Mid-Term Outcomes after Percutaneous Closure of the Secundum Atrial Septal Defect with the Figulla-Occlutech Device.

OBJECTIVES: To evaluate the mid-term outcomes after percutaneous closure of the secundum atrial septal defects (ASD) using the Figulla-Occlutech device (FOD). BACKGROUND: Transcatheter closure has become the method of choice for most patients with ASD. Although the FOD may have some advantageous characteristics there is a paucity of data on later outcomes after the use of this relatively new device. METHODS: Observational, single arm study including 200 non-consecutive patients who underwent ASD closure between 04/09 and 07/15 in 2 centers. Device performance, deployment technique, and immediate and mid-term outcomes were assessed. RESULTS: Median age and weight were 24 years (4-72) and 58 kg (15-92), respectively. Single defects were observed in 171 patients (median size of 19 mm). The remainder had multiple or multifenestrated defects. Implantation of FOD (median size of 24 mm) was successful in all (99%), but 2 patients (1 with deficient postero-inferior rim; 1 with a large ASD for the size of the child). Embolization with device retrieval occurred in 2 (1%). Median follow-up of 36 months was obtained in 172 patients. Serial echocardiographic assessment showed complete closure in all but 2 patients, in whom an additional small non-significant posterior defect was purposely left untouched. There have been no episodes of late arrhythmias, device embolization, cardiac erosion, endocarditis, thromboembolism, wire fracture, or death. CONCLUSIONS: Transcatheter closure of ASDs in older children, adolescents, and adults using the FOD was highly successful in a wide range of anatomical scenarios with high closure rates and no complications in mid-term follow-up.

New imaging modalities in the catheterization laboratory.

PURPOSE OF REVIEW: To provide an overview of the various modalities that have emerged in the last years as adjunctive tools to provide detailed imaging of the cardiovascular system in the catheterization laboratory. RECENT FINDINGS: Completion angiography after cardiac surgery for congenital heart disease using a dedicated hybrid operating cardiac suite may aid in early diagnosis and therapy of postsurgical abnormalities. The application of three-dimensional rotational digital angiography results in a more precise delineation of the three-dimensional anatomy of vascular structures outside the heart with rapid image processing and reduction of the amount of contrast used and ionizing radiation dose. Combined catheterization/magnetic resonance (MR) hybrid laboratories have the potential to accurately assess changes in the anatomy and physiology pretranscatheter and posttranscatheter interventions. Fully MR-guided transcatheter procedures have become possible in animal models. Real-time three-dimensional transesophageal echocardiography (TEE) has helped to guide transcatheter procedures in septal and valvar structures. Miniaturization of probes has expanded the applications of TEE for smaller neonates. The use of intravascular ultrasound has helped to better understand the mechanisms of vascular diseases and transcatheter treatments. SUMMARY: Knowledge and proper application of new imaging modalities during interventions in the catheterization laboratory may improve the outcomes of patients with congenital and acquired structural heart disease.

Initial experience in Brazil with the Helex septal occluder for percutaneous occlusion of atrial septal defects.

OBJECTIVE: To evaluate the initial clinical experience with the Helex septal occluder for percutaneous closure of atrial septal defects. METHODS: Ten patients underwent the procedure, 7 patients with ostium secundum atrial septal defects (ASD) with hemodynamic repercussions and 3 patients with pervious foramen ovale (PFO) and a history of stroke. Mean age was 33.8 years and mean weight was 55.4 kg. Mean diameter by transesophageal echocardiography and mean stretched ASD diameter were 11.33 3.3mm, and 15.2 3.8mm, respectively. The Qp/Qs ratio was 1.9 0.3 in patients with ASD. RESULTS: Eleven occluders were placed because a patient with 2 holes needed 2 devices. It was necessary to retrieve and replace 4 devices in 3 patients. We observed immediate residual shunt (< 2mm) in 4 patients with ASD, and in those with patent foramen ovale total occlusion of the defect occurred. No complications were noted, and all patients were discharged on the following day. After 1 month, 2 patients with ASD experienced trivial residual shunts (1mm). In 1 patient, we observed mild prolapse in the proximal disk in the right atrium, without consequences. CONCLUSION: The Helex septal occluder was safe and effective for occluding small to moderate atrial septal defects. Because the implantation technique is demanding, it requires specific training of the operator. Even so, small technical failures may occur in the beginning of the learning curve, but they do not involve patient safety.

