Troubled Judging of Bronchus Compression Due to Contrast-Filled Balloon in Three-Dimensional Rotational Angiography.

Three-dimensional rotational angiography (3DRA) is a suitable technique to detect the risk of left main bronchus (LMB) compression during left pulmonary artery (LPA) stenting in partial cavopulmonary connection and total cavopulmonary connection (TCPC). We report on a case of a 4-year-old boy with hypoplastic left heart syndrome and TCPC in which 3DRA and bronchoscopy gave conflicting information on airway patency during balloon interrogation. The balloon with high contrast concentration created a severe artifact impeding visibility of the LMB. Simultaneous flexible bronchoscopy revealed an unobstructed LMB. Repeated 3DRAs with lower contrast concentration had no artifact and showed a patent airway in accordance with the bronchoscopy. Conventional LPA stenting was performed without indication for stent ovalization. The benefit of low contrast concentration in the interrogation balloon was demonstrated in a second case of an 11-year-old boy with TCPC. The margins of the LPA and LMB were clearly visible without blank-out artifact. Oval stent procedure was necessary to prevent LMB compression. When 3DRA is used for vessel-airway interrogation, the balloon contrast concentration should be low in order to avoid artifacts. When in doubt, simultaneous flexible bronchoscopy can overcome the dilemma in airway judgment.

Epinephrine stress testing during cardiac catheterization in patients with aortic coarctation.

BACKGROUND: The severity of aortic coarctation (CoA) may be underestimated during cardiac catheterization. We aimed to investigate whether epinephrine stress testing improves clinical decision making and outcome in CoA. METHODS: We retrospectively evaluated CoA patients >50 kg with a peak systolic gradient (PSG) ≤20 mm Hg during cardiac catheterization who underwent epinephrine stress testing. Subsequent interventional management (stenting or balloon dilatation), complications, and medium-term clinical outcome were assessed. RESULTS: Fifty CoA patients underwent cardiac catheterization with epinephrine stress testing. Patients with a high epinephrine PSG (>20 mm Hg; n = 24) were younger and more likely to have a hypertensive response to exercise compared to patients with a low epinephrine PSG (≤20 mm Hg; n = 26). In total, 21 patients (88%) with a high epinephrine PSG underwent intervention, and 20 patients (77%) with a low epinephrine PSG were treated conservatively. After a mean follow-up of 25 ±â€¯18 months, there was a lower prevalence of hypertension in patients with a high epinephrine PSG who underwent intervention compared to patients with a low epinephrine PSG treated conservatively (19% vs. 76%; P = .001). In a multivariate model, intervention was independently associated with a 14.3-mm Hg reduction in systolic blood pressure (P = .001) and a decrease in the use of antihypertensive agents. CONCLUSIONS: In CoA patients with a low baseline PSG but high epinephrine PSG, percutaneous intervention is associated with a substantial reduction in systemic blood pressure and the use of antihypertensive medication. Accordingly, epinephrine stress testing may be a useful addition in the evaluation of CoA.

Endovascular coil embolization of a complex aortic arch pseudoaneurysm following arch stenting.

Pseudoaneurysm formation is a life-threatening complication of thoracic aortic stenting due to the high risk of rupture. When located in the aortic arch, anatomic features may pose difficulties in choosing the optimal treatment strategy. Here, we describe the first poststenting aortic arch pseudoaneurysm treated by endovascular coil embolization. This approach, which we performed in a multidisciplinary setting, may be a feasible alternative in patients not considered suitable for open repair or stent-grafting. As an acute pseudoaneurysm may develop and rapidly expand during the first days after aortic stenting, early follow-up imaging is preferable.

Three-Dimensional Rotational Angiography in Pediatric Patients with Congenital Heart Disease: A Literature Review.

Cardiac catheterization is a commonly used form of imaging and treatment in pediatric patients with congenital heart disease. Traditionally, two-dimensional conventional angiography was the method used, but since 2000 three-dimensional rotational angiography (3DRA) is increasingly used in the field of cardiology in both adult and pediatric patients. To investigate the use and applications of 3DRA in pediatric congenital cardiology, literature was systematically reviewed and 29 eligible articles were found. Those showed that 3DRA is already a greatly valued diagnostic and therapeutic technique in pediatric cardiology. However, the literature misses well-designed clinical, homogeneous, multicenter, prospective studies recording data in a standardized manner. These studies are necessary to ensure proper data analysis and to investigate the true advantages of 3DRA and how it exactly benefits the patients.

