Right ventricular fibrosis in adults with uncorrected secundum atrial septal defect and pulmonary hypertension: a cardiovascular magnetic resonance study with late gadolinium enhancement, native T1 and extracellular volume.

Introduction: Right ventricular (RV) fibrosis represents both adaptive and maladaptive responses to the overloaded RV condition. Its role in pulmonary hypertension (PH) associated with secundum atrial septal defect (ASD), which is the most common adult congenital heart disease (CHD), remains poorly understood. Methods: We enrolled 65 participants aged ≥18 years old with uncorrected secundum ASD who had undergone clinically indicated right heart catheterization (RHC), divided into the non-PH group (n = 7), PH group (n = 42), and Eisenmenger syndrome (ES) group (n = 16). We conducted cardiovascular magnetic resonance (CMR) studies with late gadolinium enhancement (LGE) imaging, native T1 mapping, and extracellular volume (ECV) measurement to evaluate the extent and clinical correlates of RV fibrosis. Results: LGE was present in 94% of the population and 86% of the non-PH group, mostly located at the right ventricular insertion point (RVIP) regions. LGE in the septal and inferior RV region was predominantly observed in the ES group compared to the other groups (p = 0.031 and p < 0.001, respectively). The mean LGE scores in the ES and PH groups were significantly higher than those in the non-PH group (3.38 ± 0.96 vs. 2.74 ± 1.04 vs. 1.57 ± 0.79; p = 0.001). The ES and PH groups had significantly higher degrees of interstitial RV fibrosis compared to those in the non-PH group, indicated by native T1 (1,199.9 ± 68.9 ms vs. 1,131.4 ± 47.8 ms vs. 1,105.4 ± 44.0 ms; p < 0.001) and ECV (43.6 ± 6.6% vs. 39.5 ± 4.9% vs. 39.4 ± 5.8%; p = 0.037). Additionally, native T1 significantly correlated with pulmonary vascular resistance (r = 0.708, p < 0.001), RV ejection fraction (r = -0.468, p < 0.001) and peripheral oxygen saturation (r = -0.410, p = 0.001). Conclusion: In patients with uncorrected secundum ASD, RV fibrosis may occur before the development of PH and progressively intensify alongside the progression of PH severity. A higher degree of RV fibrosis, derived from CMR imaging, correlates with worse hemodynamics, RV dysfunction, and poorer clinical conditions.

Ductal stenting vs. surgical shunting in late presenting duct-dependent pulmonary circulation: a single-center experience.

Introduction: PDA stenting is an option to mBTT shunt for younger patients; nevertheless, few reports of this palliative approach have been made for the late presenter population, especially for patients who are older than 30 days but under 5 years. This study aimed to evaluate the clinical result and intra-hospital costs of ductal stenting in late-presenting patients in comparison to surgical shunting. Methods: A single-center, retrospective cohort study was conducted from August 2016 to August 2022. This study included patients with pulmonary duct dependent CHD who were hospitalized for palliative therapy. The extracted data were baseline characteristics, clinical findings, supportive examination findings, complications, outcomes, and length of stay of the patients. Monitoring was carried out during treatment up to 30 days after the procedure. Results: A total of 143 patients were included in the analysis; 43 patients underwent PDA stent and 100 patients underwent mBTT shunt with median age of PDA stent group 110 (31-1,498) days and mBTT shunt group 174.5 (30-1,651) days. Primary outcome composite was not significant in both groups including 30 days mortality [6 (14%) vs. 14 (14%), p = 1.000], reintervention [1 (2.3%) vs. 7 (7%), p = 0.436], and 30 days rehospitalization [0 (0%) vs. 2 (2%), p = 0.319]. Secondary outcome analysis showed shorter ICU length of stay in the PDA stent group [2 (0-16) days vs. 4 (1-63) days, p = 0.002]. Conclusions: PDA stent has an outcome that is non inferior from the mBTT shunt procedure in the composite outcome including 30 days mortality, reintervention, and 30 days rehospitalization but significantly lower in ICU length of stay.

Distribution of catheterisation laboratories in Indonesia 2017-2022: a nationwide survey.

