Indications for cardiac catheterization and intervention in pediatric cardiac disease: a scientific statement from the American Heart Association

Is arterial ductal stent as effective as surgical shunt for palliation in staged repair of tetralogy of Fallot with pulmonary stenosis?

INTRODUCTION

A staged repair strategy in the form of Modified Blalock-Taussig-Thomas shunt has been performed to facilitate the growth of pulmonary valve annulus, so that patients with marginally small annulus could benefit from pulmonary valve-sparing repair. However, little has been reported on the influence of arterial ductal stent (ADS) on the growth of pulmonary annulus and pulmonary artery, with subsequent valve-sparing repair.

METHODS

Patients who underwent staged repair of tetralogy of Fallot with Pulmonary Stenosis with either ADS or surgical shunt were included. Echocardiographic and angiographic measurements of pulmonary annulus and pulmonary artery prior to initial palliation and complete repair were recorded.

RESULTS

A total of 110 patients were included, 44 (40%) patients underwent ADS and 66 (60%) patients had surgical shunt. Pulmonary annulus and pulmonary arteries grew significantly following palliation with both ADS (P = 0.011) and surgical shunt (P < 0.01), with a similar rate of increment (P = 0.205). There was no significant difference in the rate of valve-sparing repair between the 2 groups (MBTTS, 62.1% vs ADS, 47.7%, P = 0.149). However, patients who underwent ADS had shorter stays in hospital (P = 0.048). Reintervention rate and mortality rate in the interstage period were similar in both groups (P = 0.229 and P = 0.210, respectively). There was no reintervention in patients who successfully underwent valve-sparing repair following both palliation groups in the follow-up period.

CONCLUSIONS

ADS is as effective as surgical shunt as a palliative procedure in promoting the growth of pulmonary annulus and pulmonary arteries, with comparable rate of valve-sparing repair during corrective surgery.

Usefulness of exercise stress echocardiography in a patient with unilateral pulmonary branch stenosis

Exercise stress echocardiography (ESE) is a feasible and valuable tool for evaluating subclinical pulmonary hypertension (PH). However, its utility in patients with unilateral pulmonary branch stenosis remains unclear. We present a case involving a 17-year-old patient with left pulmonary branch stenosis who exhibited exercise-induced PH in the contralateral pulmonary artery as detected by ESE. Standard echocardiography was unable to visualize the left pulmonary artery clearly; therefore, computed tomography was performed, revealing a left pulmonary branch stenosis with a minimum diameter of 4.2 mm. Resting echocardiography showed a pressure gradient of 17 mmHg, calculated using the tricuspid regurgitant velocity. During ESE with a prone ergometer, the slope of the mean pulmonary arterial pressure to systemic cardiac output was 3.1 mmHg/L/min, meeting the diagnostic criteria for exercise-induced PH. The patient underwent stent implantation to treat the left pulmonary branch stenosis. Follow-up ESE demonstrated improvement, with the slope of the mean pulmonary arterial pressure to systemic cardiac output decreasing to 1.5 mmHg/L/min. These findings underscore that ESE is both feasible and effective for assessing subclinical unilateral pulmonary branch stenosis.

Learning objective

Patients with congenital unilateral peripheral branch pulmonary artery stenosis usually do not have pulmonary hypertension at rest, and identifying patients who require treatment is challenging. Exercise stress echocardiography can detect latent pulmonary hypertension of the contralateral pulmonary artery in some patients, providing valuable insights for determining treatment indications and evaluating the efficacy of catheter interventions for the stenotic lesion.

Venous Access Alone Versus Arterial and Venous Access for Patent Arterial Duct Device Closure in Childhood

BACKGROUND

The persistently patent arterial duct accounts for ~12% of congenital heart lesions. Untreated, it may result in heart failure due to volume loading of the left heart, pulmonary hypertension, and infective endarteritis. Percutaneous device closure is the preferred occlusion technique, with the standard approach consisting of femoral artery access for angiography and venous access for device delivery (AA). A venous-only strategy (VA) for angiography and device delivery can also be employed.

HYPOTHESIS

We hypothesized that VA would eliminate the need of arterial entry, reduce procedure times and radiation exposure compared to standard AA.

METHODS

This is a retrospective cohort study of isolated arterial duct device closure at the Hospital for Sick Children from January 1, 2011, through December 31, 2022. Exclusions included premature neonates, children requiring arterial access for monitoring, and those who underwent other procedures. Children were categorized based upon initial access determined by operator preference into VA or AA groups.

RESULTS

The cohort consisted of 405 children, 252 (62.2%) females, with a median age of 3.1 years (IQR 1.30-5.84), median weight 13.2 kg (IQR 9.0-19.5), and duct diameter of 2.9 mm (IQR 2.0-3.5) with no significant differences between the groups. Type A ducts were more frequent in the AA group (90% vs. 72%). The VA group included 106 children, of which 14 (13.2%) required AA conversion for angiography due to complex ductal anatomy, to assess device position before release, but remained in the VA group for analysis. Children in the VA group had lower dose area product (DAP) (p < 0.001), fluoroscopy times (p = 0.025), contrast volumes (p < 0.001), procedure times (p < 0.001), and recovery room lengths of stay (LOS) (p < 0.001). Six (5.7%) VA children required admission compared to 44 (14.7%) in the AA group (p = 0.015) with no difference in reintervention rates. Weighted regression analysis showed VA was associated with reduced admission likelihood (OR: 0.354 [0.131, 0.822], p = 0.024), DAP (coef -126.4 [-213.3, -39.4], p = 0.004), and contrast volumes (coef 31.2 [-36.6, -25.9], p < 0.001) compared to AA.

CONCLUSIONS

Venous-only access was associated with lower DAP and recovery room LOS. Additionally, VA was associated with a lower likelihood of admission with no difference in reintervention rates, suggesting procedural safety. These findings support the consideration of VA as a preferred approach for appropriate cases.

Shone᾽s complex in pediatric age group: clinical characteristics, structural components, interventions, and outcomes of a cohort from a single center

BACKGROUND

Shone's complex (SC) comprises multi-level left-sided obstructive cardiac lesions. Limited research has addressed SC in the pediatric age, especially the factors impacting outcomes. Therefore, the current work aimed to study clinical, structural, interventional aspects, and outcomes of SC cohort in childhood.

METHODS

A retrospective analysis of SC cases from a single tertiary center was conducted. Demographics and clinical data were collected. Echocardiographic data, other imaging modalities, and required interventions (surgical or transcatheter) were determined. Outcomes regarding morbidity and mortality were collected.

RESULTS

Twenty five cases were included;17 (68%) were males with a median age of one month (0.2-4.8) at presentation and 33 (5-60) months at the last follow-up. All patients were diagnosed with incomplete SC, with the commonest lesions: Parachute mitral in 86% and aortic coarctation (COA) in 72%. Cardiac multi-slice CT (MSCT) was indicated in 16 (64%), and transesophageal echocardiography in 2 (8%). No intervention was performed in 5 (20%) cases, while interventional catheterization was performed in 4 (16%) and surgery was performed in 19 (76%). The mortality rate in the cohort was 3 (12%), with age of the patient, weight, and weight Z-score at the last follow-up significantly lower in deceased cases. The proportion of cases with suppressed myocardial contractility at the initial presentation was statistically significant in the deceased group (p = 0.03). However, anthropometrics and demographics at presentation, SC components, and interventions did not differ significantly between the two groups.

CONCLUSION

Shone's complex is primarily presented in the atypical incomplete subtype. In pediatric age, parachute mitral and COA are the most common lesions. Echocardiography with MSCT could achieve a non-invasive, comprehensive diagnosis and guide the required intervention. The family should be informed of potential recurrence, progression, or reintervention for SC lesions, emphasizing the need for prolonged follow-up.

