Transient block during radiofrequency ablation well away from the His-Purkinje system: atrioventricular nodal artery trauma?

Cardiac arrhythmias occur at all ages. Cardiac mapping and ablation are established methods for curing arrhythmia substrates; however, complications may occur. We report a patient with transient Wenckebach heart block during radiofrequency ablation in the setting of Wolff Parkinson White syndrome despite the ablation catheter being well away from the atrioventricular node, and we speculate on the potential mechanism.

Optimus covered stent: Advanced covered stent technology for complex congenital heart disease.

AIM: To assess the acute results of the first human use of the Optimus covered stent in complex coarctation of the aorta. METHODS AND RESULTS: We successfully implanted the Optimus covered stent in eight cases in patients whose preprocedural anatomy looked challenging for currently available covered stents. Six of the patients had native coarctation with one recoarctation following surgical repair. There were no significant complications with reduction in the mean invasive gradient from 22 to 1 mm Hg. The length of stents used ranged from 33 to 57 mm with a median shortening after expansion of 13%. Postprocedural follow-up with magnetic resonance imaging or computed tomography has not shown evidence of fracture or migration or renarrowing. The median duration of follow-up is 10 months. CONCLUSIONS: Preliminary results show that the Optimus covered stent is safe and efficacious for use in patients with coarctation of challenging morphology. A systemic trial will be required to evaluate this stent for more widespread practice.

Closure of an aortopulmonary window using the Amplatzer Duct Occluder II.

We report two cases of transcatheter-device closure of aortopulmonary windows, a residual defect occurring after previous surgical closure, and a native lesion. The postsurgical defect was closed with an Amplatzer Duct Occluder II (AGA Medical Corporation, MN). The native lesion was not suitable for an Amplatzer Duct Occluder II device; thus, it was closed using an Amplatzer Duct Occluder (AGA Medical Corporation, MN). The Amplatzer Duct Occluder II provides an additional device for aortopulmonary window closure, but anatomy and defect characteristics dictate the most appropriate device.

Acquired left ventricular to left atrial fistula--not mitral regurgitation! Transcutaneous closure with amplatzer device.

Acquired left ventricle (LV) to left atrial (LA) fistula is a very rare complication following aortic valve replacement (AVR). This can usually be surgically repaired but the risk of re-operation is high due to repeat sternotomy and also due to other comorbidities usually seen in this population. We report a case presenting with recurrent episodes of left ventricular failure 10 years following bioprosthetic aortic valve replacement and who was diagnosed to have a communication between the LV and the LA on transesophageal echocardiography (TEE). This was treated percutaneously with an Amplatzer duct occluder (ADO) device (AGA Medical Corp.) as she was considered to be a high surgical risk.

Percutaneous management of a Fontan fenestration: in search for the ideal restriction-occlusion device.

OBJECTIVE: Most devices devices available for percutaneous closure of Fontan fenestrations tend to be bulky. The aim of this study was to evaluate a low profile custom made device and assess its efficacy and safety. PATIENTS AND METHODS: A 15 mm PFO star was used as the basis. The following modifications were made: removal of the left disc to reduce thrombogenicity in the left atrium, increase the length of the LA legs from 2 by 15 mm to 3 by 20 mm to prevent dislodgement and later adding a pivot between the left and right umbrella. A partial occluder was made by removing two opposite quadrants from the proximal disk. RESULTS: Device deployment was possible in 93% (63 of 68) patients. In five patients, the device could not be deployed and an alternative device was used. In 45 patients complete closure of the fenestration was obtained and saturations increased from 84% +/- 4% to 95% +/- 2% (P < 001). In 18 high risk patients with suboptimal Fontan circulation, a modified device was used to effect partial occlusion: saturations increased from 79% +/- 7% to 90% +/- 4% (P < 0.001); a residual shunt persisted in most patients for several months. No thrombotic events were recorded during follow-up. CONCLUSIONS: The modified PFO star device can safely be deployed in Fontan patients to occlude or restrict flow through a fenestration. It has a low profile with minimal foreign material, is non-obstructive and minimally thrombogenic.