Background: Geographical terrains of Indonesia pose a major hindrance to transportation. The difficulty of transportation affects the provision of acute time-dependent therapy such as percutaneous coronary intervention (PCI). Also, Indonesia's aging population would have a significant impact on the prevalence of acute coronary syndrome in the next decade. Therefore, the analysis and enhancement of cardiovascular care are crucial. The catheterisation laboratory performs PCI procedures. In the current study, we mapped the number and distribution of catheterisation laboratories in Indonesia. Methods: A direct survey was used to collect data related to catheterisation laboratory locations in July 2022. The population data was sourced from the Ministry of Home Affairs. The recent growth of catheterisation laboratories was examined and evaluated based on geographical areas. The main instruments for comparing regions and changes throughout time are the ratio of catheterisation laboratories per 100,000 population and the Gini index (a measure of economic and healthcare inequality. Gini index ranges from 0 to 1, with greater values indicating more significant levels of inequality). Regression analysis was carried out to see how the number of catheterisation laboratories was affected by health demand (prevalence) and economic capacity (Gross Domestic Regional Product [GDRP] per Capita). Findings: The number of catheterisation laboratories in Indonesia significantly increased from 181 to 310 during 2017-2022, with 44 of the 119 new labs built in an area that did not have one. Java has the most catheterisation laboratories (208, 67%). The catheterisation laboratory ratio in the provinces of Indonesia ranges from 0.0 in West Papua and Maluku to 4.46 in Jakarta; the median is 1.09 (IQR 0.71-1.18). The distribution remains a problem, as shown by the high catheterisation laboratory Gini index (0.48). Regression shows that distribution of catheterisation laboratories was significantly affected by GDRP and the prevalence of heart disease. Interpretation: The number of catheterisation laboratories in Indonesia has increased significantly recently, however, maldistribution remains a concern. To improve Indonesia's cardiovascular emergency services, future development of catheterisation laboratories must be better planned considering the facility's accessibility and density. Funding: Airlangga Research Fund - Universitas Airlangga.

Right ventricular outflow tract stenting for late presenter unrepaired Fallot physiology: a single-center experience.

Objectives: The purpose of this study was to assess the clinical outcome after right ventricular outflow tract (RVOT) stenting in late presenter patient with unrepaired Fallot physiology. Background: In younger patients, RVOT stenting is an alternative to mBTT shunt; however, there have been few reports of this palliative technique in late presenter population, including adults. Methods: This was a single-center, retrospective study of nonrandomized, palliated Fallot patients. Clinical outcomes such as left ventricular ejection fraction and saturation were measured in 32 individuals following RVOT stenting in adults (n = 10) and children (n = 22). The Statistical Package for Social Science (SPSS) 26.0 software was used to analyze the statistical data. Results: During the procedure, the average stent diameter and length were 8.84 ± 1.64 mm and 35.46 ± 11.23 mm, respectively. Adult patients received slightly longer stents than pediatric patients (43.60 ± 11.64 mm vs. 31.77 ± 9.07 mm). Overall, patients' saturation increased from 58.56 ± 19.03% to 91.03 ± 8.98% (p < 0.001), as did their left ventricular ejection fraction (LVEF) from 64.00 ± 18.21% to 75.09 ± 12.98% (p = 0.001). Three patients improved their LVEF from 31 to 55%, 31 to 67%, and 26 to 50%. The median length of stay was 8 (2-35) days, with an ICU stay of 2 (0-30) days. The median time from RVOT stent palliation to total repair was 3 months (range: 1 month-12 months). Conclusions: RVOT stenting is a safe and effective method for increasing saturation and ejection fraction not only in newborn infants but also in late presenters, including adults with unrepaired Fallot physiology.

Transoesophageal echocardiography-guided balloon-assisted percutaneous closure of a large secundum atrial septal defect in a pregnant woman: a case report.

