RESUMO
OBJECTIVE: Assess clinical performance of a new device for transcatheter closure of atrial septal defect (ASD). BACKGROUND: Previously-approved ASD Closure devices have known limitations. Device erosion has been associated with the AMPLATZER® septal occluder in patients with retro-aortic rim deficiency (<5 mm), while defects ≥18 mm are too large for the GORE® CARDIOFORM septal occluder. The GORE® CARDIOFORM ASD occluder (GCA), a hybrid of the approved devices, was designed to expand the eligible ASD population. METHODS: One-hundred and twenty-five ASD patients were enrolled in a prospective, multicenter registry. Descriptive clinical endpoints included: technical implant success, closure success, serious adverse events (SAE), clinically significant new arrhythmia, and wire frame fracture. Procedural outcomes and adverse events were adjudicated by an Echocardiography Core Lab and Independent Data Review Board, respectively. RESULTS: Median subject age was 12.3 years (range 2.9-84.7), with 72% of patients ≤18 years old. Median ASD stop-flow diameter was 17.0 mm (8.0-30.0), with 43% ≥18 mm. Deficient retro-aortic rim occurred in 57% of subjects, and 30% had both diameter ≥ 18 mm and deficient rim. Technical Implant Success was achieved in 120/125 (96%), though three devices were removed within 24 hr. At the scheduled 6-month evaluation, 112/117 returned for evaluation. All 112 had closure success. SAE occurred in 6/125 (4.8%) and 6/125 (4.8%) had clinically significant new arrhythmia. Wire frame fractures occurred in 37/104 (36%), without any associated clinical sequelae, residual shunt, or device instability. CONCLUSION: The GCA performed effectively and safely in this initial cohort, and led to FDA approval based on this data.
Assuntos
Cateterismo Cardíaco/instrumentação , Comunicação Interatrial/terapia , Dispositivo para Oclusão Septal , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Cateterismo Cardíaco/efeitos adversos , Criança , Pré-Escolar , Feminino , Comunicação Interatrial/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Desenho de Prótese , Sistema de Registros , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Adulto JovemRESUMO
BACKGROUND: Ablation within the aortic cusp is safe and effective in adults. There are little data on aortic cusp ablation in the pediatric literature. We investigated the safety and efficacy of aortic cusp ablation in young patients. METHODS: A retrospective, descriptive study of aortic cusp ablation in five pediatric electrophysiology centers from 2008 to 2014 was performed. All patients <21 years of age who underwent ablation in the aortic cusps were included. Factors analyzed included patient demographics, procedural details, outcomes, and complications. RESULTS: Thirteen patients met inclusion criteria (median age 16 years [range 10-20.5] and median body surface area 1.58 m2 [range 1.12-2.33]). Substrates for ablation included: nine premature ventricular contractions or sustained ventricular tachycardia (69%), two concealed anteroseptal accessory pathways (APs) (15%), one Wolff-Parkinson-White with an anteroseptal AP (8%), and one ectopic atrial tachycardia (8%). Three-dimensional electroanatomic mapping in combination with fluoroscopy was used in 12/13 (92%) patients. Standard 4-mm-tip radiofrequency (RF) current was used in 11/13 (85%) and low-power irrigated-tip RF in 2/13 (15%). Angiography was used in 13/13 and intracardiac echocardiography was additionally utilized in 3/13 (23%). Ablation locations included: eight noncoronary (62%), three left (23%), and two right (15%) cusps. Ablation was acutely successful in all patients. At median follow-up of 20 months, there was one recurrence of PVCs (8%). There were no ablation-related complications and no valvular injuries observed. CONCLUSION: Arrhythmias originating from the coronary cusps in this series were successfully and safely ablated in young people without injury to the coronary arteries or the aortic valve.
