Echocardiography-guided percutaneous closure of oval-shaped secundum atrial septal defects.

BACKGROUND: An atrial septal defect (ASD) is considered oval-shaped when its shortest diameter is less than 75% of the longest diameter. Research on percutaneous closure of oval-shaped ASDs is limited, with no known reports of non-fluoroscopic closure for this population. OBJECTIVE: To assess the effectiveness of non-fluoroscopic percutaneous closure for oval-shaped ASDs. METHODS: This single-center retrospective study evaluates patients undergoing non-fluoroscopic percutaneous closure of oval-shaped ASDs, defined by the shortest to longest diameter ratio < 0.75, a circular index of 1.33, or ultrasound visualization of an oval shape. Device size was chosen to be 0-4 mm larger than the defect's longest diameter, based on transthoracic and transesophageal ultrasound measurements. RESULTS: We identified 78 patients (33.3% children, 20.5% males) with a mean age of 27.4 ± 16.3 years and a mean weight of 46.8 ± 19.8 kg. The mean longest diameter and mean shortest diameter of ASDs were 23.3 ± 6.8 mm and 15.8 ± 5 mm, respectively. The mean ratio of the shortest to longest diameter was 0.7 ± 0.1. Percutaneous closure was not attempted in 7/78 (9%) patients. Three out of 71 (4.2%) procedures were fluoroscopy-guided upfront due to technical difficulties, and 5/71 (7%) were converted to fluoroscopy-guided closure. Overall procedural success rate was 98.6% (70/71) including 63/71 (88.7%) performed with zero fluoroscopy. Mean device size was 26.5 ± 7.1 mm. Mean procedural time was 45.3 ± 22.6 min. Eleven intraprocedural complications occurred including 6 arrhythmias, 3 pericardial effusions, and 2 device dislodgements. CONCLUSION: Transcatheter closure of oval-shaped ASD is safe and feasible. Echocardiography is adequate for adequate operative guidance.

Long-term outcomes of ventricular tachycardia ablation in repaired tetralogy of Fallot: Systematic review and meta-analysis.

Background: Ventricular tachycardia (VT) remains a risk in repaired Tetralogy of Fallot (rTOF); however, long-term benefits of VT ablation have not been established. This study compares the outcomes of rTOF patients with and without VT ablation. Methods: We searched multiple databases examining the outcomes of rTOF patients who had undergone VT ablation compared to those without ablation. Primary outcomes were VT recurrence, sudden cardiac death (SCD), and all-cause mortality. Subgroup analysis was conducted based on the type of ablation (catheter and surgical). Slow-conducting anatomical isthmus (SCAI)-based catheter ablation (CA) was also analyzed separately. The secondary outcome was the risk factors for the pre-ablation history of VT. Results: Fifteen cohort studies with 1459 patients were included, 21.4% exhibited VTs. SCAI was found in 30.4% of the population, with 3.7% of non-inducible VT. Factors significantly associated with VT before ablation included a history of ventriculostomy, QRS duration ≥180 ms, fragmented QRS, moderate to severe pulmonary regurgitation, high premature ventricular contractions burden, late gadolinium enhancement, and SCAI. Ablation was only beneficial in reducing VTs recurrence in SCAI-based CA (risk ratio (RR) 0.11; 95% CI 0.03 to 0.33. p < 0.001; I2 = 0%) with no recurrence in patients with preventive ablation (mean follow-up time 91.14 ± 77.81 months). The outcomes of VT ablation indicated a favorable trend concerning SCD and all-cause mortality (RR 0.49 and 0.44, respectively); however, they were statistically insignificant. Conclusions: SCAI-based CA has significant advantages in reducing VT recurrence in rTOF patients. Risk stratification plays a key role in determining the decision to perform ablation.

Safety and feasibility of 3D-electroanatomical mapping-guided zero or near-zero fluoroscopy catheter ablation for pediatric arrhythmias: Meta-analysis.