Long-Term and Multidisciplinary Treatment of Tetralogy of Fallot in Pediatrics

BACKGROUND

Right ventricular outflow tract (RVOT) dysfunction is a long-term postsurgical complication of tetralogy of Fallot (TOF) that needs long-term multidisciplinary treatment.

CASE SUMMARY

We report a case of TOF patient who underwent radical surgical repair in infancy and who presented with pulmonary artery stenosis and pulmonary regurgitation during follow-up. Pulmonary stent placement and percutaneous pulmonary valve implantation (PPVI) were pursued successfully when he was aged 5 and 13 years, respectively.

DISCUSSION

PPVI has been widely used as a minimally invasive treatment alternative to surgical pulmonary valve replacement. This technology has shown significant advantages in pediatric patients to improve RVOT dysfunction, relieve symptoms, optimize hemodynamic parameters, and avoid reintervention.

TAKE-HOME MESSAGE

This case provides a long-term and multidisciplinary strategy for TOF in pediatrics, with a focus on the possibility and effect of PPVI in adolescent patients.

The Fate of the Jailed Branch: Challenging the Dogma of PDA Stenting in Cases with a Pulmonary Artery Branch Originating from the PDA

Patent ductus arteriosus (PDA) stenting is evolving as the preferred method for establishing stable pulmonary blood flow in cyanotic infants, offering lower mortality, faster recovery, and shorter hospital stays. However, stenting may lead to branch pulmonary artery (BPA) jailing, potentially restricting blood flow to the jailed branch. This study analyzes patient characteristics, cardiovascular anatomy, stenting techniques, and outcomes involving BPA jailing where the BPA originates from the PDA, with a focus on the growth of the jailed BPA. A retrospective review was conducted of infants with duct-dependent pulmonary blood flow who underwent PDA stenting at Rady Children's Hospital San Diego from 2013 to 2024. Of 70 infants, 22 (31%) experienced BPA jailing due to the BPA originating from the PDA. The median age and weight at stenting were 9.5 days and 3275 g, with PDA as the sole source of pulmonary blood flow in 72% of cases. PDA type III was the most prevalent (77%). The jailed BPA showed significant distal growth (mean Nakata index increase of 117.35 mm2/m2, p = 0.0001), with symmetry maintained. Re-intervention for hypoxia was required in 55% of cases and involved ballooning, re-stenting, and strut dilation. There were no 30-day mortalities (2 late deaths occurred). Progression to Glenn palliation occurred in 12 patients, 5 had a definitive repair, 1 underwent left pulmonary artery plasty and a BT shunt and 2 await repair. PDA stenting in infants with a BPA originating from the PDA is feasible with notable distal BPA growth despite frequent re-interventions. Patients maintained pulmonary artery symmetry with excellent survival.

Echocardiographic Assessment of Cardiac Phenotype Predicts Complications and Guides Intensive Care Management Following Pulmonary Valve Balloon Dilation in Neonates With Pulmonary Atresia/Critical Pulmonary Stenosis With Intact Ventricular Septum

INTRODUCTION

Pulmonary valve balloon dilation (PVBD) has largely replaced surgical decompression as the preferred treatment for neonates with pulmonary atresia with intact ventricular septum (PAIVS) or critical pulmonary stenosis (CPS). This study aims to evaluate whether echocardiographic morphological and functional assessment can predict early complications and guide intensive care management following PVBD in this population.

METHODS

We retrospectively analyzed 27 neonates with PAIVS or CPS who underwent PVBD between 2017 and 2023. Patients were divided into Group A (tripartite right ventricle [RV], developed infundibulum) and Group B (bipartite RV, hypoplastic infundibulum). Echocardiographic, catheterization, and clinical data were reviewed and compared.

RESULTS

Group A had higher rates of transient left ventricular systolic dysfunction (92.9% vs. 15.4%, p < 0.001) and required more ventilatory and inotropic support. Group B was more prone to infundibular spasm (76.9% vs. 21.4%, p = 0.004) and often needed beta-blockers or additional pulmonary blood flow.

CONCLUSION

Echocardiographic RV phenotype is associated with specific post-PVBD complications and may help guide early post-procedural management.

Two decades after the arterial switch operation: stable right ventricular function but reduced exercise capacity

BACKGROUND

Right ventricular (RV) function and exercise capacity predict prognosis in transposition of the great arteries (TGA) after arterial switch operation (ASO). We aim to longitudinally evaluate RV dimensions, global function and exercise capacity after ASO, comparing patients with and without RV pressure overload.

METHODS

This retrospective study included TGA patients post-ASO with two cardiovascular magnetic resonance (CMRs) examinations at the University Medical Center Utrecht between 2004 and March 2024. Cardiac volumes, function, strain, and vessel dimensions were measured. Patients were categorized by RV pressure overload. Repeated exercise tests were performed in a subset. The first and second CMR were compared.

RESULTS

The cohort (111 patients, 22±8years; 71% male (79/111)) underwent the first CMR at median 13 [11-19] years post-ASO (mid-term follow-up) and the second at 21 [16-26] years post-ASO (long-term follow-up). RV volumes, function, and strain remained stable during long-term follow-up. Aortic root dimensions showed no progression during long-term follow-up (diameter: 23±5 mm/m² vs. 20±4 mm/m², p<0.001). 50% (56/111) underwent exercise testing, revealing a VO2peak decline, with 25% (14/56) having reduced VO2peak at mid-term follow-up and 46% (26/56) at long-term follow-up (mean age 21±7years) (p=0.012). This was not related to peak heart rate or chronotropic index (peakHR: R=0.115, p=0.413; chronotropic index: R=0.099, p=0.484). No differences were observed between patients with and without RV pressure overload.

CONCLUSION

Long-term exercise capacity is impaired in a significant portion of TGA patients. RV volumes, global function, strain, and aortic root dimensions remained unchanged during long-term follow-up post-ASO.

Fate of mitral regurgitation after transcatheter closure of patent ductus arteriosus: single centre study

A hemodynamically significant patent ductus arteriosus (PDA) may be associated with mitral regurgitation (MR). Available treatment strategies are - surgical PDA ligation ± mitral valve surgery and initial transcatheter PDA closure (PDA-DC) with treatment of MR subsequently, if necessary. We aimed to describe the fate of MR after PDA-DC in patients with PDA and significant MR. On retrospective review of electronic health records between 2013 and 2023, 14 eligible patients were identified. Amongst them, PDA-DC resulted in symptomatic improvement in all. A reduction in the severity of MR was noted in 12 patients (85.7 %).

Diagnostic and interventional cardiac catheterisation performed within the first 72 hours of the postoperative period in congenital heart surgery

INTRODUCTION

Cardiac catheterisation in the postoperative period emerges as a primary tool, providing effectiveness and safety in diagnosis, treatment guidance, and resolution of major residual lesions.

MATERIALS AND METHODS

This is a retrospective case-control study. We collected the clinical records of patients who underwent cardiac catheterisation between January 2003 and December 2022 within the initial 72 hours after surgery in the pediatric cardiac ICU of a national referral hospital in Mexico City. Descriptive, univariate, and multivariate analyses were performed.

RESULTS

A total of 6,243 surgeries were performed, of which 264 were cardiac catheterizations carried out within the first 72 hours of the postoperative period;these included 73 diagnostic procedures and 191 interventional procedures. One hundred and thirty-five (135) catheterisations targeted recent suture intervention sites. The primary indications for cardiac catheterisation included low cardiac output and the suspicion of major residual lesions. Approximately 65% of interventions occurred within the first 24 hours and solved 426 residual lesions. No significant associations were found between mortality, complications, and the need for surgical reintervention in patients who underwent interventional catheterisation at recent suture sites (OR 1.93;95% CI:0.94-4.07:p = 0.076). Seventeen patients (17) were extubated in the initial 24 hours post-catheterisation. Two major complications were identified: rupture of the systemic-to-pulmonary shunt in the anastomosis, and a pulmonary artery laceration requiring emergency surgery. One patient died.