Assuntos
Valva Aórtica/cirurgia , Arritmias Cardíacas/cirurgia , Ablação por Cateter/métodos , Adolescente , Arritmias Cardíacas/fisiopatologia , Mapeamento Potencial de Superfície Corporal , Criança , Técnicas Eletrofisiológicas Cardíacas , Feminino , Fluoroscopia , Humanos , Masculino , Ondas de Rádio , Estudos Retrospectivos , Resultado do Tratamento , Adulto JovemRESUMO
Current practice of sedation and anesthesia for patients undergoing pediatric and congenital cardiac catheterization laboratory (PCCCL) procedures is known to vary among institutions, a multi-society expert panel with representatives from the Congenital Heart Disease Council of the Society for Cardiovascular Angiography and Interventions, the Society for Pediatric Anesthesia and the Congenital Cardiac Anesthesia Society was convened to evaluate the types of sedation and personnel necessary for procedures performed in the PCCCL. The goal of this panel was to provide practitioners and institutions performing these procedures with guidance consistent with national standards and to provide clinicians and institutions with consensus-based recommendations and the supporting references to encourage their application in quality improvement programs. Recommendations can neither encompass all clinical circumstances nor replace the judgment of individual clinicians in the management of each patient. The science of medicine is rooted in evidence, and the art of medicine is based on the application of this evidence to the individual patient. This expert consensus statement has adhered to these principles for optimal management of patients requiring sedation and anesthesia. What follows are recommendations for patient monitoring in the PCCCL regardless of whether minimal or no sedation is being used or general anesthesia is being provided by an anesthesiologist.
Assuntos
Anestesia Geral/normas , Cateterismo Cardíaco/normas , Sedação Consciente/normas , Cardiopatias Congênitas/terapia , Guias de Prática Clínica como Assunto/normas , Sociedades Médicas/normas , Anestesia Geral/métodos , Anestesiologia/métodos , Anestesiologia/normas , Criança , Sedação Consciente/métodos , Consenso , Cardiopatias Congênitas/diagnóstico , HumanosRESUMO
OBJECTIVES: Assess impact of malattached septum primum (MASP) on transcatheter closure of interatrial communications. BACKGROUND: Large defect size and deficient rims have been described as predictors for complications and unsuccessful device placement in closure of interatrial communications. MASP is an underappreciated morphologic atrial septal variation whose prevalence in isolated atrial communications and its influence on percutaneous device closure has not been systematically assessed. METHODS: We retrospectively evaluated echocardiographic data of 328 patients scheduled for percutaneous secundum atrial septal defect (ASD) and patent foramen ovale (PFO) closure between January 2006 and January 2013. In ASD patients, defect size was measured by balloon stretch diameter while the length of the surrounding rims was measured in standard transthoracic and transesophageal views. Furthermore, the distance between septum primum and septum secundum as it attaches to the left atrial roof was evaluated in both, ASD and PFO patients. Septal anatomy of patients with procedural failure was compared to the anatomy of patients in whom the procedure was successful. RESULTS: Transcatheter defect closure was successful in 131 (92.3%) of 142 ASD patients (32.3 years ± 24.7 years) and in all 186 PFO patients (49.6 years ± 16.2 years). Thirteen (4%) patients were found to have MASP (1.6 mm-13 mm). Smaller retroaortic rim, inferior rim, and the presence of a MASP were independently associated with procedural failure in ASD patients (P = 0.02, P = 0.03, and P = 0.003, respectively). CONCLUSION: Smaller retroaortic and inferior rims, as well as MASP are independent risk factors for unsuccessful transcatheter ASD closure.