Background: Catheter ablation in the pediatric population using fluoroscopy has been known to cause adverse events. This study aims to assess the effectiveness and safety of zero fluoroscopy (ZF) and near-ZF-guided catheter ablation for the treatment of arrhythmias in the pediatric population. Methods: The PubMed, Embase, and Cochrane library databases were searched and reviewed for relevant studies. Outcomes of interest include safety, short-term, and long-term effectiveness. We classified patients ≤21 years old who underwent ZF or near-ZF ablation with fluoroscopy time ≤1.5 min as our study group and patients within the same age range who underwent conventional fluoroscopy and/or near-ZF ablation with a mean fluoroscopy time >1.5 min as our control group. Both ZF and near-ZF ablation utilized 3D-electroanatomical mapping (3D-EAM). Results: Ten studies composed of 2279 patients were included in this study. Total fluoroscopy time (MD -15.93 min, 95% CI (-22.57 - (-9.29), p < .001; I 2 = 84%)) and total procedural time (MD -22.06 min, 95% CI (-44.39 - (-0.28), p < .001; I 2 = 88%)) were significantly lower in the near-ZF group. Both ZF and near-ZF demonstrated a trend towards improved success rates compared to conventional fluoroscopy but did not achieve statistical significance for all subgroup analyses. Ablation in the study group also decreased incidence of complication compared to the control (RR 0.35; 95% CI (0.14-0.90); p = .03; I 2 = 0%). Conclusion: ZF and near-ZF ablation reduced the overall duration, compares in effectiveness, and shows a superior safety profile compared to control group.

Ductal stenting vs. surgical shunting in late presenting duct-dependent pulmonary circulation: a single-center experience.

Introduction: PDA stenting is an option to mBTT shunt for younger patients; nevertheless, few reports of this palliative approach have been made for the late presenter population, especially for patients who are older than 30 days but under 5 years. This study aimed to evaluate the clinical result and intra-hospital costs of ductal stenting in late-presenting patients in comparison to surgical shunting. Methods: A single-center, retrospective cohort study was conducted from August 2016 to August 2022. This study included patients with pulmonary duct dependent CHD who were hospitalized for palliative therapy. The extracted data were baseline characteristics, clinical findings, supportive examination findings, complications, outcomes, and length of stay of the patients. Monitoring was carried out during treatment up to 30 days after the procedure. Results: A total of 143 patients were included in the analysis; 43 patients underwent PDA stent and 100 patients underwent mBTT shunt with median age of PDA stent group 110 (31-1,498) days and mBTT shunt group 174.5 (30-1,651) days. Primary outcome composite was not significant in both groups including 30 days mortality [6 (14%) vs. 14 (14%), p = 1.000], reintervention [1 (2.3%) vs. 7 (7%), p = 0.436], and 30 days rehospitalization [0 (0%) vs. 2 (2%), p = 0.319]. Secondary outcome analysis showed shorter ICU length of stay in the PDA stent group [2 (0-16) days vs. 4 (1-63) days, p = 0.002]. Conclusions: PDA stent has an outcome that is non inferior from the mBTT shunt procedure in the composite outcome including 30 days mortality, reintervention, and 30 days rehospitalization but significantly lower in ICU length of stay.

Revisiting percutaneous balloon mitral valvotomy technique and safety in various population: an evidence-based case report and literature review.

Percutaneous balloon mitral valvotomy (PBMV) is a good and preferred therapy choice over surgical commissurotomy for patients with rheumatic mitral stenosis (MS). However, interventional cardiologists must recognize that treating patients with rheumatic MS poses unique challenges for each patient, especially in special populations such as pregnant patients or patients with arrhythmias like atrial fibrillation (AF), which can complicate procedures. Based on information from observational studies, PBMV may be a safe and efficient treatment for improving outcomes in MS women who do not have substantial subvalve illness in a specific demographic. A successful PBMV helps to tolerate hemodynamic changes during pregnancy and dramatically reduces mortality. However, there is a paucity of studies on women with poor valve morphology who are not contraindicated, and it has to be seen if PBMV is used in these situations during pregnancy. Conversely, AF leads to a lower PBMV success rate as well as worse long-term and in-hospital outcomes.

Right ventricular outflow tract stenting for late presenter unrepaired Fallot physiology: a single-center experience.