CONCLUSION

Cardiac catheterisation has evolved into a vital instrument to diagnose and resolve abnormalities and significant residual lesions without increasing the morbidity and mortality risks.

Clinical and subclinical acute brain injury caused by invasive cardiovascular procedures

Over the past 50 years, the number and invasiveness of percutaneous cardiovascular procedures globally have increased substantially. However, cardiovascular interventions are inherently associated with a risk of acute brain injury, both periprocedurally and postprocedurally, which impairs medical outcomes and increases health-care costs. Current international clinical guidelines generally do not cover the area of acute brain injury related to cardiovascular invasive procedures. In this international Consensus Statement, we compile the available knowledge (including data on prevalence, pathophysiology, risk factors, clinical presentation and management) to formulate consensus recommendations on the prevention, diagnosis and treatment of acute brain injury caused by cardiovascular interventions. We also identify knowledge gaps and possible future directions in clinical research into acute brain injury related to cardiovascular interventions.

Initial balloon versus surgical valvuloplasty in children with isolated congenital aortic stenosis: Influence on timing of aortic valve replacement

OBJECTIVE

To evaluate the influence of initial intervention on the long-term outcomes in congenital aortic stenosis.

METHODS

Two hundred forty-three children underwent initial intervention between 1997 and 2022, by surgical valvuloplasty in 92 (32% neonates, 36% infants) and balloon valvuloplasty in 151 (27% neonates, 30% infants). Twenty-eight patients (11.5%) had associated mitral valve stenosis. Competing risk analysis for death, alive after initial intervention, or alive after aortic valve replacement (AVR) was performed and factors influencing survival or AVR examined.

RESULTS

There were 9 early deaths (3.7%). During a median follow-up of 13.5 years (range, 1.5-26.7), 98 patients had reintervention on the aortic valve (40.3%), whereas 145 had AVR (59.6%) at a median age of 14.0 years (interquartile range, 9.0-17.0), which was by Ross procedure in 130 (89.6%). Of the 12 late deaths, 3 were perioperative and 9 occurred as outpatients. There were no perioperative or late deaths after AVR. AVR occurred earlier in patients who had initial balloon (12.0 years [interquartile range, 5.0-14.5]) rather than surgical (18.5 years [interquartile range, 15.5-21.5]) valvuloplasty (P < .05). Actuarial survival in the cohort was 91.3% at 25 years, with no difference between the 2 initial interventions. Critical aortic stenosis, mitral stenosis, and initial intervention as a neonate were independent risk factors for worse survival.

CONCLUSIONS

We demonstrate excellent early and late survival in patients with congenital aortic stenosis after initial balloon or surgical valvuloplasty. Whilst children who had balloon valvuloplasty had AVR earlier than those who had initial surgical valvuloplasty, patient factors had a greater influence on survival than choice of initial intervention.

One-Stop Device Closure for Ventricular Septal Defect with Atrial Septal Defect Guided by Transesophageal Echocardiography

Background

Ventricular septal defect (VSD) with atrial septal defect (ASD) is a common complex congenital heart disease. This study aimed to evaluate the clinical efficacy and safety of transesophageal echocardiography (TEE)-guided percardiac or combined percutaneous techniques for treating VSD with ASD in patients with varying anatomies.

Methods

This retrospective cohort study reviewed 40 cases of VSD with ASD treated in our center from June 2015 to July 2023. Under TEE guidance, peratrial, perventricular, or combined percardiac/percutaneous approaches were used based on the VSD type and secundum-type ASD. Follow-up examinations, including electrocardiography, transthoracic echocardiography, and X-ray, were performed after surgery at 24 hours, 1, 3, 6, and 12 months, and yearly.

Results

All patients underwent surgery successfully (100%), with 24, 5, and 11 patients undergoing simultaneous closure via the peratrial, perventricular, and combined percardiac/percutaneous approaches, respectively. Among them, there were six cases of a mild residual shunt, three instances of a mild tricuspid regurgitation, two cases of a mild aortic valve regurgitation, one case of a mild mitral regurgitation, and three cases of an incomplete right bundle branch block, all observed after VSD closure; all had resolved within 6 months of the operation. The chi-square test showed no significant differences in adverse event rates among the three surgical approaches (χ2 = 0.09, df = 2, p = 0.957). The Friedman test compared the preoperative and postoperative left ventricular end-diastolic diameter for the three approaches, providing p < 0.001, p = 0.589, and p = 0.445, respectively. None of the patients required reoperation during the follow-up period.

Conclusions

Under TEE guidance, using diverse percardiac or combined percutaneous device closure techniques for the one-stop treatment of different types of VSDs combined with ASD is safe, effective, and feasible. These approaches can be performed as a valuable alternative therapy for selected patients.

Late Outcomes of Ascending-to-Descending Bypass for Aortic Coarctation

BACKGROUND

Ascending-to-descending aortic bypass is a repair option for patients with complex aortic coarctation. This technique is reported to have minimal early morbidity and mortality; however, the long-term results of the procedure are unknown.

METHODS

This study analyzed the late outcomes of 81 consecutive patients with aortic coarctation who underwent ascending-to-descending aortic bypass through a median sternotomy from January 1985 to December 2012. The study was limited to this interval to allow for a minimum of 10-year follow-up. Fifty-two patients had recurrent coarctation after previous repair, and 44 patients had concomitant cardiac procedures at the time of ascending-to-descending bypass.

RESULTS

There was no perioperative mortality, and overall survival at 5, 10, and 20 years was 94%, 90%, and 85%, respectively, similar to an age- and sex-matched population. There were no interventions for the ascending-to-descending bypass during follow-up, and no deaths were known to be related to the bypass graft. Subsequent cardiac operations were performed through a median sternotomy in 7 patients (9%), and late imaging in 48 patients (59%) demonstrated no hemodynamically significant stenoses or pseudoaneurysms. At late follow-up, median systolic blood pressure was 124 mm Hg, and one-half of the patients were receiving either no or only 1 antihypertensive agent.

CONCLUSIONS

Ascending-to-descending aortic bypass is a safe operation with excellent long-term outcomes for adult patients with complex aortic coarctation. The procedure is durable and appears to improve systemic hypertension. Importantly, ascending-to-descending bypass does not hinder the safe performance of subsequent operations performed through a median sternotomy.

Successful Balloon Atrial Septostomy in a Premature Infant

Balloon atrial septostomy (BAS) has been a life-saving procedure for neonates with dextrotransposition of the great arteries (d-TGA) for nearly 6 decades. Yet, its application in premature and/or low-birthweight infants has been underexplored. Our case highlights a successful BAS in a 1.4-kg 2-day-old ex-30-week infant with d-TGA and a restrictive septum.

Surgical Management of a Right Coronary Artery Fistula After Failed Transcatheter Closure: A Case Report

A coronary artery fistula (CAF) is an abnormal communication between a coronary artery and a great vessel or cardiac chamber. CAFs are very rare and are mostly of congenital origin, but they can also be acquired. Patients are usually asymptomatic since the majority of CAFs are small in size; hence, most cases are usually discovered incidentally during routine angiographic investigations. Moderate or large CAFs can be symptomatic, causing angina pectoris due to coronary steal phenomenon, and can carry a high risk of serious complications such as myocardial infarction, heart failure, or even sudden cardiac death. Consequently, prompt management with the appropriate choice of intervention - surgical versus transcatheter closure - is essential to prevent such complications. We present a case of a 52-year-old male patient with a right coronary artery-coronary sinus fistula managed with surgical closure.

