Complications associated with pediatric cardiac catheterization

Congenital heart disease cardiac catheterization at Uganda Heart Institute, a 12-year retrospective study of immediate outcomes

BACKGROUND

Cardiac catheterization is an invasive diagnostic and treatment tool for congenital heart disease (CHD) with potential complications.

OBJECTIVE

To describe the immediate outcomes of patients who underwent cardiac catheterization for CHD at the Uganda Heart Institute (UHI).

METHODS

The study was a retrospective chart review of 857 patients who underwent cardiac catheterization for CHD at UHI from 1st February 2012 to 30th June 2023. Precardiac catheterization clinical data, procedure details, and post-procedure data were recorded. The statistical software SPSS was used for data analysis.

RESULTS

We studied 857 patients who underwent cardiac catheterization for CHD at UHI. Females comprised 62.8% (n = 528). The age range was 3 days to 64 years, with a mean of 5.1 years (SD 7.4). Advanced heart failure was present in 24(2.8%) of the study participants. The most common procedures were patent ductus arteriosus device closure (n = 500, 58.3%), diagnostic catheterization (n = 194, 22.5%), and balloon pulmonary valvuloplasty (n = 114, 13.0%). PDA device closure had 89.4% optimal results while BPV had 75.9% optimal performance outcome. Adverse events occurred in 52 out of 857 study participants (6.1%). Clinically meaningful adverse events (CMAES) occurred in 3.9%, (n = 33), high severity adverse events in 2.9% (n = 25) and mortality in 1.5% (n = 13). Advanced heart failure at the time of cardiac catheterization, was significantly associated with clinically meaningful adverse events (OR 52 p-value < 0.001) and mortality (OR 564, p value < 0.001).

CONCLUSION

Many patients with CHD have benefited from the cardiac catheterization program at UHI with high optimal procedure outcome results. Patients with advanced heart failure at the time of cardiac catheterization have less favorable outcomes emphasizing the need for early detection and early intervention.

Additive value of invasive haemodynamic assessment for predicting post-operative outcomes after Fontan

Routine pre-Fontan cardiac catheterization remains standard practice at most centres. However, with advances in non-invasive risk assessment, an invasive haemodynamic assessment may not be necessary for all patients.Using retrospective data from patients undergoing Fontan palliation at our institution, we developed a multivariable model to predict the likelihood of a composite adverse post-operative outcome including prolonged length of stay ≥ 30 days, hospital readmission within 6 months, and death and/or transplant within 6 months. Our baseline model included non-invasive risk factors obtained from clinical history and echocardiogram. We then incrementally incorporated invasive haemodynamic data to determine if these variables improved risk prediction.Our baseline model correctly predicted favourable versus adverse post-Fontan outcomes in 118/174 (68%) patients. Covariates associated with adverse outcomes included the presence of a systemic right ventricle (adjusted adds ratio [aOR] 2.9; 95% CI 1.4, 5.8; p = 0.004), earlier surgical era (aOR 3.1 for era 1 vs 2; 95% CI 1.5, 6.5; p = 0.002), and performance of concomitant surgical procedures at the time of Fontan surgery (aOR 2.5; 95% CI 1.1, 5.0; p = 0.026). Incremental addition of invasively acquired haemodynamic data did not improve model performance or percentage of outcomes predicted.Invasively acquired haemodynamic data does not add substantially to non-invasive risk stratification in the majority of patients. Pre-Fontan catheterization may still be beneficial for angiographic evaluation of anatomy, for therapeutic intervention, and in select patients with equivocal risk stratification.

Five-Year Outcomes of Coarctoplasty with Stents in the Pediatric Population: Results from a Retrospective Single-Center Cohort with Centrally Adjudicated Outcomes

Transcatheter stent implantation is a widely performed procedure for treating native coarctation of the aorta (CoA) in pediatric patients. However, data on mid- to long-term outcomes are limited. The aim of this study was to evaluate the mid-term safety and efficacy of transcatheter CoA stenting based on centrally adjudicated outcomes. This retrospective cohort study included patients aged 15 years or younger undergoing de novo stenting for CoA or recoarctation (reCoA) between 2006 and 2017. Immediate and 5-year outcomes were assessed. Immediate outcomes (procedural and in-hospital) were retrieved from electronic records. Rates of 5-year reCoA, stent fractures, aneurysmal/pseudoaneurysmal formation, and all-cause mortality were mid-term outcomes. The study included 274 patients (64% male and 36% female) with a median (interquartile range) age of 9 (6-12) years. Procedural success was achieved in 251 patients (91.6%). Procedural complications occurred in 4 patients (1.4%), consisting of stent migration in 1 (0.3%) and small non-expanding non-flow-limiting aortic wall injuries in 3 (1.1%). Major vascular access complications were observed in 18 patients (6.6%), acute limb ischemia in 8 (2.9%). In-hospital mortality occurred in 4 patients (1.4%). Five-year cumulative incidence rates of stent fractures, reCoA, and aortic aneurysmal/pseudoaneurysmal formation were 17/100 (17%), 73/154 (48%), and 8/101 (7.92%), respectively. Of 73 reCoAs, 47 were treated with balloon angioplasty, and 15 underwent a second stent implantation. Five-year all-cause mortality occurred in 4/251 (1.6%) patients. Coarctoplasty with stents was safe and effective in our pediatric population during a 5-year follow-up despite a high rate of reCoA.

Balloon atrial septostomy for transposition of the great arteries: Safety and experience with the Z-5 balloon catheter

BACKGROUND

Balloon atrial septostomy (BAS) is an emergent and essential cardiac intervention to enhance intercirculatory mixing at atrial level in deoxygenated patients diagnosed with transposition of the great arteries (TGA) and restrictive foramen ovale. The recent recall of several BAS catheters and the changes in the European legal framework for medical devices (MDR 2017/745), has led to an overall scarcity of BAS catheters and raised questions about the use, safety, and experience of the remaining NuMED Z-5 BAS catheter.

AIMS

To evaluate and describe the practice and safety of the Z-5 BAS catheter, and to compare it to the performance of other BAS catheters.

METHODS

A retrospective single-center cohort encompassing all BAS procedures performed with the Z-5 BAS catheter in TGA patients between 1999 and 2022.

RESULTS

A total of 182 BAS procedures were performed in 179 TGA-newborns at Day 1 (IQR 0-5) days after birth, with median weight of 3.4 (IQR 1.2-5.7) kg. The need for BAS was urgent in 90% of patients. The percentage of BAS procedures performed at bedside increased over time from 9.8% (before 2010) to 67% (2017-2022). Major complication rate was 2.2%, consisting of cerebral infarction (1.6%) and hypovolemic shock (0.5%). The rate of minor complications was 9.3%, including temporary periprocedural AV-block (3.8%), femoral vein thrombosis (2.7%), transient intracardiac thrombus (0.5%), and atrial flutter (2.2%). BAS procedures performed at bedside and in the cardiac catheterization laboratory had similar complication rates.

CONCLUSIONS

BAS using the Z-5 BAS catheter is both feasible and safe at bedside and at the cardiac catheterization laboratory with minimal major complications.

Transcatheter Ventricular Septal Defect Closure with Lifetech™ Konar-MF Occluder in Infants Under 10 kg with Only Using Venous Access

Transcatheter closure of VSD remains a complex procedure in infants with technical challenges and carries the risk of significant complications, due to its complex anatomical morphology and closed proximity to the atrioventricular valves and the conduction system. In this article, we presented transcatheter VSD closure in infants under 10 kg using the Lifetech Konar-MF device via only venous route without TEE guidance and arterial access. Between January 2021 and May 2023, a total of 34 patients weighing less than 10 kg who underwent transcatheter VSD closure antegradely with Lifetech™ Konar-Multifunctional (MF) occluder were included in the study. The mean age of the patients was 8.1 (3.5-35) months. Average weight was 6.5 kg (range 4.5-10 kg). VSD was perimembranous in 27 patients (79.4%). Successful device placement was achieved in all 34 patients. However, device embolization occurred in three patients. One of the patients was successfully implanted with a one size larger device, the surgical closure was performed other two cases. TR occurred in seven patients (20.6%) after releasing devices. None of the patients developed complete heart block. Right bundle branch block developed in two patients. Residual shunt was observed in 9 patients (six small, two moderate, and one large). During follow-up, residual shunt disappeared in six of these patients and only mild residual shunt remained in the other four patients which have not required any further intervention. Transcatheter closure of VSD with Lifetech Konar-MF device is safe and effective in infants less than 10 kg via only venous access with a high success rate and low complication rate. In these patients, transcatheter VSD closure can be performed by excluding the risk of complications that may occur due to AV loop formation, arterial intervention, endotracheal intubation and TEE use.

