Transcatheter closure of postinfarction ventricular septal defects.

Postinfarction ventricular septal defect (VSD) is a rare but fatal complication after myocardial infarction. Surgery for postinfarction VSD is considered the gold standard. However, it is associated with high morbidity and mortality, patient discomfort, need of cardiopulmonary bypass, sternotomy, and skin scarring. As a consequence, less invasive interventional techniques have been developed for postinfarction VSD closure. The current review focuses on patient selection, techniques, results, potential complications and outcome of percutaneous postinfarction closure.

Transcatheter closure of atrial septal defects without fluoroscopy: feasibility of a new method.

BACKGROUND: In an effort to reduce x-ray exposure, we developed a technique for transcatheter closure of atrial septal defects under echocardiographic guidance without fluoroscopy. To assess the efficiency of this procedure for routine use, we compared our initial results with those for the conventional procedure. METHODS AND RESULTS: Twenty-two randomly selected patients (median age 18 years; range 2 to 66 years) with atrial septal defects (n=13) or patent foramen ovale (n=9) underwent cardiac catheterization for possible interventional defect closure with echocardiography as the only imaging tool. Median stretched diameter was 9 mm (range 6 to 26 mm); median left-to-right shunt over the atrial septal defects was Qp/Qs=1.8 (range 1.5 to 2.6). An Amplatzer septal occluder was successfully implanted in 19 defects without fluoroscopy and in 3 with the help of radiography. After 1 month, complete defect closure was documented in all patients. Compared with the conventional procedure of a control group of 131 patients, procedure times were not significantly different (88 versus 100 minutes; P=0.09). However, the study group received significantly higher doses of propofol for sedation (9.9 versus 5.6 mg/kg body weight; P=0.002) owing to extended transesophageal echocardiography. CONCLUSIONS: In the majority of patients in whom transcatheter closure of interatrial communications with the Amplatzer septal occluder is possible, the procedure can be safely performed under echocardiographic guidance without fluoroscopy.

Late-diastolic forward flow in the aorta induced by left atrial contraction.

Late-diastolic forward flow is a well-described phenomenon detectable by Doppler echocardiography in the pulmonary trunk. It is supported by a restrictive right ventricular diastolic function and by a low end-diastolic pulmonary artery pressure. A similar phenomenon for the left ventricle and the aorta has not been described. We report a case of a preterm infant with aortic stenosis and endocardial fibroelastosis, who underwent balloon valvuloplasty. Restrictive left ventricular diastolic filling led to high left atrial pressure (27 mm Hg) and a very pathologic ratio of early-to-late peak velocities (2.6) for an infant of 29 weeks' gestation. In combination with a low diastolic aortic pressure (24 mm Hg) caused by moderate aortic regurgitation after intervention, a late-diastolic forward flow was detectable in the aorta during left atrial contraction with pulsed Doppler echocardiography.

Left ventricular diverticulum repair in a newborn.

We report on a male newborn requiring repair of a huge left apical diverticulum leading to progressive heart failure and extensive ventricular arrhythmia. At the age of 11 days, a modified Dor procedure using an autologous endoventricular pericardial patch was performed. Postoperatively, a significant reduction of ventricular extrasystole was evident. One year postoperatively, the infant demonstrates a normal cognitive and somatic development without clinical signs of cardiac failure.

Severe dilated cardiomyopathy as an unusual finding in a young infant with mucolipidosis type 2.

A neonate presented with mucopolysaccharidosis-like phenotypic expression and typical signs of dysostosis multiplex but without urinary excretion of glycosaminoglycans. Investigations of lysosomal enzymes in cultured fibroblasts revealed a mucolipidosis type 2, known as I-cell disease. We describe the fatal course of the patient due to complications of an uncommon dilated cardiomyopathy in this rare disease and discuss the pathogenesis.

Percutaneous transluminal angioplasty for renovascular hypertension in a neonate.