Objectives: The purpose of this study was to assess the clinical outcome after right ventricular outflow tract (RVOT) stenting in late presenter patient with unrepaired Fallot physiology. Background: In younger patients, RVOT stenting is an alternative to mBTT shunt; however, there have been few reports of this palliative technique in late presenter population, including adults. Methods: This was a single-center, retrospective study of nonrandomized, palliated Fallot patients. Clinical outcomes such as left ventricular ejection fraction and saturation were measured in 32 individuals following RVOT stenting in adults (n = 10) and children (n = 22). The Statistical Package for Social Science (SPSS) 26.0 software was used to analyze the statistical data. Results: During the procedure, the average stent diameter and length were 8.84 ± 1.64 mm and 35.46 ± 11.23 mm, respectively. Adult patients received slightly longer stents than pediatric patients (43.60 ± 11.64 mm vs. 31.77 ± 9.07 mm). Overall, patients' saturation increased from 58.56 ± 19.03% to 91.03 ± 8.98% (p < 0.001), as did their left ventricular ejection fraction (LVEF) from 64.00 ± 18.21% to 75.09 ± 12.98% (p = 0.001). Three patients improved their LVEF from 31 to 55%, 31 to 67%, and 26 to 50%. The median length of stay was 8 (2-35) days, with an ICU stay of 2 (0-30) days. The median time from RVOT stent palliation to total repair was 3 months (range: 1 month-12 months). Conclusions: RVOT stenting is a safe and effective method for increasing saturation and ejection fraction not only in newborn infants but also in late presenters, including adults with unrepaired Fallot physiology.

Transoesophageal echocardiography-guided balloon-assisted percutaneous closure of a large secundum atrial septal defect in a pregnant woman: a case report.

Background: According to the 2018 European Society of Cardiology guidelines, atrial septal defect (ASD) closure can be performed during pregnancy but is rarely indicated. In this case, we demonstrate the viability of percutaneous balloon-assisted ASD closure without fluoroscopy in a pregnant woman. Case summary: A 23-year-old G3P2A0 woman who was 20 weeks pregnant had primary complaints of breathlessness [New York Heart Association functional class (NYHA fc) III and IV] for 1 week prior to admission. A transthoracic echocardiography showed a dilatation of the right atrium (RA), a dilated right ventricle, a dilated main pulmonary artery (28.1 mm), and an oval-shaped 22 × 33 mm-sized secundum ASD with a left-to-right shunt. Despite optimal pharmacological treatment, the NYHA fc persisted. Under transoesophageal echocardiography monitoring, we introduced a 40 mm Cera™ ASD Occluder (Lifetech, China) via the delivery sheath. The device was deployed in the usual position; however, despite numerous placement adjustments, the left atrium disc kept getting dislodged to the RA and could not engage correctly. Therefore, we decided to use a balloon-assisted approach using a sizing balloon of No. 34 mm. The device was successfully positioned, and a wiggle test was conducted to make sure that the device remained stable. The patient was able to give birth to the child normally several months later. Discussion: Despite the fact that pregnant women with ASD receive a very low dose of radiation, it is nevertheless recommended to avoid radiation because this demographic is particularly vulnerable to it. It is possible to treat a large ASD in pregnant women with a successful balloon-assisted approach.

Transesophageal echocardiography-guided percutaneous closure of multiple muscular ventricular septal defects with pulmonary hypertension using single device: A case report.

Background: Surgery is typically used to correct challenging ventricular septal defects (VSDs), such as VSD with pulmonary hypertension and multiple defects. In this case report, we would like to highlight the feasibility of multiple defects VSD closure with single device percutaneously using zero-fluoroscopy technique. Case presentation: A 7-year-old child was referred with the main symptom of shortness of breath. She started experiencing repeated respiratory tract infections, feeding issues, and failure to thrive at the age of six months. Her body weight was only 18 kg. TEE revealed several muscular VSD with 2-3 mm and 12 mm diameters, 3 mm spacing between VSD, L to R shunt, AR (-), and TR mild with septal leaflet tricuspid prolapse. Following right heart catheterization (Qp:Qs 3.5, PVRi 5.23WUmsq, PVR 4.55 WU, PVR/SVR 0.16), we made the decision to correct the defect using an Amplatzer Septal Occluder (AGA) No. 16 mm using transjugular method. Full device deployment was successfully performed with several episodes of PVC storm and severe bradycardia. One and a half years after the procedure, her TVG dropped to only 18 mmHg, her visible indicators of PH subsided, and the PA dilator treatment was discontinued. Her body weight had increased to 28 kg, and she had no complaints. Conclusions: Our experience demonstrated that percutaneous closure of multiple VSD with a single device is possible, even with pulmonary hypertension.