Acute interventions for stenosed right ventricle-pulmonary artery conduit following the right-sided modification of Norwood-Sano procedure.

INTRODUCTION: The Norwood stage 1 procedure was modified by Sano with right ventricle-pulmonary artery (RV-PA) conduit replacing BT shunt. In our institution, this has been further modified by placing the conduit from the RV outflow tract to the right side of the neo-aorta. PATIENTS AND METHODS: Between April 2002 and October 2008, 227 modified Norwood procedures were performed. Eighteen had the Sano modification with the conduit to the left of the neo-aorta whereas 209 had the right-sided modification, which is the study population. A total of 18 (8.6%) patients presented with cyanosis due to conduit stenosis with median age 4 months and median weight 6.3 kg. RESULTS: Twelve patients underwent transcatheter stent placement in stenosed RV-PA conduit. A total of 16 coronary stents were implanted in 12 patients with 4 patients each receiving 2 stents. The mean saturations increased from 60% to 74%. There was one late mortality which was non-procedure related. Five patients treated with surgical take down of the RV-PA conduit and creation of a cavo-pulmonary shunt, whilst one patient had replacement of RV-PA conduit. There were no early postoperative deaths. The mean saturations improved from 54% to 75%. CONCLUSIONS: The RV-PA conduit stenosis is a life-threatening complication after the modified Norwood Stage I procedure. This may require urgent surgery to replace the conduit or to perform a cavo-pulmonary shunt but as an alternative, transcatheter stent placement can be used with equal effectiveness and with a low risk of complications. The catheter approach is less invasive and the results show that it is an excellent option to relieve the stenosis even in the right-sided RV-PA conduit.

Stenosis of the upper body arteries in association with coarctation and interrupted aortic arch.

Coarctation of the aorta and interrupted aortic arch are not usually associated with stenosis of the innominate, common carotid, or subclavian arteries. We report two patients with stenoses of combinations of these arteries, one in association with coarctation (stented later in life) and the other in association with interrupted arch (arterial stenoses surgically repaired at the time of surgery for the arch proper). Both have done well.

Isolated obstruction of the right ventricular infundibulum in a patient with Williams' syndrome.

Williams' syndrome is a rare condition that is associated with severe cardiovascular manifestations. We report a patient with Williams' syndrome who also has isolated obstruction of the right ventricular infundibulum, an association that, to the best of our knowledge, has not been previously reported.

HELEX Septal Occluder for transcatheter closure of patent foramen ovale: multicentre experience.

AIMS: Patients with cryptogenic embolic events and a patent foramen ovale (PFO) are at risk of paradoxical embolism causing recurrent cerebral events; however, transcatheter PFO closure remains controversial. The aim of this multicentre trial was to demonstrate the feasibility and safety of transcatheter closure of PFO with the HELEX Septal Occluder. METHODS AND RESULTS: The study enrolled 128 patients (66 female; mean age, 50 years). Mean (+/-SD) PFO size was 10+/-3.7 mm; 38 patients also had an atrial septal aneurysm. Device implantation was successful in 127 patients. Device-related events during implantation or follow-up were device embolisation, wire-frame fracture, and retrieval cord breaks (two cases each; no sequelae). Other adverse events included atrial arrhythmia (two patients), migraine, convulsion, and transient ischaemic attack (one case each). There were no recurrent strokes, deaths, perforations, or accumulations of thrombi on the device. Within a mean follow-up period of 21+/-11 months, complete PFO closure using one device was achieved in 114 patients (90%). Five patients with a moderate to large residual shunt received a second device. CONCLUSION: The HELEX Occluder can be used for PFO closure. Device- and procedure-related complications are rare. The closure procedure appears to reduce recurrence rates of stroke and transient ischaemic attack.