Percutaneous Closure of Patent Ductus Arteriosus in Infants 1.5 kg or Less: A Meta-Analysis.

OBJECTIVE: To investigate technical success and safety of percutaneous patent ductus arteriosus closure in infants ≤1.5 kg. STUDY DESIGN: A systematic review and meta-analysis was performed. Data sources included Scopus, Web of Science, Embase, CINAHL, Cochrane, and PubMed from inception to April 2020. Publications were included if they had a clear definition of the intervention as percutaneous patent ductus arteriosus closure in infants ≤1.5 kg. Data extraction was independently performed by multiple observers. Primary outcome was technical success and secondary outcomes were adverse events (AEs). Subgroup analysis was performed in infants ≤6.0 kg. Data were pooled by using a random-effects model. RESULTS: We included 28 studies, including 373 infants ≤1.5 kg and 69 studies enrolling 1794 infants ≤6.0 kg. In patients ≤1.5 kg, technical success was 96% (95% CI, 93%-98%; P = .16; I2 = 23%). The overall incidence of AE was 27% (95% CI, 17%-38%; P < .001; I2 = 70%) and major AEs was 8% (95% CI, 5%-10%; P = .63; I2 = 0%). There were 5 deaths related to the procedure (2%; 95% CI, 1%-4%; P = .99; I2 = 0%); 4 of these deaths occurred in infants <0.8 kg. The probability of technical failure was inversely related to age at the time of the procedure (OR, 0.9; 95% CI, 0.830-0.974; P = .009). Weight at intervention has decreased over time and procedural success has increased. CONCLUSIONS: Percutaneous patent ductus arteriosus closure is feasible in infants ≤1.5 kg with few major AEs. The procedural success rate is high, despite performing the intervention in smaller patients. PROSPERO REGISTRATION: CRD42020145230.

Hot topics in interventional cardiology: Proceedings from the society for cardiovascular angiography and interventions (SCAI) 2021 think tank.

The Society for Cardiovascular Angiography and Interventions (SCAI) Think Tank is a collaborative venture that brings together interventional cardiologists, administrative partners, and select members of the cardiovascular industry community annually for high-level field-wide discussions. The 2021 Think Tank was organized into four parallel sessions reflective of the field of interventional cardiology: (a) coronary intervention, (b) endovascular medicine, (c) structural heart disease, and (d) congenital heart disease. Each session was moderated by a senior content expert and co-moderated by a member of SCAI's Emerging Leader Mentorship program. This document presents the proceedings to the wider cardiovascular community in order to enhance participation in this discussion, create additional dialog from a broader base, and thereby aid SCAI, the industry community and external stakeholders in developing specific action items to move these areas forward.

Amplatzer Piccolo Occluder clinical trial for percutaneous closure of the patent ductus arteriosus in patients ≥700 grams.

OBJECTIVES: Characterize the safety and effectiveness of the Amplatzer Piccolo Occluder for patent ductus arteriosus (PDA) closure. BACKGROUND: The presence of a hemodynamically significant PDA has been associated with an increased risk of morbidity and mortality in children born premature. METHODS: This was a single arm, prospective, multicenter, non-randomized study to evaluate the Amplatzer Piccolo Occluder to treat PDA in patients ≥700 g. From June 2017 to February 2019, 200 patients were enrolled at nine centers, with 100 patients weighing ≤2 kg. Primary effectiveness endpoint was the rate of PDA closure at 6-month follow-up. Primary safety endpoint was the rate of major complications through 6 months. Secondary endpoint was rate of significant pulmonary or aortic obstruction through 6 months' follow-up. RESULTS: The implant success rate was 95.5% (191/200) overall and 99% in patients ≤2 kg (99/100). The primary effectiveness endpoint was achieved in 99.4% of implanted patients. Four patients experienced a primary safety endpoint event (2 transfusions, 1 hemolysis, and 1 aortic obstruction). There were no branch pulmonary artery obstructions. Five patients, all ≤2 kg, were noted to have worsening of tricuspid regurgitation (TR) after the procedure. None of the TR incidences manifested clinically. The Amplatzer Piccolo Occluder received FDA approval in January 2019 and became the first device approved for PDA closure in patients ≥700 g. CONCLUSIONS: This study supports the safety and effectiveness of the Amplatzer Piccolo Occluder, particularly in patients between 700 g and 2 kg where there is currently a significant unmet need in the United States. ClinicalTrials.gov identifier: NCT03055858.