Assuntos
Cateterismo Cardíaco/efeitos adversos , Forame Oval Patente/terapia , Comunicação Interatrial/terapia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Ecocardiografia Doppler em Cores , Ecocardiografia Transesofagiana , Feminino , Forame Oval Patente/diagnóstico por imagem , Comunicação Interatrial/diagnóstico por imagem , Comunicação Interventricular , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores de Risco , Falha de Tratamento , Adulto JovemRESUMO
BACKGROUND: Transcatheter pulmonary valve replacement (TPVR) with the self-expanding Harmony valve (Medtronic) is an emerging treatment for patients with native or surgically repaired right ventricular outflow tract (RVOT) pulmonary regurgitation (PR). Limited data are available since U.S. Food and Drug Administration approval in 2021. OBJECTIVES: In this study, the authors sought to evaluate the safety and short-term effectiveness of self-expanding TPVR in a real-world experience. METHODS: This was a multicenter registry study of consecutive patients with native RVOT PR who underwent TPVR through April 30, 2022, at 11 U.S. CENTERS: The primary outcome was a composite of hemodynamic dysfunction (PR greater than mild and RVOT mean gradient >30 mm Hg) and RVOT reintervention. RESULTS: A total of 243 patients underwent TPVR at a median age of 31 years (Q1-Q3: 19-45 years). Cardiac diagnoses were tetralogy of Fallot (71%), valvular pulmonary stenosis (21%), and other (8%). Acute technical success was achieved in all but 1 case. Procedural serious adverse events occurred in 4% of cases, with no device embolization or death. Hospital length of stay was 1 day in 86% of patients. Ventricular arrhythmia prompting treatment occurred in 19% of cases. At a median follow-up of 13 months (Q1-Q3: 8-19 months), 98% of patients had acceptable hemodynamic function. Estimated freedom from the composite clinical outcome was 99% at 1 year and 96% at 2 years. Freedom from TPVR-related endocarditis was 98% at 1 year. Five patients died from COVID-19 (n = 1), unknown causes (n = 2), and bloodstream infection (n = 2). CONCLUSIONS: In this large multicenter real-world experience, short-term clinical and hemodynamic outcomes of self-expanding TPVR therapy were excellent. Ongoing follow-up of this cohort will provide important insights into long-term outcomes.
Assuntos
Implante de Prótese de Valva Cardíaca , Próteses Valvulares Cardíacas , Insuficiência da Valva Pulmonar , Valva Pulmonar , Humanos , Adulto , Valva Pulmonar/cirurgia , Implante de Prótese de Valva Cardíaca/efeitos adversos , Cateterismo Cardíaco/efeitos adversos , Resultado do Tratamento , Insuficiência da Valva Pulmonar/cirurgia , Insuficiência da Valva Pulmonar/etiologia , Sistema de Registros , Desenho de Prótese , Estudos RetrospectivosRESUMO
Isolated peripheral pulmonary artery stenosis presenting in adulthood is an uncommon cause of right ventricular hypertension and may be misdiagnosed as primary or thromboembolic pulmonary hypertension. Treatment consists of balloon angioplasty and stenting of the affected vessels, although the procedure can be complicated by reperfusion pulmonary edema.
Assuntos
Angioplastia com Balão , Hipertensão Pulmonar/diagnóstico , Hipertensão Pulmonar/terapia , Artéria Pulmonar , Estenose da Valva Pulmonar/terapia , Adulto , Feminino , Humanos , Hipertensão Pulmonar/complicações , Artéria Pulmonar/diagnóstico por imagem , Edema Pulmonar/complicações , Estenose da Valva Pulmonar/complicações , Estenose da Valva Pulmonar/etiologia , Radiografia , Resultado do Tratamento , Pressão VentricularRESUMO
Estimation of the right ventricular systolic pressure (RVSP) using echocardiographically derived maximal instantaneous gradient across the ventricular septal defect is a well-utilized tool, which can potentially underestimate the RVSP in patients with conduction abnormalities as such its utility in these patients is questionable.
RESUMO
The hemodynamics of isolated large ventricular septal defect with an intact atrial septum results in greater mitral valve (MV) annular dilation and an increased incidence of mitral regurgitation (MR). MR will resolve in most patients after surgical VSD closure alone without MV repair.
