Coarctation Angioplasty in Young Children: Does IMPACT Registry Data Accurately Reflect Clinical Outcomes?

Balloon angioplasty for recoarctation of the aorta is routinely performed in young children and is considered successful when the systolic gradient is reduced to < 10 mmHg. IMPACT defines acute procedural success solely based on a final gradient of < 10 mmHg and stratifies participating institutions based on these acute outcomes. Between February 2012 and December 2020, IMPACT data was analyzed for 110 coarctation interventions. Electronic medical records were reviewed, and primary endpoints were one of the following: (1) final analysis end date (June 2021), (2) patient death, or (3) most recent transcatheter or surgical reintervention. 64 (58.2%) interventions had a post-procedure CA gradient < 10 mmHg. Comparison of clinical patient outcome for acute success demonstrated no significant relationship using IMPACT (p = 0.70) criteria. There was no statistically significant difference between clinical success and failure for: pre- and post-treatment systolic gradients; absolute or percent change in systolic gradient; and pre-treatment aorta diameter. Clinical outcome and patient age did show a significant difference (p = 0.0093) with better clinical outcomes in older patients. Our analysis did not reveal a statistically significant difference between IMPACT criteria for successful treatment of CA and clinical outcome. These findings underscore a need to identify other clinical metrics that better predict outcome following CA balloon angioplasty treatment.

Unusual interatrial fistula discovered during device closure of an atrial septal defect.

Atrial septal defect (ASD) closure is a common reason for referral to the cardiac catheterization laboratory. We report a case in which a relatively large Qp:Qs of 1.85:1 was demonstrated in the face of a small secundum ASD. This led to further investigation, ultimately leading to the discovery of an unusual atrial fistula. Rare cases of interatrial tunnels have been described in the literature, however, this is a unique case of a left atrial appendage to right atrial appendage fistula in the setting of a right juxtaposed left atrial appendage.

Short- and intermediate-term results of balloon aortic valvuloplasty and surgical aortic valvotomy in neonates.

BACKGROUND: Balloon aortic valvuloplasty and open surgical valvotomy are procedures to treat neonatal aortic stenosis, and there is controversy as to which method has superior outcomes. METHODS: We reviewed the records of patients at our institution since 2000 who had a balloon aortic valvuloplasty or surgical valvotomy via an open commissurotomy prior to 2 months of age. RESULTS: Forty patients had balloon aortic valvuloplasty and 15 patients had surgical valvotomy via an open commissurotomy. There was no difference in post-procedure mean gradient by transthoracic echocardiogram, which were 25.8 mmHg for balloon aortic valvuloplasty and 26.2 mmHg for surgical valvotomy, p = 0.87. Post-procedure, 15% of balloon aortic valvuloplasty patients had moderate aortic insufficiency and 2.5% of patients had severe aortic insufficiency, while no surgical valvotomy patients had moderate or severe aortic insufficiency. The average number of post-procedure hospital days was 14.2 for balloon aortic valvuloplasty and 19.8 for surgical valvotomy (p = 0.52). Freedom from re-intervention was 69% for balloon aortic valvuloplasty and 67% for surgical valvotomy at 1 year, and 43% for balloon aortic valvuloplasty and 67% for surgical valvotomy at 5 years (p = 0.60). CONCLUSIONS: Balloon aortic valvuloplasty and surgical valvotomy provide similar short-term reduction in valve gradient. Balloon aortic valvuloplasty has a slightly shorter but not statistically significant hospital stay. Freedom from re-intervention is similar at 1 year. At 5 years, it is slightly higher in surgical valvotomy, though not statistically different. Balloon aortic valvuloplasty had a higher incidence of significant aortic insufficiency. Long-term comparisons cannot be made given the lack of long-term follow-up with surgical valvotomy.

Early and late presentation of coronary artery fistula: a possible natural progression?

We present two patients, one 10 years old and another 43 years old, who both had successful transcatheter closure of left main coronary artery to right atrium fistulas. The older patient had a larger fistula as well as more symptoms and a complicated post-procedure course. Closure of medium or large coronary artery fistulas should be considered at younger ages to minimise future complications.

Global patterns in the metacommunity structuring of lake macrophytes: regional variations and driving factors.