Background: According to the 2018 European Society of Cardiology guidelines, atrial septal defect (ASD) closure can be performed during pregnancy but is rarely indicated. In this case, we demonstrate the viability of percutaneous balloon-assisted ASD closure without fluoroscopy in a pregnant woman. Case summary: A 23-year-old G3P2A0 woman who was 20 weeks pregnant had primary complaints of breathlessness [New York Heart Association functional class (NYHA fc) III and IV] for 1 week prior to admission. A transthoracic echocardiography showed a dilatation of the right atrium (RA), a dilated right ventricle, a dilated main pulmonary artery (28.1 mm), and an oval-shaped 22 × 33 mm-sized secundum ASD with a left-to-right shunt. Despite optimal pharmacological treatment, the NYHA fc persisted. Under transoesophageal echocardiography monitoring, we introduced a 40 mm Cera™ ASD Occluder (Lifetech, China) via the delivery sheath. The device was deployed in the usual position; however, despite numerous placement adjustments, the left atrium disc kept getting dislodged to the RA and could not engage correctly. Therefore, we decided to use a balloon-assisted approach using a sizing balloon of No. 34 mm. The device was successfully positioned, and a wiggle test was conducted to make sure that the device remained stable. The patient was able to give birth to the child normally several months later. Discussion: Despite the fact that pregnant women with ASD receive a very low dose of radiation, it is nevertheless recommended to avoid radiation because this demographic is particularly vulnerable to it. It is possible to treat a large ASD in pregnant women with a successful balloon-assisted approach.

Palliative interatrial septum stenting with a vascular stent in a chronic thromboembolic pulmonary hypertension patient: Is it beneficial?

BACKGROUND: Chronic thromboembolic pulmonary hypertension (CTEPH) is a serious disease that can progress and lead to a deadly outcome. Despite optimal drug therapy, pulmonary hypertension (PH) remains fatal. Untreatable right heart failure (RHF) from CTEPH is eventually a significant cause of death. However, unloading the right heart and increasing systemic output are the treatment goals in these patients. CASE PRESENTATION: A 42-year-old female presented to the emergency department with worsening dyspnea experienced for three days before admission. There were also complaints of leg edema, ascites, orthopnea, and palpitation. Physical examination revealed an attenuated second heart sound, abdominal ascites, and bilateral leg edema. She had a history of frequent readmissions due to RHF despite optimal medical therapy and was diagnosed with CTEPH 5 months ago. It was decided that the patient would undergo interatrial septal (IAS) stenting with a vascular stent of 8 mm × 39 mm × 135 cm. The results were good; her symptoms and signs of RHF improved, and she was eventually discharged from the hospital. Four months after the procedure, the patient was able to engage in physical activities without any limitations. CONCLUSIONS: A palliative IAS stent is one of the choices for intractable RHF management in patients with CTEPH. The vascular stent can be used as an alternative in order to make the interatrial connection more stable and last longer.

Efficacy and safety of transcarotid compared to transfemoral approach of patent ductus arteriosus stenting in duct-dependent cyanotic heart disease.

BACKGROUND: Minimally invasive transcatheter approaches were usually done for patent ductus arteriosus (PDA) with duct-dependent pulmonary circulation. There are two ways to establish vascular access, by using transfemoral either femoral vein (FV) or femoral artery (FA) and transcarotid artery (CA) with surgical cutdown approach to access the PDA and then provide good support for the balloon and the stent to be safely deployed. This study aims to compare the efficacy and safety of transcarotid with surgical cutdown compared to the transfemoral approach of patent ductus arteriosus stenting in duct-dependent cyanotic heart disease. RESULTS: Overall procedural complication rates were higher in the FA/FV approach than in the CA approach (51% vs. 30%). The incidence of acute limb ischemia in the FA approach is significantly higher than in the CA approach (P < 0.05). No acute thrombosis/occlusion of the carotid artery was assessed by carotid vascular ultrasound in 2-day series. CONCLUSIONS: The transcarotid approach with surgical cutdown may offer a secure and more efficient means of accessing the PDA, particularly for those emerging from the underside of the aortic arch.

Transesophageal echocardiography-guided percutaneous closure of multiple muscular ventricular septal defects with pulmonary hypertension using single device: A case report.