Duct Stenting in Duct-Dependent Systemic Blood Flow, Past, Present, and Future

Arterial duct stenting, pioneered in the early 1990s for newborns with a duct-dependent pulmonary and systemic circulation, has evolved significantly over the past decades. This progressive technique has led to the development of novel therapeutic strategies, including the Hybrid approach introduced three decades ago, and more recently, a complete transcatheter approach for treating newborns with hypoplastic left heart syndrome (HLHS). Subsequently, the transcatheter method has been extended to bi-ventricular lesions and patients with pulmonary hypertension, establishing a reverse Potts-shunt pathophysiology. Considering current experiences, this review aims to assess the strengths, weaknesses, and complications associated with ductal stenting, which represents a critical component of these complex treatment strategies. Despite advancements, the mortality rate of Norwood and Hybrid stage-1 procedures has plateaued, underscoring the importance of enhancing the quality of life of affected patients as the primary therapeutic goal. The prerequisite is a gentle, almost atraumatic medicine, particularly during the newborn period. It is essential to recognize that both the Hybrid and total transcatheter approaches demand comparable experience to Norwood surgery. Successful outcomes hinge on much more than merely inserting a stent into the duct; they require meticulous attention to detail and comprehensive management strategies.

Applications of Computational Fluid Dynamics in Congenital Heart Disease: A Review

Computational fluid dynamics (CFD) is a tool that allows for the analysis of otherwise unobservable blood flow patterns. In the context of medicine, CFD enables researchers to better understand acute and chronic pathophysiology as well as utilize modeling tools to predict blood flow patterns in response to surgical intervention. Such a tool is particularly useful in the field of congenital heart disease (CHD), where complex geometries and patient-specific pathology are common. Research applying CFD to study CHDs has significantly grown in the last twenty years, with new methodologies and recommendations being published at an even faster pace in the last decade. Many currently available reviews are focused on a particular area of progress or on the technical approaches to CFD geared toward the clinician. This review focuses on CFD application within the major domains of CHD research, specifically single ventricle defects and aortic coarctation, reviewing consensus seminal work while highlighting more recent avenues of study. Balancing discussion of CFD parameters with potential clinical implications of study results, this review not only aims to provide cardiovascular professionals context for the technical advancements being made in the field but also a sense of contemporary CFD's utility in clinical practice.

Long term follow-up of patients with patent ductus arteriosus after transcatheter closure

BACKGROUND

To investigate the concurrent, long-term, and future adverse events and assess the trend of adverse events in pediatric patients with patent ductus arteriosus (PDA) after transcatheter closure.

METHODS

A total of 1590 patients underwent transcatheter PDA closure were enrolled, including 465 patients (median age = 22 months) in the training group and 1125 patients in the validation group. Logistic regression analysis was used to assess independent risk factors associated with concurrent adverse events after closure. The chi-square test was used to evaluate the 5-year follow-up trend.

RESULTS

Multivariable logistic regression analysis indicated that low age, female, and high pulmonary end diameter were independent risk factors for concurrent adverse events after closure. For patients without concurrent adverse events and for those who with concurrent adverse events but return to normal, the Chi-square test showed no abnormal results at the 5-year follow-up. Furthermore, the follow-up data of the validation group were not significantly different from those of the training group.

CONCLUSION

The value of long-term follow-up of children may be limited for those who did not have a concurrent adverse event after closure nor for those who had a concurrent adverse event after closure but returned to normal during the 5-year follow-up period.

IMPACT

Follow-up monitoring of adverse events tended to be recommended in pediatric patients with PDA after transcatheter closure. However, follow-up in these pediatric patients is expensive and there is a risk of sedation for echocardiography examination frequently. ·Patients who had no concurrent adverse events after closure did not show any abnormality at 5-year follow-up. ·Most of the patients who had concurrent adverse events after closure returned to normal at 5-year follow-up. The value of long-term follow-up may be limited for the above patients after transcatheter PDA closure.

An in silico analysis of heart rate impact on wall shear stress hemodynamic parameters in aortic coarctation

This study examines how heart rate (HR) affects hemodynamics in a South African infant with Coarctation of the Aorta. Computed tomography angiography segments aortic coarctation anatomy; Doppler echocardiography derives inlet flow waveforms. Simulations occur at 100, 120, and 160 beats per minute, representing reduced, resting, and elevated HR levels. Turbulence was analyzed over time and space using turbulence-resolving and pulsatile large-eddy simulations. Specifically, a 60% reduction in HR led to a reduction in maximum velocity by 45%, and a 57% decrease in pressure drop. The reduction in turbulence-related metrics was less significant. The ratio of turbulent kinetic energy to total kinetic energy decreased by 2%, while turbulent wall shear stress decreased by 3%. These results demonstrate that HR significantly affects velocity and pressure drop, while turbulence arising from the coarctation region is relatively unaffected. The balance between turbulent kinetic energy and total kinetic energy shows minimal enhancement due to the complex interplay among HR, turbulence, and geometry. This complexity prompts discussion on how HR-slowing medications, such as beta-blockers or ivabradine, could positively influence hemodynamic stresses. In particular, the results indicate that while HR modulation can influence flow dynamics, it may not significantly reduce turbulence-induced shear stresses within the coarctation zone. Therefore, further investigation is necessary to understand the potential impact of HR modulation in the management of CoA, and whether interventions targeting the anatomical correction of the coarctation may be more effective in improving hemodynamic outcomes.

The effect of cardiac catheterization on thyroid functions in infants with congenital heart diseases: a prospective observational study

This study aims to determine the incidence, clinical course, and risk factors of hypothyroidism following cardiac catheter (CC) in infants with congenital heart diseases (CHD). This prospective study involved 115 patients with CHD, all aged 3 years or younger, who underwent CC, as well as 100 healthy age- and sex-matched controls. Baseline thyroid function tests (TFTs) were conducted for both the patients and controls. In the CHD cohort, TFTs were reassessed 4 weeks after the CC, and for those with abnormal TFT values at this time, the tests were repeated after 2 weeks. Levothyroxine was started for patients with persistent abnormal TFTs, at 4 weeks and 6 weeks assessments after CC. Four weeks after CC, 12% of the studied group exhibited hypothyroidism. Univariate analysis identified significant predictors of hypothyroidism following CC: aortic stenosis (RR = 10.0 (1.49-66.99), P = 0.018), duration of fluoroscopy during CC (RR = 2.12 (0.99-4.26), P = 0.05), and total iodinated contrast media (iCM) during CC (RR = 2.5 (1.35-3.55), P = 0.019). Multivariate analysis indicated that iCM dose was the sole significant predictor of developing hypothyroidism (RR = 2.10 (1.01-3.23), P = 0.04). ROC curve analysis showed that the cut-off point of iCM dose for prediction of hypothyroidism evolution is 8.7 gm/kg, (sensitivity: 83%, specificity: 65%), while the cut-off point of fluoroscopy duration which predicts the development of hypothyroidism is 24 min (sensitivity: 83%, specificity: 66%). Acquired hypothyroidism after CC persisted in 4% of this cohort for 6 months.

CONCLUSION

Higher doses of iCM and longer duration of fluoroscope during CC are risk factors for the evolution of hypothyroidism post-CC. We recommend assessing thyroid profile 4 weeks after CC, particularly in patients who received an iCM dose greater than 8.7 gm/kg and/or exposed to fluoroscopy for more than 24 min.

WHAT IS KNOWN

• The use of excess iodine leads to transient inhibition of thyroid hormones biosynthesis via the Wolff-Chaikoff effect. • Infants with congenital heart diseases (CHD) are more prone to hypothyroidism due to higher frequency of abnormal thyroid morphology and routine exposure to supraphysiological doses of iodine.

WHAT IS NEW

• Exposure to a total dose of iodinated contrast media more than 8.7 gm/kg and a fluoroscopy duration more than 24 min during cardiac catheter are risk factors for the evolution of thyroid hypofunction following cardiac catheter.