We studied community-environment relationships of lake macrophytes at two metacommunity scales using data from 16 regions across the world. More specifically, we examined (a) whether the lake macrophyte communities respond similar to key local environmental factors, major climate variables and lake spatial locations in each of the regions (i.e., within-region approach) and (b) how well can explained variability in the community-environment relationships across multiple lake macrophyte metacommunities be accounted for by elevation range, spatial extent, latitude, longitude, and age of the oldest lake within each metacommunity (i.e., across-region approach). In the within-region approach, we employed partial redundancy analyses together with variation partitioning to investigate the relative importance of local variables, climate variables, and spatial location on lake macrophytes among the study regions. In the across-region approach, we used adjusted R2 values of the variation partitioning to model the community-environment relationships across multiple metacommunities using linear regression and commonality analysis. We found that niche filtering related to local lake-level environmental conditions was the dominant force structuring macrophytes within metacommunities. However, our results also revealed that elevation range associated with climate (increasing temperature amplitude affecting macrophytes) and spatial location (likely due to dispersal limitation) was important for macrophytes based on the findings of the across-metacommunities analysis. These findings suggest that different determinants influence macrophyte metacommunities within different regions, thus showing context dependency. Moreover, our study emphasized that the use of a single metacommunity scale gives incomplete information on the environmental features explaining variation in macrophyte communities.

Factors related to Secchi depths and their stability over time as determined from a probability sample of US lakes.

A probabilistic sample of lakes in the 48 coterminous US lakes was made by the United States Environmental Protection Agency in the 2007 National Lakes Assessment. Because of the statistical design, the results of our analyses of Secchi depths (SD) apply to a population of 45,265 lakes. We found statistically significant differences in mean Secchi depths between natural (1.57 m) and man-made lakes (1.18 m). The most important variable correlated with SD was turbidity, an optical measure related to suspended particles in the water column. For most lakes, chlorophyll a was highly correlated with both turbidity and SD, but several lakes had more turbidity and lower SD than expected based on chlorophyll a alone, indicating that non-algal suspended solids were an important factor. On an ecoregion basis, the non-algal suspended solids in the lake waters were related to the average levels of suspended solids in streams located in that ecoregion, and the non-algal suspended solids were more important in man-made than natural lakes. Phosphorus and nitrogen were directly correlated with chlorophyll a and turbidity and inversely correlated with SD. Based on diatom-inferred Secchi depths for the tops and bottoms of sediment cores from lakes in Ecoregions VIII and VII (excluding lakes in Minnesota) representing 40% of the natural lakes in the US, there has been no decrease in water transparency in that population of lakes in the past 70 or more years when the US population increased by 134%. We do not have information to determine if the other 60% of lakes have or have not changed.

Resolution of inferior venous baffle leak and total venous occlusion using a bare stent and the gore(®) excluder( ®) aortic extension in transposition of the great arteries after mustard procedure.

We present a patient with a history of Mustard repair for transposition of the great arteries. The patient presented with complete inferior venous baffle obstruction and a large baffle leak after several years of cyanosis. Complete relief of the obstruction and exclusion of the baffle leak were accomplished with the use of a combination of bare metal stenting and the Gore(®) Excluder(®) aortic extender. To our knowledge, this represents the first reported use of the Gore(®) Excluder(®) aortic extender in the setting of inferior venous baffle leak and associated total inferior vena cava obstruction. © 2015 Wiley Periodicals, Inc.

Congenital Pulmonary Vein Stenosis: Encouraging Mid-term Outcome.

Congenital pulmonary vein stenosis (PVS) is a rare entity with limited outcome literature. Multiple interventional approaches have evolved including surgical and catheterization techniques. Our objective is to report our center experience and to compare short-term and mid-term outcomes among these therapeutic modalities. Retrospective study on 23 patients (n = 23) with PVS that required intervention over the last 13 years (2000-2013). Patients were divided into three groups based on type of initial intervention. Of these, 10 (43.5%) had balloon angioplasty, 3 (13.0 %) had surgical dilation, and 10 (43.5%) had surgical marsupialization. Mortality and number of re-interventions were our primary outcomes. Mean age at diagnosis was 10.9 ± 18.4 months. Mean age at initial intervention was 14.5 ± 18.0 months. Mean pre- and post-initial intervention PVS gradients were 9.2 ± 3.4 and 3.4 ± 2.2 mmHg, respectively. Mean survival time and re-intervention-free survival time were 4.8 ± 4.0 and 2.8 ± 3.4 years. No statistical significance was found between the interventions with respect to survival time (p = 0.52) and re-intervention free time (p = 0.78). High initial pre- and post-intervention gradients were significantly associated with re-intervention-free survival (p = 0.01 and p = 0.03, respectively). Patients with bilateral disease have increased mortality (p = 0.01) and decreased 5-year survival (p = 0.009) compared to patients with unilateral disease irrespective of type of intervention. No statistically significant difference in mortality or re-intervention rate was present among these different therapeutic modalities. This study has the longest follow-up so far reported in the current literature (58 months) with overall survival of 78%.