Background: Surgery is typically used to correct challenging ventricular septal defects (VSDs), such as VSD with pulmonary hypertension and multiple defects. In this case report, we would like to highlight the feasibility of multiple defects VSD closure with single device percutaneously using zero-fluoroscopy technique. Case presentation: A 7-year-old child was referred with the main symptom of shortness of breath. She started experiencing repeated respiratory tract infections, feeding issues, and failure to thrive at the age of six months. Her body weight was only 18 kg. TEE revealed several muscular VSD with 2-3 mm and 12 mm diameters, 3 mm spacing between VSD, L to R shunt, AR (-), and TR mild with septal leaflet tricuspid prolapse. Following right heart catheterization (Qp:Qs 3.5, PVRi 5.23WUmsq, PVR 4.55 WU, PVR/SVR 0.16), we made the decision to correct the defect using an Amplatzer Septal Occluder (AGA) No. 16 mm using transjugular method. Full device deployment was successfully performed with several episodes of PVC storm and severe bradycardia. One and a half years after the procedure, her TVG dropped to only 18 mmHg, her visible indicators of PH subsided, and the PA dilator treatment was discontinued. Her body weight had increased to 28 kg, and she had no complaints. Conclusions: Our experience demonstrated that percutaneous closure of multiple VSD with a single device is possible, even with pulmonary hypertension.

The outcomes of fetal aortic valvuloplasty in critical aortic stenosis: A systematic review and meta-analysis.

BACKGROUND: Critical aortic stenosis that appears in mid-gestation tends to develop to growth retardation of left ventricle, known as hypoplastic left heart syndrome (HLHS). Despite better clinical management of HLHS, the morbidity and mortality rates of univentricular circulation patients remain high. In this paper, we sought to perform a systematic review and meta-analysis to know the outcomes of fetal aortic valvuloplasty in critical aortic stenosis patients. METHODS: This systematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) statement. A systematic search on fetal aortic valvuloplasty procedure for critical aortic stenosis was performed through PubMed, Scopus, EBSCOhost, ProQuest, and Google Scholar. The primary endpoint of each group was overall mortality. We used R software (version 4.1.3) to estimate the overall proportion of each outcome using random-effects model of proportional meta-analysis. RESULTS: A total of 389 fetal subjects from 10 cohort studies were included in this systematic review and meta-analysis. Fetal aortic valvuloplasty (FAV) was successfully performed in 84% of patients. It revealed a successful conversion to biventricular circulation rate of 33% with a mortality rate of 20%. Bradycardia and pleural effusion requiring treatment were two most common fetal complications, whereas maternal complication reported was only placental abruption in one patient. CONCLUSIONS: FAV has a high technical success rate with the ability to achieve biventricular circulation and a low rate of procedure-related mortality if carried out by experienced operators.

A retrograde approach for transcatheter valvotomy procedure in infants with pulmonary atresia intact ventricular septum (PA-IVS): retrograde versus antegrade approach.

INTRODUCTION: This study evaluates the retrograde approach compared to the antegrade approach in infants with PA-IVS who underwent transcatheter pulmonary valvotomy procedure at National Cardiovascular Center Harapan Kita, Jakarta, Indonesia. MATERIAL AND METHOD: This is a single-centre retrospective study conducted from January 2017 to June 2019 consisting of infants undergoing transcatheter pulmonary valvotomy procedures from our centre. RESULTS: Among 3733 records of cardiac catheter procedure in paediatric patients during the last 3 years, there were 12 subjects with PA-IVS, where five subjects were done by antegrade approach and seven by retrograde approach. The retrograde approach is shown to excel the antegrade approach in terms of procedural time by 58.64 minutes (CI 95 % 32.97-84.29, p = 0.008) and PA-RV crossing time by 27 minutes (CI 95 % 14.01-39.99, p = 0.02). There was no significant difference in contrast used (120.23 ± 25.77 versus 150.27 ± 39.26 ml/BSA, p = 0.518), and right ventricle to pulmonary artery systolic pressure gradient after valvotomy (39.571 ± 5.814 versus 53.52 ± 29.15, p = 0.329) between the retrograde and the antegrade approach. CONCLUSION: The retrograde approach offered shorter procedural time and comparably satisfying results than the antegrade approach. The shorter procedural time was preferred due to the shorter duration of general anaesthesia, which may decrease the risk of neurodevelopmental deficits in the patient.