Construction of Femoral Vessel Nomograms for Planning Cardiac Interventional Procedures in Children 0-4 Years Old.

The objectives of this study were to construct femoral artery (FA) and femoral vein (FV) nomograms in children aged 0-4 years and to construct probability curves for the occurrence of arterial access complications based on the size of the FA. The FV and FA are commonly accessed during cardiac catheterizations in children with congenital heart diseases (CHD). However, nomograms for vessel dimensions based on child's age or size are not available. This knowledge may be helpful for interventional planning. A prospective study was performed on 400 children (age 0-4 years) with CHD undergoing cardiac catheterizations over a 3-year period. Ultrasound evaluation of the right and left FA and FV was performed under anesthesia prior to vascular access. Regression modeling was applied to derive nomograms based on quantile polynomial regression, which yielded good fit to the data judged by R-squared. GAMLSS transformation method was used to formulate smoothed percentiles. A separate prospective evaluation of FA to determine the size below which loss of pulse (LOP) are likely to occur was performed. Nomograms for FA and FV diameter and cross-sectional area against age and body surface area and probability curves for FA LOP were constructed. It is now possible to examine ultrasound-based normal sizes of femoral vein and artery in children 0-4 years of age. Femoral vessel nomograms and LOP probability curves may help with interventional planning. Future studies with larger sample size, including children of other ages may be useful.

Use of 3-D digital subtraction rotational angiography during cardiac catheterization of infants and adults with congenital heart diseases.

OBJECTIVE: To compare image quality, radiation and contrast doses required to obtain 3D-Digital subtraction rotational angiography (3D-DSRA) with 3D-Digital rotational angiography (3D-DRA) in infants (children ≤ 2 years of age) and adults with congenital heart diseases (ACHD). BACKGROUND: 3D-DRA can be performed with radiation doses comparable to bi-plane cine-angiography. However, 3D-DRA in infants requires a large contrast volume. The resolution of 3D-DRA performed in ACHD patients is limited by their soft tissue density. We hypothesized that the use of 3D-DSRA could help alleviate these concerns. METHODS: Radiation (DAP) and contrast doses required to obtain 3D-DSRA was compared with 3D-DRA in 15 age-, size-, and intervention-matched infants and 15 ACHD patients. The diagnostic quality and utility of these two modalities were scored by 4 qualified independent observers. RESULTS: Both in infants and adults, the median contrast volume for 3D-DSRA was lower than 3D-DRA (0.98 vs. 1.81 mL/kg; P < 0.001 and 0.92 vs. 1.4 mL/kg; P < 0.001, respectively) with an increased DAP (median: 188 vs. 128 cGy cm2 ; P = 0.068 and 659 vs. 427 cGy cm2 ; P = 0.045, respectively). The diagnostic quality and utility scores for rotational-angiography, and 3D-reconstruction were superior for 3D-DSRA (score = 94 vs. 80%, P = 0.03 and 90 vs.79%, P = 0.01, respectively) and equivalent for multi-planar-reformation and 3D-roadmapping in ACHD patients compared with 3D-DRA. All scores for both modalities were equivalent for infants. CONCLUSIONS: 3D-DSRA can be acquired using lower contrast volume with a mildly higher radiation dose than 3D-DRA in infants and ACHD patients. The diagnostic quality and utility scores for 3D-DSRA were higher in ACHD patients and equivalent for infants compared with 3D-DRA.

