Pediatric therapeutic cardiac catheterization: a statement for healthcare professionals from the Council on Cardiovascular Disease in the Young, American Heart Association

Closing the gap between acceptable and ideal in catheterisation for paediatric and congenital heart disease-A global view

In recent issues of the Journal of the Society for Cardiovascular Angiography and Interventions and the Journal of the American College of Cardiology: Cardiovascular Interventions, Holzer and colleagues presented an Expert Consensus Document titled: "PICS / AEPC / APPCS / CSANZ / SCAI / SOLACI: Expert consensus statement on cardiac catheterization for pediatric patients and adults with congenital heart disease." This Expert Consensus Document is a massively important contribution to the community of paediatric and congenital cardiac care. This document was developed as an Expert Consensus Document by the Pediatric and Congenital Interventional Cardiovascular Society, the Association for European Paediatric and Congenital Cardiology, the Asia-Pacific Pediatric Cardiac Society, the Cardiac Society of Australia and New Zealand, the Society for Cardiovascular Angiography and Interventions, and the Latin American Society of Interventional Cardiology, as well as the Congenital Cardiac Anesthesia Society and the American Association of Physicists in Medicine.As perfectly stated in the Preamble of this Expert Consensus Document, "This expert consensus document is intended to inform practitioners, payors, hospital administrators and other parties as to the opinion of the aforementioned societies about best practices for cardiac catheterisation and transcatheter management of paediatric and adult patients with congenital heart disease, with added accommodations for resource-limited environments." And, the fact that the authorship of this Expert Consensus Document includes global representation is notable, commendable, and important.This Expert Consensus Document has the potential to fill an important gap for this patient population. National guideline documents for specific aspects of interventions in patients with paediatric heart disease, including training guidelines, do exist. However, this current Expert Consensus Document authored by Holzer and colleagues provides truly globally applicable standards on cardiac catheterisation for both paediatric patients and adults with congenital heart disease (CHD).Our current Editorial provides different regional perspectives from senior physicians dedicated to paediatric and congenital cardiac care who are practicing in Europe, the Asia-Pacific region, Latin America, Australia/New Zealand, and North America. Establishing worldwide standards for cardiac catheterisation laboratories for children and adults with CHD is a significant stride towards improving the quality and consistency of care. These standards should not only reflect the current state of medical knowledge but should also be adaptable to future advancements, ultimately fostering better outcomes and enhancing the lives of individuals affected by CHD worldwide.Ensuring that these standards are accessible and adaptable across different healthcare settings globally is a critical step. Given the variability in resources and infrastructure globally, the need exists for flexibility and tailoring to implement recommendations.The potential impact of the Expert Consensus Document and its recommendations is likely significant, but heterogeneity of healthcare systems will pose continuing challenges on healthcare professionals. Indeed, this heterogeneity of healthcare systems will challenge healthcare professionals to finally close the gap between acceptable and ideal in the catheterisation of patients with paediatric and/or congenital heart disease.

Recommendations for centers performing pediatric heart surgery in the United States

Care and outcomes for the more than 40,000 patients undergoing pediatric and congenital heart surgery in the United States annually are known to vary widely. While consensus recommendations have been published across numerous fields as one mechanism to promote a high level of care delivery across centers, it has been more than two decades since the last pediatric heart surgery recommendations were published in the United States. More recent guidance is lacking, and collaborative efforts involving the many disciplines engaged in caring for these children have not been undertaken to date. The present initiative brings together professional societies spanning numerous care domains and congenital cardiac surgeons, pediatric cardiologists, nursing, and other healthcare professionals from diverse programs around the country to develop consensus recommendations for United States centers. The focus of this initial work is on pediatric heart surgery, and it is recommended that future efforts focus in detail on the adult congenital population. We describe the background, rationale, and methodology related to this collaborative effort, and recommendations put forth for Essential Care Centers (essential services necessary for any program), and Comprehensive Care Centers (services to optimize comprehensive and high-complexity care), encompassing structure, process, and outcome metrics across 14 domains.

Recommendations for Centers Performing Pediatric Heart Surgery in the United States

Care and outcomes for the more than 40,000 patients undergoing pediatric and congenital heart surgery in the United States annually are known to vary widely. While consensus recommendations have been published across numerous fields as one mechanism to promote a high level of care delivery across centers, it has been more than two decades since the last pediatric heart surgery recommendations were published in the United States. More recent guidance is lacking, and collaborative efforts involving the many disciplines engaged in caring for these children have not been undertaken to date. The present initiative brings together professional societies spanning numerous care domains and congenital cardiac surgeons, pediatric cardiologists, nursing, and other healthcare professionals from diverse programs around the country to develop consensus recommendations for United States centers. The focus of this initial work is on pediatric heart surgery, and it is recommended that future efforts focus in detail on the adult congenital population. We describe the background, rationale, and methodology related to this collaborative effort, and recommendations put forth for Essential Care Centers (essential services necessary for any program), and Comprehensive Care Centers (services to optimize comprehensive and high-complexity care), encompassing structure, process, and outcome metrics across 14 domains.

