RESUMEN
PURPOSE: Direct oral anticoagulants (DOACs) are not recommended in adult Fontan patients (Level of Evidence C). We hypothesized that DOACs are comparable to warfarin and do not increase thrombotic and embolic complications (TEs) or clinically significant bleeds. METHODS: We reviewed the medical records of adult Fontan patients on DOACs or warfarin at three major medical centers. We identified 130 patients: 48 on DOACs and 107 on warfarin. In total, they were treated for 810 months on DOACs and 5637 months on warfarin. RESULTS: The incidence of TEs in patients on DOACs compared to those on warfarin was not increased in a statistically significant way (hazard ratio [HR] 1.7 and p value 0.431). Similarly, the incidence of nonmajor and major bleeds in patients on DOACs compared to those on warfarin was also not increased in a statistically significant way (HR for nonmajor bleeds in DOAC patients was 2.8 with a p value of 0.167 and the HR for major bleeds was 2.0 with a p value 0.267). In multivariate analysis, congestive heart failure (CHF) was a risk factor for TEs across both groups (odds ratio [OR] = 4.8, 95% confidence interval [CI] = 1.3-17.6) and bleed history was a risk factor for clinically significant bleeds (OR = 6.8, 95% CI = 2.7-17.2). CONCLUSION: In this small, retrospective multicenter study, the use of DOACs did not increase the risk of TEs or clinically significant bleeds compared to warfarin in a statistically significant way.
Asunto(s)
Fibrilación Atrial , Accidente Cerebrovascular , Humanos , Adulto , Warfarina/efectos adversos , Anticoagulantes/efectos adversos , Estudios Retrospectivos , Fibrilación Atrial/tratamiento farmacológico , Hemorragia/inducido químicamente , Hemorragia/epidemiología , Administración Oral , Accidente Cerebrovascular/epidemiología , Estudios Multicéntricos como AsuntoRESUMEN
In a randomized, controlled trial, the Occlutech Figulla Flex II occluder was shown to be noninferior to the Amplatzer Septal Occluder. Both devices provided greater than 90% efficacy, with limited residual shunting and major complications. Although the risk of overall device erosions was low, larger and longer-term studies are needed to distinguish the differences between devices.
Asunto(s)
Foramen Oval Permeable , Defectos del Tabique Interatrial , Dispositivo Oclusor Septal , Cateterismo Cardíaco , Humanos , Diseño de Prótesis , Resultado del TratamientoRESUMEN
Children with branch pulmonary artery stenosis represent a challenging cohort for stenting Premounted stent implantation provides immediate obstruction relief and hemodynamic improvement in infants Planned stent intervention is required to account for somatic growth and next stage palliation in children Continued slenderization of adult coronary and peripheral interventions, stent technology, and delivery systems may allow for more durable solutions in light of patient size.
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Estenosis de Arteria Pulmonar , Adulto , Niño , Hemodinámica , Humanos , Lactante , Arteria Pulmonar , Soluciones , StentsRESUMEN
The Edwards Sapien S3 demonstrated clinical and technical feasibility in this cohort undergoing percutaneous pulmonary valve implantation. Traversing the tricuspid apparatus with an unsheathed delivery system continues to pose a risk for tricuspid valve injury. Future design innovations need to accommodate for large outflow tracts without adjacent aortic or coronary compression and allow for safe device delivery with minimal trauma to the tricuspid apparatus.
Asunto(s)
Implantación de Prótesis de Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Válvula Pulmonar/cirugía , Válvula Aórtica/cirugía , Uso Fuera de lo Indicado , Diseño de Prótesis , Resultado del TratamientoRESUMEN
We present a case of temporary guidewire pacing in a patient with Fontan anatomy during transcatheter aortic valve implantation. Temporary pacing was successfully achieved utilizing this method without complications. There is an increasing population of patients with complex congenital heart disease and expanding variety of transcatheter interventions. Due to limitations in vascular access and surgical anatomies, guidewire pacing may have a wide array of potential applications in pediatrics and the congenital heart disease population.
Asunto(s)
Estimulación Cardíaca Artificial/métodos , Cardiopatías Congénitas/terapia , Reemplazo de la Válvula Aórtica Transcatéter , Adolescente , Cateterismo Cardíaco , Procedimiento de Fontan , Humanos , MasculinoRESUMEN
Transcatheter pulmonary valve implantation (TPVI) within a failed bioprosthetic valve is safe and effective Coronary artery compression is a potential risk, requiring careful preimplantation balloon dilation testing Prestenting is required for TPVI in stentless conduits Improvements in right ventricular volume, pressure, pulmonary stenosis, and regurgitation can be maintained in the intermediate term Long-term risk for Melody valve endocarditis and valve dysfunction necessitates careful monitoring.
