CHD Interventions Featured Articles of May 2015

1. Balloon valvuloplasty for congenital aortic stenosis: Multi-center safety and efficacy outcome assessment.

Torres A, Vincent JA, Everett A, Lim S, Foerster SR, Marshall AC, Beekman RH 3rd, Murphy J, Trucco SM, Gauvreau K, Holzer R, Bergersen L, Porras D.

Catheter Cardiovasc Interv. 2015 May 29. doi: 10.1002/ccd.25969. [Epub ahead of print]

PMID: 26032565

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bouddjemlineMehul Patel photoComment from Dr. Younes Boudjemline (Paris) and co-editor Dr. Mehul Patel (Grand Rapids MI), editors of congenital heart disease interventions Journal Watch:  This multicentric study describes contemporary outcomes of balloon aortic valvuloplasty (BAVP) performed in 22 US centers on 373 patients with a median age of 8 months (1 day to 40 years of age).  For critical AS, acute procedural success was defined as a residual peak systolic gradient < 35 mm Hg and no more than mild aortic regurgitation (AR) and for patients with mixed aortic valve disease, a residual peak systolic gradient < 35 mm Hg without worsening of AR. Peak systolic gradient had a median of 59 [50, 71] mm Hg pre-BAVP and 22 [15, 30] mm Hg post-BAVP (P < 0.001).

Important take home points from this study include:

  1. BAVP results in fairly consistent procedural success (gradient reduction with minimal increase in AR) in 71% of patients treated at US centers where BAVP is considered first-line therapy relative to surgery.
  2. Neonatal status was the only factor associated with increased risk of high severity adverse events (OR 3.7; 95% CI 1.5– 9.0).
  3. The factors independently associated with procedural success were:
    1. first time intervention (OR 5 2.0 (1.0, 4.0) P 5 0.04)
    2. not-prostaglandin dependent, (OR=3.5 (1.5, 8.1); P50.003), and
    3. isolated cAS (absence of AR) (OR52.1 (1.1–3.9); P 5 0.03).

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2. Transcatheter fontan takedown.

Hallbergson A, Mascio CE, Rome JJ.

Catheter Cardiovasc Interv. 2015 May 6. doi: 10.1002/ccd.25963. [Epub ahead of print]

PMID: 25945427

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Comment from Dr. Younes Boudjemline (Paris) and co-editor Dr. Mehul Patel (Grand Rapids MI), editors of congenital heart disease interventions Journal Watch: Early failure of the Fontan circulation with large-volume chylous pleural effusions is rare in the current era but remains associated with a high mortality rate. Surgical Fontan takedown has evolved as one of the strategies to stabilize the circulation, improve survival, and allow for a future attempt at Fontan completion. However repeat sternotomies and redo surgery increases morbidity and mortality. The group from Children’s Hospital of Philadelphia completed transcatheter Fontan takedown in three patients with extracardiac conduits 0.8–6 months following their Fontan operations. Superior vena cava flow was redirected into only the pulmonary arteries by occluding the conduit with a vascular plug between the pulmonary arteries and fenestration and unrestrictive inferior vena cava flow was redirected into only the atrium by stenting and enlarging the fenestration. One patient had resolution of protein-losing enteropathy, two patients had improvement of plastic bronchitis and all patients had resolution of chylous effusions.  The authors conclude that transcatheter Fontan takedown is technically feasible and may be an alternative to surgical takedown in select patients with early failure of the Fontan circulation.

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3. Novel approach for the percutaneous treatment of left ventricular pseudoaneurysms.

Singh A, Kliger C, Ruiz CE.

Catheter Cardiovasc Interv. 2015 May;85(6):1092-6. doi: 10.1002/ccd.25789. Epub 2015 Jan 30.

PMID: 25533813

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Comment from Dr. Younes Boudjemline (Paris) and co-editor Dr. Mehul Patel (Grand Rapids MI), editors of congenital heart disease interventions Journal Watch:   LVPA is usually secondary to MI ( 55%), Cardiac surgery (33%) or due to trauma and infection (12%). Accurate diagnosis and individualized treatment are essential for the treatment of LVPA as untreated LVPA is associated with a high risk of morbidity and mortality. Although surgical intervention has traditionally been the standard treatment for LVPA, percutaneous closure is now an attractive alternative in the high-risk patient.  The authors report a case of a successful percutaneous LVPA closure using direct chest wall entry into the pseudoaneurysm. This novel approach can be useful when access to the LVPA is a challenge, especially in the setting of small ostial size, dense left ventricular trabeculations, angulated serpiginous tract, and presence of mechanical prostheses.