Thromboexclusion of an atypical left ventricular pseudoaneurysm.

Left ventricular pseudoaneurysm is rare in children. The gold standard for treatment has been surgical repair. Here, we describe a boy in whom an atypical left ventricular pseudoaneurysm was treated through staged transcatheter procedures. In addition, we highlight the importance of the preprocedure cardiac magnetic resonance imaging in providing invaluable information that allowed detailed planning of a management strategy for this unusual pseudoaneurysm.

Fatal Ichthyocotylurus erraticus infestation in Inca terns (Larosterna inca) in a zoological collection.

In a breeding group of Inca terns (Larosterna inca), 14 birds died without antemortem signs of illness. Other than a poor body condition and a bloody cloaca, no symptoms were observed. Gross necropsy revealed severe segmental hemorrhagic enteritis with intralesional trematodes in most birds. Histopathologic examination revealed infiltration of lymphocytes, plasma cells, and granulocytes in the lamina propria of the duodenum and cross-sections of trematodes in the lumen. The parasites were identified as Ichthyocotylurus erraticus, a trematode of fish-eating birds. The cause of the infestation most likely was the feeding of unfrozen fresh fish. We describe the first case of a lethal I. erraticus infestation in Inca terns.

Transcatheter treatment of SVC syndrome from histoplasmosis-related mediastinal fibrosis in a 9-year old male.

We report a case of mediastinal fibrosis secondary to histoplasmosis in a 9-year old male, who presented with superior vena cava syndrome. He was successfully treated by percutaneous superior vena cava stent placement in the outpatient cardiac catheterization laboratory.

Chemical immobilization of chimpanzees (Pan troglodytes) using a combination of detomidine and ketamine.

OBJECTIVE: To determine if a combination of detomidine and ketamine can be used for effective chemical immobilization of chimpanzees. STUDY DESIGN: Observational study. ANIMALS: Twenty-one adult captive chimpanzees (12 males, nine females), age 8-46 years, weighing 40.4-68.4 kg. METHODS: The chimpanzees were immobilized with intramuscular (IM) detomidine and ketamine by a darting system. Based on estimated weights, doses administered were 50 µg kg(-1) detomidine and 4 mg kg(-1) ketamine in groups 1 and 2, and 60 µg kg(-1) and 5 mg kg(-1) respectively in group 3. Eight minutes in group 1 and 15 minutes in groups 2 and 3 were allowed from the time of apparent immobilization before removing the animals from their enclosures. Body temperature, arterial haemoglobin saturation and pulse rate were measured. The time from injection to induction (recumbency and absence of voluntary movement), total anaesthetic and recovery times (with or without atipamezole) were recorded. RESULTS: Immobilization occurred within 5 minutes after darting in most animals. Early handling of the chimpanzees often resulted in arousal and required further doses of ketamine IM. Most animals were hypoxaemic and hypothermic. Occasionally, bradycardia was observed. Atipamezole resulted in an acceptable quality of recovery 10 minutes after IM injection. The duration of immobilization varied widely when no antagonist was administered. CONCLUSIONS AND CLINICAL RELEVANCE: The combination detomidine (60 µg kg(-1) ) and ketamine (5-6 mg kg(-1) ) can be used for the immobilization of chimpanzees for non- to minimally invasive procedures. A period of 15 minutes should be allowed before handling to avoid unwanted arousal. Oxygen administration is recommended to reduce hypoxaemia. Administration of atipamezole is justified to hasten recovery.

Standing sedation in captive zebra (Equus grevyi and Equus burchellii).