Medium-Term Outcomes in Pediatric Patients Undergoing Cardiac Catheterization Early After Congenital Cardiac Surgery

Safety and acute outcomes for patients who need catheterization shortly after congenital cardiac surgery has been established; literature on mid-term outcomes is lacking. We sought to evaluate the mid-term outcomes of patients who undergo early postoperative cardiac catheterization. This is a retrospective cohort study of patients who underwent cardiac catheterization within 6 weeks of congenital cardiac surgery with longitudinal follow-up and assessment of mid-term outcomes. Multivariable analysis was utilized to relate variables of interest to outcomes. 99 patients underwent cardiac catheterizations within 6 weeks of cardiac surgery between January 2008 and September 2016. Forty-six (45.5%) interventional procedures were performed at a median age of 41 days (IQR 21-192) and a median weight of 3.9 kg (3.3-6.6). During a median follow-up duration of 4.24 years (1.6-5.6) in study survivors, 61% of patients remained free from the primary endpoint (death and/or transplant). Sixty-nine patients (69.7%) underwent an unplanned surgical or catheter procedure. Renal failure at catheterization (OR 280.5, p 0.0199), inotropic medication at catheterization (OR 14.8, p 0.002), and younger age were all significantly associated with meeting the primary endpoint. Patients requiring surgical intervention as an initial additional intervention underwent more unplanned re-interventions, while patients who survived to hospital discharge demonstrated favorable mortality, though with frequent need for re-intervention. In patients requiring early postoperative cardiac catheterization, renal failure, younger age, and need for inotropic support at catheterization are significantly associated with meeting the primary endpoint.

Review of surgical treatment of iatrogenic iliofemoral artery injury in the pediatric population after catheterization

Trauma is the leading cause of death in the pediatric population. Although vascular trauma has an incidence of 6% in civilian population, iatrogenic injuries are the leading cause, and the most frequent injured vessel is the iliofemoral sector. However, little information is available and there are no guidelines about its treatment. Therefore, this review aimed to describe the information available concerning pediatric iatrogenic arterial trauma, focusing on the iliofemoral segment and present 3 cases. We described 11 articles with 171 patients, of whom 61% underwent surgery to treat iatrogenic trauma. Mean age was 3.28 years (standard deviation of 3.5 years), and 54% were female. Most iliofemoral injuries occurred after arterial catheterization for hemodynamic monitorization and therapeutic or diagnostic cardiac catheterization (due to congenital heart diseases, including septal defects, tetralogy of Fallot, aortic coarctation, and patent ductus arteriosus). For acute complications, arterial thrombosis was the leading injury, followed by pseudoaneurysm, hematoma, dissection, transection, avulsion, eversion, and combined lesions.

Safety of Continuing Anticoagulation Prior to Cardiac Catheterization in Pediatric Patients: A Los Angeles Center Experience

This is the first report specifically describing outcomes of pediatric patients who underwent cardiac catheterization while on uninterrupted anticoagulation. One hundred forty-four cardiac catheterizations were identified that met inclusion criteria at our institution from 11/2014 to 10/2019. The median age and weight of the patients were 6.3 [0.01-20.9] years and 19.3 [2.1-172.5] kg, respectively. Seventy-eight (54%) catheterizations involved inpatients. The most common cardiac diagnoses among the cohort were single ventricle (n = 41), conotruncal defects (n = 37), and structurally normal heart (n = 16). The most common indications for anticoagulation were arterial/venous thrombus (n = 45), Fontan physiology (n = 32), and mechanical valve thrombus prophylaxis (n = 27). The anticoagulation medications used were warfarin (n = 57), heparin (n = 52), enoxaparin (n = 25), fondaparinux (n = 5), rivaroxaban (n = 2), and both heparin and warfarin (n = 3). Interventions were performed in 96 cases (67%). The median length of the procedure was 122.5 [15-760] minutes, and the median time to achieve hemostasis was 18.0 [range: 5-76, IQR: 13-25] minutes. Adverse events were present in 11 cases (7.6%), and of those only 2 cases (1.4%) were bleeding-related complications. Our single-center data suggest that performing cardiac catheterization on pediatric patients while on uninterrupted anticoagulation is safe and does not substantially increase the risk of bleeding complications based on a cohort of patients that varied in age, size, diagnosis, medical complexity, and type of intervention performed. Patients on warfarin therapy for a mechanical valve are most likely to benefit from this practice, as the ability to continue warfarin therapy avoids the need for bridging and other interruption-related complications.

Congenital heart disease: addressing the need for novel lower-risk percutaneous interventional strategies

INTRODUCTION

With the advent of improved neonatal care, increasingly vulnerable higher-risk patients with complex congenital heart anomalies are presenting for intervention. This group of patients will always have a higher risk of an adverse event during a procedure but by recognising this risk and with the introduction risk scoring systems and thus the development of novel lower risk procedures, the rate of adverse events can be reduced.

AREA COVERED

This article reviews risk scoring systems for congenital catheterization and demonstrates how they can be used to reduce the rate of adverse events. Then novel low risk strategies are discussed for low weight infants e.g. patent ductus arteriosus (PDA) stent insertion; premature infants e.g. PDA device closure; and transcatheter pulmonary valve replacement. Finally, how risk is assessed and managed within the inherent bias of an institution is discussed.

EXPERT OPINION

There has been a remarkable improvement in the rate of adverse events in congenital cardiac interventions but now, as the benchmark of mortality rate is switched to morbidity and quality of life, continued innovation into lower risk strategies and understanding inherent bias when assessing risk will be key to continuing this improvement.

Effects of time of bed rest on vascular complications after cardiac catheterization in pediatric patients with congenital heart disease: A randomized controlled trial

BACKGROUND

Pediatric cardiac catheterization, which is performed by accessing the femoral vessel, requires immobilization and bed rest for 4-6 h to prevent vascular complications. Studies in adults suggest that the immobilization time for the same access can be safely reduced to approximately 2 h after catheterization. However, it is unclear whether bed-rest time can be safely decreased after catheterization in children.

OBJECTIVE

To assess the effects of bed-rest duration on bleeding, vascular complications, pain level, and the use of additional sedatives after transfemoral cardiac catheterization in children with congenital heart disease.

METHODS

This study was an open-label, randomized, controlled, posttest-only design, including 86 children who underwent cardiac catheterization. Children were allocated to receive either 2 h of bed rest (n = 42) in the experimental group or 4 h of bed rest (n = 42) in the control group following catheterization.

RESULTS

The mean age of children was 3.93 (±3.82) years in the experimental group and 5.63 (±3.97) years in the control group. There was no difference in site bleeding incidence (P = 0.214), vascular complication score (P = 0.082), pain level (P = 0.445), or additional sedation use (P = 1.000) between the two groups.

CONCLUSIONS

There were no significant hemostatic complications after 2 h of bed rest following pediatric catheterization; therefore, 2 h of bed rest was as safe as 4 h of bed rest. (Trial registration: KCT0007737).

Visibility of Pulmonary Valve and Pulmonary Regurgitation on Intracardiac Echocardiography in Adult Patients with Tetralogy of Fallot

Pulmonary regurgitation (PR) is a risk factor for sudden cardiac death in adult patients with repaired tetralogy of Fallot (TOF). However, transthoracic echocardiography (TTE) cannot fully visualize the pulmonary valve (PV) and PR. We investigated whether intracardiac echocardiography (ICE) could visualize the PV and PR better than TTE. Thirty adult patients with TOF (mean age 33 ± 15 years) scheduled for cardiac catheterization underwent ICE. The visualization of PV and the severity of PR were classified into three grades. ICE depicted the PV better than TTE (ICE vs. TTE: not visualized, partially visualized, and fully visualized: n = 1 [3%], n = 13 [43%], and n = 16 [53%] vs. n = 14 [47%], n = 13 [43%], and n = 3 [10%], p < 0.001). Especially in patients after pulmonary valve replacement (PVR), the PV was more fully visualized by ICE. The assessment of PR by TTE underestimated the severity of PR in comparison to cardiac magnetic resonance imaging (MRI) (severe PR: 8 [28%] vs. 22 [76%], p = 0.004), while there was no discrepancy between the results of ICE and MRI (21 [72%] vs. 22 [76%], p = 1.000). In comparison to TTE, ICE can safely provide better visualization of the PV and PR in adults with TOF, especially in patients who have undergone PVR.