Recommendations for Centers Performing Pediatric Heart Surgery in the United States

Care and outcomes for the more than 40,000 patients undergoing pediatric and congenital heart surgery in the United States annually are known to vary widely. While consensus recommendations have been published across numerous fields as one mechanism to promote a high level of care delivery across centers, it has been more than two decades since the last pediatric heart surgery recommendations were published in the United States. More recent guidance is lacking, and collaborative efforts involving the many disciplines engaged in caring for these children have not been undertaken to date. The present initiative brings together professional societies spanning numerous care domains and congenital cardiac surgeons, pediatric cardiologists, nursing, and other healthcare professionals from diverse programs around the country to develop consensus recommendations for United States centers. The focus of this initial work is on pediatric heart surgery, and it is recommended that future efforts focus in detail on the adult congenital population. We describe the background, rationale, and methodology related to this collaborative effort, and recommendations put forth for Essential Care Centers (essential services necessary for any program), and Comprehensive Care Centers (services to optimize comprehensive and high-complexity care), encompassing structure, process, and outcome metrics across 14 domains.

Three years of interventional pediatric cardiology experience in a newly built city hospital

Aim: The importance of interventional methods in the treatment of congenital heart disease (CHD) is increasing. In this article, we retrospectively evaluated our angiography experience for the diagnosis and treatment of congenital heart diseases in the newly built Kayseri City Hospital for 3 years. Material and Method: The demographic data of the patients, their diagnoses and information about interventions were evaluated retrospectively. Results: In our center, 291 interventional procedures were performed in a 36-month period. 71 (24%) procedures were for diagnostic evaluation and 220 (76%) procedures were for treatment. 74 (25%) atrial septal defect (ASD) closure procedures, 9 (3%) ventricular septal defect (VSD) closure procedures and 62 (21.3%) patent ductus arteriosus (PDA) closure procedures were performed via percutaneous technique. Eleven of the patients who underwent PDA closure were

Safety and Outcomes of Transcatheter Closure of Patent Ductus Arteriosus in Children With Pulmonary Artery Hypertension

To investigate whether transcatheter device closure of patent ductus arteriosus (PDA) is safe in children with pulmonary artery hypertension, we retrospectively analyzed our experience with 33 patients who underwent the procedure from January 2000 through August 2015. Pulmonary artery hypertension was defined as a pulmonary vascular resistance index (PVRI) >3 WU · m2. All 33 children (median age, 14.5 mo; median weight, 8.1 kg) underwent successful closure device implantation and were followed up for a median of 17.2 months (interquartile range [IQR], 1.0-63.4 mo). During catheterization, the median PVRI was 4.1 WU · m2 (IQR, 3.6-5.3 WU · m2), and the median mean pulmonary artery pressure was 38.0 mmHg (IQR, 25.5-46.0 mmHg). Premature birth was associated with pulmonary vasodilator therapy at time of PDA closure ( P=0.001) but not with baseline PVRI (P=0.986). Three patients (9.1%) had device-related complications (one immediate embolization and 2 malpositions). Two of these complications involved embolization coils. Baseline pulmonary vasodilator therapy before closure was significantly associated with intensive care unit admission after closure (10/12 [83.3%] with baseline therapy vs 3/21 [14.3%] without; P <0.001). Of 11 patients receiving pulmonary vasodilators before closure and having a device in place long-term, 8 (72.7%) were weaned after closure (median, 24.0 mo [IQR, 11.0-25.0 mo]). We conclude that transcatheter PDA closure can be performed safely in many children with pulmonary artery hypertension and improve symptoms, particularly in patients born prematurely. Risk factors for adverse outcomes are multifactorial, including coil use and disease severity. Multicenter studies in larger patient populations are warranted.

Transcatheter Interventions in Adult Congenital Heart Disease

This article provides a detailed review of the current practices and future directions of transcatheter interventions in adults with congenital heart disease. This includes indications for intervention, risks, and potential complications, as well as a review of available devices and their performance.

Transcatheter closure of residual patent ductus arteriosus

INTRODUCTION

Residual patent ductus arteriosus (rPDAs) can occur following surgical or transcatheter treatment, and are indicated for closure because of the risks of infective endarteritis and hemolysis in addition to the hemodynamic effect of the residual left-to-right shunt.

METHODS

This retrospective descriptive study describes our experience at two Egyptian centers (Cairo University Children's Hospital & Tanta University Hospital) with transcatheter treatment of rPDAs, from January 2009 to October 2017.

RESULTS

Twenty cases were treated: 17/20 postsurgical and 3/20 post-transcatheter, at a mean period of 13.4 ± 9.3 months from the initial procedure. The median rPDA size was 2 mm (range2-3.5 mm). Most common ductal anatomy was the conical shape. All rPDAs were successfully closed with either coils (13/20) or devices (6/20), except one case where the residual flow was within the device mesh material. Coils could be deployed from the antegrade or the retrograde approaches although the latter was associated with a higher incidence of late shunt occlusion. One case with a malpositioned device required simultaneous device and LPA stent deployment.

CONCLUSION

Transcatheter closure of rPDAs is feasible in most cases, but may be technically challenging.

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

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

Vascular Reconstruction in a Neonate after Iatrogenic Injury during Cardiac Catheterization

As technology and interventional techniques continue to evolve, both the volume and complexity of cardiac catheterizations will increase, leading to a rise in the number of complications. One of the most morbid complications of cardiac catheterization is vascular injury. We report the case of a 31-day-old, 3.0-kg infant with hypoplastic left heart syndrome who experienced a left common iliac artery disruption during cardiac catheterization resulting in a retroperitoneal hemorrhage. The extent of the vascular injury combined with the vessel caliber posed a technically challenging surgical scenario. Ultimately, the vascular supply to the left lower extremity was reconstructed by the plastic surgery team with a reverse autologous vein graft. To our knowledge, this multidisciplinary approach with the involvement of plastic surgery represents a unique case.