Assuntos
Septos Cardíacos/patologia , Insuficiência da Valva Mitral/epidemiologia , Valva Mitral/patologia , Dilatação Patológica , Feminino , Átrios do Coração , Comunicação Interventricular/epidemiologia , Hemodinâmica , Humanos , Lactente , Recém-Nascido , MasculinoRESUMO
A 3-year-old girl with Alport syndrome presented with decompensated heart failure from hypertension-induced cardiomyopathy 6 months following renal biopsy. Selective renal angiography revealed a large left renal arteriovenous fistula (AVF) with poor perfusion to the left renal parenchyma. The AVF was treated by transcatheter embolization using an Amplatzer vascular plug. Her blood pressure normalized after embolization, and her cardiac function normalized over the following 4 months.
Assuntos
Fístula Arteriovenosa/terapia , Malformações Arteriovenosas/terapia , Embolização Terapêutica/instrumentação , Hipertensão/patologia , Fístula Arteriovenosa/diagnóstico por imagem , Fístula Arteriovenosa/patologia , Malformações Arteriovenosas/diagnóstico por imagem , Malformações Arteriovenosas/patologia , Biópsia/instrumentação , Cardiomiopatia Dilatada/diagnóstico por imagem , Cardiomiopatia Dilatada/patologia , Cardiomiopatia Dilatada/terapia , Cardiotônicos/uso terapêutico , Pré-Escolar , Ecocardiografia , Feminino , Humanos , Rim/diagnóstico por imagem , Rim/patologia , Rim/cirurgia , Nefropatias/diagnóstico por imagem , Nefropatias/patologia , Nefropatias/terapia , Milrinona/uso terapêutico , Radiografia , Resultado do TratamentoRESUMO
Pulmonary arteriovenous malformations (PAVMs) are a relatively uncommon but potentially life-threatening condition manifested by cyanosis, paradoxical embolization, brain abscess, and rupture. A variety of transcatheter closure devices have been used to occlude PAVMs however risks of device embolization, incomplete closure, or large delivery systems have made each of these methods sub-optimal. The Amplatzer Vascular Plug II (AVP II) is a new multisegmented, woven nitinol cylinder that can be deployed through a small delivery catheter. The AVP II differs from the original AVP in having a finer, more tightly woven nitinol frame and three, rather than one occlusive segment. The authors report the first use of the AVP II for occlusion of bilateral large arteriovenous malformations in a patient with hereditary hemorrhagic telangiectasia.
Assuntos
Malformações Arteriovenosas/terapia , Cateterismo de Swan-Ganz/instrumentação , Artéria Pulmonar/anormalidades , Veias Pulmonares/anormalidades , Telangiectasia Hemorrágica Hereditária/terapia , Adolescente , Ligas , Malformações Arteriovenosas/diagnóstico por imagem , Cateterismo Cardíaco , Desenho de Equipamento , Humanos , Masculino , Artéria Pulmonar/diagnóstico por imagem , Veias Pulmonares/diagnóstico por imagem , Telangiectasia Hemorrágica Hereditária/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Resultado do TratamentoAssuntos
Tetralogia de Fallot , Lactente , Humanos , Tetralogia de Fallot/cirurgia , Artéria PulmonarRESUMO
Patients with the Marfan syndrome (MFS) are at risk for sudden death. The contribution of arrhythmias is unclear. This study examines the prevalence of arrhythmias in children with the MFS and their relation to clinical and/or echocardiographic factors. Data from the Pediatric Heart Network randomized trial of atenolol versus losartan in MFS were analyzed (6 months to 25 years old, aortic root diameter z-score > 3.0, no previous aortic surgery and/or dissection). Baseline 24-hour ambulatory electrocardiographic monitoring was performed. Significant ventricular ectopy (VE) and supraventricular ectopy (SVE) were defined as ≥10 VE or SVE/hour, or the presence of high-grade ectopy. Three-year composite clinical outcome of death, aortic dissection, or aortic root replacement was analyzed. There were 274 analyzable monitors on unique patients from 11 centers. Twenty subjects (7%) had significant VE, 13 (5%) significant SVE; of these, 2 (1%) had both. None had sustained ventricular or supraventricular tachycardia. VE was independently associated with increasing number of major Ghent criteria (odds ratio [OR]â¯=â¯2.13/each additional criterion, pâ¯=â¯0.03) and greater left ventricular end-diastolic dimension z-score (ORâ¯=â¯1.47/each 1 unit increase in z-score, pâ¯=â¯0.01). SVE was independently associated with greater aortic sinotubular junction diameter z-score (ORâ¯=â¯1.56/each 1 unit increase in z-score, pâ¯=â¯0.03). The composite clinical outcome (14 events) was not related to VE or SVE (p ≥ 0.3), but was independently related to heart rate variability (higher triangular index). In conclusion, in this cohort, VE and SVE were rare. VE was related to larger BSA-adjusted left ventricular size. Routine ambulatory electrocardiographic monitoring may be useful for risk stratification in select MFS patients.
