Results of pulmonary balloon valvuloplasty persist and improve at late follow-up in isolated pulmonary valve stenosis.

BACKGROUND: Pulmonary balloon valvuloplasty is a safe and effective treatment for children with pulmonary valve stenosis. A few studies evaluate the long-term outcomes of the procedure, particularly the degree of pulmonary regurgitation. We evaluated the outcomes of children >1 year following valvuloplasty for pulmonary valve stenosis. METHODS: A retrospective analysis of children with pulmonary valve stenosis following pulmonary balloon valvuloplasty at a single institution was performed. Clinic summaries, catheterisation data, and echocardiographic data were reviewed. Inclusion criteria were isolated pulmonary valve stenosis, age <19 years at the time of intervention, and at least one echocardiogram performed at least 1 year after valvuloplasty. RESULTS: A total of 53 patients met inclusion criteria. The median age at valvuloplasty was 0.4 years (0.01-10.6 years). The last follow-up was 4.8±2.3 years following valvuloplasty. The pre-valvuloplasty peak instantaneous gradient by echocardiography was 60.6±14.6 mmHg. The peak gradient at the first postoperative echocardiography was reduced to 25.5±12 mmHg (p<0.001), and further decreased to 14.8±15.8 mmHg (p<0.001) at the most recent follow-up. The degree of regurgitation increased from before valvuloplasty to after valvuloplasty (p<0.001) but did not progress at the most recent follow-up (p=0.17). Only three patients (5.7%) required re-intervention for increasing pulmonary stenosis (two surgical; one repeat balloon). No significant procedural complications occurred. CONCLUSIONS: Pulmonary balloon valvuloplasty remains a safe and effective treatment for children with isolated pulmonary valve stenosis, with excellent long-term outcomes and no mortality. A few patients require further intervention. Long-term follow-up demonstrates decreased, residual stenosis. Patients have a small, acute increase in pulmonary regurgitation following valvuloplasty, but no long-term progression.

Bone density in children with single ventricle physiology.

Children with chronic diseases are at risk for low bone mineral density (BMD). There are no studies of BMD in children with congenital heart disease and particularly single ventricle (SV). Children with this defect are often treated with warfarin, suspected to negatively impact BMD in adults. We assessed BMD in patients with SV physiology and compared the BMD of subjects taking warfarin to those who were not. Subjects 5-12 years with SV were included. BMD z scores by dual-energy X-ray absorptiometry of the spine and total body less head (TBLH) were obtained. Calcium intake, activity level, height, and Tanner stage were assessed. Linear regression models and t tests were used to investigate differences between participants and normative data as well as between subjects' subgroups. Twenty-six subjects were included and 16 took warfarin. Mean BMD z score at the spine was significantly lower than expected at -1.0 ± 0.2 (p < 0.0001), as was the BMD z score for TBLH at -0.8 ± 0.2 (p < 0.0001). Those results remained significant after adjusting for height. Subjects who were on warfarin tended to have lower BMD at both the spine and TBLH than those who were not, with a z score difference of 0.6 ± 0.46 at the spine (p = 0.106) and a difference of 0.4 ± 0.34 at TBLH (p = 0.132). BMD is significantly reduced in children with SV. Warfarin appears to lower BMD but the effect is less conclusive. Continued evaluation is recommended for these patients at risk for reduced bone density. Evaluation of other cardiac patients on warfarin therapy should also be considered.

Balloon angioplasty of recoarctation of the neoaortic arch after the Norwood operation: factors affecting outcome and recurrence.

BACKGROUND: Balloon angioplasty (BA) is effective in relieving neoaorta recoarctation (reCoa) after the Norwood procedure. However, recurrence is not uncommon and risk factors for success and recurrence require further elucidation. We report the results of BA for reCoa following the Norwood procedure. We examine acute results and risk factors associated with success and recurrence after BA. METHODS: Patients who underwent BA between November 2000 and June 2010 were studied. Factors for immediate success and recurrence after BA were determined using logistic regression. Recurrence-free survival was evaluated using the Kaplan-Meier curve. RESULTS: Forty-seven angioplasties were performed in 39 patients. Mean age at catheterization was 5.0 ± 4.1 months. BA was successful in 40 angioplasties (85.1%). A higher preprocedure gradient across the coarctation (P = 0.04) and a higher ratio of balloon to descending aorta (P = 0.01) were associated with success. Six patients required redilation. Risk factors for recurrence included older age at Norwood (P = 0.02), younger age (P = 0.03), lower weight (P = 0.04) and smaller body surface area at balloon angioplasty (BA) (P = 0.04), and shorter duration between surgery and angioplasty (P = 0.03). Freedom from recurrence from the first catheterization was 82% after 6 months and 78% after 1 year. There were no neurologic sequelae or deaths. CONCLUSIONS: BA is effective acutely and long term with limited morbidity and mortality. Recurrence occurs usually within the first year. Delay in performing the initial angioplasty may be beneficial in reducing the risk of recurrence, but further study is needed.