Asunto(s)
Bioprótesis , Implantación de Prótesis de Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Válvula Pulmonar/cirugía , Animales , Cateterismo Cardíaco , Xenoinjertos , PorcinosRESUMEN
Recurrent coarctation postoperative Norwood is poorly tolerated in single ventricle patients. Although transcatheter balloon angioplasty is considered first line, it often leads to inadequate or non-durable relief of obstruction. Transcatheter stent implantation provides excellent relief of obstruction but necessitates staged redilation to account for somatic growth in children. Stent technology, delivery systems, and procedural techniques will need to evolve to obviate reported adverse events mainly due to patient size.
Asunto(s)
Angioplastia de Balón , Coartación Aórtica , Procedimientos de Norwood , Aorta , Niño , Humanos , StentsRESUMEN
BACKGROUND: There are limited mechanical circulatory support options for patients with single ventricle (SV) anatomy. This is a multicenter, retrospective study of the Impella pump to support the systemic ventricle in a cohort of SV patients with Fontan circulation. METHODS: Patients with SV anatomy supported with an Impella device from 2012 to 2015 were included. Demographic information, indication for support, adverse events and short-term outcome data were collected. RESULTS: Ten patients were included. The median age and weight at implant was 26 years (4-38 years) and 64 kg (15-102 kg). Indications for support were systemic ventricular failure with cardiogenic shock (n = 8) or high-risk electrophysiology (EP) procedures (n = 2). The median duration of support was 49 hr (2.7-264 hr). Support was discontinued for ventricular recovery in five patients, transition to another device in two patients, completion of EP procedure in two patients and death in one patient. Survival to hospital discharge was 80%. Adverse events occurred in 4 patients. There were two cases of hemolysis, one case of increasing aortic valve insufficiency with implant and one asymptomatic access site thrombus. There were no bleeding or thromboembolic events. CONCLUSIONS: Impella devices can provide temporary support for the systemic ventricle in SV patients as a bridge to recovery or additional device. Procedural survival and adverse event profiles are favorable. © 2017 Wiley Periodicals, Inc.
Asunto(s)
Procedimiento de Fontan/efectos adversos , Cardiopatías Congénitas/cirugía , Corazón Auxiliar , Disfunción Ventricular Izquierda/terapia , Función Ventricular Izquierda , Adolescente , Adulto , Preescolar , Ecocardiografía Doppler en Color , Ecocardiografía Transesofágica , Europa (Continente) , Femenino , Procedimiento de Fontan/mortalidad , Cardiopatías Congénitas/mortalidad , Cardiopatías Congénitas/fisiopatología , Mortalidad Hospitalaria , Humanos , Masculino , Diseño de Prótesis , Recuperación de la Función , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos , Disfunción Ventricular Izquierda/etiología , Disfunción Ventricular Izquierda/mortalidad , Disfunción Ventricular Izquierda/fisiopatología , Adulto JovenAsunto(s)
Prótesis e Implantes , Arteria Pulmonar , Hemodinámica , Esperanza , Humanos , Resultado del TratamientoAsunto(s)
Enfermedades de la Aorta , Lesiones del Sistema Vascular , Niño , Humanos , Stents , Resultado del TratamientoRESUMEN
We report a case of simultaneous transcatheter systemic and pulmonary venous baffle obstruction stenting in a post operative Mustard patient with d-transposition of the great arteries.