Assuntos
Arritmias Cardíacas/etiologia , Arritmias Cardíacas/fisiopatologia , Síndrome de Marfan/complicações , Síndrome de Marfan/fisiopatologia , Adolescente , Antagonistas Adrenérgicos beta/uso terapêutico , Adulto , Bloqueadores do Receptor Tipo 1 de Angiotensina II/uso terapêutico , Arritmias Cardíacas/diagnóstico por imagem , Arritmias Cardíacas/tratamento farmacológico , Atenolol/uso terapêutico , Criança , Pré-Escolar , Ecocardiografia , Eletrocardiografia Ambulatorial , Feminino , Humanos , Lactente , Losartan/uso terapêutico , Masculino , Estudos RetrospectivosAssuntos
Procedimentos Cirúrgicos Cardíacos , Complicações Pós-Operatórias/etiologia , Síndrome do Desconforto Respiratório/etiologia , Tetralogia de Fallot/complicações , Tetralogia de Fallot/cirurgia , Extubação , Gasometria , Hemodinâmica , Humanos , Lactente , Masculino , Monitorização Intraoperatória , Oxigenoterapia , Respiração com Pressão Positiva , Complicações Pós-Operatórias/terapia , Radiografia , Respiração Artificial , Síndrome do Desconforto Respiratório/diagnóstico por imagem , Síndrome do Desconforto Respiratório/terapia , Tetralogia de Fallot/diagnóstico por imagem , Desmame do RespiradorRESUMO
OBJECTIVES: The goal of this study was to identify factors associated with radiofrequency catheter ablation (RFCA) outcomes of intra-atrial re-entrant tachycardia (IART). BACKGROUND: Radiofrequency catheter ablation of IART is difficult. The influence of patient and procedural factors and novel technologies on outcomes is unknown. METHODS: Acute and chronic RFCA outcomes were studied in patients with congenital heart disease and IART. Clinical status was measured using a multiaxis severity score. Multivariate analyses identified associations of clinical, procedural and technological factors with outcomes. RESULTS: A total of 177 procedures were performed in 134 patients; 139 procedures (79%) resulted in RFCA of > or =1 IART circuit and 117 (66%) in RFCA of all targeted circuits. Multivariate analysis associated acute success with irrigated ablation and absence of atrial fibrillation. Twenty-two complications were noted, nine related to vascular access. Electroanatomic mapping failed to decrease procedure or fluoroscopy time. Improvement in clinical status occurred in most patients (severity score preablation: 6.2 +/- 1.6, postablation: 3.0 +/- 2.3, p < 0.0001). At mean follow-up of 25 +/- 11 months, 42% of patients had IART recurrence and 28% required cardioversion. Six deaths occurred (1.8%/patient-year), and two patients underwent transplant. Chronic outcomes were associated with higher right atrial saturations, use of electroanatomic mapping, fewer IART circuits encountered and acute procedural success. CONCLUSIONS: Improvement of acute RFCA outcomes was contemporaneous with introduction of novel technologies. Intra-atrial re-entrant tachycardia recurrence was common, and no effect on mortality was discerned, but most patients had effective palliation of symptoms. Chronic outcome predictors included the underlying disease severity, application of novel technologies and successful ablation of all targeted arrhythmia circuits.
