Gellis L, Banka P, Marshall A, Emani S, Porras D.
Catheter Cardiovasc Interv. 2015 Oct;86(4):692-700. doi: 10.1002/ccd.25930. Epub 2015 Apr 24.
Select item 26253506
Comment from Pr. Younes Boudjemline (Paris) and co-editor Dr. Mehul Patel (MSU, MI), editors of congenital heart disease interventions Journal Watch: The morbidity of pulmonary regurgitation over time after TOF repair has led to greater interest in PV-sparing repair strategies. This strategy in patients with tri leaflet PV with z-scores – 3.5 to -1.0 is emerging as a durable method to prevent PR and resultant RV volume overload. There is however some tradeoff with residual, multilevel RVOTO to maintain valve competence. Intraoperative dilation of the pulmonary valve in these patients is feasible and provides good immediate relief of obstruction as noted from prior studies. In this retrospective study from Boston Children’s Hospital, the authors report outcomes of follow up balloon dilatation (BD) of RVOTO on 34 patients who had initial valve-sparing repair of tetralogy of Fallot. There was a significant drop in the gradient with an increased risk of PR after balloon dilatation with freedom from reintervention of 64% at 1 year and 46% at 3 years. A balloon to annulus ratio (BAR) of 1.2 to 1.4 was used although it was not standardized; one patient experienced an RVOT tear with BAR more than 1.4. Exclusive valvar obstruction was associated with a longer freedom from reintervention, while a ratio of RV pressure to aortic systolic pressure pre-BD of >1 and a final RVOT gradient ≥40 mmHg post-BD were associated with shorter freedom from reintervention. Balloon dilatation in this population is presumed to work by splitting of the fused commissures and also by stretching the hypoplastic annulus promoting longitudinal growth.
Take home points:
- Repair of TOF with pulmonary valve preservation in patients with z-scores – 3.5 to -1.0 is emerging as a durable method to prevent PR and resultant RV volume overload. There is however some tradeoff with residual multilevel RVOTO to maintain valve competence.
- Balloon dilatation for such recurrent, multilevel RVOTO after valve-sparing repair is an effective option; however, there is an increased risk of PR.
- Patients with exclusively valvar obstruction had a better response to balloon dilatation.
- RV/Ao pressure ratio of > 1 and post balloon dilatation residual gradient of > 40 mm Hg are predictors of repeat interventions.
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 Oct;36(7):1363-75. doi: 10.1007/s00246-015-1167-8. Epub 2015 May 21.
Select item 25981566
Comment from Pr. Younes Boudjemline (Paris) and co-editor Dr. Mehul Patel (MSU, MI), editors of congenital heart disease interventions Journal Watch: Although high-severity sedation and airway-related mortality rate is lower when compared to overall mortality rate of pediatric and congenital catheterization, it is extremely important to preplan and coordinate care with the cardiac anesthesia team for a smooth procedure with good outcome. The authors retrospectively reviewed prospectively collected data from multicenter Congenital Cardiac Catheterization Project on Outcomes (C3PO) on sedation and airway practices on 13,611 pediatric and congenital heart patients who underwent catheterization at eight institutions from 2007 to 2010. A small fraction of 94 patients (0.69%) had serious sedation/airway-related adverse events. These occurred more so in i) smaller patients (<4 kg), ii) patients with non-cardiac comorbidities and iii) patients with low mixed venous oxygen saturation; (iv) single ventricle < 50 % or two ventricles < 60 %. With a heterogenous practice noted across various centers, general anesthesia with airway support was used as first line in 9379 (69%), procedural sedation only without airway support in 4232 (31%) of which 75 (1.77%) patients were converted to assisted ventilation/general anesthesia. The risk factors for conversion included i) young age (<12 months), ii) higher-risk procedure and iii) continuous pressor/inotrope requirement. Keeping these predictors in mind it is important to risk stratify patients and carefully select the most appropriate mode of anesthesia.
Take home points:
- The study highlights an important aspect of periprocedural care and reports a low rate of serious sedation/airway-related adverse events in a large multicentric population from the C3PO database.