Association of Slender Patent Ductus Arteriosus Combined With PFO Related to the Transient Ischemic Attack: A Rare Case Report

It was a rare case of a 52-year-old female with a slender PDA combined with PFO related to a transient ischemic attack that did not improve with aspirin and/or clopidogrel treatment. We closed the PDA using the ADO-II occluder and closed the PFO with the occluder, resulting in symptom resolution.

Timing of discharge of pediatric patients post cardiac catheterization

BACKGROUND

Same-day discharge after cardiac catheterization may be safe for some patients. This study aimed to review our experience with same-day discharge after pediatric cardiac catheterization following the implementation of a fast-track protocol.

OBJECTIVES

Evaluate the feasibility of same-day discharge after pediatric cardiac catheterization and identify risk factors for prolonged hospital stay.

DESIGN

Retrospective review.

SETTING

Pediatric cardiology department.

PATIENTS AND METHODS

Data from patients who underwent cardiac catheterization were recorded over 17 months, from January 2022 to May 2023, focusing on pediatric cardiac catheterization procedures, including demographics, clinical, echocardiographic, catheterization data, and outcomes. Criteria were set to determine the possibility of same-day discharge post-cardiac catheterization.

MAIN OUTCOME MEASURES

The primary outcome was the length of hospital stay post-cardiac catheterization. Secondary outcomes included identifying risk factors for prolonged hospital stay (more than 12 hours) and any associated complications.

SAMPLE SIZE

300 patients.

RESULTS

Of the 300 patients, 201 (67%) were discharged on the same day (with less than 12 hours' hospital stay), and 57 patients (19%) stayed overnight. The median length of stay (LOS) after pediatric cardiac catheterization was 8.7 hours (25th percentile: 7.5 hours, 75th percentile: 23.8 hours). No complications were reported in patients discharged on the same day. The majority of procedures were interventional cardiac catheterizations (242 cases, 80.7%), with most patients (166 cases, 55.3%) discharged on the same day of the procedure. The most common age group was between 3 to 6 months (114 patients, 38%). Regression analysis revealed that cardiac catheterization in neonates and infants less than 3 months old, more complex interventions such as patent ductus arteriosus stenting and right ventricular outflow tract stenting, interventions in the aortic valve, and the occurrence of complications were associated with prolonged hospital stay.

CONCLUSION

Same-day discharge following catheterization is feasible for the majority of pediatric patients and can contribute to reduced healthcare costs and improved patient satisfaction. We developed a fast-track protocol for assessing the timing of discharge after pediatric cardiac catheterization, outlining potential indications and contraindications for same-day discharge. Factors associated with prolonged hospital stays include interventions in the neonatal period and procedure-related complications. Careful patient selection and monitoring impleare essential to ensure optimal outcomes.

LIMITATIONS

The retrospective nature of the study and the single-center experience may limit the generalizability of the findings.

The Surgical Significance of Phenotypic Variability in the Setting of Tetralogy of Fallot

The phenotypic feature of tetralogy of Fallot is anterocephalad deviation of the muscular outlet septum, or its fibrous remnant, relative to the septoparietal trabeculation, coupled with hypertrophy of septoparietal trabeculations. Although this feature permits recognition of the entity, no two cases are identical. Once diagnosed, treatment is surgical. The results of surgical treatment have improved remarkably over recent decades. The results are now sufficiently excellent, including those in the developing world, that attention is now directed toward avoidance of morbidity, while still seeking, of course to minimize any fatalities due to surgical intervention. It is perhaps surprising that attention thus far has not been directed on the potential significance of phenotypic variation relative to either mortality or morbidity subsequent to surgical correction. The only study we have found specifically addressing this variability focused on the extent of aortic override, and associated malformations, but made no mention of variability in the right ventricular margins of the interventricular communication, nor the substrates for subpulmonary obstruction. In this review, therefore, we assessed the potential significance of known morphological variability to the outcomes of surgical intervention in over 1,000 individuals undergoing correction by the same surgeon in a center of excellence in a developing country. We sought to assess whether the variations were associated with an increased risk of postoperative death, or problems of rhythm. In our hands, double outlet ventriculoarterial connection was associated with increased risk of death, while the presence of a juxta-arterial defect with perimembranous extension was associated with rhythm problems.

Transcatheter Interventions in Adults With Fontan Palliation

The Fontan circuit is associated with chronically elevated systemic venous pressures and decreased cardiac output, often leading to circuit failure. Managing Fontan circuit failure is complex and requires multiple therapeutic options. Transcatheter interventions have emerged as a reliable approach. They can alleviate obstructions and improve cyanosis by enhancing pulmonary blood flow and oxygen saturation. These procedures can also increase cardiac output and reduce systemic venous pressure, contributing to patient stabilization. In addition, they help mitigate volume overload and decrease the risk of bleeding during heart or combined heart and liver transplants. In recent years, percutaneous interventions have rapidly evolved and become a key therapeutic option for addressing various aspects of Fontan circuit failure. These interventions should be considered integral to the management strategy for this specific patient population.

How We Would Treat Our Own Congenital Cardiac Catheterization Laboratory Patient

The field of congenital cardiac catheterization (CCC) has changed dramatically since it began 8 decades ago. New techniques and devices have expanded the indications for interventional catheterization. Heart teams who care for patients in the pediatric and congenital cardiac catheterization laboratory are confronted with a growing number of patients presenting for a wide range of increasingly technically challenging cases. Multiple societies have published expert guidelines for CCC management to provide recommendations for best practice. We reviewed risk stratification strategies for CCC and describe our institution's comprehensive, multidisciplinary approach to the periprocedural management of patients with congenital heart disease undergoing cardiac catheterization, using the index case of a 6-year-old patient with multiple heart defects. We concluded that risk stratification and a comprehensive, multidisciplinary team approach that begins when a procedure is booked is essential to inform management and optimize outcomes. Clinical decision-making should be informed by expert guidelines and evolving risk stratification research.

Long-Term Results of the Atrial Septal Defect Occluder ASSURED Trial for Combined Pivotal/Continued Access Cohorts

BACKGROUND

The GORE CARDIOFORM ASD Occluder (GCA, W. L. Gore & Associates) was approved in 2019 for ostium secundum atrial septal defect (ASD) closure.

OBJECTIVES

This study sought to report the combined pivotal and continued access cohorts of the ASSURED (Safety and Efficacy Study of Transcatheter Closure of Ostium Secundum ASDs) trial results through 36 months.

METHODS

This prospective, multicenter, single-arm trial evaluated procedural and clinical outcomes of ASD closure with the GCA. The primary endpoints were 6-month closure success following device implantation and composite clinical success (deployment/retention of device, safety, and closure). Technical and procedure success, safety, clinically significant new arrhythmia (CSNA) secondary endpoints, and wire frame fracture (WFF, with fluoroscopy) at 6 and 36 months were evaluated.

RESULTS

Of 569 patients (median age of 10.4 years and median weight of 35.0 kg) who underwent attempted secundum ASD closure, 526 were technical successes. The mean stop-flow ASD diameter was 17.6 ± 5.3 mm. All 478 patients with 6-month imaging achieved closure success. Composite clinical success at 6 and 36 months was achieved in 87.6% (468/534) and 84.0% (351/418) of patients, respectively. Technical failure occurred in 8.1% (43/548), 30-day device- or procedure-related serious adverse event in 3.9% (21/534), and 6-month device events in 2.8% (15/534) of patients. At 30 days, 21 of 569 patients (3.7%) had CSNA. At 6 months, 138 of 436 (31.7%) patients had WFFs and 105 of 185 (56.8%) at 36 months (without sequelae).

