Transcatheter pulmonary valve perforation using chronic total occlusion wire in pulmonary atresia with intact ventricular septum

Radiofrequency Perforation of an Atretic Pulmonary Valve with a Modified Coronary Wire and Electrocautery Pencil

Radiofrequency (RF) perforation of an atretic pulmonary valve is commonly performed in patients with pulmonary atresia with intact ventricular septum with specifically designed RF wires. In difficult anatomy or low-resource centers, this may instead be successfully performed with a modified coronary guide wire and an electrocautery surgical pencil.

Pulmonary Atresia with Intact Ventricular Septum, a National Comparison Between Interventional and Surgical Approach, in Combination with a Systemic Literature Review

This study aimed to compare long-term morbidity in patients with pulmonary atresia with intact ventricular septum (PA-IVS) treated with catheter-based intervention (group A) versus those undergoing heart surgery (group B) as initial intervention. Additionally, we conducted a systematic literature review on PA-IVS treatment. All neonates born in Sweden with PA-IVS between 2007 and 2019 were screened for inclusion. The inclusion criterion was decompression of the right ventricle for initial intervention. Medical records were reviewed, as well as the initial preoperative angiogram, and the diagnostic echocardiogram. Comparisons between groups were performed with Mann-Whitney U-test and Fisher´s exact test. A systematic literature review of original studies regarding treatment of PA-IVS (2002 and onward) was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, to assess the outcomes of patients with PA-IVS. 34 (11 females) patients were included, 18 in group A and 16 in group B. There was no mortality in either group. Follow-up time ranged from 2 to 15 years (median 9). All attempted perforations in group A were successful, and 16 out of 18 patients reached biventricular circulation. In the surgical group 15 out of 16 patients reached biventricular circulation. The literature review presented heterogeneity in standards for treatment. This retrospective population-based multicenter study demonstrates that both catheter-based intervention and heart surgery are safe procedures. Our results are comparable to, or exceed, those in the systematic literature review. The systematic literature review displays a great heterogeneity in study design, with no definitive golden standard treatment.

Current status of transcatheter intervention for complex right ventricular outflow tract abnormalities

Various transcatheter interventions for the right ventricular outflow tract (RVOT) have been introduced and developed in recent decades. Transcatheter pulmonary valve perforation was first introduced in the 1990s. Radiofrequency wire perforation has been the approach of choice for membranous pulmonary atresia in newborns, with high success rates, although complication rates remain relatively common. Stenting of the RVOT is a novel palliative treatment that may improve hemodynamics in neonatal patients with reduced pulmonary blood flow and RVOT obstruction. Whether this option is superior to other surgical palliative strategies or early primary repair of tetralogy of Fallot remains unclear. Transcatheter pulmonary valve replacement has been one of the biggest innovations in the last two decades. With the success of the Melody and SAPIEN valves, this technique has evolved into the gold standard therapy for RVOT abnormalities with excellent procedural safety and efficacy. Challenges remain in managing the wide heterogeneity of postoperative lesions seen in RVOT, and various technical modifications, such as pre-stenting, valve ring modification, or development of self-expanding systems, have been made. Recent large studies have revealed outcomes comparable to those of surgery, with less morbidity. Further experience and multicenter studies and registries to compare the outcomes of various strategies are necessary, with the ultimate goal of a single-step, minimally invasive approach offering the best longer-term anatomical and physiological results.

Transcatheter Interventions for Neonates with Congenital Heart Disease: A Review

Newborns with congenital heart disease often require interventions linked to high morbidity and mortality rates. In the last few decades, many transcatheter interventions have become the first-line treatments for some critical conditions in the neonatal period. A catheter-based approach provides several advantages in terms of procedural time, length of hospitalization, repeatability and neurodevelopmental issues (usually related to cardiopulmonary bypass). The main transcatheter procedures will be reviewed, as they are now valid alternatives to conventional surgical management.

A retrograde approach for transcatheter valvotomy procedure in infants with pulmonary atresia intact ventricular septum (PA-IVS): retrograde versus antegrade approach

INTRODUCTION

This study evaluates the retrograde approach compared to the antegrade approach in infants with PA-IVS who underwent transcatheter pulmonary valvotomy procedure at National Cardiovascular Center Harapan Kita, Jakarta, Indonesia.

MATERIAL AND METHOD

This is a single-centre retrospective study conducted from January 2017 to June 2019 consisting of infants undergoing transcatheter pulmonary valvotomy procedures from our centre.