Nine Grevy's zebras (Equus grevyi) and three Burchell's zebras (Equus burchellii) were immobilized in a standing position a total of 70 times for minor, nonpainful procedures over a 9-yr period. Standing sedation was successfully obtained with a combination of detomidine and butorphanol on 47 occasions (67.1%). Detomidine i.m. (median 0.10 mg/kg; range: 0.07-0.21) was administered by dart, followed 10 min later by butorphanol i.m. (median 0.13 mg/kg; range 0.04-0.24). The dosages were varied depending on the initial demeanor of the animal. On 23 occasions (32.9%), small amounts of etorphine (median 2.5 microg/kg; range 1.1-12.3 microg/kg) plus acepromazine (median 10 microg/kg; range 4.4-50 microg/kg) (as in Large Animal-Immobilon) had to be administered i.m. to gain sufficient sedation. In these latter cases, the animals were either excited or known for their aggressive character. The zebras were sufficiently immobilized for the length of most procedures (<45 min) without supplementation. At the end of the procedure, the animals were given atipamezole (2 mg per 1 mg detomidine used) and naltrexone (0.1 mg/kg) to reverse the sedative effects, irrespective of whether etorphine was used or not. Standing sedation, using the combination of the alpha-2 agonist detomidine and the partial agonist-antagonist opioid butorphanol (in some cases supplemented with etorphine + acepromazine), proved to be a very efficacious and safe method to be used in zebras under zoo conditions for short-lasting, nonpainful procedures.

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.

African manatee (Trichechus senegalensis) habitat suitability at Lake Ossa, Cameroon, using trophic state models and predictions of submerged aquatic vegetation.

The present study aims at investigating the past and current trophic status of Lake Ossa and evaluating its potential impact on African manatee health. Lake Ossa is known as a refuge for the threatened African manatees in Cameroon. Little information exists on the water quality and health of the ecosystem as reflected by its chemical and biological characteristics. Aquatic biotic and abiotic parameters including water clarity, nitrogen, phosphorous, and chlorophyll concentrations were measured monthly during four months at each of 18 water sampling stations evenly distributed across the lake. These parameters were then compared with historical values obtained from the literature to examine the dynamic trophic state of Lake Ossa. Results indicate that Lake Ossa's trophic state parameters doubled in only three decades (from 1985 to 2016), moving from a mesotrophic to a eutrophic state. The decreasing nutrient gradient moving from the mouth of the lake (in the south) to the north indicates that the flow of the adjacent Sanaga River is the primary source of nutrient input. Further analysis suggests that the poor transparency of the lake is not associated with chlorophyll concentrations but rather with the suspended sediments brought-in by the Sanaga River. Consequently, our model demonstrated that despite nutrient enrichment, less than 5% of the lake bottom surface sustained submerged aquatic vegetation. Thus, shoreline emergent vegetation is the primary food available for the local manatee population. During the dry season, water recedes drastically and disconnects from the dominant shoreline emergent vegetation, decreasing accessibility for manatees. The current study revealed major environmental concerns (eutrophication and sedimentation) that may negatively impact habitat quality for manatees. The information from the results will be key for the development of the management plan of the lake and its manatee population. Efficient land use and water management across the entire watershed may be necessary to mitigate such issues.

Circulation of Babesia Species and Their Exposure to Humans through Ixodes Ricinus.

Human babesiosis in Europe has been attributed to infection with Babesia divergens and, to a lesser extent, with Babesia venatorum and Babesia microti, which are all transmitted to humans through a bite of Ixodes ricinus. These Babesia species circulate in the Netherlands, but autochthonous human babesiosis cases have not been reported so far. To gain more insight into the natural sources of these Babesia species, their presence in reservoir hosts and in I. ricinus was examined. Moreover, part of the ticks were tested for co-infections with other tick borne pathogens. In a cross-sectional study, qPCR-detection was used to determine the presence of Babesia species in 4611 tissue samples from 27 mammalian species and 13 bird species. Reverse line blotting (RLB) and qPCR detection of Babesia species were used to test 25,849 questing I. ricinus. Fragments of the 18S rDNA and cytochrome c oxidase subunit I (COI) gene from PCR-positive isolates were sequenced for confirmation and species identification and species-specific PCR reactions were performed on samples with suspected mixed infections. Babesia microti was found in two widespread rodent species: Myodes glareolus and Apodemus sylvaticus, whereas B. divergens was detected in the geographically restricted Cervus elaphus and Bison bonasus, and occasionally in free-ranging Ovis aries. B. venatorum was detected in the ubiquitous Capreolus capreolus, and occasionally in free-ranging O. aries. Species-specific PCR revealed co-infections in C. capreolus and C. elaphus, resulting in higher prevalence of B. venatorum and B. divergens than disclosed by qPCR detection, followed by 18S rDNA and COI sequencing. The non-zoonotic Babesia species found were Babesia capreoli, Babesia vulpes, Babesia sp. deer clade, and badger-associated Babesia species. The infection rate of zoonotic Babesia species in questing I. ricinus ticks was higher for Babesia clade I (2.6%) than Babesia clade X (1.9%). Co-infection of B. microti with Borrelia burgdorferi sensu lato and Neoehrlichia mikurensis in questing nymphs occurred more than expected, which reflects their mutual reservoir hosts, and suggests the possibility of co-transmission of these three pathogens to humans during a tick bite. The ubiquitous spread and abundance of B. microti and B. venatorum in their reservoir hosts and questing ticks imply some level of human exposure through tick bites. The restricted distribution of the wild reservoir hosts for B. divergens and its low infection rate in ticks might contribute to the absence of reported autochthonous cases of human babesiosis in the Netherlands.