Dramatic Dose Reduction in Three-Dimensional Rotational Angiography After Implementation of a Simple Dose Reduction Protocol.

Previously, median effective dose (ED) of 1.6 mSv per three-dimensional rotational angiography (3DRA) has been reported. This study evaluated ED and image quality in 3DRA after implementation of a simple dose reduction protocol in pediatric catheterizations. Simple conversion factors between 3DRA ED and readily available parameters at the cathlab were determined. The dose reduction protocol consisted of frame reduction (60-30 frames/s (f/s)), active collimation of the X-ray beam, usage of a readily available low dosage program, and a pre-3DRA run check. EDs were calculated with Monte Carlo PCXMC 2.0. Three observers blindly assessed 3DRA image quality of the dose reduction and normal-dose cohort. Between October 2014 and October 2015, 84 patients (median age 4.3 years) underwent 100 3DRAs with a median ED of 0.54 mSv (0.12-2.2) using the dose reduction protocol. Median ED in the normal-dose cohort (17 3DRAs) was 1.6 mSv (1.2-4.9). Image quality in the dose reduction cohort remained excellent. Correlations between ED and dose area product (DAP) and ED and skin dose were found with a ρ of 0.82 and 0.83, respectively. ED exposure of the entire catheterization was reduced to 2.64 mSv. Introduction of a simple protocol led to 66% dose reduction in 3DRA and 79% in the entire catheterization. 3DRA image quality in this group remained excellent. In 3DRA ED correlates well with DAP and skin dose, parameters readily available at the cathlab.

Early and midterm outcomes of bare metal stenting in small children with recurrent aortic coarctation.

AIMS: The aim of this study was to report our experience with the Cook Formula stent in the treatment of (recurrent) coarctation of the aorta in children below 12 kg. METHODS AND RESULTS: In vitro study of the Cook Formula 418 (8 mm) and 535 (8 and 10 mm) stents demonstrated successful down-crimping on smaller balloons and predictable fracturing patterns. Between November 2012 and January 2019, one patient with native, one patient with post-interventional and thirteen patients with post-surgical coarctation of the aorta underwent implantation of a Cook Formula stent. Patient and procedural characteristics were obtained as well as procedural success, complications, and follow-up. Median age was 4.3 months and median weight 5.5 kg. Arterial sheath size ranged from 5 to 7 Fr. In-stent diameters of 3.7 to 8.8 mm were obtained with a median residual gradient of 0 mmHg. Major complications consisted of periprocedural haemodynamic instability (n=1), dissection of the iliac artery (n=1) and non-deployment with surgical removal (n=1). Re-dilations were performed after a median interval of 24.3 months. Median follow-up was 31.7 months. CONCLUSIONS: The bare metal Cook Formula stent provides a durable and effective alternative to reoperation and balloon dilatation for native as well as post-surgical aortic coarctation in children below 12 kg.

Oval stenting in left pulmonary artery stenosis: a novel double balloon technique to prevent airway compression in single ventricle.

AIMS: Left pulmonary artery (LPA) stenosis is common in patients with cavopulmonary connections. Stent implantation is the treatment of choice but may be complicated or contraindicated by left main bronchus (LMB) compression due to limited retro-aortic space after a Damus-Kaye-Stansel (DKS) or Norwood operation. This study describes a novel double balloon technique of LPA stenting in patients at risk of LMB compression. METHODS AND RESULTS: A cohort study was performed in 11 patients who underwent LPA stenting with an oval stent technique between 2015 and 2018. Retro-aortic anatomy was evaluated periprocedurally by three-dimensional rotational angiography (3DRA). Pre-existing LMB compression was demonstrated by 3DRA in seven out of eight patients who had undergone previous LPA stenting and in one patient without stenting. Primary ovalisation with immediate stent implantation on double balloons was performed in one patient. Ten patients had secondary ovalisation with single balloon stent implantation followed by the double balloon technique for ovalisation. The procedures were successful in all patients and guaranteed LMB patency without increasing pre-existing compression. CONCLUSIONS: The 3DRA-guided oval stent technique with double balloon inflation is successful in treating LPA stenosis after a DKS or Norwood operation in patients at risk of bronchial compression, guaranteeing LMB patency without increasing pre-existing compression.