CONCLUSIONS

In this large congenital ASD device trial, the GCA had acceptable results. WFFs, although common, did not result in any clinical sequelae. The unique features, size range, and safety profile expand the options for secundum ASD closure. (Safety and Efficacy Study of Transcatheter Closure of Ostium Secundum ASDs [ASSURED]; NCT02985684).

Bicuspid Aortic Valve in Children and Young Adults for Cardiologists and Cardiac Surgeons: State-of-the-Art of Literature Review

Bicuspid aortic valve disease is the most prevalent congenital heart disease, affecting up to 2% of the general population. The presentation of symptoms may vary based on the patient's anatomy of fusion, with transthoracic echocardiography being the primary diagnostic tool. Bicuspid aortic valves may also appear with concomitant aortopathy, featuring fundamental structural changes which can lead to valve dysfunction and/or aortic dilatation over time. This article seeks to give a comprehensive overview of the presentation, treatment possibilities and long-term effects of this condition. The databases MEDLINE, Embase, and the Cochrane Library were searched using the terms "endocarditis" or "bicuspid aortic valve" in combination with "epidemiology", "pathogenesis", "manifestations", "imaging", "treatment", or "surgery" to retrieve relevant articles. We have identified two types of bicuspid aortic valve disease: aortic stenosis and aortic regurgitation. Valve replacement or repair is often necessary. Patients need to be informed about the benefits and drawbacks of different valve substitutes, particularly with regard to life-long anticoagulation and female patients of childbearing age. Depending on the expertise of the surgeon and institution, the Ross procedure may be a viable alternative. Management of these patients should take into account the likelihood of somatic growth, risk of re-intervention, and anticoagulation risks that are specific to the patient, alongside the expertise of the surgeon or centre. Further research is required on the secondary prevention of patients with bicuspid aortic valve (BAV), such as lifestyle advice and antibiotics to prevent infections, as the guidelines are unclear and lack strong evidence.

Estimating pulmonary arterial remodeling via an animal-specific computational model of pulmonary artery stenosis

Pulmonary artery stenosis (PAS) often presents in children with congenital heart disease, altering blood flow and pressure during critical periods of growth and development. Variability in stenosis onset, duration, and severity result in variable growth and remodeling of the pulmonary vasculature. Computational fluid dynamics (CFD) models enable investigation into the hemodynamic impact and altered mechanics associated with PAS. In this study, a one-dimensional (1D) fluid dynamics model was used to simulate hemodynamics throughout the pulmonary arteries of individual animals. The geometry of the large pulmonary arteries was prescribed by animal-specific imaging, whereas the distal vasculature was simulated by a three-element Windkessel model at each terminal vessel outlet. Remodeling of the pulmonary vasculature, which cannot be measured in vivo, was estimated via model-fitted parameters. The large artery stiffness was significantly higher on the left side of the vasculature in the left pulmonary artery (LPA) stenosis group, but neither side differed from the sham group. The sham group exhibited a balanced distribution of total distal vascular resistance, whereas the left side was generally larger in the LPA stenosis group, with no significant differences between groups. In contrast, the peripheral compliance on the right side of the LPA stenosis group was significantly greater than the corresponding side of the sham group. Further analysis indicated the underperfused distal vasculature likely moderately decreased in radius with little change in stiffness given the increase in thickness observed with histology. Ultimately, our model enables greater understanding of pulmonary arterial adaptation due to LPA stenosis and has potential for use as a tool to noninvasively estimate remodeling of the pulmonary vasculature.

Clinical Care for Cardiovascular Disease in Patients With Williams-Beuren Syndrome

Williams-Beuren syndrome (WBS) is a congenital multisystem disorder affecting the cardiovascular, central nervous, and musculoskeletal systems. Cardiovascular abnormalities, which consist principally of vascular stenoses, occur in approximately 80% of people with WBS and are the predominant cause of early morbidity and mortality. Supravalvar aortic stenosis and peripheral pulmonary artery stenosis are the most common stenotic lesions in WBS, though other stenoses often occur, including stenoses of the coronary arteries. Approximately one-third of people with WBS undergo cardiovascular interventions. The risk of sudden cardiac death is markedly higher than the general population, with most events occurring in the periprocedural period. Because of the rarity of WBS and the often-complex nature of the cardiovascular abnormalities, most physicians, including cardiologists, have limited experience in caring for patients with WBS. Further, heretofore, clinical cardiovascular management guidelines based on international expert consensus have not been available. This state-of-the-art review provides a comprehensive synopsis of the cardiovascular abnormalities in WBS and presents clinical management guidelines based on the authors' expert consensus.

Echocardiogram-Guided Balloon Valvuloplasty of the Aortic Valve in Neonates and Infants Reduces Contrast Exposure with Maintained Efficacy and Less Aortic Regurgitation

Balloon aortic valvuloplasty (BAV) is performed in children with significant aortic stenosis (AS). Traditionally, contrast angiography measures the annulus and assesses aortic regurgitation (AR) after each dilation. Echocardiographic guidance is hypothesized to reduce contrast and radiation exposure, without compromising efficacy or safety. Patients < 10 kg undergoing BAV from 2013 to 2022 were retrospectively investigated. Agreement between echocardiographic and angiographic annulus measurements was assessed. Echocardiogram-guided (eBAV) and traditional angiogram-guided (tBAV) outcomes were compared controlling for weight, critical AS, and other congenital heart disease (CHD). Twelve eBAV and 19 tBAV procedures were performed. The median age was 33 days, median weight was 4.3 kg, 7 patients (23%) had critical AS, and 9 patients (29%) had other CHD. Annulus measurements by intraprocedural echocardiography and angiography displayed excellent correlation (ICC 0.95, p < 0.001). eBAV patients received less contrast (0.5 vs 3.5 ml/kg, p < 0.01). Five recent eBAV procedures were performed contrast free. Radiation exposure was not statistically different between the eBAV and tBAV groups (155 vs 313 µGy·M2, p = 0.12). One eBAV patient (8%) and 3 tBAV patients (16%, p = 0.62) experienced serious adverse events. Technical success (gradient < 35 mmHg and increase in AR by ≤ 1 grade) occurred in 11 eBAV patients (92%) and 16 tBAV patients (84%, p = 0.22). AR increased in 2 eBAV patients (17%) and 8 tBAV patients (44%, p = 0.02). eBAV was associated with similar efficacy and significantly lower contrast exposure and risk of aortic regurgitation. There was strong agreement between aortic valve annulus measurements by intraprocedural echocardiography and angiography, ultimately permitting contrast free BAV.

Embolization of a Large Right-Coronary-Artery-to-Left-Atrium Fistula in a Three-Year-Old Child: A Case Report

OBJECTIVES

Coronary artery fistulas (CAFs) are rare congenital anomalies with an occurrence rate of 0.002-0.3%. The right coronary artery (RCA) is reportedly the most common site of origin of CAFs, but fistulas draining to the left atrium (LA) are rare. We presented a three-year-old boy with a symptomatic congenital RCA-to-LA fistula, which was successfully percutaneously occluded with an Amplatzer vascular plug 4 (AVP4).

CASE REPORT

The diagnosis was made by echocardiography when he was two months old. During the follow-up period of 2 years, a progressive dilatation of the RCA and enlargement of the left ventricle was detected, so treatment for congestive heart failure was initiated. At the age of three, the patient presented with a history of occasional mild central chest pain and discomfort and mild dyspnea on exertion. On a 24 h ECG Holter monitor, the depression of ST segments was registered. CT angiography highlighted a large type B RCA fistula to the LA, which extended along the atrioventricular sulcus. The proximal RCA diameter was 7 mm. The fistula was tortuous, with segmental narrowing and three curves. Cardiac catheterization was performed across the right femoral artery on the three-year-old boy (body weight: 13 kg). Across the 4F Judkins right guiding catheter, an AVP4 of 5 mm was placed in the distal part of the CAF connected with the delivery cable. After 15 min, ECG changes were not registered, so the device was released. Immediate post-deployment angiography demonstrated complete CAF occlusion, with satisfying flow in the distal coronary artery. The patient was discharged after four days. In the short-term follow-up period, the boy was symptom-free.