Radiation dose benchmarks in pediatric cardiac catheterization: A prospective multi-center C3PO-QI study

OBJECTIVES

This study sought to update benchmark values to use a quality measure prospectively.

BACKGROUND

Congenital Cardiac Catheterization Outcomes Project - Quality Improvement (C3PO-QI), a multi-center registry, defined initial radiation dose benchmarks retrospectively across common interventional procedures. These data facilitated a dose metric endorsed by the American College of Cardiology in 2014.

METHODS

Data was collected prospectively by 9 C3PO-QI institutions with complete case capture between 1/1/2014 and 6/30/2015. Radiation was measured in total air kerma (mGy), dose area product (DAP) (µGy*M² ), DAP per body weight, and fluoroscopy time (min), and reported by age group as median, 75^th and 95^th %ile for the following six interventional procedures: (1) atrial septal defect closure; (2) aortic valvuloplasty; (3) treatment of coarctation of the aorta; (4) patent ductus arteriosus closure; (5) pulmonary valvuloplasty; and (6) transcatheter pulmonary valve implantation.

RESULTS

The study was comprised of 1,680 unique cases meeting inclusion criteria. Radiation doses were lowest for pulmonary valvuloplasty (age <1 yrs, median mGy: 59, DAP: 249) and highest in transcatheter pulmonary valve implantation (age >15 yrs, median mGy: 1835, DAP: 17990). DAP/kg standardized outcome measures across weights within an age group and procedure type significantly more than DAP alone. Radiation doses decreased for all procedures compared to those reported previously by both median and median weight-based percentile curves. These differences in radiation exposure were observed without changes in median fluoroscopy time.

CONCLUSIONS

This study updates previously established benchmarks to reflect QI efforts over time. These thresholds can be applied for quality measurement and comparison. © 2017 Wiley Periodicals, Inc.

Initial experience with the 3.3 Fr Mongoose® pigtail catheter for aortic angiography during patent ductus arteriosus closure in small patients

BACKGROUND

Smaller femoral arterial sheaths may be associated with fewer vascular complications. The 3.3 Fr Mongoose^® Pediavascular pigtail catheter is a catheter that allows higher flow rates, potentially resulting in improved angiographic quality. We reviewed our experience with this small catheter during patent ductus arteriosus (PDA) closure.

MATERIALS AND METHODS

Review of patients ≤20 kg in whom the Mongoose^® catheter was used during PDA closure from 12/13 to 4/15. Angiographic efficacy and procedural details were compared to ten 4 Fr catheter cases. Comparisons were performed using Mann-Whitney U-test; P < 0.05 was statistically significant.

RESULTS

Twelve (9 female) patients were catheterized with a 3.3 Fr Mongoose^®. Median weight 10.5 kg (range 6.4-18.2), height 81 cm (range 37-111), and body surface area (BSA) 0.47 m² (range 0.33-0.75) were similar to ten patients (3 females) in the 4 Fr control group (P = NS); median weight 9.9 kg (range 6-16.8), height 80 cm (range 64-102), and BSA 0.46 m2 (range 0.31-0.74). Angiographic quality was subjectively adequate with both with no difference in the median pixel density between the two techniques (3.3 Fr: 76.7 [range 33.5-90] and 4 Fr: [70; 38-102]; P = NS). Contrast used was similar between the groups (3.3 Fr: median 4.2 ml/kg and 4 Fr: 4.9 ml/kg; P = NS). Median radiation dose was similar in the two groups (3.3 Fr: 28.1 mGy [range 17.2-38] and 4 Fr: 38 mGy [range 20.4-58.5]; P = NS). All ducts were closed at latest follow-up (P = NS). No complications were encountered.

CONCLUSIONS

The 3.3 Fr Mongoose^® allowed similar angiography to the 4 Fr pigtail catheter, allowing safe and effective transcatheter PDA closure in small children.

Cardiac MRI in patients with complex CHD following primary or secondary implantation of MRI-conditional pacemaker system

OBJECTIVES

In patients with CHD, cardiac MRI is often indicated for functional and anatomical assessment. With the recent introduction of MRI-conditional pacemaker systems, cardiac MRI has become accessible for patients with pacemakers. The present clinical study aims to evaluate safety, susceptibility artefacts, and image reading of cardiac MRI in patients with CHD and MRI-conditional pacemaker systems. Material and methods CHD patients with MRI-conditional pacemaker systems and a clinical need for cardiac MRI were examined with a 1.5-T MRI system. Lead function was tested before and after MRI. Artefacts and image readings were evaluated using a four-point grading scale.

RESULTS

A total of nine patients with CHD (mean age 34.0 years, range 19.5-53.6 years) received a total of 11 cardiac MRI examinations. Owing to clinical indications, seven patients had previously been converted from conventional to MRI-conditional pacemaker systems. All MRI examinations were completed without adverse effects. Device testing immediately after MRI and at follow-up showed no alteration of pacemaker device and lead function. Clinical questions could be addressed and answered in all patients.

CONCLUSION

Cardiac MRI can be performed safely with high certainty of diagnosis in CHD patients with MRI-conditional pacemaker systems. In case of clinically indicated lead and box changing, CHD patients with non-MRI-conditional pacemaker systems should be considered for complete conversion to MRI-conditional systems.