Inverse problems in blood flow modeling: A review

Mathematical and computational modeling of the cardiovascular system is increasingly providing non-invasive alternatives to traditional invasive clinical procedures. Moreover, it has the potential for generating additional diagnostic markers. In blood flow computations, the personalization of spatially distributed (i.e., 3D) models is a key step which relies on the formulation and numerical solution of inverse problems using clinical data, typically medical images for measuring both anatomy and function of the vasculature. In the last years, the development and application of inverse methods has rapidly expanded most likely due to the increased availability of data in clinical centers and the growing interest of modelers and clinicians in collaborating. Therefore, this work aims to provide a wide and comparative overview of literature within the last decade. We review the current state of the art of inverse problems in blood flows, focusing on studies considering fully dimensional fluid and fluid-solid models. The relevant physical models and hemodynamic measurement techniques are introduced, followed by a survey of mathematical data assimilation approaches used to solve different kinds of inverse problems, namely state and parameter estimation. An exhaustive discussion of the literature of the last decade is presented, structured by types of problems, models and available data.

Rejection surveillance in pediatric heart transplant recipients: Critical reflection on the role of frequent and long-term routine surveillance endomyocardial biopsies and comprehensive review of non-invasive rejection screening tools

BACKGROUND

Despite significant medical advances in the field of pediatric heart transplantation (HT), acute rejection remains an important cause of morbidity and mortality. Endomyocardial biopsy (EMB) remains the gold-standard method for diagnosing rejection but is an invasive, expensive, and stressful process. Given the potential adverse consequences of rejection, routine post-transplant rejection surveillance protocols incorporating EMB are widely employed to detect asymptomatic rejection. Each center employs their own specific routine rejection surveillance protocol, with no consensus on the optimal approach and with high inter-center variability. The utility of high-frequency and long-term routine surveillance biopsies (RSB) in pediatric HT has been called into question.

METHODS

Sources for this comprehensive review were primarily identified through searches in biomedical databases including MEDLINE and Embase.

RESULTS

The available literature suggests that the diagnostic yield of RSB is low beyond the first year post-HT and that a reduction in RSB intensity from high-frequency to low-frequency can be done safely with no impact on early and mid-term survival. Though there are emerging non-invasive methods of detecting asymptomatic rejection, the evidence is not yet strong enough for any test to replace EMB.

CONCLUSION

Overall, pediatric HT centers in North America should likely be doing fewer RSB than are currently performed. Risk factors for rejection should be considered when designing the optimal rejection surveillance strategy. Noninvasive testing including emerging biomarkers may have a complementary role to aid in safely reducing the need for RSB.

A large basal left ventricular pseudoaneurysm following pediatric cardiac surgery

Left ventricular pseudoaneurysm (LV-PSA) is a rare complication in children, usually developing after cardiac surgery, percutaneous procedures, infections, or trauma. Herein, we report a case of large basal submitral LV-PSA in a 36-day-old baby, detected 26 days after cardiac operation for hypoplastic arch, aortic coarctation, and small ventricular septal defect. No complications occurred in the first postoperative course, and early postoperative echocardiograms were normal. Despite large dimension of pseudoaneurysm, the baby presented with only mild tachypnea. The baby was successfully operated. Pseudoaneurysm, besides rare, could have an extremely broad and insidious clinical presentation and had to be considered in post-cardiac surgery follow-up echocardiogram at any time lapse.

Complicaciones relacionadas con el cateterismo cardíaco pediátrico y cardiopatías congénitas

INTRODUCTION

Congenital heart diseases are the most common congenital abnormalities in newborns with a prevalence of 1%. Therapeutic and diagnostic cardiac catheterization has revolutionized the treatment of these diseases; however, it can be associated with complications.

OBJECTIVE

To describe the incidence and type of complications associated with pediatric cardiac catheterization in a reference center for congenital heart defects.

METHODOLOGY

Retrospective observational study, with analytical intention based on records of cardiac catheterization performed on patients with congenital and acquired heart disease.

RESULTS

2,688 records were included for nine consecutive years. 53.9% were men, 21.3% with ages between 2 and 5 years and 20.3% between 6 months and 2 years. 63.5% of the procedures were elective. The prevalence of complications in the first 24 hours after catheterization was 6.7% (4.2% minor and 2.4% major). Early death occurred in 0.8% of the procedures. Factors associated with complications were age at catheterization <28 days (OR 2.18, 95% CI [1.28-3.70]), precatheter oxygen saturation <79% (OR 2.15, 95% CI [1.02-4.53]), use of pre-catheter inotropics (OR 3.00, 95% CI [1.68-5.33]). The variables included in the model explain 38% of the variance of post-cardiac catheterization complications in patients younger than 18 years.

DISCUSSION

Cardiac catheterization is associated with major and minor complications including death. The associated factors were less than 28 days, lower oxygen saturation and use of pre-catheter inotropics.

Infrared thermography as an adjunctive tool for detection of femoral arterial thrombosis after cardiac catheterization: A prospective, pilot study

OBJECTIVES

To assess the utility of infrared thermography (IRT), to map skin temperature, in the detection of femoral arterial (FA) thrombosis after cardiac catheterization.

BACKGROUND

Ultrasound is a validated method for thrombus detection but is generally reserved as a confirmatory test for clinical suspicion due to various constraints.

METHODS

Prospective study of infants and children undergoing cardiac catheterization via FA access, comparing IRT and pulse examination. The thermograms, displayed in a color map with each pixel representing a temperature, were examined by qualitative assessment of symmetry in thermal patterns and quantitative image analysis with abnormal thermographic asymmetry defined as a difference of >10% between limbs.

RESULTS

In the 20 children enrolled, excellent agreement was found between the two methods with a Kappa value of 0.89. The median thermographic asymmetry in the nine children with pulse loss was 36 (13-76)%. Using receiver operating characteristic analysis, the asymmetrical pattern of ≥18% between limbs predicted the need for anticoagulation with a sensitivity of 100% and specificity of 89%. The area under the curve was 0.97 (95% confidence interval: 0.95-1). Children with absent pulse requiring anticoagulation showed a slower recovery in thermal asymmetry compared to those with a reduced pulse. By qualitative IRT assessment, all children with absent pulse requiring anticoagulation were correctly identified by 10 independent assessors.

CONCLUSIONS

This pilot study showed that IRT is feasible and reliable as an adjunctive tool for thrombus detection postcatheterization and treatment monitoring. Specific advantages of IRT include portability, affordability, and contactless image acquisition.

Safety and feasibility of the paediatric post-cardiac catheterisation Wrap: a pilot study

OBJECTIVE

The paediatric post-cardiac catheterisation Wrap (Wrap), an innovative medical safety device, swaddles young paediatric patients in a supine position aiding in immobilisation post-cardiac catheterisation. This pilot study investigated the feasibility and safety of using the Wrap on young paediatric patients during their bed rest period following cardiac catheterisation with femoral access.

SETTING

Boston Children's Hospital Cardiac Catheterization Lab.

PARTICIPANTS

20 patients, ages 1-5 years and weighing 3-25 kg.

METHODS

Investigator-developed tools used to collect data included the Demographic and Outcome Measures Data Tool, the Parent/Caregiver Satisfaction, and Provider Ease of Use tools. They measured:1.The feasibility of using the Wrap2.Wrap ease of use from the nurse providers' perspective3.Parent satisfaction related to the Wrap4.Frequency of Wrap non-bleeding-related adverse events5.Frequency of rebleeding at femoral groin access sites.

RESULTS

The Wrap was feasible and safe; increased nurse provider satisfaction by allowing visualisation of the groin access sites while minimising the need for hands-on care; and increased parent satisfaction by allowing parents to hold and provide comfort while their child was on bed rest.

IMPLICATIONS FOR RESEARCH

The Wrap is a safe alternative to the current practice of swaddling with a bath blanket. Further studies are warranted to assess the Wrap's effectiveness in reducing the incidence of rebleeding events in the post-cardiac catheterisation period and explore clinical use outside of the Cardiac Catheterization Lab.

Transcatheter device closure of patent ductus arteriosus by exclusive venous access under echocardiographic guidance without angiography

INTRODUCTION

The standard transcatheter technique to profile the patent ductus arteriosus requires arterial access through the femoral artery and is associated with arterial complications, longer fluoroscopic time, contrast volume, and longer hospital stay.

AIM OF THE STUDY

To compare exclusive transvenous access with the standard procedures for patent ductus arteriosus closure and evaluate whether exclusive venous approach is a safe and effective alternative.

METHODS

A total of 320 patients were included. A detailed echocardiographic evaluation of the duct morphology was performed. Patients were classified into group 1 included patients who underwent exclusive femoral venous access, without any injections of contrast media and group 2 included patients who underwent arterial and venous access.

RESULTS

Arterial access was achieved in 210 (65.6%). Successful closure of patent ductus arteriosus was achieved in 109 (99.1%) patients in group 1 and in 203 (96.7%) patients in group 2. The patent ductus arteriosus was large and was referred for surgical closure in one patient from group 1 and 7 patients from group 2. Residual patent ductus arteriosus was seen in 6 cases from group 1 (5.4%) and 12 patients from group 2 (5.7%). None of the cases in group 1 had vascular complications, while vascular complications were seen in 20 cases, all of them in group 2 (9.5%). Nonvascular complications were seen in one patient from group 1 (0.9%) and 15 patients in group 2 (7.1%). The procedure time and fluoroscopy times were less in patients with exclusive transvenous access.