Clinical evaluation of a radio-protective cream for the hands of the pediatric interventional cardiologist.

OBJECTIVES: The aim of this study was to evaluate the effectiveness of UltraBLOX™ radiation attenuating hand cream during lengthy cardiac catheterization procedures in children. BACKGROUND: The hands of interventional cardiologists receive high doses of radiation due to their proximity to the X-ray beam. Radiation attenuating gloves have about a 26% attenuation rate, but reduce dexterity and tactile sensation. The UltraBLOX™ cream is a new FDA-approved X-ray attenuating cream that can be applied to the operator's hands for radio-protection. METHODS: Two nanoDot™ dosimeters were secured side by side on the dorsum of the operator's (n = 2) left hand close to the wrist. One dosimeter and the rest of the hand were covered with 0.2 mm layer of the cream. The other dosimeter was unshielded. Procedures were performed using 110 kVp fluoroscopy at 15 pulses/sec. The measurements were categorized into four groups dependent on the duration of the procedure. The patients in all four groups were well matched for age and size. RESULTS: Procedural and cumulative hand radiation doses were higher with longer procedural duration. The overall % attenuation by the cream was 39.7% (28.6-51.5) and was unaffected by the length of the procedure (median: 40.9% at 30 min and 41.4% at 180 min; P = 0.66) or the dose of radiation. The kappa statistic for interobserver agreement for good tactile sensitivity was 0.82. CONCLUSIONS: UltraBLOX™ cream provides a new option for radio-protection for the hands of interventional cardiologists without impairing tactile sensitivity. There was no decrease in attenuation up to 180 min. © 2016 Wiley Periodicals, Inc.

Acute and midterm results following perventricular device closure of muscular ventricular septal defects: A multicenter PICES investigation.

OBJECTIVES: To describe acute and mid-term results of hybrid perventricular device closure of muscular ventricular septal defects (mVSDs). BACKGROUND: Perventricular device closure of mVSDs can mitigate technical limitations of percutaneous closure and need for cardiopulmonary bypass or ventriculotomy with a surgical approach. METHODS: This is a multicenter retrospective cohort study of patients undergoing hybrid perventricular mVSD device closure from 1/2004 to 1/2014. Procedural details, adverse events, outcomes, and follow-up data were collected. Patients were divided into two groups: (1) simple (mVSD closure alone) and (2) complex (mVSD closure with concomitant cardiac surgery). RESULTS: Forty-seven patients (60% female) underwent perventricular mVSD device closure at a median age of 5.2 months (IQR 1.8-8.9) and weight of 5.1 kg (IQR 4.0-6.9). Procedural success was 91% [100% (n = 22) simple and 84% (n = 21/25) complex]. Adverse events occurred in 19% (9/47) [9% (2/22) simple and 28% (7/25) complex]. Hospital length of stay (LOS) was shorter in the simple vs. complex group (4 vs. 14 days, P < 0.01). At mid-term follow-up of 19.2 months (IQR 2.3-43) 90% of pts had complete mVSD closure; none developed late heart block, increased atrioventricular (AV) valve insufficiency or ventricular dysfunction. CONCLUSIONS: Perventricular device closure of simple mVSD was associated with a high rate of procedural success, few adverse events, and short hospital LOS. Procedural adverse events were associated with the presence of concomitant complex surgery. Residual mVSD, AV valve insufficiency, or ventricular dysfunction were uncommon at mid-term follow-up. © 2017 Wiley Periodicals, Inc.

Management of hypoplastic left heart syndrome with intact atrial septum: a two-centre experience.