Asunto(s)
Angioplastia de Balón/métodos , Operación de Switch Arterial/efectos adversos , Enfermedad Veno-Oclusiva Pulmonar/terapia , Stents , Síndrome de la Vena Cava Superior/terapia , Transposición de los Grandes Vasos/cirugía , Adulto , Operación de Switch Arterial/métodos , Cateterismo Cardíaco/métodos , Terapia Combinada , Femenino , Fluoroscopía/métodos , Estudios de Seguimiento , Humanos , Circulación Pulmonar/fisiología , Venas Pulmonares/diagnóstico por imagen , Enfermedad Veno-Oclusiva Pulmonar/diagnóstico por imagen , Medición de Riesgo , Síndrome de la Vena Cava Superior/diagnóstico por imagen , Transposición de los Grandes Vasos/diagnóstico por imagen , Resultado del Tratamiento , UltrasonografíaRESUMEN
BACKGROUND: Atrial tachyarrhythmias are common and difficult to treat in adults with congenital heart disease. Dronedarone has proven effective in patients without congenital heart disease, but data are limited about its use in adults with congenital heart disease of moderate to great complexity. METHODS: A single-center, retrospective chart review of 21 adults with congenital heart disease of moderate to great complexity who were treated with dronedarone for atrial tachyarrhythmias was performed. RESULTS: The median (IQR) age at dronedarone initiation was 35 (27.5-39) years. Eleven patients (52%) were male. Ten patients (48%) had New York Heart Association class I disease, 10 (48%) had class II disease, and 1 (5%) had class III disease. Ejection fraction at initiation was greater than 55% in 11 patients (52%), 35% to 55% in 9 patients (43%), and less than 35% in 1 patient (5%). Prior treatments included ß-blockers (71%), sotalol (38%), amiodarone (24%), digoxin (24%), and catheter ablation (38%). Rhythm control was complete in 5 patients (24%), partial in 6 (29%), and inadequate in 10 (48%). Two patients (10%) experienced adverse events, including nausea in 1 (5%) and cardiac arrest in 1 (5%), which occurred 48 months after initiation of treatment. There were no deaths during the follow-up period. The median (IQR) follow-up time for patients with complete or partial rhythm control was 20 (1-54) months. CONCLUSION: Dronedarone can be effective for adult patients with congenital heart disease and atrial arrhythmias for whom more established therapies have failed, and with close monitoring it can be safely tolerated.
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Antiarrítmicos , Dronedarona , Cardiopatías Congénitas , Humanos , Dronedarona/uso terapéutico , Dronedarona/efectos adversos , Masculino , Estudios Retrospectivos , Femenino , Adulto , Cardiopatías Congénitas/complicaciones , Cardiopatías Congénitas/fisiopatología , Antiarrítmicos/uso terapéutico , Antiarrítmicos/efectos adversos , Resultado del Tratamiento , Frecuencia Cardíaca/efectos de los fármacos , Frecuencia Cardíaca/fisiología , Fibrilación Atrial/tratamiento farmacológico , Fibrilación Atrial/fisiopatología , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/complicaciones , Amiodarona/uso terapéutico , Amiodarona/efectos adversos , Amiodarona/análogos & derivados , Factores de TiempoRESUMEN
In the pediatric and congenital heart disease (CHD) population, tricuspid valve (TV) disorders are complex due to the variable TV morphology, its sophisticated interaction with the right ventricle as well as associated congenital and acquired lesions. While surgery is the standard of care for TV dysfunction in this patient population, transcatheter treatment for bioprosthetic TV dysfunction has been performed successfully. Detailed and accurate anatomic assessment of the abnormal TV is essential in the preoperative/preprocedural planning. Three-dimensional transthoracic and 3D transesophageal echocardiography (3DTEE) provides added value to 2-dimensional imaging in the characterization of the TV to guide therapy and 3DTEE serves as an excellent tool for intraoperative assessment and procedural guidance of transcatheter treatment. Notwithstanding advances in imaging and therapy, the timing and indication for intervention for TV disorders in this population are not well defined. In this manuscript, we aim to review the available literature, provide our institutional experience with 3DTEE, and briefly discuss the perceived challenges and future directions in the assessment, surgical planning, and procedural guidance of (1) congenital TV malformations, (2) acquired TV dysfunction from transvenous pacing leads, or following cardiac surgeries, and (3) bioprosthetic TV dysfunction.
RESUMEN
Heart failure (HF) is common in adult congenital heart disease (ACHD) patients; however, use of continuous-flow ventricular assist devices (CF-VADs) remains rare. We reviewed outcomes of patients with congenital heart disease greater than or equal to 18 years of age at the time of CF-VAD implant at the affiliated pediatric and adult institutions between 2006 and 2020. In total, 18 ACHD patients (15 with great anatomical complexity) received 21 CF-VADs. Six patients (median age 34 years) received seven percutaneous CF-VADs with a median duration of support of 20 days (3-44 days) with all patients survived to hospital discharge and two patients were bridged to durable CF-VADs. Fourteen patients (median age 38 years) received durable CF-VADs. Thirteen patients (93%) survived to hospital discharge and the median duration of support was 25.8 months (6.4-52.1 months). Estimated survival on durable CF-VAD at 1, 3, and 5 years was 84%, 72%, and 36%, respectively. Three patients were successfully bridged to transplantation. Device-related complications include cerebrovascular accident (n = 5), driveline infection (n = 3), device infection requiring chronic antibiotic therapy (n = 4), gastrointestinal bleeding (n = 6), and presumed pump thrombosis (n = 5). These results show percutaneous and durable CF-VADs can support ACHD patients with advanced HF.