CONCLUSION

Patent ductus arteriosus device closure without arterial access can be accomplished safely and effectively.

Recoartación de la aorta en pacientes sometidos a angioplastia percutánea con o sin implantación de stent

Objetivo:

La coartación de la aorta puede ser tratada quirúrgicamente o con angioplastia con balón. El objetivo de nuestro estudio fue describir los resultados postangioplastia percutánea con balón con o sin implantación de stent para coartación de la aorta y establecer la incidencia de recoartación en el seguimiento.

Método:

Estudio de cohorte, se incluyeron pacientes de cualquier edad en un periodo de seguimiento de nueve años.

Resultados:

Se incluyeron 89 pacientes, un 69.0% hombres. La media de seguimiento para todos los participantes fue de 33.66 meses. Al 32.5% se les implantó un stent en angioplastia; de los cuales el 24.1% se recoartaron durante el seguimiento. En el grupo sin stent se recoartaron un 36.6%. No hubo diferencia significativa en las curvas de supervivencia de los dos grupos (p = 0.889).

Conclusiones:

La implantación de stent durante la angioplastia con balón para tratar coartación de aorta no influyó en la incidencia de recoartación de la aorta; pero factores como la hipertensión arterial preangioplastia y el gradiente final de angioplastia > 20 mmHg se asoció con recoartación de la aorta.

Noninvasive quantification of cerebrovascular pressure changes using 4D Flow MRI

PURPOSE

Hemodynamic alterations are indicative of cerebrovascular disease. However, the narrow and tortuous cerebrovasculature complicates image-based assessment, especially when quantifying relative pressure. Here, we present a systematic evaluation of image-based cerebrovascular relative pressure mapping, investigating the accuracy of the routinely used reduced Bernoulli (RB), the extended unsteady Bernoulli (UB), and the full-field virtual work-energy relative pressure ( ν WERP) method.

METHODS

Patient-specific in silico models were used to generate synthetic cerebrovascular 4D Flow MRI, with RB, UB, and ν WERP performance quantified as a function of spatiotemporal sampling and image noise. Cerebrovascular relative pressures were also derived in 4D Flow MRI from healthy volunteers ( n = 8 ), acquired at two spatial resolutions (dx = 1.1 and 0.8 mm).

RESULTS

The in silico analysis indicate that accurate relative pressure estimations are inherently coupled to spatial sampling: at dx = 1.0 mm high errors are reported for all methods; at dx = 0.5 mm ν WERP recovers relative pressures at a mean error of 0.02 ± 0.25 mm Hg, while errors remain higher for RB and UB (mean error of -2.18 ± 1.91 and -2.18 ± 1.87 mm Hg, respectively). The dependence on spatial sampling is also indicated in vivo, albeit with higher correlative dependence between resolutions using ν WERP (k = 0.64, R2 = 0.81 for dx = 1.1 vs. 0.8 mm) than with RB or UB (k = 0.04, R2 = 0.03, and k = 0.07, R2 = 0.07, respectively).

CONCLUSION

Image-based full-field methods such as ν WERP enable cerebrovascular relative pressure mapping; however, accuracy is directly dependent on utilized spatial resolution.

Low profile sheaths in pediatric neurointervention: a multicenter experience

BACKGROUND

Pediatric neurointervention is challenged by the appropriateness of adult catheters and devices. This multicenter report on the smallest groin access sheaths offers technical notes and clinical outcomes in the pediatric neurointerventional population.

METHODS

All pediatric neurointerventional cases from 2019 to 2021 were reviewed for use of a 3.3F Pediavascular or a 4F Merit Prelude Ideal low profile sheath. Hospital records were reviewed for complications and technical notes and compared with arterial groin access with the 4F Terumo Pinnacle in infants less than 1 year old, before the low profile sheaths at one author's institution were introduced.

RESULTS

From January 1, 2019 to March 31, 2021 there were 347 procedures performed at Boston Children's Hospital and University of Wisconsin. Forty-four procedures in 26 patients were identified in which a 3.3F (38 cases, 20 patients) or 4F (6 cases, 6 patients) sheath was used. The average age was 2.2 years (1.5 days to 18 years). Retinoblastoma intra-arterial chemotherapy infusion (18 of 44) was the most common indication. The remaining procedures comprised vein of Galen embolization (12), diagnostic cerebral angiography (13), and one preoperative tumor embolization. Morbidity included a groin hematoma and decreased pulses (4.5%). No major groin complications occurred. There was no statistically significant difference compared with the historical cohort (132 procedures), which had seven instances of decreased pulses (5.3%, p>0.05).

CONCLUSION

The 3.3F Pediavascular and 4F Merit Prelude Ideal sheaths are easily incorporated into the pediatric neurointerventionalist's armamentarium for infants and readily accommodate various microcatheters for distal embolization and catheterization.

Residual Lesion Diagnostics in Pediatric Postcardiotomy Extracorporeal Membrane Oxygenation and Its Outcomes

BACKGROUND

To assess the impact of diagnostic procedures in identifying residual lesions during extracorporeal membrane oxygenation (ECMO) on survival after pediatric cardiac surgery.

METHODS

Between January 2012 and December 2017, 74 patients required postcardiotomy ECMO. Patients were retrospectively divided into 2 groups: Group I underwent only echocardiography ([echo only] 46 patients, 62.2%) and group II (echo+) underwent additional diagnostic tests (ie, computed tomography [CT] or cardiac catheterization; 28 patients, 37.8%). Propensity score matching was used to balance the 2 groups by baseline characteristics.

RESULTS

Two equal groups (28 patients in each group) were formed by propensity score matching. Fourteen (50%) patients in the echo-only group and 20 (71%) patients in the echo+ group were successfully weaned from ECMO (P = .17). Four (14.3%) patients survived in the echo-only group and 15 (53.5%) patients survived in the echo+ group (P = .004). Patients in the echo+ group had a lower chance of dying compared to the echo-only group (odds ratio, 0.14.6; 95% CI, 0.039-0.52; P = .003). The residual lesions, which may have served as a mortality factor, were found by autopsy in 8 (40%) patients in the echo-only group, while none were found in the echo+ group (P = .014).

CONCLUSIONS

The autopsies of patients who died despite postcardiotomy ECMO support showed that in 40% of cases that had been investigated by echo only, residual lesions that had not been detected by echocardiography were present. The cardiac catheterization and CT during ECMO are effective and safe for identifying residual lesions. Early detection and repair of residual lesions may increase the survival rate of pediatric cardiac patients on ECMO.

Evaluation of carotid artery access in comparison with femoral artery access in neonatal percutaneous stenting of ductus arteriosus

BACKGROUND

Patent ductus arteriosus stenting in duct-dependent pulmonary circulation is a challenging procedure. Percutaneous carotid artery access for ductal stenting has proven to be feasible; however, comparison with femoral artery access in terms of procedure details and complications either immediate or late is scarce. Therefore, we evaluated carotid artery access in comparison with femoral artery for stenting of patent ductus arteriosus.

METHODS

Forty neonates were reviewed, 20 were stented via carotid artery access, and 20 via the traditional femoral artery access. Comparison variables were neonatal demographics at the procedure, angiographic ductal anatomy, procedure details, and immediate complications. Follow-up Doppler ultrasound on access site was performed to document late complications.

RESULTS

Median age of included cases was 10.5 (3-28) days with complex ductal anatomy more frequently accessed via carotid artery than femoral. Immediate access-related complications were significantly higher with femoral than carotid artery access; 9 (45%) versus 3 (15%) respectively, p = 0.038. With carotid access, we had only one case with small pseudoaneurysm and acute hemiparesis 3 days after the procedure. Delayed local complications were more common with femoral access (15%) than carotid access (5%), mild stenosis in one case, and severe in another with femoral access; while with transcarotid arterial access, only one case had mild narrowing.

CONCLUSION

Percutaneous carotid artery access in neonates is a more convenient approach for patent ductus arteriosus stenting especially with complex ductal anatomy. Moreover, local complications are limited and vascular patency is better preserved, in comparison with trans-femoral arterial access. However, the potential for neurological adverse events should not be overlooked.

Model-based iterative reconstruction for 320-detector row CT angiography reduces radiation exposure in infants with complex congenital heart disease

PURPOSE

We investigated the impact of model-based iterative reconstruction (MBIR) on 320-detector row computed tomography angiography (CTA) in infants with complex congenital heart disease (CHD).