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4. Pharmacokinetics of sirolimus-eluting stents implanted in the neonatal arterial duct.

Lee KJ, Seto W, Benson L, Chaturvedi RR.

Circ Cardiovasc Interv. 2015 May;8(5). pii: e002233. doi: 10.1161/CIRCINTERVENTIONS.114.002233.

PMID: 25940522

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Comment from Dr. Younes Boudjemline (Paris) and co-editor Dr. Mehul Patel (Grand Rapids MI), editors of congenital heart disease interventions Journal Watch: Sirolimus-eluting stents may have clinical advantages over bare-metal stents in the extremely proliferative environment of the neonatal arterial duct. However, little is known regarding sirolimus pharmacokinetics in the newborn and its immunosuppressive actions. This is a retrospective review of nine neonates who received a single sirolimus-eluting stent with a total sirolimus dose of 245 μg (n=1), 194 μg (n=5), or 143 μg (n=3). Peak sirolimus concentrations were 13.6±4.5 μg/L (24.8 μg/L highest) and clearance was 0.042±0.03 L/hour (noncompartmental analysis) and 0.051 L/hour (95% credible intervals 0.037–0.069, nonlinear mixed model). Sirolimus remained >5 μg/L, the trough level used in oral immunosuppressive therapy, for (95% credible interval) 15.9 (11.4, 22.8), 12.9 (7.6, 19.0), and 8.4 (2.3, 14.5) days for the 245, 194, and 143 μg sirolimus dose stents, respectively. In neonates after sirolimus-eluting stent implantation, peak sirolimus levels were 20× higher and clearance 30× lower than previously reported in older children and adults. Sirolimus levels were within the immunosuppressive range for a prolonged period, but with no observable clinically significant adverse outcomes.

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Transcatheter closure of postmyocardial infarction, iatrogenic, and postoperative ventricular septal defects: The Mayo Clinic experience.

Egbe AC, Poterucha JT, Rihal CS, Taggart NW, Cetta F, Cabalka AK, Pollak PM, Reeder GS, Hagler DJ.

Catheter Cardiovasc Interv. 2015 May 29. doi: 10.1002/ccd.25989. [Epub ahead of print]

PMID: 26033272

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Comment from Dr. Younes Boudjemline (Paris) and co-editor Dr. Mehul Patel (Grand Rapids MI), editors of congenital heart disease interventions Journal Watch:  The authors retrospectively reviewed of 27 cases of transcatheter VSD closure (post-MI = 18 and non-ischemic = 9) performed from 1999 to 2013. Adverse events were defined as death, device embolization, hemolysis requiring blood transfusion, heart block and reintervention. In the post-MI VSD subgroup, mean age and follow-up was 69 ±11 and 7.367 years, respectively. AE occurred in 8 (44%) patients (death-3, device embolization-1, hemolysis-1, surgical VSD closure-2, reintervention-1). Event-free survival was 56% at 1 month and 5 years, and all AE occurred in the periprocedural period. Cardiogenic shock and VSD closure in acute phase were independent predictors of AE. In the non-ischemic VSD subgroup, mean age and follow-up was 49 ± 15 and 8.768 years, respectively. AE occurred in 3 (33%) patients (late death-1, surgical VSD closure-2). For the entire cohort, freedom from death was 89% and 85% at 1 month and 5 years, and event-free survival was 70% and 61% at 1 month and 5 years. The authors conclude that transcatheter closure of post-MI VSD carries a moderate risk of periprocedural complications but low event rates afterwards. By comparison, device closure of non-ischemic VSD has lower periprocedural morbidity but some patients continued to experience AE during follow-up.

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6. Growth of the atrial septum after amplatzer device closure of atrial septal defects in young children.

Gossett JG, Mansfield L, Acevedo J, Lay AS, Rychlik K, Wax DF.