AIM: To report on the first case of successful percutaneous transluminal renal artery angioplasty in a neonate. CASE REPORT: a 5-d-old neonate was admitted with cardiorespiratory failure. Monitoring of blood pressure revealed severe arterial hypertension. Doppler sonography detected stenotic flow in the right renal artery. A (99m)Tc-MAG3 scan revealed highly diminished elimination by the right kidney. Selective renin levels were 23,968 ng/l in the right and 3770 ng/l in the left renal vein and the aorta. Percutaneous transluminal angioplasty using a 2 x 10 mm balloon catheter was performed on the 8th day of life. RESULTS: The patient was discharged from hospital normotensive without anti-hypertensive medication. During 8 mo follow-up the blood pressure remained normal, Doppler sonography revealed no recurrent artery stenosis, and renal function improved. CONCLUSION: Neonatal percutaneous transluminal angioplasty for renal artery stenosis may be feasible in selected patients.

Stent implantation for recurrent interatrial obstruction in an infant with hypoplastic left heart syndrome.

We report the case of a 19-month-old girl with hypoplastic left heart syndrome who, after Norwood stage 1 and 2 procedures, developed recurrent interatrial obstruction and was treated effectively with stent implantation. The stent was explanted electively 14 months after implantation and showed almost no endothelium formation. Therefore, there was no need for redo atrioseptectomy and the surgical intervention could be staged electively.

Papillary fibroelastoma of the left atrium in a 3-year-old boy.

A 3 year old boy presented with a cardiac murmur. Except for mildly impaired physical condition that was more likely due to asthmatic bronchitis, he was asymptomatic. Cardiac echocardiography disclosed a large tumor in the left atrium originating from the interatrial septum. The patient was immediately referred to surgery for excision of the tumor. Histological examination of the tumor showed a typical papillary fibroelastoma. The occurrence of a papillary fibroelastoma in a child is a rarity.

Methaemoglobinaemia after cardiac catheterisation: a rare cause of cyanosis.

Two young women had unexpected cyanosis a few hours after cardiac catheterisation for electrophysiological investigation. The first patient had atrioventricular septal defect, had undergone repeated surgical interventions, and was referred because of atrial flutter. The second patient had ablation of an accessory pathway in Wolff-Parkinson-White syndrome. Local anaesthesia was performed with 40 ml prilocaine 2%. Cyanosis with oxygen saturation of 85% developed in both patients a few hours after the electrophysiological investigation. The patients were transferred to the intensive care unit and for the first patient a considerable diagnostic effort was made to rule out morphological complication. Finally methaemoglobinaemia of 16.7% and 33.4%, respectively, was found. Cyanosis resolved within 24 hours and did not reappear. Underlying glucose-6-phosphate dehydrogenase deficiency and erythrocyte-methaemoglobin reductase deficiency were ruled out. Physicians should be aware of this rare side effect of local anaesthetics in patients with unexpected cyanosis.

Echocardiographically guided closure of a patent foramen ovale during pregnancy after recurrent strokes.

BACKGROUND: Stroke during pregnancy and puerperium is a severe complication that causes high morbidity and mortality. A patent foramen ovale (PFO) allowing paradoxical embolism is one identified risk factor. CASE: A 25-year-old pregnant woman with PFO suffered from recurrent cerebral embolism. To prevent recurrent cerebral embolism during pregnancy, delivery, and puerperium, interventional closure of the PFO was performed without fluoroscopy under echocardiographic guidance. The postinterventional course was uneventful. CONCLUSION: Percutaneous transvenous closure of a PFO during pregnancy is feasible without the use of fluoroscopy.

Rapid right ventricular pacing is an alternative to adenosine in catheter interventional procedures for congenital heart disease.