RESULTS

Among 3733 records of cardiac catheter procedure in paediatric patients during the last 3 years, there were 12 subjects with PA-IVS, where five subjects were done by antegrade approach and seven by retrograde approach. The retrograde approach is shown to excel the antegrade approach in terms of procedural time by 58.64 minutes (CI 95 % 32.97-84.29, p = 0.008) and PA-RV crossing time by 27 minutes (CI 95 % 14.01-39.99, p = 0.02). There was no significant difference in contrast used (120.23 ± 25.77 versus 150.27 ± 39.26 ml/BSA, p = 0.518), and right ventricle to pulmonary artery systolic pressure gradient after valvotomy (39.571 ± 5.814 versus 53.52 ± 29.15, p = 0.329) between the retrograde and the antegrade approach.

CONCLUSION

The retrograde approach offered shorter procedural time and comparably satisfying results than the antegrade approach. The shorter procedural time was preferred due to the shorter duration of general anaesthesia, which may decrease the risk of neurodevelopmental deficits in the patient.

Transcatheter Cardiac Interventions in the Newborn: JACC Focus Seminar

For neonates with critical congenital heart disease requiring intervention, transcatheter approaches for many conditions have been established over the past decades. These interventions may serve to stabilize or palliate to surgical next steps or effectively primarily treat the condition. Many transcatheter interventions have evidence-based records of effectiveness and safety, which have led to widespread acceptance as first-line therapies. Other techniques continue to innovatively push the envelope and challenge the optimal strategies for high-risk neonates with right ventricular outflow tract obstruction or ductal-dependent pulmonary blood flow. In this review, the most commonly performed neonatal transcatheter interventions will be described to illustrate the current state of the field and highlight areas of future opportunity.

Type I and II pulmonary atresia with intact ventricular septum in infants: a 10-year experience in initial surgery at one center

Background

To explore the effect of initial surgery for type I and II pulmonary atresia with intact ventricular septum (PA/IVS).

Methods

50 children with type I PA/IVS and 50 with type II PA/IVS who had undergone initial surgery were enrolled. Children with Type I were divided into groups A (n = 25) and B (n = 25). Group A had received BT shunt combined with PDA ligation and balloon dilatation of pulmonary valve, whereas group B had undergone BT shunt combined with PDA ligation and pulmonary valve incision. Children with type II were divided into groups C (n = 25) and D (n = 25). Group C had received BT shunt combined with PDA ligation, right ventricular outflow tract (RVOT) incision and transannular patch. Group D had undergone BT shunt combined with PDA ligation, RVOT incision, transannular patch and artificial pulmonary valve implantation. The differences in mechanical ventilation time, length of ICU stay, mortality rate, tricuspid Z value, tricuspid regurgitation, oxygen saturation, pulmonary regurgitation, McGoon ratio, pulmonary artery transvalvular pressure, survival rate were compared between groups A and B, between groups C and D respectively.

Results

The ventilator assistance time and length of ICU stay were greater in group C than in group D (80.96 ± 8.42 h vs. 65.16 ± 4.85 h, P = 0.045; 222.00 ± 11.72 h vs. 162.48 ± 7.91 h, P = 0.048). The pulmonary artery transvalvular pressure was significantly higher in group A than in group B at 3, 6, 12, 24 and 36 months after surgery (64.86 ± 4.13 mmHg vs. 53.04 ± 5.64 mmHg, P = 0.045; 69.47 ± 1.93 mmHg vs. 55.95 ± 4.04 mmHg, P = 0.005; 80.16 ± 3.76 mmHg vs. 73.24 ± 2.34 mmHg, P = 0.035; 62.95 ± 5.64 mmHg vs. 48.47 ± 7.44 mmHg, P = 0.04; 53.69 ± 4.89 vs. 45.77 ± 3.26, P = 0.02). Furthermore, the tricuspid Z value was significantly greater in group B than in group A at 3 and 24 months after surgery (− (1.37 ± 0.04) vs. − (1.43 ± 0.06), P = 0.03; − (0.41 ± 0.06) vs. − (0.51 ± 0.11), P = 0.02).

Conclusions

The effect of BT shunt combined with PDA ligation and pulmonary valve incision is superior to BT shunt combined with PDA ligation and balloon dilatation of pulmonary valve, and the effect of BT shunt combined with PDA ligation, RVOT incision, transannular patch and artificial pulmonary valve implantation is superior to BT shunt combined with PDA ligation, RVOT incision and transannular patch.

