Pulmonary Artery Stenosis in Tetralogy of Fallot

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

Heart failure in adult congenital heart disease: tetralogy of Fallot

The number of rTOF patients who survive into adulthood is steadily rising, with currently more than 90% reaching the third decade of life. However, rTOF patients are not cured, but rather have a lifelong increased risk for cardiac and non-cardiac complications. Heart failure is recognized as a significant complication. Its occurrence is strongly associated with adverse outcome. Unfortunately, conventional concepts of heart failure may not be directly applicable in this patient group. This article presents a review of the current knowledge on HF in rTOF patients, including incidence and prevalence, the most common mechanisms of heart failure, i.e., valvular pathologies, shunt lesions, left atrial hypertension, primary left heart and right heart failure, arrhythmias, and coronary artery disease. In addition, we will review information regarding extracardiac complications, risk factors for the development of heart failure, clinical impact and prognosis, and assessment possibilities, particularly of the right ventricle, as well as management strategies. We explore potential future concepts that may stimulate further research into this field.

New developments in adult congenital heart disease

Congenital heart disease (CHD) affects 0.8% of live births and over the past decades technical improvements and large-scale repair has led to increased survival into adulthood of over 95% of the new-born. A new group of patients, those who survived their congenital heart defect, has emerged but late complications including heart failure, pulmonary hypertension (PH), arrhythmias, aneurysms and endocarditis appeared numerous, with a huge impact on mortality and morbidity. However, innovations over the past years have changed the landscape of adult CHD dramatically. In the diagnostic process important improvements have been made in the use of MRI, biomarkers, e‑health concepts and 3D visualisation of anatomy. Care is now concentrated in specialised centres, with a continuous emphasis on education and the introduction of weekly multidisciplinary consultations on diagnosis and intervention. Surgery and percutaneous intervention have been refined and new concepts applied, further reducing the burden of the congenital malformations. Research has matured from case series to global networks. Currently, adults with CHD are still facing high risks of early mortality and morbidity. By global collaboration and continuous education and development and innovation of our diagnostic and therapeutic arsenal, we will improve the perspectives of these young patients.

Image quality and radiation dose of ECG-triggered High-Pitch Dual-Source cardiac computed tomography angiography in children for the evaluation of central vascular stents

Assess image quality and radiation dose of ECG-triggered High-Pitch Dual-Source CTA for the evaluation central vascular stents in children. We included all children ≤ 21 years old with one or more central vascular stents and available prospective ECG-triggered High-Pitch Dual-Source CTA performed at our institution between January 2015 and August 2017. Demographic and scanner information was retrieved. Two board-certified pediatric radiologists blinded to the clinical data, independently reviewed and scored each case using a four-point quality score. Scores 1, 2 and 3 were considered of diagnostic image quality. Inter-observer agreement and non-parametric test were used. 18 patients (10 girls, 8 boys) with a mean age of 9.47 ± 7.38 years (mean ± SD) met inclusion criteria. Thirty-two central vascular stents were evaluated. Mean quality score was 2.07 ± 0.94 with 12.5% (4/32) of the cases classified as unevaluable. Interobserver agreement was excellent (k = 0.86). There is no significant difference between quality score and stent location (p = 0.07). There is a significant difference with stent material as all non-diagnostic scores were only seen in covered stents made of platinum-iridium (p < 0.001). There was no association between image quality and age, height, weight, BSA, heart rate, radiation dose or stent lumen size (p > 0.05). ECG-triggered high-pitch spiral DS-CTA offers appropriate image quality for assessment of central vascular stents in children.

Utilizing Hybrid Techniques to Maximize Clinical Outcomes in Congenital Heart Disease

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Twenty years of experience with intraoperative pulmonary artery stenting

OBJECTIVES

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Changing Landscape of Congenital Heart Disease

Congenital heart disease is the most frequently occurring congenital disorder affecting ≈0.8% of live births. Thanks to great efforts and technical improvements, including the development of cardiopulmonary bypass in the 1950s, large-scale repair in these patients became possible, with subsequent dramatic reduction in morbidity and mortality. The ongoing search for progress and the growing understanding of the cardiovascular system and its pathophysiology refined all aspects of care for these patients. As a consequence, survival further increased over the past decades, and a new group of patients, those who survived congenital heart disease into adulthood, emerged. However, a large range of complications raised at the horizon as arrhythmias, endocarditis, pulmonary hypertension, and heart failure, and the need for additional treatment became clear. Technical solutions were sought in perfection and creation of new surgical techniques by developing catheter-based interventions, with elimination of open heart surgery and new electronic devices enabling, for example, multisite pacing and implantation of internal cardiac defibrillators to prevent sudden death. Over time, many pharmaceutical studies were conducted, changing clinical treatment slowly toward evidence-based care, although results were often limited by low numbers and clinical heterogeneity. More attention has been given to secondary issues like sports participation, pregnancy, work, and social-related difficulties. The relevance of these issues was already recognized in the 1970s when the need for specialized centers with multidisciplinary teams was proclaimed. Finally, research has become incorporated in care. Results of intervention studies and registries increased the knowledge on epidemiology of adults with congenital heart disease and their complications during life, and at the end, several guidelines became easily accessible, guiding physicians to deliver care appropriately. Over the past decades, the landscape of adult congenital heart disease has changed dramatically, which has to be continued in the future.