Catheter Cardiovasc Interv. 2015 May 27. doi: 10.1002/ccd.26041. [Epub ahead of print]

PMID: 26013563

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Comment from Dr. Younes Boudjemline (Paris) and co-editor Dr. Mehul Patel (Grand Rapids MI), editors of congenital heart disease interventions Journal Watch: The authors retrospectively studied preprocedural septal measurements change after ASO and the effect of somatic growth on these dimensions in 33 patients. The mean age was 5.2 ±3.2 years with 4.0 ± 2.2 years follow-up. All septal measurements decreased after ASO. Thirty-one of 33 devices (94%) contacted the aortic root after ASO; all remained in contact at follow-up with only the IVC rim growing significantly over time. Change in BSA predicted an asymmetric septal growth with increases in superior (P = 0.01) and IVC (P = 0.005) rims and no increase in aortic or AVV rims. No episodes of erosion occurred. The authors conclude that ASDs in young children are not central in the septum, but proximate to the aorta. After ASO, the device remains in close proximity to the aorta. With somatic growth, the septum grows asymmetrically, and device position relative to the aorta is constant. Future multicentric studies that would immensely improve our understanding on the aortic rim dynamics with age and possibly on the mechanism of erosion.

7. Chronological changes in stenosis of translocated coronary arteries on angiography after the arterial switch operation in children with transposition of the great arteries: comparison of myocardial scintigraphy and angiographic findings.

Sugiyama H, Tsuda E, Ohuchi H, Yamada O, Shiraishi I.

Cardiol Young. 2015 May 21:1-6. [Epub ahead of print]

PMID: 25994511

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Comment from Dr. Younes Boudjemline (Paris) and co-editor Dr. Mehul Patel (Grand Rapids MI), editors of congenital heart disease interventions Journal Watch: The authors studied a total of 110 neonates with transposition of the great arteries after arterial switch operation. There were three (2.7%) late deaths in the group. The remaining 107 patients except for one underwent follow-up angiography. Angiography showed coronary artery stenosis in nine (8.4%), with right coronary artery lesions in two and left main trunk lesions in seven. In two patients, right coronary artery stenosis regressed during follow-up. In left main trunk lesions, the severity of stenosis improved in four, did not change in one, and progressed to total occlusion in two patients. In children with coronary artery stenosis, myocardial scintigraphy showed perfusion defects in five out of six (83%) with left main trunk with >75% stenosis and in four out of four with left main trunk stenosis >90%. In contrast, patients whose coronary artery stenosis disappeared during follow-up had no perfusion defects on scintigraphy. The authors conclude that angiographic regression of ostial stenosis of the transplanted coronary artery was observed. The stenosis regressed over time in six patients; two coronary arteries with 99% stenosis and delayed angiographic enhancement of the distal coronary artery resulted in total occlusion within 1 year after the arterial switch operation. Combination of angiography and myocardial scintigraphy could be useful to differentiate deceptive stenosis from progressive stenosis.

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8. Sedation and Anesthesia in Pediatric and Congenital Cardiac Catheterization: A Prospective Multicenter Experience.

Lin CH, Desai S, Nicolas R, Gauvreau K, Foerster S, Sharma A, Armsby L, Marshall AC, Odegard K, DiNardo J, Vincent J, El-Said H, Spaeth J, Goldstein B, Holzer R, Kreutzer J, Balzer D, Bergersen L.

Pediatr Cardiol. 2015 May 21. [Epub ahead of print]

PMID: 25991570

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Comment from Dr. Younes Boudjemline (Paris) and co-editor Dr. Mehul Patel (Grand Rapids MI), editors of congenital heart disease interventions Journal Watch: The authors sought to identify current sedation/anesthesia practices, the serious adverse event rate related to airway, sedation, or anesthesia, and the rate of intra-procedural conversion from procedural sedation to the use of assisted ventilation or an artificial airway from data on 13,611 patients who underwent catheterization at eight institutions from 2007 to 2010. Ninety-four (0.69 %) serious sedation/airway-related adverse events occurred; events were more likely to occur in smaller patients patients with non-cardiac comorbidities and patients with low mixed venous oxygen saturation. Cardiac catheterization in pediatric/congenital patients was associated with a low rate of serious sedation/airway-related adverse events. Smaller patients with non-cardiac comorbidities or low mixed venous oxygen saturation may be at higher risk. Patients under 1 year of age, undergoing high-risk procedures, or requiring continuous pressor/inotrope support may be at higher risk of requiring conversion from procedural sedation to assisted ventilation/general anesthesia.