The outcomes of fetal aortic valvuloplasty in critical aortic stenosis: A systematic review and meta-analysis.

BACKGROUND: Critical aortic stenosis that appears in mid-gestation tends to develop to growth retardation of left ventricle, known as hypoplastic left heart syndrome (HLHS). Despite better clinical management of HLHS, the morbidity and mortality rates of univentricular circulation patients remain high. In this paper, we sought to perform a systematic review and meta-analysis to know the outcomes of fetal aortic valvuloplasty in critical aortic stenosis patients. METHODS: This systematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) statement. A systematic search on fetal aortic valvuloplasty procedure for critical aortic stenosis was performed through PubMed, Scopus, EBSCOhost, ProQuest, and Google Scholar. The primary endpoint of each group was overall mortality. We used R software (version 4.1.3) to estimate the overall proportion of each outcome using random-effects model of proportional meta-analysis. RESULTS: A total of 389 fetal subjects from 10 cohort studies were included in this systematic review and meta-analysis. Fetal aortic valvuloplasty (FAV) was successfully performed in 84% of patients. It revealed a successful conversion to biventricular circulation rate of 33% with a mortality rate of 20%. Bradycardia and pleural effusion requiring treatment were two most common fetal complications, whereas maternal complication reported was only placental abruption in one patient. CONCLUSIONS: FAV has a high technical success rate with the ability to achieve biventricular circulation and a low rate of procedure-related mortality if carried out by experienced operators.

Clinical outcomes of COVID-19 infection in congenital heart disease: A single-center experience in Indonesia.

Background: Congenital heart disease (CHD) patients are thought to be vulnerable to COVID-19 complications. In this study, we would like to assess the outcomes and clinical characteristics in COVID-19 CHD patients. Method: A single-center, observational study was conducted in National Cardiovascular Center Harapan Kita (NCCHK). This study included patients with CHD who were hospitalized for COVID-19. The extracted data were baseline characteristics, clinical findings, supportive examination findings, complications, outcomes, and length of stay of the patients. The data were then analyzed using SPSS 26.0 software. Result: Twenty-six patients with CHD and COVID-19 infection were included in our study. There were 24 resolved cases and 2 deaths, four patients experienced complications such as renal insufficiency (1), sepsis (2), and multiorgan failure (1). The median length of stay was 13 days. The most common symptoms experienced by the patients were breathlessness (65.4%), cough (57.7%), and fever (42.3%). Conclusion: We observed a relatively mild COVID-19 clinical course despite prior research showing that patients with cardiovascular comorbidities, such as CHD, have a higher case-fatality rate. This could be because of the smaller sample size, non-standardized diagnosis, severity, treatment, and age group.

Double Stenting in 19-Year-Old Patient With Tetralogy of Fallot With Prior Fractured Stent.

A 19-year-old patient with tetralogy of Fallot was referred to the cath lab because of persistent desaturation and a fractured right ventricular outflow tract stent. Restenting was done because the infundibular stenosis was very tight. Total repair was completed 1 week after the procedure, and at that time, the patient's hemodynamics had greatly improved. (Level of Difficulty: Advanced.).

Echocardiography-Guided Percutaneous Patent Ductus Arteriosus Closure: 1-Year Single Center Experience in Indonesia.