Double shunt technique for hybrid palliation of hypoplastic left heart syndrome: a case report.

We report a technique to palliate hypoplastic left heart syndrome, with no PDA stenting, but with double polytetrafluoroethylene shunt from pulmonary artery to ascending and descending aorta by combined thoracotomies. A 30-day-old female was operated with this technique. Five months after first operation, the child was submitted to Norwood/Glenn operation. Good hemodinamic recovery and initial clinical evolution was observed. The child was extubated in 8th post operatory day and reentubated in the next day due to pulmonary infection. Despite antibiotic treatment, the child died after systemic infectious complications.

Hybrid management of a large atrial septal defect and a patent ductus arteriosus in an infant with chronic lung disease.

We report a case wherein a dysmorphic four-month-old infant (weighing 4.5 kgs) with an 8 mm atrial septal defect (ASD), a 1.5 mm patent ductus arteriosus (PDA), a 2 mm mid-muscular ventricular septal defect (VSD) associated with chronic lung disease, and severe pulmonary hypertension, was successfully managed using a hybrid approach, without the use of cardiopulmonary bypass (CPB). Through a median sternotomy, the PDA was ligated and the ASD was closed with a 9 mm Amplatzer septal occluder implanted through peratrial access. The VSD was left untouched. Serial echocardiograms showed complete closure of the ASD and PDA, with progressive normalization of the pulmonary artery (PA) pressures within three months. The child rapidly gained weight and was weaned from sildenafil and oxygen administration. After 12 months, the VSD closed spontaneously and the child remained well, with normal PA pressures. A hybrid approach without the use of CPB should be considered in the management of infants with congenital heart disease, associated with chronic lung disease and pulmonary hypertension.

Experiência Inicial com o Implante Percutâneo da Válvula Melody® no Brasil / Initial Experience with Percutaneous Implantation of the MelodyTM Valve in Brazil

Introdução: Stress is associated with cardiovascular diseases.O implante percutâneo da válvula pulmonar é uma alternativa para condutos com disfunção. Descrevemos aqui a primeira experiência com o implante da válvula Melody® no Brasil. Métodos: Foram selecionados pacientes com estenose ou insuficiência pulmonar significativa em condutos de 16 a 22 mm. Foram empregadas técnicas padronizadas. Factibilidade, segurança e eficácia desse procedimento foram avaliadas. Resultados: Desde dezembro de 2013, dez pacientes (média de idade e peso de 16,5 anos e 49 kg, respectivamente) foram submetidos ao procedimento com intervalo médio de 11,9 ± 8,6 anos desde a última cirurgia. Insuficiência pulmonar foi indicação para o tratamento em três pacientes, estenose em dois e lesão mista em cinco. A válvula Melody® foi implantada com sucesso em todos os casos. A média da pressão sistólica do ventrículo direito e a relação ventrículo direito/ventrículo esquerdo diminuíram de 49,2 ± 15,9 para 35,8 ± 5,7 mmHg e de 0,55 ± 0,18 para 0,39 ± 0,08 mmHg (p < 0,01 para ambos). Não observamos estenose e nem insuficiência pulmonar residual significativa. Um paciente teve extravasamento contido requerendo um stent coberto e um segundo implante valvular. Todos os pacientes receberam alta do hospital em 72 horas. As válvulas funcionaram adequadamente ...

Background: Transcatheter pulmonary valve implantation is an alternative for dysfunctional conduits. We report the first experience with the MelodyTM valve implantation in Brazil. Methods: Patients with significant pulmonary stenosis or significant pulmonary insufficiency in conduits measuring 16 to 22 mm were enrolled. Standardized techniques were employed. The feasibility, safety and efficacy of this procedure were assessed. Results: From December 2013, ten patients (mean age and weight of 16.5 years and 49 kg, respectively) have undergone the procedure with a mean interval of 11.9 ± 8.6 years since the last surgery. Pulmonary insufficiency was an indication for treatment in three patients, pulmonary stenosis in two, and mixed lesion in five. The MelodyTM valve was successfully implanted in all cases. Mean right ventricular systolic pressure and right ventricle/left ventricle ratio decreased from 49.2 ± 15.9 to 35.8 ± 5.7 mmHg and from 0.55 ± 0.18 to 0.39 ± 0.08 mmHg (p < 0.01 for both). Significant residual pulmonary stenosis or pulmonary insufficiency was not observed. One patient had a contained conduit tear requiring a covered stent and a second valve implantation. All patients were discharged within 72 hours. The valves were properly functioning in a mean follow-up of 4.1 ± 2.2 months with no complications. Conclusions: Transcatheter MelodyTM valve implantation was feasible, safe and effective ...