UNLABELLED: Introduction Hypoplastic left heart syndrome with an intact atrial septum is a poor predictor of outcomes. Prenatal assessment of pulmonary venous Doppler and emergent postnatal cardiac intervention may be associated with better outcomes. Materials and methods A retrospective review of all hypoplastic left heart syndrome patients in two centres over a 5-year period was performed. Group 1 included patients with adequate inter-atrial communication. Group 2 included patients with prenatal diagnosis with an intact atrial septum who had immediate transcatheter intervention. Group 3 included patients with intact atrial septum who were not prenatally diagnosed and underwent either delayed intervention or no intervention before stage 1 palliation. Primary outcome was survival up to stage 2 palliation. RESULTS: The incidence of hypoplastic left heart syndrome with a restrictive atrial communication was 11.2% (n=19 of 170). Overall survival to stage 2 or heart transplantation was 85% and 67% for Groups 1 and 2, respectively (n=129/151, n=8/12; p=0.03), and 0% (n=0/7) for Group 3. Survival benefits were observed between Groups 2 and 3 (p<0.001). Foetal pulmonary vein Doppler reverse/forward velocity time integral ratio of ⩾18% (sensitivity, 0.99, 95% CI, 0.58-1; specificity, 0.99, 95% CI, 0.96-1) was predictive of the need for emergent left atrial decompression. CONCLUSION: Using a multidisciplinary approach and foetal pulmonary vein Doppler, time-saving measures can be instituted by delivering prenatally diagnosed neonates with hypoplastic left heart syndrome with intact atrial septum close to the cardiac catheterisation suite where left atrial decompression can be performed quickly and safely that may improve survival.

Management of anomalous circumflex coronary artery from the neo-pulmonary artery in an adolescent following neonatal arterial switch operation.

A 15-year-old male with transposition of the great arteries presented with exertional chest pain. He was found to have a circumflex coronary artery from the neo-pulmonary artery that had not been transferred during his arterial switch operation. The circumflex coronary artery, fed through collaterals from a re-implanted single coronary artery, resulted in coronary steal. This report describes a management pathway to treat this rare anomaly.

Unzipping of small diameter stents: an in vitro study.

OBJECTIVE: The purpose of this study was to determine if small-diameter stents can be unzipped in vitro. BACKGROUND: Small-diameter stents can relieve stenosis in infant blood vessels. As the child grows, refractory stenosis may result. If an implanted stent can be intentionally fractured along its length-"unzipped," it can be redilated to the eventual adult vessel diameter. METHODS: Stents of diameters ≤6 mm were dilated using angioplasty balloons until they fractured. The change in length-diameter (dL/dD ratio), and the yield-point-force (σy ) for each stent was calculated. RESULTS: Thirty-four coronary (CS), 11 biliary, and 10 nitinol peripheral stents (median diameter = 4, 5, and 6 mm; range = 2.75-4.5, 4-6, 6 mm, respectively) were tested. Stainless-steel (SS) CS unzipped predictably at twice their nominal diameter with minimal shortening (n = 24, median dL/dD = 0.4). Nitinol stents fractured in a disorganized fashion. The remaining stents unzipped, had disorganized fractures, and shortened significantly (dL/dD>1). A dL/dD ratio of<1 had a strong, positive correlation with the ability to unzip (Pearson rho = 0.94). By multivariate regression analysis, SS alloy, and closed-cell design were found to be significant predictors (P < 0.05) for unzipping. Optimal cut-off points for stents to unzip included, strut-thickness = 112 µm, alloy-density = 7.7 g/cm(3) , dL/dD ratio = 0.12 and σy = 108Mpa (Youden's index = 0.8, 0.4, 0.8, and 0.5, respectively). CONCLUSIONS: Stainless-steel, coronary stents of a closed-cell design unzip at twice their nominal diameter without significant shortening when serially dilated. This study may encourage the implantation of small stents in infant blood vessels and aid in selection of appropriate stent type.

3-year follow-up of a prospective, multicenter study of the Amplatzer Piccolo™ Occluder for transcatheter patent ductus arteriosus closure in children ≥ 700 grams.