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9. Coronary Wall Structural Changes in Patients With Kawasaki Disease: New Insights From Optical Coherence Tomography (OCT).

Dionne A, Ibrahim R, Gebhard C, Bakloul M, Selly JB, Leye M, Déry J, Lapierre C, Girard P, Fournier A, Dahdah N.

J Am Heart Assoc. 2015 May 19;4(5). pii: e001939. doi: 10.1161/JAHA.115.001939.

PMID: 25991013 Free Article

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Comment from Dr. Younes Boudjemline (Paris) and co-editor Dr. Mehul Patel (Grand Rapids MI), editors of congenital heart disease interventions Journal Watch:  The authors performed OCT in 18 patients aged 12.4 ± 5.5 years, 9.0 ± 5.1 years following onset of KD. Of those, 14 patients (77.7%) had a history of CAA (7 with giant CAA and 7 with regressed CAA at time of OCT). The most frequent abnormality observed on OCT was intimal hyperplasia (15 patients, 83.3%) seen at both aneurysmal sites and angiographically normal segments. Disappearance of the media, and presence of fibrosis, calcifications, macrophage accumulation, neovascularization, and white thrombi were also seen. OCT proved safe and insightful in the setting of KD, with the potential to add diagnostic value in the assessment of coronary abnormalities in KD. The depicted coronary structural changes correspond to histological findings previously described.


10. Left Ventricular Remodeling and Function in Children with Biventricular Circulation After Fetal Aortic Valvuloplasty.

Friedman KG, Freud L, Escobar-Diaz M, Banka P, Emani S, Tworetzky W.

Pediatr Cardiol. 2015 May 15. [Epub ahead of print]

PMID: 25972285

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Comment from Dr. Younes Boudjemline (Paris) and co-editor Dr. Mehul Patel (Grand Rapids MI), editors of congenital heart disease interventions Journal Watch: The authors evaluated LV remodeling pattern, risk factors for pathologic LV remodeling, and the association between LV remodeling pattern and LV function in patients after fetal aortic valvuloplasty. Median age at follow-up was 4.7 years (range 1.0–12.5). Cardiac interventions were common. At latest follow-up, no patient had hypoplastic LV. Nineteen patients (55 %) had dilated LV, and five (16 %) patients had severely dilated LV. LV remodeling patterns were as follows: 12 (35 %) normal ventricle, 11 (32 %) mixed hypertrophy, 8 (24 %) eccentric hypertrophy or remodeling, and 3 (9 %) concentric hypertrophy. Univariate factors associated with pathologic LV remodeling were long-standing AR, cardiac interventions, EFE resection, and aortic or mitral regurgitation, moderate at most recent follow-up. In multivariate analysis, only long- standing AR fraction remained associated with pathologic remodeling. Pathologic LV remodeling was associated with depressed ejection fraction, lower septal E ́ , and higher E/E ́. The authors conclude that pathologic LV remodeling, primarily eccentric or mixed hypertrophy, is common in BiV patients after FAV and is related to LV loading conditions imposed by valvar disease. Pathologic remodeling is associated with both systolic and diastolic dysfunction in this population.

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11. Achievable radiation reduction during pediatric cardiac catheterization: How low can we go?

Borik S, Devadas S, Mroczek D, Jin Lee K, Chaturvedi R, Benson LN.

Catheter Cardiovasc Interv. 2015 May 22. doi: 10.1002/ccd.26024. [Epub ahead of print]

PMID: 26011560

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Comment from Dr. Younes Boudjemline (Paris) and co-editor Dr. Mehul Patel (Grand Rapids MI), editors of congenital heart disease interventions Journal Watch: The authors studied 5,196 cases, which included 2,819 interventional, 710 endomyocardial biopsies and 1,667 diagnostic studies to assess the effectiveness of radiation-reduction measures implemented during pediatric catheterization. Radiation-reduction measures included pulsed-fluoroscopy at 7.5 pulses/ second (0.032–0.045 mGy/pulse), an air-gap magnification technique for children <20 kg, operator awareness, and additional exposure reduction techniques through projection optimization. The absolute exposure was significantly greater in larger children. Reduction of fluoroscopy acquisition to 7.5 pulses/second nearly halved radiation exposure (P < 0.001).

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