A Novel Peptide Elabela is Associated with Hypertension-Related Subclinical Atherosclerosis.

INTRODUCTION: Elabela is a newly identified peptide which, alongside apelin, acts as an endogenous ligand that activates the angiotensin receptor-like 1 receptor. Previous studies have shown the association of elabela with hypertension, but information about the role of elabela in hypertension-related subclinical atherosclerosis is scarce. AIM: We aimed to determine the elabela levels in hypertensive patients and explore its association with subclinical atherosclerosis. METHODS: A total of 104 subjects with hypertension were included in the study. Elabela levels were measured using an enzyme-linked immunosorbent assay, by first extracting the peptide following the manufacturer's instructions. Subclinical atherosclerosis was assessed by measuring the carotid intima-media thickness (IMT) using ultrasound. RESULTS: Compared to stage 1, elabela levels decreased in stage 2 hypertension (0.23 [0.13, 0.45] ng/ml vs. 0.14 [0.09, 0.23] ng/ml; P = 0.000), and in the group with increased carotid IMT compared to normal IMT (0.24 [0.13, 0.38] ng/ml vs. 0.15 [0.10, 0.23] ng/ml; P = 0.005). Additionally, a linear correlation analysis showed that elabela had a significant negative correlation with systolic blood pressure (r = - 0.340, P = 0.000) and carotid IMT (r = - 0.213; P = 0.030). In multivariate analysis, lower elabela levels were associated with a higher cardiovascular risk group in this study (OR 5.0, 95% CI 1.8-13.5, P < 0.001). CONCLUSIONS: This study demonstrated for the first time that circulating elabela declined in a higher stage of hypertension and hypertensive patients with increased carotid IMT, implicating that elabela may be involved in the pathogenesis of hypertension-associated subclinical atherosclerosis.

Impact of older age at Fontan completion on mid-term survival.

BACKGROUND: The optimum age of Fontan completion remains unknown. Currently, the majority of centers worldwide are performing Fontan completion at 2-4 years of age. In Indonesia, lack of awareness and limited resources probably explain why patients seek treatment at advanced stage. This study aimed to evaluate the impact of older age at Fontan completion on mid-term survival. RESULTS: A single-center retrospective cohort study was performed on 261 patients who underwent Fontan completion between 2008 and 2019 and survived to discharge. The patients were followed up until April 2020, with a median follow-up period of 3 years (range 0-12 years). The median age was 5 years (range 2-24 years). The survival rates of patients with the age at operation ≤ 6 years and > 6 years were 92.1% and 82.8%, respectively. A subgroup analysis showed that the survival rates for age < 4 years, 4-6 years (reference age), 6-8 years, 8-10 years, 10-18 years, and > 18 years were 85.7%, 94.8%, 85.4%, 78.8%, 85.7%, and 66.7%, respectively. Age at Fontan completion of > 6 years (HR 3.84; p = 0.020) was associated with a lower 12-year survival rate. The age at operation of 8-10 years (HR 6.79; p = 0.022) and > 18 years (HR 15.30; p = 0.006) had the worst survival rates. CONCLUSIONS: An older age at Fontan completion (> 6 years) significantly reduced mid-term survival rate. The age at Fontan of 8-10 years and > 18 years had higher risk of mid-term death than age of 4-6 years.

Double Stenting in 19-Year-Old Patient With Tetralogy of Fallot With Prior Fractured Stent.

A 19-year-old patient with tetralogy of Fallot was referred to the cath lab because of persistent desaturation and a fractured right ventricular outflow tract stent. Restenting was done because the infundibular stenosis was very tight. Total repair was completed 1 week after the procedure, and at that time, the patient's hemodynamics had greatly improved. (Level of Difficulty: Advanced.).

Echocardiography-Guided Percutaneous Patent Ductus Arteriosus Closure: 1-Year Single Center Experience in Indonesia.