Assuntos
Ablação por Cateter/métodos , Cardiopatias Congênitas/complicações , Taquicardia Supraventricular/cirurgia , Fatores Etários , Análise de Variância , Mapeamento Potencial de Superfície Corporal , Seguimentos , Cardiopatias Congênitas/classificação , Cardiopatias Congênitas/cirurgia , Humanos , Taquicardia Supraventricular/etiologia , Resultado do TratamentoRESUMO
Automated external defibrillators (AEDs) are currently not recommended for use in children under 1 year of age. We report the first description of successful AED defibrillation in an infant using a 50 J shock and provide rationale for employing these life-saving devices in infants at risk for sudden cardiac death.
Assuntos
Desfibriladores , Cardioversão Elétrica/instrumentação , Parada Cardíaca/diagnóstico , Parada Cardíaca/terapia , Síndrome de Wolff-Parkinson-White/diagnóstico , Cardioversão Elétrica/métodos , Eletrocardiografia , Feminino , Seguimentos , Humanos , Lactente , Resultado do TratamentoRESUMO
OBJECTIVES: Patients with tetralogy of Fallot and diminutive pulmonary arteries are at risk for suprasystemic right ventricular pressure and right ventricular failure after complete repair. We report the short-term outcome and medium-term follow-up after using a fenestrated ventricular septal defect patch as a component of staged repair in selected patients. METHODS: We reviewed 47 patients with tetralogy of Fallot and diminutive pulmonary arteries whose ventricular septal defect patch was fenestrated, either electively or as a rescue technique, at a single institution between 1984 and 2001. RESULTS: Early mortality was 10.6% and occurred only in patients who underwent rescue fenestration. Review of medium-term follow-up (median, 39 months) revealed 4 late deaths; an additional 4 patients experienced right ventricular failure despite fenestration. Most (7/8) of these late events occurred in patients who underwent planned fenestration. Excessive left-to-right shunt through the fenestration developed in only 2 patients. CONCLUSIONS: Fenestrated patch closure of the ventricular septal defect in patients with tetralogy of Fallot and diminutive pulmonary arteries resulted in 10.6% early mortality. Used preemptively in selected patients, this technique is associated with no surgical mortality and a low incidence of excessive left-to-right shunt (4%). Early survivors remain at risk for late death and right ventricular failure despite fenestration.
Assuntos
Procedimentos Cirúrgicos Cardíacos/mortalidade , Procedimentos Cirúrgicos Cardíacos/métodos , Comunicação Interatrial/cirurgia , Retalhos Cirúrgicos , Tetralogia de Fallot/mortalidade , Tetralogia de Fallot/cirurgia , Anormalidades Múltiplas/diagnóstico , Anormalidades Múltiplas/mortalidade , Anormalidades Múltiplas/cirurgia , Adolescente , Adulto , Angiografia , Cateterismo Cardíaco , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Seguimentos , Comunicação Interatrial/diagnóstico , Comunicação Interatrial/mortalidade , Humanos , Lactente , Masculino , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/mortalidade , Probabilidade , Atresia Pulmonar , Estudos Retrospectivos , Medição de Risco , Análise de Sobrevida , Tetralogia de Fallot/diagnóstico , Resultado do TratamentoRESUMO
A survey on the follow-up practices of patients with implantable cardioverter defibrillators (ICDs) in Canada was conducted by the Canadian Working Group on Cardiac Pacing in 1999. The survey identified the need for national guidelines. The present guidelines for ICD follow-up represent a consensus statement of the Canadian Working Group on Cardiac Pacing. They recommend that patients be assessed before hospital discharge, at two to 12 weeks following implantation, six months after implantation, and at a minimum of every six months thereafter. More frequent assessments may be required for some patients depending on associated cardiovascular problems and specific ICD devices. A typical follow-up visit should include a targeted cardiovascular assessment, interrogation of the ICD, review of telemetered data, assessment of the underlying rhythm, pacing and sensing thresholds, lead impedance and appropriate reprogramming of ICD parameters to optimize device function and longevity.