OBJECTIVE: This study describes 3-year follow-up of 200 infants weighing ≥ 700 grams who underwent transcatheter patent ductus arteriosus (PDA) closure with the Amplatzer Piccolo™ Occluder. STUDY DESIGN: Between June 2017 and February 2019, 200 children were enrolled in this U.S. study (NCT03055858). PDA closure, survival, and device- or procedure-related events were evaluated. A total of 156 of the available 182 patients (86%) completed the study. RESULTS: The implant success rate was 95.5% (191/200). At 3 years, PDA closure was observed in 100% (33/33) of patients. Survival was >95% with 9 reported deaths. No deaths were adjudicated as device- or procedure-related. Notable events included aortic obstruction (2) requiring stent placement and tricuspid regurgitation (5), for which no interventions were required. CONCLUSIONS: This follow-up study demonstrates high rates of PDA closure, low serious complication rates, and survival > 95% at 3 years. The Amplatzer Piccolo™ Occluder is a safe and effective therapy for PDA treatment in premature infants. CLINICALTRIALS: gov identifier: NCT0305585.

Coronary artery-to-pulmonary artery fistula in a case of pulmonary atresia with ventricular septal defect.

Pulmonary atresia with ventricular septal defect (PA-VSD) can be associated with varying pulmonary artery connections. The origin of pulmonary blood flow can vary greatly among patients, and some case reports have described the presence of left coronary artery-to-pulmonary artery fistula. Two cases of patients found to have coronary artery-to-pulmonary artery fistula in the settings of PA-VSD are reported.

Hypoplastic left heart syndrome and aortic atresia-mitral stenosis variant: role of myocardial protection strategy and impact of ventriculo-coronary connections after stage I palliation.

Aortic atresia-mitral stenosis (AA-MS) has been implicated as a determinant of outcome after Stage-1 palliation (S1P) in hypoplastic left heart syndrome (HLHS).Studies evaluating the association of AA-MS with ventriculo-coronary connections (VCC) and mortality report conflicting results. The significance of VCC, myocardial protection, and shunt strategy after S1P has yet to be determined. Between January 2005 and July 2009, 100 neonates with HLHS underwent S1P. Mitral and aortic valves and presence of VCC were assessed. Antegrade continuous cold blood cardioplegia was administered throughout the vast extent of the neo-aortic reconstruction. A right ventricle-to-pulmonary shunt was used for an ascending aortic diameter of 0.6 mm/kg or less. Survival analysis was performed to determine predictors and assess impact of AA-MS and VCC on hospital and interstage mortality. Twenty-seven (of 100) patients had AA-MS. The mean age and weight at S1P were 6.5 ± 2.8 days and 3.09 ± 0.47 kg, respectively. VCC were found in 56% of AA-MS. Twenty-two had Norwood-Sano, 3 had classic Norwood, and 2 had hybrid S1P. VCC were associated with AA-MS, endocardial fibroelastosis, and ascending aortic size <2 mm (P < 0.05) but not higher mortality (P = ns). Operative and interstage survival for AA-MS after S1P was 85.2 and 71%, respectively (not statistically different compared to all other subtypes; P = ns). Actuarial survival after S1P at 1, 3, 6, 12, and 36 months was 92.9 ± 4.9, 78.6 ± 7.8, 75 ± 8.2, 71.3 ± 8.3, and 71.3 ± 8.3%, respectively. Intact atrial septum and post-S1P renal dysfunction (P < 0.05) were independent predictors of hospital and interstage mortality. In patients with HLHS, AA-MS carries no survival disadvantage after S1P during the hospital and interstage period regardless of VCC. Intact atrial septum and post-S1P renal dysfunction predict early and interstage mortality. Myocardial protection and shunt strategy might influence the outcome in this HLHS variant.

Percutaneous Stage 1 Palliation for Hypoplastic Left Heart Syndrome.