Use of beta-blockers in the post-operative period of Sano modification of the Norwood procedure with persistent cyanosis.

Persistent cyanosis is a frequent complication in the post-operative period of Sano modification of the Norwood procedure. It may be explained by a dynamic proximal shunt stenosis of the synthetic conduit that links the right ventricle to the pulmonary artery, as detected by echo cardiographic study. The use of beta-blockers in the post-operative period has been recently described in order to improve the arterial oxygen saturation. In this report, we describe the use of propranolol in two patients undergoing Sano modification of the Norwood procedure, in whom a gradient reduction in the synthetic conduit, increase in the levels of arterial oxygen saturation, decrease in heart rate, and increase in blood pressure were observed, thus resulting in clinical improvement. We conclude that the use of beta-blockers in these cases was beneficial.

Experiência inicial com novo amplatzer TM cardiac plug para oclusão percutânea do apêndice atrial esquerdo / Initial experience with the new amplatzer TM cardiac plug for percutaneous closure of the left atrial appendage

Introdução: A formação de trombos no apêndice atrial esquerdo (AAE) constitui a principal causa de fenômenos tromboembólicos em pacientes com fibrilação atrial (FA). A anticoagulação oral é considerada terapia de primeira linha na prevenção de tromboembolismo associado à FA. Apesar de comprovada eficácia, a terapia com anticoagulantes orais está associada a inúmeras limitações. A oclusão percutânea do AAE surgiu como uma nova estratégia para prevenção de acidentes vasculares cerebrais em pacientes com FA considerados de alto risco e não candidatos a tratamento com anticoagulantes. Métodos: Relatamos a experiência inicial da oclusão percutânea do AAE utilizando o novo dispositivo AmplatzerTM Cardiac Plug (ACP – AGA Medical Corp., Golden Valley, Estados Unidos) em pacientes com FA e escore CHADS2 > 2, não elegíveis à terapêutica com anticoagulantes. Os procedimentos foram realizados sob anestesia geral e monitoração por ecocardiografia transesofágica tridimensional em tempo real. Resultados: Três pacientes do sexo masculino, com média de idade de 79 anos e escores CHADS2 2, 3 e 5, foram submetidos a implante do dispositivo por via transeptal sem complicações, resultando em oclusão imediata do AAE e alta hospitalar após dois dias. No seguimento de 50 dias, todos os pacientes se apresentavam bem clinicamente e a ecocardiografia transtorácica confirmou oclusão total do AAE e ausência de complicações. Conclusões: A oclusão percutânea do AAE com ACP parece ser uma alternativa terapêutica atrativa na prevenção de eventos tromboembólicos em pacientes com FA e contraindicações ou limitações para anticoagulação oral.

Background: Thrombus formation in the left atrial appendage (LAA) is the main cause of thromboembolic events in patients with non-valvular atrial fibrillation (AF). Oral anticoagulantsare considered first-line therapy for stroke prevention in AF patients. Despite its proven efficacy, long-term oral anticoagulation is associated to innumerous limitations. PercutaneousLAA closure has emerged as a new strategy for stroke prevention in high risk AF patients who are not candidatesfor long term oral anticoagulation therapy. Methods: We report the initial experience with percutaneous occlusionof the LAA using the new AmplatzerTM Cardiac Plug (ACP – AGA Medical Corp., Golden Valley, USA) in patients withAF and CHADS2 score > 2 who were not eligible for anticoagulation therapy. Procedures were carried out undergeneral anesthesia and 3D transesophageal echocardiographymonitoring in real time. Results: Three male patients, mean age of 79 years and CHADS2 2, 3 and 5 scores had thedevice successfully implanted using a transeptal approach with no complications, resulting in immediate LAA occlusion and hospital discharge two days later. At the 50-day followup,all patients were clinically well with complete LAA occlusion and no complications at transthoracic echocardiography. Conclusions: Percutaneous LAA occlusion with thenew ACP seems to be an attractive alternative to prevent thromboembolic events in patients with AF and contraindications or limitations for anticoagulation therapy.