CONCLUSIONS

In our experience, given the existence of the left-to-left shunt and the more pronounced exercise-induced coronary steal phenomenon that occurs in medium-sized and large CAFs, occlusion is necessary to prevent the further progression of clinical signs and symptoms.

Coronary Artery Anomalies: Diagnosis & Management

Coronary artery anomalies encompass a spectrum of congenital abnormalities affecting the origin, course, or termination of the major epicardial coronary arteries. Despite their rarity, coronary artery anomalies represent a significant burden on cardiovascular health due to their potential to disrupt myocardial blood flow and precipitate adverse cardiac events. While historically diagnosed postmortem, the widespread availability of imaging modalities has led to an increased recognition of coronary artery anomalies, particularly in adults. This review synthesizes current knowledge on the classification, mechanisms, and clinical implications of coronary anomalies, focusing on prevalent variants with significant clinical impact. We discuss strategies for medical and surgical management, as well as contemporary screening recommendations, acknowledging the evolving understanding of these anomalies. Given the breadth of possible variants and the limited data on some presentations, this review provides a framework to aid clinicians in the recognition and management of coronary anomalies, with a particular emphasis on their stratification by anatomical location. By consolidating existing knowledge and highlighting areas of uncertainty, this review aims to enhance clinical decision-making and improve outcomes for individuals with coronary anomalies.

Brazilian Guideline for Exercise Testing in Children and Adolescents - 2024

CLASSES OF RECOMMENDATION

LEVELS OF EVIDENCE

Multi-Source Data and Knowledge Fusion via Deep Learning for Dynamical Systems: Applications to Spatiotemporal Cardiac Modeling

Advanced sensing and imaging provide unprecedented opportunities to collect data from diverse sources for increasing information visibility in spatiotemporal dynamical systems. Furthermore, the fundamental physics of the dynamical system is commonly elucidated through a set of partial differential equations (PDEs), which plays a critical role in delineating the manner in which the sensing signals can be modeled. Reliable predictive modeling of such spatiotemporal dynamical systems calls upon the effective fusion of fundamental physics knowledge and multi-source sensing data. This paper proposes a multi-source data and knowledge fusion framework via deep learning for dynamical systems with applications to spatiotemporal cardiac modeling. This framework not only achieves effective data fusion through capturing the physics-based information flow between different domains, but also incorporates the geometric information of a 3D system through a graph Laplacian for robust spatiotemporal predictive modeling. We implement the proposed framework to model cardiac electrodynamics under both healthy and diseased heart conditions. Numerical experiments demonstrate the superior performance of our framework compared with traditional approaches that lack the capability for effective data fusion or geometric information incorporation.

The effects of percutaneous branch pulmonary artery interventions in biventricular congenital heart disease: study protocol for a randomized controlled Dutch multicenter interventional trial

BACKGROUND

Branch pulmonary artery (PA) stenosis is one of the most common indications for percutaneous interventions in patients with transposition of the great arteries (TGA), tetralogy of Fallot (ToF), and truncus arteriosus (TA). However, the effects of percutaneous branch PA interventions on exercise capacity remains largely unknown. In addition, there is no consensus about the optimal timing of the intervention for asymptomatic patients according to international guidelines. This trial aims to identify the effects of percutaneous interventions for branch PA stenosis on exercise capacity in patients with TGA, ToF, and TA. In addition, it aims to assess the effects on RV function and to define early markers for RV adaptation and RV dysfunction to improve timing of these interventions.

METHODS

This is a randomized multicenter interventional trial. TGA, ToF, and TA patients ≥ 8 years with a class IIa indication for percutaneous branch PA intervention according to international guidelines are eligible to participate. Patients will be randomized into the intervention group or the control group (conservative management for 6 months). All patients will undergo transthoracic echocardiography, cardiac magnetic resonance (CMR) imaging, and cardiopulmonary exercise testing at baseline, 6 months, and 2-4 years follow-up. Quality of life (QoL) questionnaires will be obtained at baseline, 2 weeks post intervention or a similar range for the control group, and 6 months follow-up. The primary outcome is exercise capacity expressed as maximum oxygen uptake (peak VO2 as percentage of predicted). A total of 56 patients (intervention group n = 28, control group n = 28) is required to demonstrate a 14% increase in maximum oxygen uptake (peak VO2 as percentage of predicted) in the interventional group compared to the control group (power 80%, overall type 1 error controlled at 5%). Secondary outcomes include various parameters for RV systolic function, RV functionality, RV remodeling, procedural success, complications, lung perfusion, and QoL.

DISCUSSION

This trial will investigate the effects of percutaneous branch PA interventions on exercise capacity in patients with TGA, ToF, and TA and will identify early markers for RV adaptation and RV dysfunction to improve timing of the interventions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05809310. Registered on March 15, 2023.

Impact of Age and of the Patent Ductus Arteriosus on Pulmonary Hemodynamics in Children with Complete Atrioventricular Septal Defect

Complete atrioventricular septal defect (CAVSD) can lead to the development of pulmonary obstructive vascular disease due to high pulmonary blood flow and pressures. This study aimed to evaluate the changes in pulmonary hemodynamics with aging and with patent ductus arteriosus (PDA) in children with CAVSD. We retrospectively evaluated 137 children (94% with trisomy 21, median age of 195 (25-2963) days, 58.4% female) with CASVD referred to cardiac catheterization from January 2000 to December 2020. Those with associated congenital heart disease, except PDA, had been excluded. They were divided into three age terciles (T1, T2, and T3). Aging was directly associated with higher mean (T1: 34.2 ± 9.1; T2: 37.1 ± 5.8; T3: 42 ± 10.6 mmHg, p < 0.001) and diastolic (T1: 19.4 ± 5.3; T2 21.6 ± 5.0; T3: 26.0 ± 9.5 mmHg, P < 0.001) pulmonary arterial pressures, and with higher pulmonary vascular resistance (T1: 3.24 ± 1.69, T2: 3.47 ± 1.19; T3: 4.49 ± 3.91 Wu.m2, p = 0.023). This resulted in a loss of eligibility for anatomical correction, which became evident only after 300 days of age. PDA was associated with a higher mean (37.2 [35.9; 38.5] vs. 41.3 [37.5; 45.0] mmHg, p = 0.049) and diastolic (21.7 [20.7; 22.6] vs. 26.4 [24.1; 29.0] mmHg, p = 0.001) pulmonary pressure, and resistor-compliance time (0.28 [0.26; 0.29] vs. 0.36 [0.31; 0.40], p = 0.001) after adjusting for age and sex. In children with CAVSD, aging was associated with worsening of pulmonary vascular hemodynamics, particularly when PDA was associated, resulting in loss of eligibility for anatomical correction after 10 months of age as the first surgical option.

Extra-anatomical Bypass in a Case of Recoarctation and Previous Cardiac Surgery

A complex clinical case of aortic recoarctation is presented. The case is a 61-year-old comorbid patient with two previous aortic and cardiac operations. At the age of 10, the patient underwent surgery for post-ductal coarctation of the aorta (adult type) at the typical site, where the stenotic area was completely resected, and an end-to-end anastomosis was performed through a left-sided thoracotomy. Ten years ago, the patient also had mitral valve replacement with a metallic prosthesis due to severe mitral insufficiency, performed via median sternotomy. The patient was admitted to the cardiac surgery unit due to symptoms suggestive of aortic re-stenosis due to status post repair of coarctation of the aorta (resection with end-to-end anastomosis). An extra-anatomic bypass was performed between the ascending and abdominal aorta, with the graft passing through a new diaphragm opening in front of the hilus of the right lung.