Percutaneous Pulmonary Valve Implantation: Current Status and Future Perspectives.

Patients with congenital heart disease (CHD) with right ventricle outflow tract (RVOT) dysfunction need sequential pulmonary valve replacements throughout their life in the majority of cases. Since their introduction in 2000, the number of percutaneous pulmonary valve implantations (PPVI) has grown and reached over 10,000 procedures worldwide. Overall, PPVI has been proven safe and effective, but some anatomical variations can limit procedural success. This review discusses the current status and future perspectives of the procedure.

Medium-term systemic blood pressure after stenting of aortic coarctation: a systematic review and meta-analysis.

OBJECTIVE: Long-term prognosis of patients with coarctation of the aorta (CoA) is impaired due to the high prevalence of hypertension and consequent cardiovascular complications. Although stent implantation results in acute anatomical and haemodynamic benefit, limited evidence exists regarding the late clinical outcome. In this meta-analysis, we aimed to evaluate the medium-term effect of stent placement for CoA on systemic blood pressure (BP). METHODS: PubMed, EMBASE and Cochrane databases were searched for non-randomised cohort studies addressing systemic BP ≥12 months following CoA stenting. Meta-analysis was performed on the change in BP from baseline to last follow-up using a random-effects model. Subgroup analyses and meta-regression were conducted to identify sources of heterogeneity between studies. RESULTS: Twenty-six studies with a total of 1157 patients and a median follow-up of 26 months were included for final analysis. Meta-analysis showed a 20.3 mm Hg (95% CI 16.4 to 24.1 mm Hg; p<0.00001) reduction in systolic BP and an 8.2 mm Hg (12 studies; 95% CI 5.2 to 11.3 mm Hg; p<0.00001) reduction in diastolic BP. A concomitant decrease in the use of antihypertensive medication was observed. High systolic BP and peak systolic gradient at baseline and stenting of native CoA were associated with a greater reduction in systolic BP at follow-up. CONCLUSIONS: Stent implantation for CoA is associated with a significant decline in systolic and diastolic BP during medium-term follow-up. The degree of BP reduction appears to be dependent on baseline systolic BP, baseline peak systolic gradient, and whether stenting is performed for native or recurrent CoA.

Primary coronary stent implantation is a feasible bridging therapy to surgery in very low birth weight infants with critical aortic coarctation.

BACKGROUND: Surgical treatment of critical aortic coarctation (CoA) is difficult in very low birth weight (VLBW) infants ≤1500 g and preferably postponed until 3 kg with prostaglandins (PGE). OBJECTIVES: To investigate the procedure and outcome of primary coronary stent implantation as bridging therapy to surgery in VLBW infants with CoA. METHODS: Retrospective evaluation of primary CoA stenting in VLBW infants from 2010 to 2015. RESULTS: Five VLBW infants with a median gestational age of 29 weeks (27-32) underwent primary CoA stenting. Indication was cardiac failure in 4 and severe hypertension in 1 patient. Age and weight at intervention were 14 days (range 12-16) and 1200 g (680-1380), respectively. Stent diameter ranged 3-5 mm. The femoral artery used for intervention was occluded in all infants without clinical compromise. Severe restenosis and aneurysm occurred in 1 VLBW infant and was successfully treated with covered coronary stents. Median age at surgical correction was 200 days (111-804) and weight 5500 g (4500-11,400). No reinterventions were required during a median postoperative follow-up of 2.8 years (0.1-5.0). Neurodevelopmental outcomes were normal and comparable between patients and siblings (4/5 gemelli). CONCLUSIONS: Primary coronary stent implantation in VLBW infants with critical CoA is a feasible bridging therapy to surgery.