Surgical palliation for hypoplastic left heart syndrome still carries significant morbidity and mortality in neonates. We previously described a percutaneous stage 1 palliation (PS1P) in a swine experiment. Here we report the human application of the PS1P for hypoplastic left heart syndrome in the United States. The procedure is performed through a 4F sheath in the femoral vein. Bilateral pulmonary flow restrictors are implanted in the proximal branch pulmonary arteries and a stent within the ductus arteriosus. PS1P could postpone surgical repair beyond the neonatal period. It offers a simple, less invasive alternative to currently available operations for newborns with HLHS.

Resource Allocation and Decision Making for Pediatric and Congenital Cardiac Catheterization During the Novel Coronavirus SARS-CoV-2 (COVID-19) Pandemic: A U.S. Multi-Institutional Perspective.

BACKGROUND: The novel coronavirus (COVID-19) pandemic has placed severe stress on healthcare systems around the world. There is limited information on current practices in pediatric cardiac catheterization laboratories in the United States (US). OBJECTIVES: To describe current practice patterns and make recommendations regarding potential resource allocation for congenital cardiac catheterization during the COVID-19 pandemic. METHODS: A web-based survey was distributed regarding case candidacy and catheterization laboratory preparedness. Centers were categorized based on the current degree of disease burden in that community (as of April 1, 2020). Data and consensus opinion were utilized to develop recommendations. RESULTS: Respondents belonged to 56 unique US centers, with 27 (48.2%) located in counties with a high number of COVID-19 cases. All centers have canceled elective procedures. There was relative uniformity (>88% agreement) among centers as to which procedures were considered elective. To date, only three centers have performed a catheterization on a confirmed COVID-19 positive patient. Centers located in areas with a higher number of COVID-9 cases have been more involved in a simulation of donning and doffing personal protective equipment (PPE) than low-prevalence centers (46.7% vs 10.3%, respectively; P<.001). Currently, only a small fraction of operators has been reassigned to provide clinical services outside their scope of practice. CONCLUSIONS: At this stage in the COVID-19 pandemic, pediatric/congenital catheterization laboratories have dramatically reduced case volumes. This document serves to define current patterns and provides guidance and recommendations on the preservation and repurposing of resources to help pediatric cardiac programs develop strategies for patient care during this unprecedented crisis.

Transcatheter Pulmonary Valve Replacement With the Sapien Prosthesis.

BACKGROUND: There are limited published data focused on outcomes of transcatheter pulmonary valve replacement (TPVR) with either a Sapien XT or Sapien 3 (S3) valve. OBJECTIVES: This study sought to report short-term outcomes in a large cohort of patients who underwent TPVR with either a Sapien XT or S3 valve. METHODS: Data were entered retrospectively into a multicenter registry for patients who underwent attempted TPVR with a Sapien XT or S3 valve. Patient-related, procedural, and short-term outcomes data were characterized overall and according to type of right ventricular outflow tract (RVOT) anatomy. RESULTS: Twenty-three centers enrolled a total of 774 patients: 397 (51%) with a native/patched RVOT; 183 (24%) with a conduit; and 194 (25%) with a bioprosthetic valve. The S3 was used in 78% of patients, and the XT was used in 22%, with most patients receiving a 29-mm (39%) or 26-mm (34%) valve. The implant was technically successful in 754 (97.4%) patients. Serious adverse events were reported in 67 patients (10%), with no difference between RVOT anatomy groups. Fourteen patients underwent urgent surgery. Nine patients had a second valve implanted. Among patients with available data, tricuspid valve injury was documented in 11 (1.7%), and 9 others (1.3%) had new moderate or severe regurgitation 2 grades higher than pre-implantation, for 20 (3.0%) total patients with tricuspid valve complications. Valve function at discharge was excellent in most patients, but 58 (8.5%) had moderate or greater pulmonary regurgitation or maximum Doppler gradients >40 mm Hg. During limited follow-up (n = 349; median: 12 months), 9 patients were diagnosed with endocarditis, and 17 additional patients underwent surgical valve replacement or valve-in-valve TPVR. CONCLUSIONS: Acute outcomes after TPVR with balloon-expandable valves were generally excellent in all types of RVOT. Additional data and longer follow-up will be necessary to gain insight into these issues.