Introduction: Since the first successful percutaneous closure under transesophageal echocardiographic (TEE) guidance, many centers explored transcatheter procedures without fluoroscopy. This single-center study is aimed to show the feasibility and safety of percutaneous patent ductus arteriosus (PDA) closure under echocardiography-only guidance during our 1-year experience. Methods: Patients with PDA were recruited for percutaneous PDA closure guided by either fluoroscopy or echocardiography-only in National Cardiovascular Center Harapan Kita (ClinicalTrials.gov Identifier: NCT05321849, clinicaltrials.gov/ct2/show/NCT05321849). Patients were evaluated clinically and radiologically using transthoracic echocardiography (TTE) at 6, 24, and 48 h after the procedure. The primary endpoint was the procedural success. Secondary endpoints were the procedural time and the rate of adverse events. Results: A total of 60 patients underwent transcatheter PDA closure, 30 patients with fluoroscopy and 30 patients with echocardiography guidance. All patients had successful PDA closure. There were only residual shunts, which were disappeared after follow-up in both groups, but one patient with a fluoroscopy-guided procedure had moderate tricuspid regurgitation with suspected thrombus in the tricuspid valve. The procedural time was not significantly different between the fluoroscopy and echocardiography groups.

Reversed Potts Shunt Outcome in Suprasystemic Pulmonary Arterial Hypertension: A Systematic Review and Meta-Analysis.

BACKGROUND: Reversed Potts shunt has been a prospective approach to treat suprasystemic pulmonary hypertension, particularly when medication treatment fails to reduce right ventricular afterload. OBJECTIVE: This meta-analysis aims to review the clinical, laboratory, and hemodynamic parameters after a reversed Potts shunt in suprasystemic pulmonary hypertension patients. METHODS: Six electronic databases were searched from the date of inception to August 2021, where the obtained studies were evaluated according to the PRISMA statement. The effects of shunt creation were evaluated by comparing preprocedural to postprocedural or follow-up parameters, expressed as a mean difference of 99% confidence interval. Quality assessment was conducted using the STROBE statement. RESULTS: Seven studies suited the inclusion criteria which were included in this article. A reduction in upper and lower limb oxygen saturation [Upper limb: St. Mean difference -0.55, 99% CI -1.25 to 0.15; P=0.04; I2=6%. Lower limb: St. Mean difference -4.45, 99% CI -7.37 to -1.52; P<0.00001; I2=65%]. Reversed Potts shunt was shown to improve WHO functional class, 6-minute walk distance, NTpro-BNP level, and hemodynamic parameters including tricuspid annular plane systolic excursion, interventricular septal curvature, and end-diastolic right ventricle/left ventricle ratio. CONCLUSION: Reversed Potts shunt cannot be said to be relatively safe, although it allows improvement in the clinical and functional status in patients with suprasystemic PAH. Reversed Potts shunt procedure may be the last resort for drug-resistant pulmonary hypertension as it is considered a high-risk procedure performed on patients with extremely poor conditions.

Pharmacology Management in Improving Exercise Capacity of Patients with Fontan Circulation: A Systematic Review and Meta-analysis.

BACKGROUND: The Fontan procedure is currently the mainstay therapy for single functional ventricles. However, with prolonged follow-up duration, various complications have been observed that seriously influence the quality of life of patients. OBJECTIVES: The aim of this meta-analysis is to compare the effectiveness of pharmacologic agents in improving exercise capacity in patients with Fontan circulation. METHODS: This meta-analysis was conducted according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement and has been registered in the International Prospective Register for Systematic Reviews database with registration no. 282352. Quality assessments of the included studies were assessed using the Strengthening Reporting of Observational Studies in Epidemiology (STROBE) statement. RESULTS: Twelve studies met the predetermined inclusion criteria and were included in this metaanalysis. This meta-analysis found that treatment with bosentan significantly improved New York Heart Association Functional Class (NYHA FC) in Fontan patients (standard mean difference - 0.59, 95% CI -0.94 - -0.25; P=0.0008; I2 = 1%). However, the use of bosentan (P=0.66) and sildenafil (P=0.13) did not show a significant improvement in the maximum rate of oxygen consumption (VO2 max). CONCLUSION: This meta-analysis shows that people with Fontan circulation may benefit from using bosentan as it decreases postexercise heart rate and improves NYHA FC and 6-minute walking test results. Therefore, indirectly improving exercise capacity. Nonetheless, considerable work is required to strengthen our knowledge in improving the exercise capacity of Fontan patients.