An interdisciplinary consensus approach to pulmonary hypertension in developmental lung disease

It is increasingly recognised that diverse genetic respiratory disorders present as severe pulmonary hypertension (PH) in the neonate and young infant, but many controversies and uncertainties persist regarding optimal strategies for diagnosis and management to maximise long-term outcomes. To better define the nature of PH in the setting of developmental lung disease (DEVLD), in addition to the common diagnoses of bronchopulmonary dysplasia and congenital diaphragmatic hernia, we established a multidisciplinary group of expert clinicians from stakeholder paediatric specialties to highlight current challenges and recommendations for clinical approaches, as well as counselling and support of families. In this review, we characterise clinical features of infants with DEVLD/DEVLD-PH and identify decision-making challenges including genetic evaluations, the role of lung biopsies, the use of imaging modalities and treatment approaches. The importance of working with team members from multiple disciplines, enhancing communication and providing sufficient counselling services for families is emphasised to create an interdisciplinary consensus.

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.

Segmentation of Heart Sound Signal Based on Multi-Scale Feature Fusion and Multi-Classification of Congenital Heart Disease

Analyzing heart sound signals presents a novel approach for early diagnosis of pediatric congenital heart disease. The existing segmentation algorithms have limitations in accurately distinguishing the first (S1) and second (S2) heart sounds, limiting the diagnostic utility of cardiac cycle data for pediatric pathology assessment. This study proposes a time bidirectional long short-term memory network (TBLSTM) based on multi-scale analysis to segment pediatric heart sound signals according to different cardiac cycles. Mel frequency cepstral coefficients and dynamic characteristics of the heart sound fragments were extracted and input into random forest for multi-classification of congenital heart disease. The segmentation model achieved an overall F1 score of 94.15% on the verification set, with specific F1 scores of 90.25% for S1 and 86.04% for S2. In a situation where the number of cardiac cycles in the heart sound fragments was set to six, the results for multi-classification achieved stabilization. The performance metrics for this configuration were as follows: accuracy of 94.43%, sensitivity of 95.58%, and an F1 score of 94.51%. Furthermore, the segmentation model demonstrates robustness in accurately segmenting pediatric heart sound signals across different heart rates and in the presence of noise. Notably, the number of cardiac cycles in heart sound fragments directly impacts the multi-classification of these heart sound signals.

Minimally Invasive Surgical Repair of Simple Congenital Heart Defects Using the Right Vertical Infra-Axillary Thoracotomy Approach

OBJECTIVE

To evaluate the safety and efficacy of surgical repair for patients diagnosed with simple congenital heart defects (CHD) using the minimally invasive right vertical infra-axillary minithoracotomy (RVIAT) approach.

METHODS

We retrospectively reviewed the clinical data of consecutive patients who underwent minimally invasive RVIAT for repair of CHD between August 2019 and August 2022. There were 382 patients who underwent 8 primary procedures and were included in this study.

RESULTS

The median age of the patients was 16.2 (interquartile range [IQR], 7.2 to 41.9) months, and the median weight of the patients was 8.8 (IQR, 6.5 to 14) kg. The preoperative diagnoses were as follows: ventricular septal defect, atrial septal defect, partial anomalous pulmonary venous return, partial atrioventricular septal defect, cor triatriatum, complete atrioventricular septal defect, and myxoma. The mean aortic cross-clamp time, bypass time, and operation time were 45.4 ± 19.3 min, 65.6 ± 23.1 min, and 154.5 ± 29.7 min, respectively. There was no in-hospital mortality or conversion to median sternotomy. Two patients (0.5%) required early reoperation; 1 due to postoperative bleeding and 1 for permanent pacemaker implantation. Other complications included trivial residual shunts (23 of 382, 6%), pleural effusion (3 of 382, 0.8%), pneumothorax (0.8%), and wound infection (4 of 382, 1%). There were 2 late noncardiac deaths. Late reoperation was performed on 1 patient with progressive aortic valve regurgitation who required aortic valvuloplasty.

CONCLUSIONS

RVIAT is a minimally invasive approach that can be safely performed on patients with simple CHDs. RVIAT may be a good alternative approach for median sternotomy and cardiac intervention.

Cardiac Catheterization Post Congenital Cardiac Surgery: Analysis of Risk Factors for Mortality and Literature Review

Background Diagnostic and interventional cardiac catheterization plays a significant role in the management of congenital heart defects with acceptable risks. Its role has also evolved in sick children but is associated with higher risks due to technical difficulties and co-morbidity factors. Some of the post-cardiac surgery children who show resistance to conventional management during the early postoperative period usually have residual defects or obstructions. Trans-catheter intervention (TCI) in such high-risk circumstances and relatively sick children is challenging, demands much expertise, and should be backed up by a competent multidisciplinary team. Some cases improve clinically, while others may require surgical or transcatheter re-intervention for a positive outcome. There is minimal data so far regarding the major complications after interventional cardiac catheterization during the immediate postoperative period after cardiac surgery. We analyzed multiple factors, including age, sex, weight, the initial diagnosis, and the time interval between surgery and TCI, to stratify the possible risks for mortality after TCI during the immediate postoperative period after cardiac surgery. Results Thirty-five patients fulfilled the inclusion criteria and underwent 43 interventional procedures. Five patients could not survive. Four had stent angioplasties on natural vasculature and one patient had in synthetic conduit. None of the mortality was related to the procedure. Multivariable risk factor analysis confirmed a moderate positive correlation coefficient (r) of 0.8017 between the variables. Still, it was not statistically significant if compared among subgroups or among the mortality and survival groups. Conclusion Interventional cardiac catheterization in sick children during the immediate postoperative period can be carried out without much-added risks in expert hands and under the supervision of a multi-disciplinary team. Though no conclusions could be drawn, our study adds to the limited existing data that could inspire others to perform such procedures on sick children. Moreover, the trend in our results indicated a large sample size could have identified a possible risk factor for mortality.

Hybrid treat-and-repair strategy for large patent ductus arteriosus: a proof-of-concept case report

Background

In cases of atrial septal defect with pulmonary arterial hypertension (PAH), a treat-and-repair strategy that adopts pulmonary vasodilator therapy and subsequent defect closure is postulated to be effective. However, this strategy has not been applied to the large patent ductus arteriosus (PDA) with PAH.

Case summary

A 10-year-old girl with trisomy 21 was referred to our hospital for the treatment of a large PDA with PAH. Cardiac catheterization and angiography revealed a type C tubular PDA with a minimal diameter of 8.1 mm, an increase in mean pulmonary artery pressure (mPAP) of 60 mmHg, a ratio of pulmonary to systemic blood flow (Qp/Qs) of 2.7, and pulmonary artery resistance (Rp) of 7.1 U/m2. Because she was categorized in the grey zone for operability, we adopted a hybrid treat-and-repair strategy in which palliative surgical duct banding was performed before pulmonary vasodilator therapy to prevent excessive pulmonary blood flow and was followed by transcatheter closure of the PDA. Postoperatively, we confirmed the flow-restricted duct with a minimal diameter of 3.3 mm, decreased Qp/Qs 1.38, high mPAP 40 mmHg, and Rp 7.3 U/m2. Six months after treatment with macitentan and tadalafil, we confirmed a decrease in Rp 4.1 U/m2 as well as low Qp/Qs 1.12, which was low enough for the duct occlusion. The transcatheter occlusion of the surgically created type A conical duct was easily and safely performed. In the mid-term follow-up, favourable haemodynamics and improved exercise were confirmed.

Discussion

This is the first proof-of-concept case report to show the successful hybrid treat-and-repair strategy for large PDA, which warrants further investigation.