Transcatheter closure of patent ductus arteriosus: past, present and future

This review aims to describe the past history, present techniques and future directions in transcatheter treatment of patent ductus arteriosus (PDA). Transcatheter PDA closure is the standard of care in most cases and PDA closure is indicated in any patient with signs of left ventricular volume overload due to a ductus. In cases of left-to-right PDA with severe pulmonary arterial hypertension, closure may be performed under specific conditions. The management of clinically silent or very tiny PDAs remains highly controversial. Techniques have evolved and the transcatheter approach to PDA closure is now feasible and safe with current devices. Coils and the Amplatzer Duct Occluder are used most frequently for PDA closure worldwide, with a high occlusion rate and few complications. Transcatheter PDA closure in preterm or low-bodyweight infants remains a highly challenging procedure and further device and catheter design development is indicated before transcatheter closure is the treatment of choice in this delicate patient population. The evolution of transcatheter PDA closure from just 40 years ago with 18F sheaths to device delivery via a 3F sheath is remarkable and it is anticipated that further improvements will result in better safety and efficacy of transcatheter PDA closure techniques.

State of the art catheter interventions in adults with congenital heart disease

Catheter interventions in adults with congenital heart disease have rapidly advanced. Transcatheter valve repair and replacement techniques have been added to the existing spectrum of well-established procedures. This review summarizes current transcatheter management strategies for congenital cardiac anomalies seen in the adult population.

Early echocardiographic changes after percutaneous implantation of the Edwards SAPIEN transcatheter heart valve in the pulmonary position

OBJECTIVES

To evaluate echocardiographic changes after SAPIEN valve implantation in the pulmonary position.

BACKGROUND

The feasibility of the SAPIEN transcatheter pulmonary valve (TPV) has recently been demonstrated. We evaluated changes in pulmonary valve function and the right ventricle after SAPIEN TPV placement.

METHODS

We evaluated echocardiograms at baseline, discharge, 1 and 6 months after TPV placement in 33 patients from 4 centers. Pulmonary insufficiency severity was graded 0-4. TPV peak and mean gradients were measured. Right ventricular (RV) size and function were quantified using routine measures derived from color, spectral, and tissue Doppler indices and two-dimensional echocardiography.

RESULTS

At baseline, 94% patients demonstrated pulmonary insufficiency grade 2-4. This decreased to 12% patients at 6 months (P < 0.01). TPV peak (P < 0.01) and mean gradient (P < 0.01) decreased. RV end-diastolic area indexed to body surface area (BSA) (P < 0.01), Tricuspid regurgitation (TR) gradient (P < 0.01), and the ratio of TR jet area to BSA (P < 0.01) decreased. Tricuspid inflow peak E:A, tissue Doppler imaging (TDI): septal E' and A', TDI: tricuspid A' improved between baseline and discharge, but trended back to baseline by 6-month follow-up. Tricuspid valve annulus z-score, RV area change, tricuspid annular plane systolic excursion (TAPSE), RV dP/dt, tricuspid E:E', and TDI: tricuspid annulus E' showed no change.

CONCLUSION

Improvements in pulmonary insufficiency and stenosis, RV size, and TR gradient and severity are seen after SAPIEN TPV placement. Selected indices of RV diastolic function improve immediately after TPV implantation, but return to baseline by 6 months. RV systolic function is unchanged.

The effects of ranitidine and hydrocortisone on the complications of femoral artery obstruction treated by streptokinase following cardiac catheterization in pediatric patients with congenital heart diseases

Background:

The most important complication following cardiac catheterization required urgent therapeutic management is vessel obstruction and arterial thrombosis. The morbidity following this complication can be decreased by surgery intervention and/or thrombolytic drugs.

Objectives:

In this study we evaluated the effects of ranitidine and hydrocortisone on pediatric patients with congenital heart diseases who suffered from femoral artery obstruction following cardiac catheterization on decreasing the events after streptokinase administration.

Materials and Methods:

This semi experimental study was conducted on 47 patients among 600 cases who underwent cardiac catheterization from April 2002 to December 2011.The patients suffered from distal vessel obstruction following cardiac catheterization with no response to surgery intervention, were enrolled and divided in two groups. Streptokinase was administrated in both groups. Patients in group 2 (25 cases), received ranitidine and hydrocortisone before streptokinase administration. In group 1 (22 cases), the loading dose of streptokinase was 2000IU/kg/ in 20-30 minutes/ infusion and thereafter streptokinase was administrated 1000 IU /kg/hour. In group 2, the loading dose was 3000IU/kg in 20-30 minutes /infusion and 1500 IU/kg/hour as maintenance dose. The infusion dose of streptokinase was decreased and then terminated in 2-3 hours by the time arterial pulse was detected by pulse oximetry.

Results:

There were 13 (59, 1%) male and 9 (40.9%) female patients in group 1. In group 2, there were 15 (60%) male and 10 (40%) female cases (P = 0.949). Patients in both groups were matched well regarding age, body weight, height and the duration of streptokinase infusion (P < 0.05). The incidence of hematoma was higher in group 1 than group 2 (P = 0.032). the patients of Group 1 required more blood transfusion than group 2 because the incidence of bleeding was more in the first group (P = 0.042). 12 patients in group 1 required fresh frozen plasma transfusion versus 4 patients in group 2 (P = 0.049). Local oozing was detected more in group 1 (P = 0.042). Significant bleeding was occurred in 6 cases in group 1; however this event did not occurrin any patients in group 2 (P = 0.007). Although 4 patients in group 1 suffered from anaphylactic shock after streptokinase administration but no patients in group 2 did. (P = 0.041).