The Use of Chronic Total Occlusion (CTO) Wires for Perforation of Atretic Pulmonary Valve; Two Centers Experience

Pulmonary valve atresia with intact ventricular septum (PA-IVS) can be treated either surgically or transcatheterly for eligible patients. Perforation of pulmonary valves using chronic total occlusion (CTO) guidewires has been reported as an alternative to radiofrequency (RF) perforation. We sought to report our experience with CTO guidewires for perforation of atretic pulmonary valves and subsequent balloon dilatation (with or without patent ductus arteriosus stenting) in patients with PA-IVS from two centers. A retrospective study was carried out on PA-IVS patients who underwent intervention between March 2014 and September 2019, in which CTO guidewire was employed for pulmonary valve perforation. A total of 26 patients were identified. The median age and weight of the patients were 5.2 days (range 1-21 days) and 3.1 kg (range 2.2-3.8 kg), respectively. All patients were situs solitus, except one patient with left atrial isomerism. The right ventricle (RV) morphology was bipartite in 22/26 patients and tripartite in 4/26 patients. Before the procedure, the mean saturation was 76% (range 70-86%) while the patients were under prostaglandin infusion. The pulmonary valve perforation attempt was performed with the Asahi Conquest Pro 9 CTO wire (n = 6) or Asahi Pro 12 CTO wire (n = 18) and/or Asahi Miracle CTO wire (n = 2). The procedure was successful in 20/26 (77%) patients using CTO wires. We analyzed the efficiency of CTO wire based on the subtypes: Conquest Pro 9 in 6/6 (100%) patients, Conquest Pro 12 in 12/18 (67%) patients, and Miracle in 2/2 (100%) patients. Before CTO wire usage in 3 patients, radiofrequency (RF) perforation was unsuccessful. Among these 3 patients, pulmonary valve perforation was successful in 2 patients with CTO wire; hence, in the remaining patient, perforation was also unsuccessful with CTO wire. After CTO wire perforation was unsuccessful in 6 patients, RF perforation was attempted in 3 patients (2 successful attempts and 1 unsuccessful attempts), and one patient as referred to surgery. Desaturation was persistent in 19 cases, which necessitated ductus arteriosus stenting. Early procedural complication was observed in 3/26 (11%) patients. Two of these patients had vascular complications due to the sheath, which was treated with heparin infusion and streptokinase, and the remaining patient had sudden bradycardia and cardiac arrest during the procedure and did not respond to cardiac resuscitation. CTO wires should be keep in mind for atretic pulmonary valve perforation as a first choice or when RF perforation is unsuccessful.

Transcatheter closure of post-procedural right ventricular pseudoaneurysms in a neonate with pulmonary atresia

Post-procedural right ventricular pseudoaneurysm is a rare but life-threatening complication of interventional catheterisation. We describe a 3-day-old newborn who underwent transcatheter intervention for pulmonary atresia with a complication of right ventricular pseudoaneurysms, and transcatheter embolisation of the pseudoaneurysms was performed at 3-week-old. It is the first described case that receives transcatheter closure of right ventricular pseudoaneurysms in a newborn with a favourable outcome.

Optimal management of pulmonary atresia with intact ventricular septum in a developing country: the art of pulmonary valve mechanical perforation in the era of CTO hardware

BACKGROUND

Transcatheter valve mechanical perforation (TVMP) in pulmonary atresia with intact ventricular septum (PAIVS) is an acceptable yet challenging alternative to radiofrequency.

AIMS

To evaluate and compare safety, feasibility, and efficiency of two TVMP techniques.

METHODS

Clinical data of neonates with PAIVS who underwent an attempt for TVMP between 2009 and 2019 were retrospectively reviewed. Patients were divided into two groups according to perforation technique: using the stiff end of a percutaneous transluminal coronary angioplasty (PTCA) ordinary 0.014" wire (group A) and subsequently with the floppy tip of a chronic total occlusion (CTO) guidewire (group B). The technical aspects, procedural and discharge outcomes of both groups were compared.

RESULTS

A total of 19 antegrade TVMP procedures (Group A, n=10, and Group B, n=9) were attempted in 18 neonates with an overall success rate of 73.7% and no procedure-related mortality. Groups' analysis showed that the introduction of CTO hardware maximized procedure success rates (P=0.002) with zero failure and misperforations (P=0.022). The significant drop in perforation time (P < 0.001) and irradiation exposure (P=0.006) allowed additional ductal stenting during the same procedure, optimizing patients' clinical outcomes and shortening overall hospital stay. Discharged patients had room air mean oxygen saturation of 91.4% (± 5.5) with no evidence of heart failure.

CONCLUSIONS

In selected cases of PAIVS, TVMP using CTO wires is a safer, highly efficient, and simplified alternative to other mechanical perforation techniques. It substantially revolutionized the management of PAIVS in our center optimizing short-term prognosis.

Hybrid Approach to Right Ventricle Decompression in Muscular Pulmonary Atresia with Intact Ventricular Septum

Muscular pulmonary atresia with intact ventricular septum (PA/IVS) in neonates is traditionally managed by surgery. We describe hybrid approach to decompress the right ventricle (RV) and establish RV to pulmonary artery connection in a neonate avoiding cardiopulmonary bypass. A 21-gauge access needle was used to perforate the atretic pulmonary valve via periventricular approach followed by stent placement. This case is an example of how patients with congenital heart disease can be palliated in creative ways through thoughtful collaboration between surgical and interventional cardiology teams.