- Smaller patients with non-cardiac comorbidities or low mixed venous oxygen saturation may be at higher risk of adverse events.
- 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. With proper pre procedure risk stratification and planning, intraprocedural conversions may be reduced.
Friedman KG, Freud L, Escobar-Diaz M, Banka P, Emani S, Tworetzky W.
Pediatr Cardiol. 2015 Oct;36(7):1502-9. doi: 10.1007/s00246-015-1193-6. Epub 2015 May 15.
Select item 25972284
Comment from Pr. Younes Boudjemline (Paris) and co-editor Dr. Mehul Patel (MSU, MI), editors of congenital heart disease interventions Journal Watch: Early, primary in-utero cardiac abnormality may prevent normal heart development and cause irreversible secondary structural changes. The idea of fetal cardiac intervention stems from this understanding and focuses on anantenatal intervention targeting the primary abnormality to allow normal flow and hemodynamics and thus normal heart development. Fetal aortic valvuloplasty (FAV) has shown promise in preventing the progression of aortic stenosis to hypoplastic left-heart syndrome with 40–50% of patients achieving biventricular (BiV) circulation after technically successful FAV. However, even after FAV, intrinsic endomyocardial abnormalities altered loading conditions with altered endomyocardial mechanics may lead to abnormal LV remodeling and function. The authors studied 34 patients who underwent FAV and followed up for a median interval of 4.7 years. Interestingly no patient evolved to HLHS, 19 patients (55%) had a dilated LV, and 5 (16%) patients had a severely dilated LV. The remodeled LV at last follow up showed normal LV in 12 (35%), mixed hypertrophy in 11 (32%), eccentric hypertrophy in 8 (24%), and concentric hypertrophy in 3 (9%). Univariate factors associated with pathologic LV remodeling included long-standing AR, ³2 cardiac interventions, EFE resection, and aortic or mitral regurgitation ³ moderate at most recent follow-up. On multivariate analysis, only long-standing AR fraction remained associated with pathologic remodeling. Pathologic LV remodeling, likely due to myocardial fibrosis and endocardial fibroelastosis rather than hypertrophy as primary mechanisms, gives rise to diastolic dysfunction after FAV.
Take home points:
- Longstanding AR after FAV is a significant predictor for pathologic LV remodeling, primarily eccentric or mixed hypertrophy.
- Pathologic remodeling after FAV is associated with both systolic and diastolic dysfunction in this population.
Esch JJ, Porras D, Bergersen L, Jenkins KJ, Marshall AC.
Pediatr Cardiol. 2015 Oct; 36(7):1357-62. doi: 10.1007/s00246-015-1165-x. Epub 2015 Apr 4.
Select item 25835203
Comment from Pr. Younes Boudjemline (Paris) and co-editor Dr. Mehul Patel (MSU, MI), editors of congenital heart disease interventions Journal Watch: Pulmonary vein stenosis (PVS), usually a progressive condition requiring multiple interventions for palliation, imposes a high burden of morbidity and mortality on affected children. Working on the systemic side carries a significant risk of thromboembolism and stroke. The authors reviewed 406 pediatric catheterizations in 144 patients involving PVS angioplasty and/or stent placement performed at Boston Children’s Hospital between July 2005 and February 2014. Eleven (2.7%) catheterizations were complicated by clinically apparent systemic embolic events, comprising 10 strokes (one with associated hepatic embolism) and 1 renal infarct. The prevalence of clinically evident stroke among this cohort was 7.6%. Using a prior (uncomplicated) catheterization as a control, the authors sought to identify potentially modifiable risk factors for systemic embolic events. Interestingly complicated and uncomplicated angioplasties did not appear to differ in case time, contrast dose, anticoagulation management, use of cutting balloons, number of catheter exchanges, or the size of the long sheath used. Significant nonembolic adverse events were common, occurring in 25% of catheterizations.
Take home points:
- Systemic embolism appears to inherently complicate PVS angioplasty at a rate much higher than that described for other congenital catheterizations.
- Unfortunately there are no modifiable or operator-dependent factors identified so far.
- Whether a cerebral protection device could reduce the risk of stroke is yet to be seen.