METHODS

Seventy infants with complex CHD who underwent 320-detector row CTA (40 boys and 30 girls; age range, 0-22 months; median age, 60 days) were retrospectively evaluated. First, the images were reconstructed by filtered back projection (FBP), hybrid iterative reconstruction (HIR), or MBIR in 20 cases, and variables were compared among the three iterative reconstruction methods (IR test). Second, the variables were compared between 25 cases scanned using HIR and 25 cases scanned using MBIR, with a 20 standard deviation noise level for both. Attenuation values and contrast-to-noise ratios (CNRs) of the great vessels and heart chambers were calculated. Total dose-length products were recorded for all patients (radiation dose: RD test).

RESULTS

In the IR test, the mean CNR values were 4.8±1.3 for FBP, 6.9±1.4 for HIR, and 8.2±1.7 for MBIR (P < 0.0001). The best subjective image qualities in the great vessels and heart chambers were obtained with MBIR. In RD testing, no significant differences between HIR and MBIR in image quality (CNR: HIR, 8.4±2.4; MBIR, 8.3±2.4) were observed. The effective dose was significantly lower for MBIR than for HIR (0.7±0.2 vs. 1.1±0.3 mSv; P < 0.001).

CONCLUSION

The MBIR algorithm significantly improved image quality and decreased radiation exposure in 320-row CTA of infants with complex CHD, providing an alternative to FBP or HIR that is both safer and produces better results.

Anomalous Origin of the Coronary Artery from the Pulmonary Artery in Children and Adults: A Pictorial Review of Cardiac Imaging Findings

Anomalous origin of the coronary artery from the pulmonary artery is a rare and potentially fatal congenital heart defect. Up to 90% of infants with an anomaly involving the left coronary artery die within the first year of life if left untreated. Patients who survive beyond infancy are at risk of sudden cardiac death. Cardiac CT and MRI are increasingly being used for the accurate diagnosis of this anomaly for prompt surgical restoration of the dual coronary artery system. Moreover, life-long imaging surveillance after surgery is necessary for these patients. In this pictorial review, multimodal cardiac imaging findings of this rare and potentially fatal coronary artery anomaly are comprehensively discussed, and representative images are provided to facilitate the understanding of this anomaly.

Non-invasive estimation of relative pressure for intracardiac flows using virtual work-energy

Intracardiac blood flow is driven by differences in relative pressure, and assessing these is critical in understanding cardiac disease. Non-invasive image-based methods exist to assess relative pressure, however, the complex flow and dynamically moving fluid domain of the intracardiac space limits assessment. Recently, we proposed a method, νWERP, utilizing an auxiliary virtual field to probe relative pressure through complex, and previously inaccessible flow domains. Here we present an extension of νWERP for intracardiac flow assessments, solving the virtual field over sub-domains to effectively handle the dynamically shifting flow domain. The extended νWERP is validated in an in-silico benchmark problem, as well as in a patient-specific simulation model of the left heart, proving accurate over ranges of realistic image resolutions and noise levels, as well as superior to alternative approaches. Lastly, the extended νWERP is applied on clinically acquired 4D Flow MRI data, exhibiting realistic ventricular relative pressure patterns, as well as indicating signs of diastolic dysfunction in an exemplifying patient case. Summarized, the extended νWERP approach represents a directly applicable implementation for intracardiac flow assessments.

Percutaneous catheter interventions via Glidesheath Slender in small children

BACKGROUND

Catheterization in small children should be performed with the lowest diameter introducer sheaths to prevent permanent vessel damage. The objective of this study is to evaluate the clinical safety and efficacy of the Glidesheath Slender in small children.

METHODS AND RESULTS

We present a group of 52 patients (male: n = 36) with median age 118.5 days (min. 3; max. 1302), median weight: 5.3 kg (min. 1.4; max. 14.0), median height: 60.5 cm (min. 39; max. 102), and median body surface area 0.28 m2 (min. 0.12; max. 0.63) in whom percutaneous catheter interventions (n = 55) were performed via a Glidesheath Slender. In 49 children, the intervention was performed from femoral access (artery n = 35; vein n = 14) in 2 from the axillary arterial access and in 1 from the jugular venous access. In all patients, the vessel access was obtained under ultrasound guidance. After the catheterization, the pulse on the peripheral arteries (posterior tibial artery or radial artery) was palpable in all patients, and no signs for vessel dysfunction were present.

CONCLUSION

The Glidesheath Slender effectively reduces the outer sheath diameter for various types of interventions in small children by one French, reducing the risk of vessel complications (stenosis, occlusion). Interventions via Glidesheath Slender in small patients are safe and feasible and extend the transcatheter possibilities in small children with congenital heart diseases.

Comparison of isolated venous approach with the standard approach in children undergoing patent ductus arteriosus device closure

BACKGROUND

Transcatheter device closure is a safe procedure recommended in children with patent ductus arteriosus (PDA). While the standard procedure uses arterial and venous femoral access, it poses risk of vascular complications especially in young infants. Isolated venous approach has been tried in a few studies and was found to be non-inferior to the standard technique. In this prospective observational study, we have compared the two vascular approaches of PDA device closure in pediatric patients and have also studied the feasibility of this approach in young children with weight < 6 kg.

RESULTS

PDA device occlusion was performed with either one of the approaches-venous alone (group I) or standard approach (group II) in a total of 135 children enrolled prospectively. The baseline data, procedural outcomes, vascular complications, and radiation dose were compared between the two groups. Fifty-two and 83 children were included in group I and group II, respectively. A total of 22 children (16%) (13 in group I; 9 in group II) had weight < 6 kg. In group II, 6 children (7.2%) had vascular site complications treated with heparin infusion with two children requiring thrombolysis. Another child in group II developed intravascular hemolysis following residual shunt, requiring surgical device retrieval and closure. No significant differences were observed in mean fluoroscopic time (p = 0.472) and air kerma between the two groups (p = 0.989).

CONCLUSION

Transcatheter PDA device closure without arterial access is a feasible and safe option in children including young infants. This technique avoids the risk of vascular complications although requires careful case selection.

The effect of the duration of the procedure on the risk of complications during pediatric cardiac catheterization

Background

This study aims to evaluate the frequency of and associated risk factors for adverse events caused by cardiac catheterization procedures in pediatric patients.

Methods

Between January 2009 and January 2012, a total of 599 pediatric patients (320 males, 279 females; mean age 5.4±4.7 years; range, 1 day to 21 years) who underwent cardiac catheterization in our cardiac catheterization laboratory were retrospectively analyzed. Demographic and clinical data of the patients including the duration of the procedure, management of anesthesia, the American Society of Anesthesiologists class, and Catheterization Risk Score for Pediatrics, and procedure-related serious adverse events were recorded.

Results

The incidence of procedure-related serious adverse events was 9.18%. Potential risk factors associated with serious adverse events were identified as interventional heart catheterization, high scores obtained from the Catheterization Risk Score for Pediatrics, the use of endotracheal tube in airway control, and prolonged procedural duration.

Conclusion

Our study results suggest that prolonged duration of catheterization is a potential risk factor for procedure-related adverse events and the duration of the procedure needs to be included as a variable in the Catheterization Risk Score for Pediatrics scoring system for predicting procedure-related adverse events.

Emerging predictors of femoral artery occlusion after pediatric cardiac catheterization

The Objective was to review the prevalence of femoral artery occlusion (FAO) after cardiac catheterization in children up to 12 years old from two centers in China and identify its related risk factors. After collecting clinical data from patients who had undergone pediatric cardiac catheterization, univariate and multivariate analysis were used to evaluate the correlations between FAO and clinical factors, including sex, age, height, weight, sheath size, operation time, therapeutic strategy, sheath/age, sheath/height and sheath/weight. The ROC curve was also used to assess the influence of risk factors to predict FAO. FAO occurred in 19 (0.9%) out of 2,084 children following cardiac catheterization. Patients with younger age, lower height, longer operation time, electrophysiological (EP) diagnosis or/and therapy for arrhythmias, higher Sheath/Age, higher Sheath/Height and higher Sheath/Weight ratios had higher risk for FAO compared to their respective control groups (p < 0.05). In the multivariate analysis, sheath/age and operation time were independent risk factors for FAO. Patients with operation time > 77.5 min or sheath/age > 0.5334 had a significantly higher risk for FAO. Operation time and sheath/age were confirmed as significant and independent risk factors associated with FAO. Operation time > 77.5 min and sheath/age > 0.5334 could effectively predict high risk of FAO after pediatric cardiac catheterization.

