative recoarctation in infants and children

The purpose of this article is to present immediate and follow-up results of balloon angioplasty of aortic recoarctations following previous surgery in infants and children. During a 45-month period that ended in June 1989, nine infants and children, ages 6 months to 7 years, underwent balloon angioplasty of recoarctation with resultant reduction in peak-to-peak systolic pressure gradient from 52 +/- 20 mm Hg (mean +/- SD) to 16 +/- 8 mm Hg (p less than 0.001) and increase in coarctation segment size from 3.4 +/- 1.4 mm to 6.1 +/- 1.6 mm (p less than 0.01). None required surgical intervention. There were no significant complications. Follow-up catheterization (16 +/- 7 months) data in six children and follow-up clinical (17 +/- 6 months) data in all children were available for review. Both the residual coarctation pressure gradient (6 +/- 6 mm Hg) and coarctation segment size (8.2 +/- 2.4 mm) remain improved (p less than 0.001) when compared with pre-balloon angioplasty values and the pressure gradient fell further (p less than 0.01) when compared with that measured immediately after balloon angioplasty. None developed restenosis, although one child required surgical relief of severe narrowing of isthmus of the aortic arch. None developed aneurysms. On the basis of this experience and that reported in the literature and because of high morbidity and mortality rates associated with repeat surgery for postoperative recoarctation, we recommend balloon angioplasty as the procedure of choice for relief of postoperative recoarctation with significant hypertension.

Percutaneous balloon pulmonary valvuloplasty in sickle cell anemia: a case report

Percutaneous balloon pulmonary valvuloplasty was performed on a 19-year-old female who had moderate pulmonary valve stenosis with sickle cell anemia. The patient developed sickle cell crisis resulting in occipital infarction, but she made a good recovery. We describe this case and the methods of reducing the risk of sickle cell crisis.

Balloon aortic valvuloplasty: results of the Valvuloplasty and Angioplasty of Congenital Anomalies Registry

Data from 204 children and infants who underwent aortic balloon valvuloplasty between 1982 and 1986, reported to the Valvuloplasty and Angioplasty of Congenital Anomalies Registry, were reviewed. Valvuloplasty was successful in 192 of 204 children, reducing the peak systolic left ventricular ejection gradient from 77 +/- 2 to 30 +/- 1 mm Hg, p less than 0.001. The same degree of aortic stenosis gradients reduction was noted in both the 38 children under 1 year of age and in the 166 children over 1 year of age. Significant complications included death, aortic regurgitation and femoral artery thrombosis or damage. The incidence of these complications correlated with the age of the child, the ratio of valvuloplasty balloon size/anulus size, or both. The data suggest that percutaneous balloon valvuloplasty provides effective acute relief of valvar aortic stenosis in both infants and children. However, long-term follow-up data are necessary before balloon valvuloplasty can be established as a treatment of choice for congenital valvar aortic stenosis.

Balloon dilation catheters

Catheter therapy has gained an important role in the treatment of congenital heart disease. The cumulative experience with vascular and valvular balloon dilations has demonstrated low mortality and morbidity with short-term results similar to surgery. Currently, balloon dilation is an accepted treatment for valvular pulmonary stenosis, distal pulmonary artery stenosis, recurrent coarctation, rheumatic mitral stenosis, congenital valvular aortic stenosis, and intra-atrial baffle obstruction. Except for patients at high surgical risk, balloon dilation of native coarctation is considered investigational at most institutions but accepted at others. No conclusive evaluation is yet possible for dilation of bioprosthetic valves and membranous subaortic stenosis. Individual pulmonary veins appear undilatable. Various devices are available for closure of extra- and intracardiac communications. Transcatheter closure of aortopulmonary collaterals and arteriovenous malformations is now well established at some centers. In selected patients, therapeutic embolization of surgical shunts can replace surgery. Transcatheter closure of the patent ductus arteriosus has become routine at some centers. Nonsurgical closure of atrial and ventricular septal defects has entered clinical trials, and preliminary results appear very promising. Blade atrioseptostomy and foreign body retrieval are well established. Improvement of existing procedures and implementation of new concepts will consolidate the role of catheter therapy in congenital and acquired heart disease.

Balloon angioplasty of aortic coarctation: a review

Since the initial report of balloon coarctation angioplasty in 1982, several workers used this technique in native coarctation and postoperative recoarctation. Immediate and intermediate-term follow-up results are generally good with a small chance for recoarctation and aneurysmal formation at the site of coarctation. The causes of recoarctation were identified and include age less than 1 year, isthmus hypoplasia, and a small coarcted aortic segment. Despite good immediate and follow-up results, recommendations for use of balloon angioplasty as a treatment procedure of choice are clouded by the reports of development of aneurysms at the site of coarctation. We feel that balloon coarctation angioplasty is the treatment of choice in neonates and small infants, while general use of this technique in both native and postoperative coarctations in older children should await follow-up results in larger numbers of children at selected centers.