Ductal stenting to improve pulmonary blood flow in pulmonary atresia with intact ventricular septum and critical pulmonary stenosis after balloon valvuloplasty

OBJECTIVE

To assess the feasibility, safety, and efficiency of ductal stenting in pulmonary atresia with intact ventricular septum or critical pulmonary stenosis after balloon pulmonary valvuloplasty.

BACKGROUND

Ductal stenting in pulmonary atresia with intact ventricular septum is a re-emerging and promising technique. There is little data available on its outcomes after establishing prograde pulmonary blood flow.

METHODS

We retrospectively reviewed all neonates with pulmonary atresia with intact ventricular septum or critical pulmonary stenosis who underwent ductal stenting after balloon valvuloplasty. Ductal stenting was performed either in the same setting (group A) or a few days later after balloon valvuloplasty (group B). We compared the two groups.

RESULTS

Eighteen coronary stents were transvenously delivered and successfully deployed in 18 newborns. There was no procedure-related mortality. The median hospital stay post-intervention was 6 days with a mean discharge oxygen saturation of 94%. Group A had a shorter overall hospital stay with a shorter overall time of irradiation but with a longer overall procedural time. On a follow-up of 18 months, no re-intervention for stent failure or overflow was undertaken. The median stent patency based on echocardiography was 12 months.

CONCLUSION

Stenting the arterial duct in pulmonary atresia with intact ventricular septum or critical pulmonary stenosis is a feasible, safe, and efficient technique. It avoids surgery or long hospital stay with prostaglandin infusion. The minimal 6 months stent longevity provides a period of time long enough to decide whether the right ventricular diastolic function is normalised or Glenn surgery is still needed.

Transcatheter perforation of atretic pulmonary valve by the stiff end of a coronary wire in neonates with pulmonary atresia with intact ventricular septum: A solution in developing countries

Objectives

To evaluate the safety of using the stiff end of a coronary wire to perforate an atretic pulmonary valve (PV) in patients with pulmonary atresia with intact ventricular septum (PAIVS).

Background

Radiofrequency perforation is an accepted modality to perforate the PV in patients PAIVS. However, the high cost precludes its widespread use.

Patients and methods

This is a single-center experience that spanned from March 2013 to January 2016 and involved 13 neonates who were severely cyanotic with PAIVS and with ductal-dependent pulmonary circulation. The stiff end of a coronary wire was used to perforate the atretic PV anterogradely, followed by balloon pulmonary valvuloplasty.

Results

The mean age of patients was 3.9 ± 2.7 days and their mean weight was 2.8 ± 0.19 kg. The mean oxygen saturation was 77.1 ± 3.2%. All had membranous pulmonary atresia, with patent infundibulum and tripartite right ventricle. The valve was successfully perforated in 11 out of 13 patients. Death occurred in two patients (15.4%) owing to heart failure and sepsis. Patent ductus arteriosus stenting was performed 2 days after the procedure in one patient because of cyanosis followed by one and half ventricle repair at of age 5 months. Two patients (15.4%) had one and a half ventricle repair at age of 5 months and 6 months owing to insufficient anterograde pulmonary flow. Two patients (15.4%) underwent second intervention with balloon dilatation of the valve. The remaining seven patients (53.8%) had no further intervention. Two cases (15.4%) had femoral artery thrombosis treated with streptokinase. The mean duration of follow-up was 13.17 ± 7 months. There was significant improvement in the degree of tricuspid incompetence. There was a significant growth in the tricuspid valve annulus during the follow-up (the mean Z score increased from −0.8 ± 0.9 to 0.1 ± 0.9) (p = 0.003). There was also a significant increase in the tricuspid valve annulus/mitral valve annulus ratio as its mean increased from 0.73 ± 0.10 to 0.86 ± 0.11 during follow-up (p < 0.001).

Conclusion

Perforation of the atretic PV in selected cases with membranous atresia and patent infundibulum using the stiff end of a coronary wire is an effective alternative to using radiofrequency perforation.

Central perforation of atretic pulmonary valve using coronary microcatheter

Percutaneous perforation of pulmonary valve, using 0.014” guidewires meant for coronary artery chronic total occlusion (CTO), is increasingly being performed for select cases of pulmonary atresia with intact ventricular septum (PA-IVS). Despite growing experience, procedural failures and complications are not uncommon. Even in infants treated successfully, the orifice created in the atretic pulmonary valve is eccentric. In this report, we present usefulness of coronary microcatheter in alignment of perforating coronary guidewire to the center of atretic pulmonary valve resulting in central perforation.