Stents as Bridge to Arterial Switch Operation for D-Transposition of Great Arteries Late Presenter.

We report a 5-month-old infant with dextro-transposition of great arteries (D-TGA) with intact ventricular septum (IVS) who had low left ventricular mass index, small patent ductus arteriosus (PDA), and stretched patent foramen ovale. The patient had respiratory failure due to pneumonia. The surgical intervention was considered very high risk. Thus, the patient underwent PDA stenting with balloon predilation technique followed by atrial septal stenting with false impression of dislodgement-"pseudo-dislodgement" because of inadvertent retraction of patent foramen ovale that was confirmed by transthoracic echocardiography guidance. After the procedure, the left ventricular mass index improved and patient was planned for arterial switch operation. The combined approach of PDA and atrial septal stenting may provide potential nonsurgical method of ventricular preparation for D-TGA/IVS late presenter, acting as a bridge to arterial switch operation especially those living in remote areas.

A Comparative Effectiveness Systematic Review and Meta-analysis of Drugs for the Prophylaxis of Junctional Ectopic Tachycardia.

BACKGROUND: Junctional Ectopic Tachycardia (JET) is an arrhythmia originating from the AV junction, which may occur following congenital heart surgery, especially when the intervention is near the atrioventricular junction. OBJECTIVE: The aim of this systematic review and meta-analysis is to compare the effectiveness of amiodarone, dexmedetomidine, and magnesium in preventing JET following congenital heart surgery. METHODS: This meta-analysis was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement, where 11 electronic databases were searched from the date of inception to August 2020. The incidence of JET was calculated with the relative risk of 95% Confidence Interval (CI). Quality assessment of the included studies was assessed using the Consolidated Standards of Reporting Trials (CONSORT) 2010 statement. RESULTS: Eleven studies met the predetermined inclusion criteria and were included in this meta-analysis. Amiodarone, dexmedetomidine, and magnesium significantly reduced the incidence of postoperative JET [Amiodarone: risk ratio 0.34; I2= 0%; Z=3.66 (P=0.0002); 95% CI 0.19-0.60. Dexmedetomidine: risk ratio 0.34; I2= 0%; Z=4.77 (P<0.00001); 95% CI 0.21-0.52. Magnesium: risk ratio 0.50; I2= 24%; Z=5.08 (P<0.00001); 95% CI 0.39-0.66]. CONCLUSION: All three drugs have shown promising results in reducing the incidence of JET. Our systematic review found that dexmedetomidine is better in reducing the length of ICU stays as well as mortality. In addition, dexmedetomidine also has the least pronounced side effects among the three. However, it should be noted that this conclusion was derived from studies with small sample sizes. Therefore, dexmedetomidine may be considered as the drug of choice for preventing JET.

Case report: Right atrial appendage hybrid access to bailout a stuck stent from the inferior vena cava of a small child.

A three-month-old baby boy (5. 4 Kg) with pulmonary atresia, subaortic ventricular septal defect (VSD), and patent ductus arteriosus (PDA) was sent for ductal stenting from the femoral vein. The route to the PDA was extremely tortuous and the procedure was complicated with a stent stuck in the abdominal inferior vena cava (IVC). Transfemoral stent recapture was technically laborious and the stent was successfully recaptured across a 10-Fr right atrial appendage (RAA) hybrid access avoiding a cardiopulmonary bypass (CBP). The PDA was subsequently stented for the femoral artery with satisfactory clinical outcomes.

Transcatheter pulmonary balloon valvuloplasty of severe valvar pulmonary stenosis and atrial septal defect in patient with severe cyanosis and very low ventricle ejection fractions: a bailout procedure.

Most cases of severe or critical pulmonary stenosis are detected early and interventional management is routine within the first days of life. We present a case of a thirteen-year-old boy diagnosed with pulmonary stenosis and atrial septal defect with low ventricle ejection fraction. The patient underwent staged pulmonary balloon valvuloplasty and interventional atrial septal defect closure with good results.