Catheter closure of atrial septal defect in anatomically corrected malposition with left juxtaposition of the atrial appendages using intracardiac echocardiography.

Anatomically corrected malposition is characterized by abnormally related great vessels and atrioventricular and ventriculoarterial concordance. It is often associated with juxtaposition of the atrial appendages where the plane of the atrial septum is abnormally oriented. We describe the device closure of an atrial septal defect in a patient with such a lesion under intracardiac echocardiography guidance.

Mid-term follow up of perventricular device closure of muscular ventricular septal defects.

BACKGROUND: Surgical and transcatheter management of muscular ventricular septal defects (MVSD) have independent drawbacks. Hybrid procedures are becoming increasingly utilized to manage congenital cardiac lesions including MVSDs. This report describes the mid-term results of perventricular device closure of MVSDs at a single institution. METHODS: The cardiology database of patients who underwent attempted perventricular MVSD closure from a single institution was reviewed. RESULTS: Between January 2004 and December 2009, six patients underwent attempted perventricular MVSD closure in the operating room. Mean age was 9.8 ± 9.1 months; mean weight was 7.2 ± 3.7 kg. In five patients, closure was successful without use of bypass. In one patient, the device embolized to the left ventricle after release and patch closure of the MVSD was performed on cardiopulmonary bypass. The mean interval from the procedure to the most recent echocardiogram for the patients with successful perventricular closure was 39.8 ± 25.2 months. Three patients demonstrated no residual shunt at the last echocardiogram. Two patients had mild, hemodynamically insignificant shunting; one had a left ventricular pseudoaneurysm that was embolized during repeat catheterization. CONCLUSIONS: Perventricular closure of MVSDs is attractive because it overcomes the limitations of surgery and catheterization. Additionally, it spares the need for cardiopulmonary bypass and its comorbidities. In some instances, however, successful deployment of the device is not possible. Our mid-term results demonstrate overall success but identify possible complications that are not immediately identified in the short term.

Abdominal coarctation and associated comorbidities in children.

OBJECTIVE: The purpose of this study is to report a single institution's experience with abdominal coarctation in children and report associated comorbidities. BACKGROUND: Abdominal coarctation is a rare condition, accounting for less than 2% of aortic coarctations. Single patients with abdominal coarctation have been reported with additional vascular disease in pediatric patients. METHODS: Our echocardiography database between January 2001 and January 2012 was searched to identify all patients with abdominal coarctation. Relevant clinical data were reviewed. RESULTS: Nine patients were identified with abdominal coarctation. Median age at diagnosis was 4.7 years (IQR 1.1-14.3 years). Additional cardiac diagnoses were found in three patients: one had moderate aortic regurgitation and aortic root dilatation; one had mild aortic regurgitation, severe mitral regurgitation, and atrial flutter; and one had a thoracic coarctation previously repaired. Eight patients (89%) had an associated noncardiac comorbidity. Comorbidities included: Takayasu arteritis (n = 3), systemic lupus erythematosus (n = 1), epidermal nevus syndrome (n = 1), abdominal hemangioma (n = 1), Williams syndrome (n = 1), and renal artery stenosis (n = 2). Intervention was performed in four patients (57%): two underwent surgical grafting and two had angioplasty with stent placement. Patients with surgical grafting required no further intervention, whereas both patients who underwent angioplasty and stenting required further stent placement. CONCLUSION: Abdominal coarctation is a rare anomaly. It is frequently associated with other vascular abnormalities. Vasculitis should be suspected in children with abdominal coarctation. All patients, even if treated, require continued close observation.

Outcome of cardiac thrombi in infants.

Use of central lines in the neonatal intensive care unit (NICU) has led to the formation of intracardiac thrombi. A paucity of data exists on the management of neonatal cardiac thrombi, with the few reported cases focusing on outcomes following thrombolytic therapy. This study was undertaken to evaluate the outcome of cardiac thrombi in neonates who do not receive thrombolytic therapy. Nineteen patients younger than 3 months of age diagnosed with cardiac thrombi were included. All 19 patients had a central line. Management consisted of a combination of antibiotics and low-molecular-weight heparin (n = 16) or surgical removal (n = 2). In one case, no treatment was instituted. One patient was lost to follow-up after partial resolution of the thrombus. Complete thrombus resolution occurred in 18 patients, 9 with negative blood cultures and 9 with positive blood cultures. It took longer for resolution of thrombi associated with positive blood cultures than for sterile thrombi. No patient had evidence of thrombus embolization. From these data we concluded that the natural history of cardiac thrombi is resolution. Infected thrombi require more prolonged therapy. Surgery is seldom required and thrombolytics are not usually necessary for clot resolution.