Construction of Femoral Vessel Nomograms for Planning Cardiac Interventional Procedures in Children 0-4 Years Old

The objectives of this study were to construct femoral artery (FA) and femoral vein (FV) nomograms in children aged 0-4 years and to construct probability curves for the occurrence of arterial access complications based on the size of the FA. The FV and FA are commonly accessed during cardiac catheterizations in children with congenital heart diseases (CHD). However, nomograms for vessel dimensions based on child's age or size are not available. This knowledge may be helpful for interventional planning. A prospective study was performed on 400 children (age 0-4 years) with CHD undergoing cardiac catheterizations over a 3-year period. Ultrasound evaluation of the right and left FA and FV was performed under anesthesia prior to vascular access. Regression modeling was applied to derive nomograms based on quantile polynomial regression, which yielded good fit to the data judged by R-squared. GAMLSS transformation method was used to formulate smoothed percentiles. A separate prospective evaluation of FA to determine the size below which loss of pulse (LOP) are likely to occur was performed. Nomograms for FA and FV diameter and cross-sectional area against age and body surface area and probability curves for FA LOP were constructed. It is now possible to examine ultrasound-based normal sizes of femoral vein and artery in children 0-4 years of age. Femoral vessel nomograms and LOP probability curves may help with interventional planning. Future studies with larger sample size, including children of other ages may be useful.

Pediatric Anesthesia Outside the Operating Room: Case Management

Anesthesiology teams care for children in diverse locations, including diagnostic and interventional radiology, gastroenterology and pulmonary endoscopy suites, radiation oncology units, and cardiac catheterization laboratories. To provide safe, high-quality care, anesthesiologists working in these environments must understand the unique environmental and perioperative considerations and risks involved with each remote location and patient population. Once these variables are addressed, anesthesia and procedural teams can coordinate to ensure that patients and families receive the same high-quality care that they have come to expect in the operating room. This article also describes some of the considerations for anesthetic care in outfield locations.

Accessing Femoral Arteries Less than 3 mm in Diameter is Associated with Increased Incidence of Loss of Pulse Following Cardiac Catheterization in Infants

To evaluate whether avoidance of a risk factor associated with loss of pulse (LOP) following femoral artery (FA) catheterization in infants identified from previous study, was associated with decreased incidence of LOP during a prospective evaluation. Since initiation of routine ultrasound guided femoral arterial access (UGFAA) for infants undergoing catheterization in Jan 2003-Dec 2011 (Period-1), our incidence of LOP had stayed steady. Prospective evaluation between Jan 2012-Dec 2014 (Period-2), identified FA-diameter < 3 mm as risk factor for LOP. Between Jan 2015-Dec 2018 (Period-3), an initiative to avoid UGFAA for FA-diameter < 3 mm was implemented to determine whether that led to a decreased incidence of LOP. FA-diameter was measured prior to USGFAA and ratio of outer diameter of arterial sheath to luminal diameter of cannulated artery (OD/AD ratio) was calculated during Periods-2 and 3. The incidence and risk factors for LOP were assessed during the three periods. FA-access rates dropped significantly during Period-3 (56.7% vs. 93.8% and 90.4% during Periods-1 and 2, respectively, p < 0.001). Incidence of LOP in Period-3 decreased to 2.7% compared to 12.5% (Period-1) and 17.4% (Period-2) (p < 0.001). By multivariate analysis, FA size < 3 mm and an OD/AD ratio > 40% were the only significant independent predictors for LOP (OR 6.48, 95% CI 2.3-11.42, p < 0.001 and OR 4.16, 95% CI 1.79-8.65, p < 0.01, respectively). Access of femoral artery < 3 mm and OD/AD ratio > 50% are associated with increased incidence of LOP. Avoidance of these factors may help decrease complications in infants undergoing cardiac catheterizations.

Geometry of the pulmonary arteries before the Fontan operation: can we influence it during the Norwood procedure?

OBJECTIVES

The right ventricle-to-pulmonary artery (RV-PA) shunt provides stable haemodynamics after the Norwood procedure but can influence development of the central pulmonary arteries (PAs). The goal of this study was to analyse the geometry of the central PAs in children with hypoplastic left heart syndrome before the Fontan operation with respect to the RV-PA shunt site and the type of the second-stage operation.

METHODS

A total of 161 children with hypoplastic left heart syndrome, median age 2.7 (range 1.3-9.8) years and median weight 12.7 (range 7.6-26.1) kg, underwent the Fontan operation after having had the Norwood procedure with an RV-PA shunt. The patients were divided into 2 groups: left-sided RV-PA (L-RV-PA) (n = 129) with the shunt on the left and right-sided RV-PA (n = 32) with the shunt on the right side of the neoaorta. Angiographic data obtained before the Fontan and all cardiac catheterization interventions were analysed retrospectively.

RESULTS

Between the second and third stages, as well as directly before the Fontan operation, the L-RV-PA group required more PA catheter interventions (P = 0.001 and P = 0.03). In this group, the minimal left PA diameter was smaller than that in the R-RV-PA group (P = 0.021). Leaving the shunt open until the Fontan operation increased the rate of PA interventions in the L-RV-PA group (P = 0.001), but there is no evidence of the impact on the development of the left PAs (P = 0.075). There is also no evidence that the type of the second-stage procedure influences the intervention rate before the Fontan procedure (P = 0.14).

CONCLUSIONS

Children who have the L-RV-PA shunt require more PA catheter interventions. The right-sided RV-PA shunt and the subsequent Glenn anastomosis in the place of the shunt are associated with distortion-free and more symmetrical development of the central PAs.

Imaging Spectrum of Double-Outlet Right Ventricle on Multislice Computed Tomography

Double-outlet right ventricle is a complex congenital heart disease that encompasses various common and rare subtypes. Surgical management of these patients needs to be individualized owing to extremely variable morphology and hemodynamics. Imaging plays a crucial role in determination and characterization of outflow tract morphology. The assessment of ventricular septal defect routability with identification of associated anomalies has therapeutic implications in these patients. Multislice computed tomography with advanced 3-dimensional postprocessing techniques and dose-reduction strategies is invaluable in defining the anatomy and morphology of double-outlet right ventricle with simultaneous assessment of associated anomalies.

Different unfractionated heparin doses for preventing arterial thrombosis in children undergoing cardiac catheterization

BACKGROUND

The role of cardiac catheterization in pediatrics has progressed significantly over the last two decades, evolving from a primary diagnostic tool to a primary treatment modality in children with congenital heart disease. Vascular complications, particularly arterial thrombosis, are among the most common unwanted post-cardiac catheterization events. In 1974, unfractionated heparin proved to be superior to placebo in decreasing the incidence of arterial thrombosis in pediatric patients. However, the optimal dose of unfractionated heparin to be utilized in this setting remains a matter of controversy. This is an update of the review first published in 2014.

OBJECTIVES

To evaluate the use of low-dose (< 100 units/kg) versus high-dose (≥ 100 units/kg) unfractionated heparin administered as an intravenous bolus at the time of initiation of cardiac catheterization (that is, immediately after arterial puncture), with or without subsequent heparin maintenance doses, for the prevention of post-procedural arterial thrombosis in children.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 15 October 2019. We planned to undertake reference checking of identified trials to identify additional studies. No language restrictions were applied.

SELECTION CRITERIA

We included randomized or quasi-randomized trials that compared low dose to high dose unfractionated heparin administered prior to cardiac catheterization. We selected studies conducted in children aged 0 to 18 years.

DATA COLLECTION AND ANALYSIS

The first screening of potentially eligible studies was conducted by one of the authors (MLA). The second screening, risk of bias assessment and data extraction were independently conducted by two authors (MLA, LRB). Outcomes (thrombotic events, bleeding complications, other complications) were treated as dichotomous variables. The effect measures used were risk ratio (RR), risk difference (RD) and number needed to treat (NNT), with 95% confidence intervals (CI). We assessed the certainty of evidence for each outcome using the GRADE approach.

MAIN RESULTS

We identified no new studies for inclusion in this review. In total, two studies with a total of 492 participants were included. We had concerns about risk of bias for one of the two studies. The certainty of the evidence for our key outcomes was downgraded to moderate due to risk of bias concerns and imprecision. The confidence interval for the risk of arterial thrombotic events was compatible with benefits of either high or low unfractionated heparin dose regimens (RR low-dose versus high-dose 1.06, 95% CI 0.58 to 1.92). Only one of the studies reported the frequency of bleeding events and found no clear difference in the incidence of major or minor bleeding events between arms (RR low-dose versus high-dose 2.96, 95% CI 0.12 to 71.34 for major bleeding events; RR low-dose versus high-dose 1.38, 95% CI 0.46 to 4.13 for minor bleeding). This study also reported on the incidence of deep vein thrombosis when comparing the high versus low dose of heparin and reported a non-significant difference (RR low-dose versus high-dose 0.34, 95% CI 0.01 to 8.28). The other study lacked information about bleeding. Additional side effects of heparin other than bleeding events were not reported in either of the studies.