Uso de betabloqueador no pós-operatório de cirurgia de Norwood modificada por Sano com cianose persistente / Use of beta-blockers in the post-operative period of Sano modification of the Norwood procedure with persistent cyanosis

A cianose persistente constitui complicação freqüente no pós-operatório da cirurgia de Norwood modificada por Sano. Sua ocorrência pode ser explicada pela obstrução dinâmica da anastomose proximal do conduto sintético, que liga o ventrículo direito ao tronco pulmonar, evidenciada à ecocardiografia. A fim de melhorar a saturação arterial de oxigênio, foi recentemente descrita a utilização de betabloqueador, no período pós-operatório. Neste relato, descrevemos a utilização de propranolol em dois casos de cirurgia de Norwood modificada por Sano, demonstrando diminuição do gradiente no tubo sintético, aumento dos níveis de saturação arterial de oxigênio, diminuição da freqüência cardíaca e aumento da pressão arterial, traduzido em melhora clínica. Concluímos que autilização de betabloqueador nesses casos mostrou-se benéfica.

Persistent cyanosis is a frequent complication in the post-operative period of Sano modification of the Norwood procedure. It may be explained by a dynamic proximal shunt stenosis of the synthetic conduit that links the right ventricle to the pulmonary artery, as detected by echo cardiographic study. The use of beta-blockers in the post-operative period has been recently described in order to improve the arterial oxygen saturation. In this report, we describe the use of propranolol in two patients undergoing Sano modification of the Norwood procedure, in whom a gradient reduction in the synthetic conduit, increase in the levels of arterial oxygen saturation, decrease in heart rate, and increase in blood pressure were observed, thus resulting in clinical improvement. We conclude that the use of beta-blockers in these cases was beneficial.

Experiência inicial no Brasil com a prótese Helex para oclusão percutânea de defeitos interatriais / Initial experience in Brazil with the Helex septal occluder for percutaneous occlusion of atrial septal defects

OBJECTIVE: To evaluate the initial clinical experience with the Helex septal occluder for percutaneous closure of atrial septal defects. METHODS: Ten patients underwent the procedure, 7 patients with ostium secundum atrial septal defects (ASD) with hemodynamic repercussions and 3 patients with pervious foramen ovale (PFO) and a history of stroke. Mean age was 33.8 years and mean weight was 55.4 kg. Mean diameter by transesophageal echocardiography and mean stretched ASD diameter were 11.33 ± 3.3mm, and 15.2 ± 3.8mm, respectively. The Qp/Qs ratio was 1.9 ± 0.3 in patients with ASD. RESULTS: Eleven occluders were placed because a patient with 2 holes needed 2 devices. It was necessary to retrieve and replace 4 devices in 3 patients. We observed immediate residual shunt (< 2mm) in 4 patients with ASD, and in those with patent foramen ovale total occlusion of the defect occurred. No complications were noted, and all patients were discharged on the following day. After 1 month, 2 patients with ASD experienced trivial residual shunts (1mm). In 1 patient, we observed mild prolapse in the proximal disk in the right atrium, without consequences. CONCLUSION: The Helex septal occluder was safe and effective for occluding small to moderate atrial septal defects. Because the implantation technique is demanding, it requires specific training of the operator. Even so, small technical failures may occur in the beginning of the learning curve, but they do not involve patient safety

Estado atual da oclusão percutânea do canal arterial, da comunicação interatrial tipo Ostium secundum e da comunicação interventricular / Current status of the percutaneous occlusion of the patent ductus arteriosus, secundum atrial septal defects and ventricular septal defects

O cateterismo intervencionista pediátrico teve grande avanço nos últimos dez anos. Neste artigo os autores revisam os resultados do tratamento percutâneo das cardiopatias congênitas mais comuns com fluxo esquerdo direito. Os casos de canal arterial e de comunicação interatrial do tipo ostium secundum, em sua maioria, são passíveis de serem tratados por via percutânea, com alta eficácia e baixa morbidade, substituindo o tratamento cirúrgico convencional com inequívocas vantagens, tornando-se o método de escolha na maioria dos grandes centros mundiais. Casos de comunicação interventricular dos tipos muscular e perimembranoso também são factíveis de serem tratados com dispositivos intracardíacos, com resultados iniciais animadores, demonstrando alta eficácia e baixa morbidade. Seguimento maior desses pacientes é necessário antes de conclusões definitivas.