OBJECTIVE: To describe the use of rapid right ventricular pacing to facilitate balloon stability during balloon dilatation procedures for congenital heart disease. SETTING: Tertiary paediatric cardiac centre. DESIGN AND PATIENTS: This was a prospective pilot study of 37 consecutive patients with congenital aortic stenosis undergoing elective balloon dilatation. If the first dilatation manoeuvre failed due to balloon displacement, rapid right ventricular pacing at a rate of 220 beats/min was performed during repeat balloon inflation. INTERVENTIONS: Balloon aortic valvotomy and rapid right ventricular pacing. MAIN OUTCOME MEASURES: Balloon stability versus displacement during balloon dilatation and procedure related complications. RESULTS: Initial balloon displacement occurred and rapid right ventricular pacing was performed in 14 patients. The balloon remained in stable position in 11 patients. In three patients the balloon was displaced. In two of them an increase of the pacing rate to 240 beats/min provided balloon stability. In one patient stability was obtained at an unchanged pacing rate after correction of a suboptimal balloon position. No sustained arrhythmias occurred. There were no other procedure related complications. CONCLUSIONS: Rapid right ventricular pacing is a safe and effective method to provide balloon stability during balloon dilatation of the aortic valve. It may be applied in other fields of catheter intervention where it is desirable to maintain stable device positions during the critical phase of the procedure.

Diagnostic catheterization and balloon sizing of atrial septal defects by echocardiographic guidance without fluoroscopy.

To avoid x-ray exposure prior to interventional closure of atrial septal defects (ASDs), we recently developed a technique for diagnostic catheterization and balloon sizing of the defect by echocardiographic guidance without fluoroscopy. We report on our first experiences with this technique. Fourteen patients with atrial septal perforations (mean age, 23 years; range, 1-66 years) underwent diagnostic catheterization and balloon sizing prior to possible interventional defect closure. Mean size of the defects was 16 mm (7-29 mm). Mean left-to-right shunt was Qp/Qs = 2.0 (range, 1.0-4.0). Without fluoroscopy, the procedures were performed in two children by transthoracic echocardiography (TTE) and in 12 patients by both TTE and transesophageal echocardiography (TEE). Mean procedure time was 59 minutes (range, 35-90 minutes). We conclude that oxymetry, pressure recordings, and the estimation of the balloon-stretched size of atrial septal perforations can be performed safely by echocardiographic guidance without fluoroscopy. The x-ray exposure for patient selection prior to a transcatheter closure of an ASD can be avoided with this technique.

Syncope in a child owing to intramural course of the left coronary artery.

UNLABELLED: Coronary abnormalities are a rare cause of syncope or sudden death in childhood or adolescence. We report on a 14-y-old girl who had suffered for many years from repeated syncope after or during exertion. She had to be resuscitated twice. The left coronary artery arose from the right coronary aortic sinus and took a proximal intramural course. After successful reimplantation, the patient has now been free of symptoms for 12 mo. The pitfalls of differential diagnosis of this rare anomaly are discussed. CONCLUSION: Investigation of the coronary anatomy is indicated in otherwise unexplained chest pain, syncope or life-threatening events.

Transcatheter closure of atrial septal defects under echocardiographic guidance without X-ray: initial experiences.

BACKGROUND: Transcatheter closure of atrial septal defects is performed under fluoroscopy, but echocardiography has gained an important role in the procedure. With the new Amplatzer Septal Occluder a device has become available which is easy to implant with minimal fluoroscopy time. We developed an interventional procedure with this device under transesophageal echocardiography alone without fluoroscopy. METHODS AND RESULTS: Four patients (3 to 16 years of age, bodyweight 14 to 60 kg) with atrial septal defects centrally located in the oval fossa were elected for transcatheter closure. After sedation with midazolam and propofol a diagnostic and interventional catheterization was performed in all cases without fluoroscopy. Oxymetric shunt was Qp: Qs = 1.7 (1.5 to 2.1). Under transesophageal echocardiography, the defects were sized over the wire with a balloon catheter. Mean balloon stretched diameter was 10 mm (7 to 14 mm). Under transesophageal echocardiography an Amplatzer Septal Occluder was placed into the defect. In two patients this was achieved with a 5 MHz monoplane pediatric transducer, in two patients a 10mm 5 MHz multiplane probe was used. Complete closure was achieved in all patients and no complications were encountered. CONCLUSION: We conclude that in selected cases with an atrial septal defect located in the oval fossa and clear-cut echocardiographic findings, an Amplatzer Septal Occluder can be safely deployed under echocardiographic guidance alone.