Conclusions:

Based on the results of this study, we concluded that streptokinase was able to remove the vessel thrombosis at the site of cardiac catheterization and ranitidine and hydrocortisone administration before streptokinase may be effective in order to reduce the complications related to thrombolytic drugs; however the experience of the performer is an issue of concern in this matter.

Catheter interventions in congenital heart disease without regular catheterization laboratory equipment: the chain of hope experience in Rwanda

This report describes the feasibility and safety of cardiac catheterization in a developing country without access to a regular cardiac catheterization laboratory. The equipment used for imaging consisted of a monoplane conventional C-arm X-ray system and a portable ultrasound machine using the usual guidewires and catheters for cardiovascular access. In this study, 30 patients, including 17 children younger than 2 years and 2 adults, underwent catheterization of the following cardiac anomalies: patent ductus arteriosus (20 patients) and pulmonary valve stenosis (9 patients, including 2 patients with critical stenosis and 3 patients with a secundum atrial septal defect). Except for two cases requiring surgery, the patients were treated successfully without complications. They all were discharged from hospital, usually the day after cardiac catheterization, and showed significant clinical improvement in the follow-up evaluation. Cardiac catheterization can be performed safely and very effectively in a country with limited resources. If patients are well selected, this mode of treatment is possible without the support of a sophisticated catheterization laboratory.

Usefulness of Doppler derived end diastolic flow gradient across the patent ductus arteriosus in selecting coils for ductal occlusion

Transcatheter closure of patent ductus arteriosus (PDA) with coils is accepted as an alternative to surgical ligation. We evaluated whether flow gradient across PDA, obtained by Doppler echocardiography, can aid in selecting coils for percutaneous ductal occlusion. 79 consecutive patients with PDA, who underwent successful percutaneous coil occlusion were retrospectively reviewed. Patients with other structural heart disease and pulmonary hypertension with right-to-left shunt were excluded. Echocardiogram and cardiac catheterization were done in all patients. Gianturco (Occluding Spring Emboli; Cook, Bloomington, IN) non-detachable coils of 0.038 and 0.052-inch core sizes were used for ductal occlusion. Trough diastolic gradient was correlated with the size and the number of coils used. Mean age was 8.6 years (range 1.3 to 27 years); 24 males and 55 females; PDA diameter ranged from 1.3 to 4.5 mm. Number of coils used varied from 1 to 4. Echocardiography measured PDA size was 2.5 ± 0.6 mm and significantly differed from angiographically measured size 2.9 ± 0.6 mm (P = 0.05). End diastolic gradient below 38 mmHg predicted use of multiple coils or coils with larger surface area. End diastolic gradient correlated inversely with total surface area of the coils, which indirectly predicted size and number of coils. Thus, the prediction of the size and the number of coils for PDA occlusion can be assisted by the trough diastolic gradients of PDA.

Characterization of radiation exposure and effect of a radiation monitoring policy in a large volume pediatric cardiac catheterization lab

OBJECTIVES

This study aimed to characterize radiation dose during cardiac catheterization in congenital heart disease and to assess changes in dose after the introduction of a radiation monitoring policy.

BACKGROUND

Minimizing radiation exposure is an important patient safety initiative and relatively few data are available characterizing radiation dose for the broad spectrum of congenital cardiac catheter-based interventions.

METHODS

Radiation dose data were reviewed on all cases since 7/1/05 at a single large center. Procedures were classified according to 20 common case types then subdivided into five age categories. Groups with <20 cases were excluded. Radiation dose was estimated by cumulative air KERMA (mGy) and DAP (dose area product, μGym(2)) which were reported as median and interquartile range (IQR). We also examined differences in radiation dose before and after the implementation of a radiation policy.

RESULTS

Between 7/1/05 and 12/10/08, 3,365 cases were identified for inclusion. Radiation dose increased with age and procedural complexity. Patients were characterized into low, medium, and high dose categories relative to each other. "Low" dose cases included isolated pulmonary or aortic valvotomy, pre-Fontan assessment, and ASD closure. "High" dose cases involved multiple procedures in pulmonary arteries or veins. After introduction of a radiation policy, there was a significant decrease in radiation dose across a variety of case types, particularly among infants and young children.

CONCLUSIONS

Radiation dose in congenital cardiac catheterization varies by age and procedure type. A radiation monitoring and notification policy may have contributed to reduced radiation dose.

Balloon atrial septostomy through internal jugular vein in a 45-day-old child with transposition of great arteries

Balloon atrial septostomy is a common palliative procedure in D-transposition of great arteries. It is technically easy before 2-3 weeks of age when the septum primum is thin. Femoral vein or umbilical vein, when available, is the common access used for this procedure. In situations when these accesses are not available or in case of inferior vena cava interruption, trans-hepatic access is used. Internal jugular vein (IJV) access is not used as it is difficult to enter the left atrium through this route. We describe a case of successful Balloon atrial septostomy done through IJV in a 45-day-old child with emphasis on the technique, hardware and precautions necessary during the procedure.

Current approaches to pediatric heart catheterizations

Sedation for pediatric cardiac catheterization is a common requirement in many institutions. As the field of cardiac catheterization has evolved, the provision of sedation for these procedures has been varied. Increasingly the demand is for dedicated personnel focused on monitoring and delivery of sedation while in the catheterization suite. This article describes the considerations one must use when undertaking these cases.