Intraoperative balloon valvuloplasty in pulmonary valve stenosis

Balloon valvuloplasty was used in the operating room on 7 patients to visually assess the valvular changes induced by inflation of a balloon catheter. All patients had typical pulmonary valve stenosis and an associated cardiac condition which necessitated surgery. Of 23 fused commissures present, 21 were successfully opened with a single balloon inflation. In 2 patients, damage to the leaflets was observed. In 1 patient there was partial detachment and in the other a small tear was noted at the margin of one leaflet. These intraoperative results may be similar to the results obtained with percutaneous balloon valvuloplasty.

Percutaneous balloon valvuloplasty in neonates with critical aortic stenosis

Percutaneous balloon valvuloplasty was attempted in 10 newborn infants with critical aortic valve stenosis and severe congestive heart failure. Three had a very small left ventricle and aortic anulus. In one infant, the aortic valve could not be passed, and in another infant, a technical error resulted in severe valvular damage, aortic insufficiency and death. Among the eight patients who had effective dilation, the stenosis was relieved in seven as assessed by a significant decrease in transvalvular pressure gradient, improvement of left ventricular contraction and eventual inversion of the ductal shunting. The procedure failed in the only patient whose dilation was performed with an undersized balloon. Aortic insufficiency occurred in three infants and was severe (perforated cusp) in one, moderate in one whose valve was dilated with an excessively large balloon and mild and transient in one. None of the three infants with a very small left ventricle recovered (two died and one underwent cardiac transplantation). Among the seven infants with a left ventricle of acceptable size, three underwent subsequent aortic valvotomy; one of these died and two bad good results. The remaining four are doing well 16 +/- 5 months later (mean +/- SD) with mild to moderate residual aortic stenosis and normal left ventricular function. In conclusion, percutaneous balloon valvuloplasty is an acceptable alternative to surgery in neonates with critical aortic valve stenosis. Incidence of complications and good relief of the obstruction depend on a careful technique. Immediate results are similar to those of surgery. Late prognosis depends on the quality of the left heart structures.

Balloon pulmonary valvuloplasty: a review

Balloon pulmonary valvuloplasty has been used successfully over the last few years for the relief of moderate to severe valvar pulmonic stenosis in neonates, infants, children, and adults. Both immediate and intermediate term follow-up results have been well documented by cardiac catheterization studies. Electrocardiographic and echo-Doppler evaluation at follow-up is reflective of the results and may avoid the need for recatheterization. The results of balloon valvuloplasty are either comparable to or better than those reported with surgical valvuloplasty. The causes of restenosis have been identified, and appropriate modifications in the technique, particularly the recommended use of a balloon/annulus ratio of 1.2 to 1.5, should give better results than previously documented. Complications of the procedure have been minimal. Further refinement of the catheters and technique may reduce the complication rate even further. The indications for balloon valvuloplasty have not been clearly defined but should probably be similar to those used for surgical valvotomy; only patients with moderate to severe valvar pulmonic stenosis are candidates for balloon valvuloplasty. Previous surgery and pulmonary valve dysplasia are not contraindications for balloon valvuloplasty. The procedure is also applicable to pulmonary stenosis associated with other complex cardiac defects and stenosis of bioprosthetic valves in pulmonary position. Miniaturatization of balloon/catheter systems to further reduce the complication rate and documentation of favorable result at 5- to 10-year follow-up are necessary.

Impact of two-dimensional and Doppler echocardiography on care of children aged two years and younger

To determine the impact of 2-dimensional (2-D) and Doppler echocardiography on the care of children aged 2 years and younger with suspected cardiac disease, the clinical management and outcome for the years 1975 (pre-2-D/Doppler era, 161 patients) and 1985 (2-D/Doppler era, 206 patients) were compared. Differences were: (1) decreased catheterization at our institution (48% vs 21%, p less than 0.0001); (2) trend toward decreased recatheterization of patients with referral catheterization (62% vs 38%, p = 0.08); (3) increased operation without preoperative catheterization (10% vs 37%, p less than 0.001); and (4) decreased preoperative catheterization for 7 anomalies (patent ductus arteriosus, ventricular septal defect, atrial septal defect, atrioventricular canal, aortic stenosis, tetralogy of Fallot and complete transposition of great arteries). Operative mortality rates were not statistically different in the years compared. Also, the operative mortality rates in 1985 for patients with and without preoperative catheterization were not statistically different. In 1975, cardiac catheterization changed the primary clinical diagnosis in 21%. In 1985, the primary diagnosis was not changed by catheterization; however, 2-D and Doppler echocardiography changed the diagnosis in 18%. The change in utilization of cardiac catheterization appears to be most closely related to the maximal utilization of a substitute imaging and hemodynamic modality--namely, 2-D and Doppler echocardiography.