Feasibility and Safety of Unzipping Small Diameter Stents in the Blood Vessels of Piglets.

OBJECTIVES: This study sought to determine the feasibility and safety of unzipping small-diameter stents (SDS) in a growing animal model. BACKGROUND: SDS implanted to relieve stenosis of blood vessels in infants may result in refractory stenosis as the child grows. If stents can be longitudinally fractured-unzipped-then the target vessel can potentially be redilated to the eventual adult vessel diameter. METHODS: Fifty stents (diameter 4 to 7 mm) were implanted in 5 neonatal piglets (mean age and weight = 1.5 weeks and 3.4 kg). Pre-mounted coronary (CS) (n = 24), biliary (BS) (n = 14), nitinol (NS) (n = 3), and renal stents (RS) (n = 9) were implanted in pulmonary arteries (n = 13), systemic arteries (n = 25), and systemic veins (n = 12). Three months later (median weight = 32 kg), unzipping was attempted by dilating the stents. RESULTS: All CS and RS unzipped at twice their nominal diameter with <20% shortening. None of the NS unzipped. The BS shortened the most (∼40%), with only 69% of the stents unzipping. Stainless steel CS and RS with an open cell design were significant predictors (p ≤ 0.01) for unzipping. On histopathology, unzipping of the BS caused the most medial dissection and vessel wall injury, while unzipping of the CS caused the least. CONCLUSIONS: Unzipping of small-diameter CS and RS implanted in systemic and pulmonary vessels is more feasible than the BS and NS. This study may encourage the implantation of small stents in infant blood vessels and aid in selection of appropriate stent type.

Significance of low peak Doppler velocity in the proximal sano conduit in hypoplastic left heart syndrome.

BACKGROUND: The Sano modification of the Norwood operation is a well-established first step palliation for hypoplastic left heart syndrome (HLHS). Theoretically, the first point of resistance to pulmonary flow should be in the proximal Sano, generating high Doppler flow velocity. Paradoxically, however, some patients have low gradients in the proximal Sano conduit. The objective of this study was to determine the hemodynamic and anatomic significance of low proximal Sano Doppler flow velocity and its clinical implications. METHODS: Doppler-derived peak gradients in the proximal Sano conduits were measured in HLHS patients after Norwood-Sano surgery over a 4-year period and confirmed by cardiac catheterization within 2 to 4 weeks. Clinical outcomes of patients with proximal Sano gradients of 30 mm Hg or less (group 1) were compared with patients whose gradient was greater than 30 mm Hg (group 2). RESULTS: Of the 53 patients, 21 (40%) belonged to group 1. Patients in group 1 had smaller ostial right and left pulmonary artery (PA) diameter (3.2 ± 1.2 mm versus 4.5 ± 1.8 mm, p = 0.03; and 3.4 ± 1.2 mm versus 5.6 ± 2.1 mm, p = 0.01) when compared with patients in group 2. Patients (7 of 10) who needed either balloon angioplasty of a distal Sano or proximal branch PA were from group 1 (p = 0.01). Patients in group 1 had higher rates of unintended PA interventions (33% versus 9%) and complications (48% versus 16%) compared with group 2. CONCLUSIONS: Low peak Doppler flow velocity in the proximal Sano correlates with the presence of either distal Sano stenosis or proximal branch PA stenosis. These patients require close follow-up in the interstage period and may need earlier intervention.

Shunt reintervention and time-related events after Norwood operation: impact of shunt strategy.