Surgical Removal of Duct Occluder Device under Mild Hypothermia without Cardiopulmonary Bypass

Because the use of percutaneous intervention is increasing for the closure of the patent ductus arteriosus, the procedure-related complications are also on rise, with migration of the device being most common. The routine practice is to remove the migrated duct occluder device under cardiopulmonary bypass. Amplatzer duct occluder used in a 4-month-old infant dislodged into the descending thoracic aorta. It was removed by the posterolateral thoracotomy under mild hypothermia through juxtaductal aortotomy between the aortic cross-clamps. The use of cardiopulmonary bypass is thus avoided.

Pediatric cardiac interventions

The field of pediatric cardiac interventions has witnessed a dramatic increase in the number and type of procedures performed. We review the most common procedures performed in the catheter laboratory. Lesions are divided according to their physiological characteristics into left-to-right shunting lesions (atrial septal defect, patent ductus arteriosus, ventricular septal defect), right-to-left shunting lesions (pulmonary stenosis, pulmonary atresia/intact ventricular septum), right heart obstructive lesions (peripheral arterial pulmonic stenosis, right ventricular outflow tract obstruction), and left heart obstructive lesions (aortic valve stenosis, coarctation of the aorta). In addition, a miscellaneous group of lesions is discussed.

Implantation of stents for treatment of recurrent and native coarctation in children weighing less than 20 kilograms

We report our experience with implantation of stents for treatment of recurrent and native aortic coarctation in children weighing less than 20 kilograms. We treated 9 such patients between March, 2003, and January, 2006. In 2 patients, the coarctation had not previously been treated, while in 7 it had recurred after surgery. The patients had a median weight of 14 kilograms, with a range from 5.5 to 19 kilograms. Balloon dilation was needed in 1 patient before the stent was implanted. We used Palmaz Genesis XD stents in 7 patients, these having lengths from 19 to 29 millimetres, 1 Palmaz Genesis 124P stent, and 1 peripheral JoStent with a diameter of 6 to 12 millimetres. Implantation was effective in all patients. Immediately after implantation, the mean peak systolic gradient decreased from 30 millimetres of mercury, the range having been 15 to 50 mm, to 3 millimetres of mercury, with the final range from zero to 10 mm. There were no complications, with no observations of aneurysms, dissections, or dislocated stents. In 1 patient, the peripheral pulse was weak secondary to arterial access, but treatment with Heparin led to complete resolution. It was necessary to re-dilate the stent in another patient, while 2 others are scheduled for redilation because of growth-related restenosis. Our findings suggest that implantation of stents can produce excellent relief of the gradient produced by recurrent or native coarctation. The process is safe and effective in patients weighing less than 20 kilograms.

Coronary artery fistula: single-center experience spanning 17 years

BACKGROUND

Coronary artery fistula (CAF) is an uncommon form of congenital heart disease. It is often diagnosed incidentally during angiograms. We have reported on clinical characteristics, diagnosis, and management of CAF.

METHODS

Retrospective review of a tertiary referral institution's database identified 30 patients with CAF between 1987 and 2004. Mean follow-up was 31.61 +/- 48.03 months.

RESULTS

Mean age was 60 +/- 12.7 years. Most common site of CAF origin was the left anterior descending artery (LAD) (14, 46.7%). The most common site of drainage was the main pulmonary artery (15, 50%). Therapeutic strategies were based on symptoms and shunt size. Conservative management was the option in 17 patients (56.7%) with small shunts and mild or no symptoms. Patients with moderate/severe symptoms and/or large shunts were treated with either percutaneous embolization (6, 20%) or surgical ligation (7, 23.3%). Four patients (13.3%) died during follow-up. No deaths were reported in the embolization group, two patients died of cancer in the conservative management group, and two patients died in the surgical group due to cardiac tamponade and cancer, respectively.

CONCLUSIONS

Origin of CAF was predominantly from the left system. Clinical presentations were variable depending on type, size of fistula, and the presence of other cardiac conditions. Management of CAF is still controversial and treatment of adult asymptomatic patients with nonsignificant shunting is still a matter of debate. Newer imaging modalities may enhance noninvasive diagnosis. A national registry is necessary for further insights into optimal treatment for large fistulae and the natural history of smaller fistulae.

Development of a reexpandable covered stent for children

The use of covered stents in children is limited by the need for a large long sheath for delivery and the impossibility of redilation once implanted. The authors developed a reexpandable covered stent implantable in children through a small sheath and evaluated its clinical feasibility in mini piglets. An original Palmaz stent was covered with a polyurethane membrane that could be stretched up to 700%. Under general anesthesia, the authors implanted the covered stents in six mini piglets using a long sheath with a diameter approximately 1 French larger than the recommended size required to deliver an uncovered Palmaz stent. The implantation technique was similar to conventional stent implantation. In six piglets, the stent could be redilated from 7.5 to 8.7 mm 28-70 days after implantation. Macroscopic and microscopic examination showed intimal coverage of the coating with minimal inflammatory reaction around the stent. Our newly designed reexpandable stent covered with a polyurethane membrane is promising for use in children.

New transcatheter techniques for creation or enlargement of atrial septal defects in infants with complex congenital heart disease

OBJECTIVES

To describe a series of 8 consecutive infants (5 with transposition of the great arteries [TGA] and 3 with hypoplastic left heart syndrome [HLHS]) who underwent nonconventional septostomy techniques.

BACKGROUND

For some complex congenital heart defects, an unrestrictive atrial septal defect (ASD) is essential to achieve an adequate cardiac output and/or systemic saturation. In some scenarios, the use of conventional septostomy techniques may be technically difficult, hazardous, and/or ineffective.