Percutaneous balloon angioplasty for native coarctation of the aorta

Twenty-six children, aged 5 weeks to 14.7 years, underwent percutaneous balloon angioplasty for a discrete native coarctation of the aorta. The procedure reduced the systolic coarctation gradient acutely in all children. The mean systolic gradient decreased by 75%, from 48.6 +/- 2.4 before to 12.3 +/- 1.9 mm Hg after angioplasty (p less than 0.001). Long-term results were evaluated in 14 children by follow-up catheterization 12 to 26 months (mean 15.3) after angioplasty. At follow-up, the residual gradient averaged 11.7 +/- 3.7 mm Hg (range -5 to 36) and had not changed from that measured immediately after angioplasty (p = 0.64). Compared with preangioplasty values, the systolic pressure in the ascending aorta had improved substantially at follow-up (116.0 +/- 3.2 versus 143.9 +/- 3.1 mm Hg, p less than 0.001). On the basis of follow-up data, two groups of children were identified: Group 1 consisted of nine children with a good result, defined as a residual gradient less than 20 mm Hg and no aneurysm; Group 2 consisted of five children with a poor result, four with a residual gradient greater than 20 mm Hg (range 25 to 36) and one with an aneurysm at the dilation site. There was no statistical difference between the two groups in age at angioplasty, balloon size, ratio of balloon to isthmus diameters, follow-up duration, heart rate or cardiac output. However, of the four children with a residual gradient greater than 20 mm Hg, two were the youngest in the study, and in two the aorta was inadvertently dilated with a balloon 4 to 5 mm smaller than the isthmus diameter.(ABSTRACT TRUNCATED AT 250 WORDS)

Balloon dilatation of unoperated aortic coarctation: immediate results and one year follow up

Fifteen patients aged 1-19 years (mean 10.9) with previously unoperated aortic coarctation underwent percutaneous balloon angioplasty between January 1985 and February 1986. Nine (60%) were hypertensive at presentation. Under general anaesthetic the systolic coarctation gradient was 24-50 mm Hg (mean 29) and the coarctation diameter was 4-9 mm (mean 5.5). Meditech balloon catheters 8-18 mm in diameter were inflated 1-4 times at 410-760 kPa. After dilatation the systolic coarctation gradient decreased to 0-20 mm Hg (mean 6) and the coarctation diameter increased to 7-20 mm (mean 12). One patient developed a fusiform aneurysm of the aorta at the coarctation site immediately after the procedure. At reinvestigation 6-16 months (mean 12.5) after dilatation 14 of the 15 patients were normotensive. In 13 patients the residual coarctation gradient was 0-10 mm Hg (mean 3). Two patients had recoarctation with residual gradients of 20 and 24 mm Hg and underwent successful repeat dilatation. One patient had developed a small discrete aneurysm at the coarctation site. Balloon angioplasty is thus a safe and effective method of relieving unoperated aortic coarctation. The frequency of aortic aneurysm and recoarctation is small and probably related to balloon size. This early experience is encouraging, but long term results and further experience are required before this approach is used to treat coarctation generally.

Angioplasty for primary treatment of aortic coarctation: immediate results in two adult patients

Two adult patients with severe aortic coarctation were treated by angioplasty performed percutaneously through the right femoral artery. A 20 mm balloon catheter was used, being inflated several times within the stenosis. The final angiographic result was excellent in both cases. The gradients were 38 and 46 mm Hg before and 5 and 3 mm Hg after angioplasty, respectively. The arterial pulses in the legs were normal after the procedure and no complication was observed.

Catheter induced pseudostenosis of the right pulmonary artery: a technical note

A case of pseudostenosis of the right pulmonary artery caused by a catheter in the azygos vein is presented. The recognition of this pseudolesion occurred when a repeat catheterization prior to angioplasty, demonstrated a normal right pulmonary artery.

Double balloon technique for dilation of valvular or vessel stenosis in congenital and acquired heart disease

Despite the generally excellent success with balloon dilation for the stenotic lesions of congenital and acquired heart disease, technical difficulties sometimes prevent satisfactory results. Such technical difficulties include: a large diameter of the anulus of the stenotic lesion relative to available balloon diameter, difficulty in the insertion or removal of the larger balloon catheters, and permanent damage to or obstruction of the femoral vessels by the redundant deflated balloon material of the large balloons. A double balloon technique was initiated to resolve these difficulties. With this method, percutaneous balloon angioplasty catheters were inserted in right and left femoral vessels, placed side by side across the stenotic lesion and inflated simultaneously. Dilation procedures using the two balloon technique were performed in 41 patients: 18 with pulmonary valve stenosis, 14 with aortic valve stenosis, 5 with mitral valve stenosis, 3 with vena caval obstruction following the Mustard or Senning procedure and 1 with tricuspid valve stenosis. Patient ages ranged from 1 to 75 years (mean 17.8) and patient weights ranged from 8.9 to 89 kg (mean 42.3). Balloon catheter sizes ranged from 10 to 20 mm in diameter. Average maximal pressure gradient in mm Hg before dilation was 61 in pulmonary stenosis, 68 in aortic stenosis, 21 in mitral stenosis, 12 in tricuspid stenosis and 25 in vena caval stenosis. Average maximal valvular pressure gradient after dilation was 13 in pulmonary stenosis, 24 in aortic stenosis, 4 in mitral stenosis, 0 in tricuspid stenosis, and 1 in vena caval stenosis. No major complications were encountered with the procedures.(ABSTRACT TRUNCATED AT 250 WORDS)