AUTHORS' CONCLUSIONS

Due to the limitations of the current evidence, small number of included studies, and lack of details reported in one study, we are unable to determine the effects of different dosing regimens of unfractionated heparin for the prevention of vascular thrombosis during cardiac catheterization in children. Further adequately powered, randomized clinical trials are needed.

Reperfusion Injury with Compartment Syndrome Following Systemic Thrombolysis for Cardiac Catheterization-Related Arterial Thrombosis in an Infant

Systemic thrombolysis is increasingly used for management of arterial thrombosis following cardiac catheterization, and complications apart from bleeding manifestations are not well reported. We report the case of an infant with lower limb ischemia secondary to femoral arterial thrombosis, which developed after cardiac catheterization. Systemic thrombolysis resulted in successful reperfusion of the lower limb. However, the infant subsequently developed compartment syndrome, requiring an emergent fasciotomy. This case highlights the importance of surveillance for the development of reperfusion injury-related compartment syndrome postsystemic thrombolysis for arterial thrombosis.

Recoarctation of the aorta after the Norwood procedure may be treated during the second stage of the surgical palliation

OBJECTIVES

Recoarctation of the aorta (re-CoA) after the Norwood procedure is traditionally treated during catheter-based aortoplasty (CB-A) performed as a separate procedure preceding stage II surgical palliation (S II SP). Our goal was to determine the efficacy of the protocol according to which re-CoA after the Norwood procedure in patients with hypoplastic left heart syndrome is treated during S II SP using hybrid catheter-based aortoplasty.

METHODS

We compared 2 groups of infants who developed re-CoA after the Norwood procedure and were treated at the same institution: In group I (n = 18), CB-A was traditionally performed before S II SP; in group II (n = 15), CB-A was performed during S II SP using a hybrid procedure (catheter access was through an aortic cannula routinely used for cardiopulmonary bypass). The right ventricular fractional area change was analysed.

RESULTS

The CB-A was performed effectively in both groups. S II SP was performed at a younger age in group II (5.4 ± 0.3 vs 6.0 ± 0.4 months; P = 0.003), with lower body weight (5.6 ± 0.5 vs 6.0 ± 0.4; P = 0.03, respectively). The duration of hospital stay did not differ between the groups (10.6 ± 6.2 vs 11.6 ± 6.4 days; P = 0.91). The right ventricular fractional area change measured before S II SP was higher in group I (39.7 ± 4.2% vs 36.8 ± 3.6%, respectively; P = 0.009), but the difference was not seen 1 month after S II SP (41.0 ± 5.6 vs 39.8 ± 4.1; P > 0.05). The total radiation dose was significantly lower in group II.

CONCLUSIONS

re-CoA after the Norwood procedure in patients with hypoplastic left heart syndrome can be treated effectively during S II SP using a hybrid procedure. The strategy allows for reduction of the total radiation dose and of the number of procedures and does not prolong the postoperative course, even in patients with decreased right ventricular systolic function.

Echocardiography-guided percutaneous closure of perimembranous ventricular septal defects without arterial access and fluoroscopy

Background

Traditional percutaneous device closure of perimembranous ventricular septal defects (PmVSDs) is a minimally invasive technique, but can result in high radiation exposure and can result in potential arterial complications. Here, we aimed to assess the safety and feasibility of device closure of PmVSDs via the femoral vein approach under transesophageal echocardiography (TEE) guidance in children.

Methods

From January 2014 to December 2017, a total of 46 PmVSD patients (mean age, 6.5 ± 2.3 years [range, 4.2–12.0 years]; mean body weight 22.1 ± 6.6 kg [range, 16.0–38.5 kg]; VSD diameter, 4.1 ± 0.6 mm [range, 3.2–5.0 mm]) underwent attempted transcatheter closure via the femoral vein approach under the guidance of TEE without fluoroscopy.

Results

The transcatheter occlusion procedure under TEE guidance was successful in 44 (95.7%) patients. Surgery was necessary in 2 (4.3%) patients. The procedure duration was 28.2 ± 8.7 min (range, 12.0–42.0 min). One patient had immediate post-operative trivial residual shunt and three patients had immediate incomplete right bundle branch block (IRBBB) after operation; the new IRBBB in 1 case was noted in the first postoperative month. No residual shunt was noted at 3 months after the procedure, and no intervention related complications were detected at 1–24 months follow-up.

Conclusions

Percutaneous device closure of PmVSDs under TEE guidance solely by femoral vein approach is effective and safe, avoids radiation exposure, potential arterial complications and a surgical incision.

Electronic supplementary material

The online version of this article (10.1186/s12887-019-1687-0) contains supplementary material, which is available to authorized users.

Unanticipated admissions to paediatric cardiac critical care after cardiac catheterisations

OBJECTIVES

Cardiac catheterisation is commonly used for diagnosis and therapeutic interventions in paediatric cardiology. The inherent risk of the procedure can result in unanticipated admissions to critical care. Our goals were to provide a qualitative description of characteristics and evaluation of children admitted unexpectedly to the cardiac critical care unit (CCCU).

METHODS

A retrospective single centre review of cardiac catheterisation procedures was done between 1 January, 2003 and 30 April, 2013.

RESULTS

Of 9336 cardiac catheterisations performed, 146 (1.6%) were admitted from the catheterisation laboratory to the CCCU and met inclusion criteria. Of these 146 patients, 117 (1.3%) met criteria for unexpected admission and 29 (0.3%) were planned admissions. The majority admitted unexpectedly were below 1 year of age without co-morbidity aside from heart disease. Patients with planned admissions were significantly more likely to have single ventricle physiology, undergoing angiography or transferred for observation. Most unplanned admissions were triggered by interventional catheterisations or procedure-related complications. Patients received mechanical ventilation as the main CCCU management. Eighteen patients needed either cardiopulmonary resuscitation and/or extracorporeal membrane oxygenation during their catheterisation. About 106/117 (90.6%) patients survived to hospital discharge with no deaths in the planned admission group.

CONCLUSIONS

Admission to CCCU following cardiac catheterisation was uncommon and tended to occur in younger children undergoing interventional procedures. Outcomes did not differ between patients experiencing planned and unplanned CCCU admission. Ongoing development of risk stratification tools may help to decrease unplanned CCCU admissions. Further studies are needed to determine whether unplanned admission following paediatric cardiac catheterisation should be utilised as a quality indicator.

Cardiac catheterisation in infants weighing less than 2500 grams

OBJECTIVES

The aim of the study was to report the outcome of cardiac catheterisation in low-weight patients.

BACKGROUND

Data regarding cardiac catheterisation in infants weighing &lt;2500 g are scarce.

METHODS

We reviewed all cardiac catheterisations performed in infants weighing &lt;2500 g between January 2000 and May 2016. An analysis with respect to the type of procedure, the complexity of procedure (procedure type risk), and haemodynamic vulnerability index was finally carried out. We report the occurrence of deaths and complications using the adverse event severity score.

RESULTS

A total of 218 procedures were performed on 211 patients. The mean age and weight were, respectively, 15 ± 26 days (range, 0-152) and 2111 ± 338 g (range, 1000-2500). Procedures were interventional and diagnostic, respectively, in 174 (80%) and 44 (20%) patients. Out of 218, 205 (94%) were successful. Eleven complications (5%) occurred - six with an adverse event severity score of 4 and five with an adverse event severity score of 3. Ten patients (91%) showed a favourable outcome, and one died (stent thrombosis few hours after patent ductus arteriosus stenting). No correlation was found between lower weight and occurrence of death (p = 0.68) or complications (p = 0.23). The gravity scores (procedure type risk and haemodynamic vulnerability index) were not predictive of complications.

CONCLUSIONS

Cardiac catheterisation in infants weighing &lt;2500 g appears feasible and effective with low risk. The weight should not discourage from performing cardiac catheterisation in this population.

Anesthesia for high-risk procedures in the catheterization laboratory

Recent advances in catheterization and imaging technology allow for more complex procedures to be performed in the catheterization laboratory. A number of lesions are now amenable to a percutaneous procedure, eliminating or at least postponing the need for a surgical intervention. Due to the increase in the complexity of the procedures performed, the involvement of anesthesiologists and their close collaboration with the interventional cardiologists have increased. It is important to understand the physiology and pathophysiology of the patients and to anticipate the plans and the potential complications in order to manage them. We are witnessing a rise in the number of complex interventions in newborns and infants, such as balloon valvotomy (critical aortic stenosis, pulmonary stenosis), radio frequency perforation (of pulmonary atresia and intact ventricular septum), right ventricular outflow tract stenting (in Tetralogy of Fallot), ductal stenting (in some ductus-dependent pulmonary circulation), and combined with a surgical procedure (hybrid procedure for hypoplastic left heart syndrome). Multiple registries have been created in order to understand and improve outcomes of patients with congenital heart disease undergoing catheterization procedures and to develop performance and quality metrics, from which data regarding anesthetic-related risks can be extrapolated. Experienced personnel and a multidisciplinary team approach with direct communication among the team members is a must to ensure anticipation and management of critical events when they occur.