METHODS

Use of transhepatic approach, cutting balloons, and radiofrequency perforation with stenting of the atrial septum.

RESULTS

The size of the ASD and the oxygen saturation increased in all patients with no major complications. In those with TGA, the ASDs were considered to be of good size at the arterial switch operation. Two of the 3 patients with hybrid palliation for HLHS have developed some degree of obstruction within the interatrial stent over 2-3 months. At surgery, the stents were found to be secured within the septum with one showing significant fibrous ingrowth after uneventful removal. The other had some nonobstructive ingrowth.

CONCLUSIONS

Creation or enlargement of ASDs in infants using new nonconventional transcatheter techniques is feasible, safe, and effective, at least in the short-to-mid-term follow-up. Infants with TGA seem to benefit the most because the procedure results in satisfactory clinical stability for subsequent early surgical intervention. In infants with HLHS palliated by a hybrid approach, stent implantation to the atrial septum seems to buy enough time to bring them to the phase II safely despite progressive in-stent obstruction.

Real-time MRI guided atrial septal puncture and balloon septostomy in swine

Cardiac perforation during atrial septal puncture (ASP) might be avoided by improved image guidance. X-ray fluoroscopy (XRF), which guides ASP, visualizes tissue poorly and does not convey depth information. Ultrasound is limited by device shadows and constrained imaging windows. Alternatively, real-time MRI (rtMRI) provides excellent tissue contrast in any orientation and may enable ASP and balloon atrial septostomy (BAS) in swine. Custom MRI catheters incorporated "active" (receiver antenna) and "passive" (iron or gadolinium) elements. Wholly rtMRI-guided transfemoral ASP and BAS were performed in 10 swine in a 1.5T interventional suite. Hemodynamic results were measured with catheters and velocity encoded MRI. Successful ASP was performed in all 10 animals. Necropsy confirmed septostomy confined within the fossa ovalis in all. BAS was successful in 9/10 animals. Antenna failure in a re-used needle led to inadvertent vena cava tear prior to BAS in 1 animal. ASP in the same animal was easily performed using a new needle. rtMRI illustrated clear device-tissue-lumen relationships in multiple orientations, and facilitated simple ASP and BAS. The mean procedure time was 19 +/- 10 minutes. Septostomy achieved a mean left to right shunt ratio of 1.3:1 in these healthy animals. Interactive rtMRI permits rapid transcatheter ASP and BAS in swine. Further technical development may enable novel applications.

The Influence of Percutaneous Closure of Patent Ductus Arteriosus on Left Ventricular Size and Function

OBJECTIVES

We aimed to evaluate the effect of percutaneous closure of patent ductus arteriosus (PDA) on left ventricular (LV) hemodynamics.

BACKGROUND

Today, most PDAs are closed percutaneously. Little is known, however, about hemodynamic changes after the procedure.

METHODS

Of 37 children (ages 0.6 to 10.6 years) taken to the catheterization laboratory for percutaneous PDA closure, the PDA was closed in 33. Left ventricular diastolic and systolic dimensions, volumes, and function were examined by two-dimensional (2D) and three-dimensional (3D) echocardiography and serum concentrations of natriuretic peptides measured before PDA closure, on the following day, and 6 months thereafter. Control subjects comprised 36 healthy children of comparable ages.

RESULTS

At baseline, LV diastolic diameter measured >+2 SD in 5 of 33 patients. In 3D echocardiography, a median LV diastolic volume measured 54.0 ml/m2 in the control subjects and 58.4 ml/m2 (p < 0.05) in the PDA group before closure and 57.2 ml/m2 (p = NS) 6 months after closure. A median N-terminal brain natriuretic peptide (pro-BNP) concentration measured 72 ng/l in the control group and 141 ng/l in the PDA group before closure (p = 0.001) and 78.5 ng/l (p = NS) 6 months after closure. Patients differed from control subjects in indices of LV systolic and diastolic function at baseline. By the end of follow-up, all these differences had disappeared. Even in the subgroup of patients with normal-sized LV at baseline, the LV diastolic volume decreased significantly during follow-up.

CONCLUSIONS

Changes in LV volume and function caused by PDA disappear by 6 months after percutaneous closure. Even the children with normal-sized LV benefit from the procedure.

Pulmonary balloon valvuloplasty in a fetus with critical pulmonary stenosis/atresia with intact ventricular septum and heart failure

Outcome of fetuses with critical pulmonary stenosis (critical PS) or atresia of the pulmonary valve (PA) with intact ventricular septum (IVS) is closely related with right ventricle hypoplasia and its consequent hemodynamics. Fetal echocardiography not only allows early detection of this condition but also monitors its normally unfavorable evolution. These cases may benefit from intrauterine intervention relieving outflow tract obstruction in order to achieve a biventricular circulation. Successful valvuloplasty of the pulmonary valve was performed in a fetus with critical PS-IVS and heart failure at 25 weeks. After the procedure there was a significant improvement in fetal hemodynamics. Follow-up scans at 34 weeks detected a significant restenosis with signs of circulatory failure leading to premature delivery of the baby. An immediate postnatal valvuloplasty successfully completed the ultimate objective of biventricular repair. Fetal pulmonary valvuloplasty is feasible and may change the natural history of the disease in fetuses with critical PS-IVS.