Percutaneous closure of patent ductus arteriosus: a multiinstitutional registry comparing multiple devices.

BACKGROUND: There are no guidelines and multiple devices available now for closure of PDA. OBJECTIVE: We sought to determine which devices are used and their outcomes. METHODS: Prospectively collected data on closure of PDA at 12 US catheterization labs was entered into the MAGIC data registry between November 2005 and September 2008. RESULTS: PDA closure was accomplished in 357 of 359 attempted closures during the study period. Mean age, weight, and minimum ductal diameter were 4.3 ± 6.8 years, 18.7 ± 18.4 kg, and 2.1 ± 1.4 mm, respectively. Devices used were Gianturco coils (161/359), Amplatzer Duct Occluder (ADO, 174/359), Flipper coils (18/359), and other devices (6/359). Gianturco coils had the least fluoroscopy and contrast exposure (8.7 ± 7.5 min, P = 0.00001, 2.6 ± 1.4 cm(3) kg(-1), P = 0.00001). Immediate angiographic success rates were 96.9% (156/161) for Gianturco coils, 89.7% (156/174) for the ADO, 100% (18/18) for Flipper coils, and 66.7% (4/6) for other devices. Major complication rates were 0.6% for Gianturco coils (1/161), 1.7% for ADO (3/174), and 83.3% for other devices (4/6). Minor complication rates by device were 1.9% for Gianturco coils (3/161), 2.3% for ADO (4/174), and 16.7% (1/6) for other devices. CONCLUSIONS: Gianturco coils, the ADO and Flipper coils were immediately successful with low complication profiles. The ADO and Gianturco coils were the predominate devices. The ADO was the device of choice for PDA > 3 mm with good success. In PDA < 3 mm, the Gianturco coil is as effective and safe as the ADO with less cost, less radiation, and less contrast exposure. © 2010 Wiley-Liss, Inc.

Successful TPV Implantation in a Pregnant Patient With Right Ventricle to Pulmonary Artery Conduit Obstruction.

A patient with repaired double outlet right ventricle presented during early gestation with heart failure symptoms due to severe right ventricle-pulmonary artery conduit stenosis and insufficiency. In the first trimester, she underwent transcatheter therapy with Melody pulmonary valve implantation with excellent hemodynamic results and completed pregnancy without significant maternal complications. (Level of Difficulty: Advanced.).

Comparison of 'post-patent ductus arteriosus ligation syndrome' in premature infants after surgical ligation vs. percutaneous closure.

OBJECTIVE: To compare the incidence of post-PDA ligation syndrome after surgical vs. percutaneous closure of PDAs in very low birth weight (VLBW) infants. STUDY DESIGN: Cohort study comparing 59 infants who underwent surgical ligation with 25 infants who underwent percutaneous closure. Comparisons between groups were made using two-sample t-tests and a Fisher's exact test. Comparisons of pre vs. post variables within each group were made using paired t-tests. RESULTS: Patients who underwent surgical ligation had a higher need for initiation of post-procedure hemodynamic support (12/59 vs. 0/24, p = 0.016), a higher post-procedure peak FiO2 (0.64 vs. 0.43, p = 0.004), and a larger absolute change in peak FiO2 (0.23 vs. 0.09, p = 0.008). CONCLUSION: VLBW infants who had percutaneous closure of their PDA did not experience post ligation syndrome and had less escalation of respiratory support compared with infants who underwent surgical ligation.