BACKGROUND: The use of right ventricle-to-pulmonary artery shunt (RV-PA) is thought to improve postoperative hemodynamics in hypoplastic left heart syndrome (HLHS). Proximal shunt obstruction often prompts early reintervention. Description of our technique and analysis of outcomes after Norwood operation using RV-PA shunt (NRVPA) was undertaken. METHODS: Between January 2005 and June 2009, 100 consecutive neonates with HLHS underwent stage-1 palliation (S1P). Sixty-five had NRVPA. From 56 survivors, 52 (86. 2%) reached pre-Glenn cardiac catheterization. The RV-PA shunt was constructed using nonringed polytetrafluoroethylene with reversed beveling and hood augmentation of its anterior wall. The PA size, Nakata index, pulmonary to systemic blood flow ratio, and any pre-Glenn intervention were studied. The RV function and NRVPA diastolic reversal flow were assessed. RESULTS: Mean age and weight at S1P were 6. 6 ± 3. 5 days and 3. 21 ± 0. 57 kg, respectively. No shunt reversal flow to RV was noted the first 48 hours after S1P by echocardiogram. No patient had shunt revision after hospital discharge from S1P. Mean age and weight at stage-2 palliation were 14. 9 ± 5. 1weeks and 5. 4 ± 2. 1 kg, respectively. No patient had proximal shunt stenosis. Six patients with distal shunt stenosis and associated central PA hypoplasia (32% ± 17% PA diameter reduction), 3 with left PA and 2 with right PA) stenoses had balloon angioplasty. The pulmonary to systemic blood flow ratio between patients requiring pre-stage-2 palliation intervention and patients without intervention was 1. 05 ± 0. 3 versus 1. 13 ± 0. 37 (p = 0. 09). Right PA and left PA growth was balanced (right PA/left PA 0. 99 ± 0. 3; right PA 26. 8 ± 11. 5 mm(2) versus left PA 27. 2 ± 12. 3 mm(2); p = 0. 1). Freedom from significant RV dysfunction for S1P survivors at 3, 6, 12, 36, and 48 months was 94.4% ± 3.1%, 88.7% ± 4.4%, 86.7% ± 4.7%, 83.9% ± 5.3%, and 79.7 ± 6.7%, respectively. CONCLUSIONS: Norwood RV-PA promotes balanced branch PA growth. The RV-to-PA shunt with proximal valvelike hood modification significantly reduces proximal anastomotic stenosis and need for early shunt revision. Limited early shunt diastolic reversal flow into the RV and subsequent early unloading of RV during BDG might preserve ventricular performance.

Mitral stenosis and aortic atresia in hypoplastic left heart syndrome: survival analysis after stage I palliation.

BACKGROUND: Mitral stenosis with aortic atresia (MS-AA) has been implicated as a risk factor for decreased survival after stage 1 palliation for hypoplastic left heart syndrome. Conflicting results were reported in the literature evaluating the association of anatomic subtypes and mortality. Our objective was to determine whether MS-AA is associated with increased mortality after stage 1 palliation. METHODS: Between January 2005 and May 2009 100 consecutive neonates with hypoplastic left heart syndrome underwent stage 1 palliation. Echocardiograms were reviewed for patency of the mitral and aortic valves as well as presence of ventriculocoronary connections (VCC). Patients were divided into (1) mitral and aortic atresia (MA-AA), (2) MS-AA, and (3) mitral and aortic stenosis groups. Survival analysis was performed, and impact of MS-AA and VCC on early and midterm survival was assessed. RESULTS: Of the 100 patients, 31 had MA-AA, 42 had mitral stenosis and aortic stenosis, and 27 had MS-AA (15 with VCC and 12 without). Stage 1 palliation 30-day survival was 90% for the entire cohort and 88.9% for the MS-AA subtype (not significantly different). Six-month survival was 70% overall and 70.4% for MS-AA (not significantly different). When VCC was taken into account, MS-AA with VCC reached 93% survival (versus 50% for MS-AA without VCC; p < 0.01). CONCLUSIONS: Stage 1 palliation for hypoplastic left heart syndrome is associated with satisfactory hospital and midterm survival regardless of anatomic subtype. The variants MS-AA and MA-AA are associated with smaller ascending aorta. Mitral stenosis with aortic atresia or VCC did not adversely influence survival.