Dutch survey of coronary artery fistulas in adults: Congenital solitary fistulas

AIMS

Congenital coronary artery fistulas are frequently identified in adult and pediatric populations and they have been associated with various clinical and morphological features. The purpose of this study was to define the clinical and coronary angiographic morphological characteristics of adult patients with congenital solitary CAFs in the Dutch Registry.

METHODS AND RESULTS

Fifty-one patients with angiographically documented CAFs were reviewed for clinical evaluation, used non-invasive and invasive diagnostic tools and treatment modalities. Unilateral CAFs were predominant (80%) and 84% of the patients were symptomatic. The most common presenting symptom was angina pectoris (57%). Angina pectoris was present in a quarter of the patients in the absence of coronary artery disease (CAD). Significant CAD was present in 49% of the patients. Twenty-nine percent of the CAFs showed aneurysmal formation, underlying their potential hazard of rupture. Myocardial infarction occurred in 18% of the patients. In 27% of CAFs multiplicity of the origin was found and nearly all fistulas were tortuous (97%). Treatment modalities were conservative medical in 70%, percutaneous transluminal embolisation in 5% and surgical ligation in 25% of the cases. Multiple micro-fistulas from the coronary arteries to the left ventricle were excluded from the study.

CONCLUSION

In this national survey series, congenital solitary CAFs can be presented with typical angina pectoris in the absence of obstructive CAD. Fistula-related coronary artery was infrequently involved in the development of ipsilateral myocardial infarction. Tortuousity and multiplicity of the CAFs may determine, for the individual patient, the choice of the currently available treatment modalities.

Real-time magnetic resonance imaging-guided stenting of aortic coarctation with commercially available catheter devices in Swine

BACKGROUND

Real-time MR imaging (rtMRI) is now technically capable of guiding catheter-based cardiovascular interventions. Compared with x-ray, rtMRI offers superior tissue imaging in any orientation without ionizing radiation. Translation to clinical trials has awaited the availability of clinical-grade catheter devices that are both MRI visible and safe. We report a preclinical safety and feasibility study of rtMRI-guided stenting in a porcine model of aortic coarctation using only commercially available catheter devices.

METHOD AND RESULTS

Coarctation stenting was performed wholly under rtMRI guidance in 13 swine. rtMRI permitted procedure planning, device tracking, and accurate stent deployment. "Active" guidewires, incorporating MRI antennas, improved device visualization compared with unmodified "passive" nitinol guidewires and shortened procedure time (26+/-11 versus 106+/-42 minutes; P=0.008). Follow-up catheterization and necropsy showed accurate stent deployment, durable gradient reduction, and appropriate neointimal formation. MRI immediately identified aortic rupture when oversized devices were tested.

CONCLUSIONS

This experience demonstrates preclinical safety and feasibility of rtMRI-guided aortic coarctation stenting using commercially available catheter devices. Patients may benefit from rtMRI in the future because of combined device and tissue imaging, freedom from ionizing radiation, and the ability to identify serious complications promptly.

Real-time magnetic resonance imaging to guide pediatric endovascular procedures

Although x-ray fluoroscopy (XRF) has guided diagnostic and therapeutic transcatheter procedures for decades, certain limitations still exist. XRF still visualizes tissue poorly and relies on projection of shadows that do not convey depth information. Adjunctive echocardiography overcomes some of these limitations but still suffers suboptimal or unreliable imaging windows. Furthermore, ionizing radiation exposure in children imparts a cancer risk. An interventional platform using real-time magnetic resonance imaging (MRI) may offer superior image guidance without radiation. Although there are many remaining challenges, but real-time MRI has the potential to revolutionize transcatheter therapeutics.

Is routine cardiac catheterization necessary in the management of patients with single ventricles across staged Fontan reconstruction? No!

With the advent of cardiac magnetic resonance imaging and high-resolution echocardiography, cardiac catheterization is unnecessary in clinical protocols in the "routine" single ventricle patient. Catheterization adds little to clinical care in these cases, and there are significant risks and costs associated with it. Catheterization should be reserved for cases in which noninvasive evaluations are equivocal, conflictory, demonstrate deterioration, or needed for intervention. This article delineates the role of noninvasive evaluations relative to cardiac catheterization in the routine single ventricle patient.

Proposals for future training in interventional paediatric cardiology

Training in all medical disciplines is currently undergoing a major overhaul. There is a move away from the old concept of training as an apprentice, towards more structured programmes of training. Proposals have recently been made to shorten higher specialist training to 3-4 years, thus producing "generalist" consultants to meet the growing need for service. Advanced subspeciality training can then be undertaken by those with the ability, and desire, to do so following the core training. In the near future, therefore, subspeciality training will need to meet the needs of those undertaking core training, and those wishing to develop a higher degree of expertise. It will have to be focused, to allow skills appropriate to the future practice to be undertaken as a consultant to be developed efficiently. We propose a new scheme for training in interventional paediatric cardiology as a template for subspeciality training. The scheme proposes training at three levels. The first level, basic training, is required of all trainees. Training for the intermediate level will be required for those proposing to carry out diagnostic cardiac catheterisation and basic intervention. Training at the advanced level will be needed by those who wish to carry out a wide range of interventional procedures. A curriculum is proposed for each level, detailing skills that must be attained. Attendance at procedures needs to be driven by the educational needs of the trainee, rather than the requirements of the service. Objective methods are suggested to allow assessment of competence. These should supersede log-books, which document only procedural numbers. Training may be needed for the trainers to ensure that teaching and assessment achieve agreed standards of excellence.