Asunto(s)
Cardiopatías Congénitas , Insuficiencia Cardíaca , Trasplante de Corazón , Corazón Auxiliar , Niño , Humanos , Adulto , Resultado del Tratamiento , Estudios Retrospectivos , Estudios Multicéntricos como AsuntoAsunto(s)
Cardiomiopatía Hipertrófica/terapia , Diabetes Mellitus Tipo 2/terapia , Oxigenación por Membrana Extracorpórea/métodos , Hipertensión Pulmonar/terapia , Complicaciones del Embarazo/terapia , Índice de Severidad de la Enfermedad , Adulto , Cardiomiopatía Hipertrófica/complicaciones , Cardiomiopatía Hipertrófica/diagnóstico por imagen , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/diagnóstico por imagen , Femenino , Humanos , Hipertensión Pulmonar/complicaciones , Hipertensión Pulmonar/diagnóstico por imagen , Recién Nacido , Masculino , Embarazo , Complicaciones del Embarazo/diagnóstico por imagen , UltrasonografíaRESUMEN
Platypnea-orthodeoxia syndrome, a rare condition characterized by posture-related dyspnea, is usually caused by an intracardiac shunt, hepatopulmonary syndrome, or shunting resulting from severe pulmonary disease. We report the case of a 33-year-old woman who presented with increasing dyspnea and oxygen desaturation when she sat up or arose. Our diagnosis was platypnea-orthodeoxia syndrome. A lead of a previously implanted pacemaker exacerbated a severe tricuspid regurgitant jet that was directed toward the patient's intra-atrial septum. Percutaneous closure of a small secundum atrial septal defect eliminated right-to-left shunting and substantially improved the patient's functional status. In addition to this case, we discuss this unusual condition.
Asunto(s)
Disnea/etiología , Defectos del Tabique Interatrial/complicaciones , Hipoxia/etiología , Adulto , Cateterismo Cardíaco/métodos , Ecocardiografía Transesofágica , Femenino , Defectos del Tabique Interatrial/diagnóstico , Humanos , SíndromeRESUMEN
OBJECTIVE: Adult Fontan patients are at increased risk for thrombosis and thromboembolic complications leading to increased morbidity and mortality. Most are prescribed antiplatelet or anticoagulant therapy for thromboprophylaxis; novel oral anticoagulants (NOACs) are uncommonly used given lack of data on their use in this population and generalized concerns regarding Fontan patients' abnormal coagulation. We report the largest single-center experience with the use of NOACs for treatment and prophylaxis of thrombosis and thromboembolism in adult Fontan patients. RESULTS: A retrospective chart review identified 21 patients (11 female, 10 male), median age 33 years (18-50) at first initiation, who were prescribed a NOAC on 27 different occasions. The main indications for anticoagulation were arrhythmia (N = 12), thrombosis (N = 8), and persistent right to left shunts (N = 2); one patient was initially on anticoagulation for arrhythmia but restarted for thrombosis. The most common indications for initiation of a NOAC over warfarin were patient/provider preference (N = 11), labile international normalized ratio (INR) (N = 5), initiation of therapy elsewhere (N = 3), and history of poor clinical follow-up (N = 2). Over a cumulative 316 months of patient therapy, one new thrombotic event was noted. No major or nonmajor bleeding events occurred, and 10 patients experienced minor bleeding that did not require the cessation of therapy. One patient died from multiorgan system failure following an unwitnessed, out of hospital arrest. At present, 10 patients remain on NOAC therapy in the setting of ongoing arrhythmia (N = 4), history of stroke (N = 2), history of pulmonary embolism (N = 2), history of deep vein thrombosis (N = 1), and history of right ventricle thrombus (N = 1). CONCLUSIONS: While our study is limited by size, our results suggest that NOACs may be a non-inferior alternative to traditional anticoagulation and that further study is warranted.