Catheterization Performed in the Early Postoperative Period After Congenital Heart Surgery in Children

The aim of this study was to describe pediatric patients who underwent early postoperative cardiac catheterization after congenital heart surgery, their clinical indications, findings, interventions, and complications in a cardiovascular center. A descriptive retrospective study was performed. All catheterizations performed within 6 weeks after congenital heart surgery between January 2004 and December 2014 were reviewed. We analyzed 101 early postoperative catheterizations. They were performed on median postoperative day five (IQR: 0-39); the median age was 64 days (IQR: 22-240). The most common diagnoses were single ventricle (53%), left heart obstruction (12%), and tetralogy of fallot or pulmonary atresia with ventricular septal defect (11%). Most common indications were persistent cyanosis (53%), low cardiac output (24%), and residual defect on echocardiogram (20%). Most frequent findings during the catheterization were pulmonary artery stenosis (29%), surgical conduit obstruction (12%), and coarctation or hypoplasia of the aorta (11%). Forty-six (45%) procedures involved intervention. Most frequent interventions were pulmonary artery, aorta, and Blalock-Taussig fistula angioplasty with or without stent implantation. There were adverse effects in 11 cases (11%), and 30-day mortality was 28% (28 patients) with the majority unrelated to the catheterization directly. Although early postoperative catheterizations are high-risk procedures, they are currently a very good option to solve acute problems in critically ill patients. This study provides relevant information for a better understanding and approach to this complex group of patients.

Percutaneous ultrasound guided thrombin injection for axillary artery pseudoaneurysm following stenting of the arterial duct in two infants: Case report with review of literature

We report pseudoaneurysm of the axillary artery following stenting of the arterial duct in two infants. They were both successfully managed by ultrasound guided thrombin injection with preservation of native arterial flow. We also review the relevant literature.

Impact of Congenital Cardiac Catheterization Project on Outcomes-Quality Improvement (C3PO-QI) in LMICs

Background

The importance of registries for collaborative quality improvement has been overlooked in low/middle-income countries (LMIC). Aga Khan University Hospital (AKUH) in Pakistan joined the Congenital Cardiac Catheterization Project on Outcomes-Quality Improvement (C3PO-QI) in March 2017 with the goal of leveraging international collaboration to improve patient care and institutional standards.

Methods

The C3PO-QI key driver-based approach was used, with certain modifications, for process re-engineering in AKUH's congenital cardiac catheterisation laboratory (CCL) to reduce radiation exposure during cardiac catheterisation procedures (the primary outcome of C3PO- QI). Educating staff and standardising procedural documentation were the principal goals of the process re-engineering. Data survey was used to assess staff knowledge, attitude and practice before and after the initiative. Additionally, case demographics and outcomes were compared between AKUH and C3PO-QI centres.

Results

There was an increase in appropriate recording of radiation surrogates (0%-100%, p=0.00) and in the percentage of cases that met the established benchmark of 'Ideal documentation' (35% vs 95%, p=0.001). There was also an increase in self-reported staff interest during the case (25% vs 75%, p=0.001). AKUH versus C3PO-QI data showed similar demographic characteristics. There was a slight over-representation of diagnostic cases (42% vs 32%) as compared with interventional (58% vs 68%) at AKUH. Furthermore, interventional procedures were predominately PDA and ASD device closures (n=19 and 15, respectively). The frequency of adverse events were the same between AKUH and collaborative sites.

Conclusion

Collaborative efforts between developed and LMIC CCL are significant in advancing system-level processes.

Estimation of Cardiovascular Relative Pressure Using Virtual Work-Energy

Many cardiovascular diseases lead to local increases in relative pressure, reflecting the higher costs of driving blood flow. The utility of this biomarker for stratifying the severity of disease has thus driven the development of methods to measure these relative pressures. While intravascular catheterisation remains the most direct measure, its invasiveness limits clinical application in many instances. Non-invasive Doppler ultrasound estimates have partially addressed this gap; however only provide relative pressure estimates for a range of constricted cardiovascular conditions. Here we introduce a non-invasive method that enables arbitrary interrogation of relative pressures throughout an imaged vascular structure, leveraging modern phase contrast magnetic resonance imaging, the virtual work-energy equations, and a virtual field to provide robust and accurate estimates. The versatility and accuracy of the method is verified in a set of complex patient-specific cardiovascular models, where relative pressures into previously inaccessible flow regions are assessed. The method is further validated within a cohort of congenital heart disease patients, providing a novel tool for probing relative pressures in-vivo.

Transcatheter cardiac interventions in neonates with congenital heart disease: A single centre experience

Objective

Percutaneous cardiac catheterization has been used as a diagnostic tool and as a therapeutic option in neonates with congenital heart disease (CHD). This study aimed to evaluate the procedural and short-term follow-up data of newborns who underwent cardiac catheterization procedures.

Methods

This retrospective study reviewed demographic, diagnostic and clinical data from the medical records of newborns who underwent percutaneous transcatheter interventions to treat CHD.

Results

Forty-six newborns were included in the study. The median gestational week and weight were 35.0 weeks and 2723 g, respectively. The median time to the procedure was 7.6 days. Aortic and pulmonary balloon valvuloplasty, ductal stenting, atrial balloon/blade septostomy and coronary fistula embolization procedures were used. The overall success rate was 73.9% (34 of 46 patients) with a complication rate of 28.3% (13 of 46 patients). Eleven patients (23.9%) underwent reinterventions after initial catheterization. Five patients (10.9%) died in the first 48 h after their procedures.

Conclusions

Interventional cardiological procedures applied during the neonatal period provide alternative life-saving methods to surgery, especially in developing countries where surgical outcomes are poor and newborn mortality rates are high.

Evaluation of pulmonary artery stenosis in congenital heart disease patients using functional diagnostic parameters: An in vitro study

Congenital pulmonary artery (PA) stenosis is often associated with abnormal PA hemodynamics including increased pressure drop (Δp) and reduced asymmetric flow (Q), which may result in right ventricular dysfunction. We propose functional diagnostic parameters, pressure drop coefficient (CDP), energy loss (E_loss), and normalized energy loss (E¯_loss) to characterize pulmonary hemodynamics, and evaluate their efficacy in delineating stenosis severity using in vitro experiments. Subject-specific test sections including the main PA (MPA) bifurcating into left and right PAs (LPA, RPA) with a discrete LPA stenosis were manufactured from cross-sectional imaging and 3D printing. Three clinically-relevant stenosis severities, 90% area stenosis (AS), 80% AS, and 70% AS, were evaluated at different cardiac outputs (COs). A benchtop flow loop simulating pulmonary hemodynamics was used to measure Q and Δp within the test sections. The experimental Δp-Q characteristics along with clinical data were used to obtain pathophysiologic conditions and compute the diagnostic parameters. The pathophysiologic Q_LPA decreased as the stenosis severity increased at a fixed CO. CDP_LPA, E_loss,LPA (absolute), and E¯_loss,LPA (absolute) increased with an increase in LPA stenosis severity at a fixed CO. Importantly, CDP_LPA and E¯_loss,LPA had reduced variability with CO, and distinct values for each LPA stenosis severity. Under variable CO, a) CDP_LPA values were 14.5-21.0 (70% AS), 60.7- 2.2 (80% AS), ≥ 261.6 (90% AS), and b) E¯_loss,LPA values (in mJ per Q_LPA) were -501.9 to -1023.8 (70% AS), -1247.6 to -1773.0 (80% AS), -1934.5 (90% AS). Hence, CDP_LPA and E¯_loss,LPA are expected to assess the true functional severity of PA stenosis.

Ultrasound Imaging of the Inferior Vena Cava to Confirm Correct Guidewire Placement After Femoral Venous Cannulation in Critically Ill Neonates: A Case Report

Ultrasound-guided femoral venous cannulation is frequently performed in neonates. Identification of femoral vessels under ultrasound navigation is unreliable and time consuming in hemodynamically unstable neonates with feeble femoral arterial pulse. Confirming the guidewire placement in a femoral vein is a crucial step for preventing inadvertent femoral artery dilation, which may be a challenging task in an emergency situation. We describe 2 incidents wherein guidewires placed via femoral veins in neonates were detected in the inferior vena cava on abdominal ultrasound. We advocate abdominal inferior vena cava imaging to confirm the correct placement of a guidewire placed via femoral vein in emergency situations.