Introduction: Since the first successful percutaneous closure under transesophageal echocardiographic (TEE) guidance, many centers explored transcatheter procedures without fluoroscopy. This single-center study is aimed to show the feasibility and safety of percutaneous patent ductus arteriosus (PDA) closure under echocardiography-only guidance during our 1-year experience. Methods: Patients with PDA were recruited for percutaneous PDA closure guided by either fluoroscopy or echocardiography-only in National Cardiovascular Center Harapan Kita (ClinicalTrials.gov Identifier: NCT05321849, clinicaltrials.gov/ct2/show/NCT05321849). Patients were evaluated clinically and radiologically using transthoracic echocardiography (TTE) at 6, 24, and 48 h after the procedure. The primary endpoint was the procedural success. Secondary endpoints were the procedural time and the rate of adverse events. Results: A total of 60 patients underwent transcatheter PDA closure, 30 patients with fluoroscopy and 30 patients with echocardiography guidance. All patients had successful PDA closure. There were only residual shunts, which were disappeared after follow-up in both groups, but one patient with a fluoroscopy-guided procedure had moderate tricuspid regurgitation with suspected thrombus in the tricuspid valve. The procedural time was not significantly different between the fluoroscopy and echocardiography groups.

Reversed Potts Shunt Outcome in Suprasystemic Pulmonary Arterial Hypertension: A Systematic Review and Meta-Analysis.

BACKGROUND: Reversed Potts shunt has been a prospective approach to treat suprasystemic pulmonary hypertension, particularly when medication treatment fails to reduce right ventricular afterload. OBJECTIVE: This meta-analysis aims to review the clinical, laboratory, and hemodynamic parameters after a reversed Potts shunt in suprasystemic pulmonary hypertension patients. METHODS: Six electronic databases were searched from the date of inception to August 2021, where the obtained studies were evaluated according to the PRISMA statement. The effects of shunt creation were evaluated by comparing preprocedural to postprocedural or follow-up parameters, expressed as a mean difference of 99% confidence interval. Quality assessment was conducted using the STROBE statement. RESULTS: Seven studies suited the inclusion criteria which were included in this article. A reduction in upper and lower limb oxygen saturation [Upper limb: St. Mean difference -0.55, 99% CI -1.25 to 0.15; P=0.04; I2=6%. Lower limb: St. Mean difference -4.45, 99% CI -7.37 to -1.52; P<0.00001; I2=65%]. Reversed Potts shunt was shown to improve WHO functional class, 6-minute walk distance, NTpro-BNP level, and hemodynamic parameters including tricuspid annular plane systolic excursion, interventricular septal curvature, and end-diastolic right ventricle/left ventricle ratio. CONCLUSION: Reversed Potts shunt cannot be said to be relatively safe, although it allows improvement in the clinical and functional status in patients with suprasystemic PAH. Reversed Potts shunt procedure may be the last resort for drug-resistant pulmonary hypertension as it is considered a high-risk procedure performed on patients with extremely poor conditions.

Pharmacology Management in Improving Exercise Capacity of Patients with Fontan Circulation: A Systematic Review and Meta-analysis.

BACKGROUND: The Fontan procedure is currently the mainstay therapy for single functional ventricles. However, with prolonged follow-up duration, various complications have been observed that seriously influence the quality of life of patients. OBJECTIVES: The aim of this meta-analysis is to compare the effectiveness of pharmacologic agents in improving exercise capacity in patients with Fontan circulation. METHODS: This meta-analysis was conducted according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement and has been registered in the International Prospective Register for Systematic Reviews database with registration no. 282352. Quality assessments of the included studies were assessed using the Strengthening Reporting of Observational Studies in Epidemiology (STROBE) statement. RESULTS: Twelve studies met the predetermined inclusion criteria and were included in this metaanalysis. This meta-analysis found that treatment with bosentan significantly improved New York Heart Association Functional Class (NYHA FC) in Fontan patients (standard mean difference - 0.59, 95% CI -0.94 - -0.25; P=0.0008; I2 = 1%). However, the use of bosentan (P=0.66) and sildenafil (P=0.13) did not show a significant improvement in the maximum rate of oxygen consumption (VO2 max). CONCLUSION: This meta-analysis shows that people with Fontan circulation may benefit from using bosentan as it decreases postexercise heart rate and improves NYHA FC and 6-minute walking test results. Therefore, indirectly improving exercise capacity. Nonetheless, considerable work is required to strengthen our knowledge in improving the exercise capacity of Fontan patients.

Case report: Right atrial appendage hybrid access to bailout a stuck stent from the inferior vena cava of a small child.

A three-month-old baby boy (5. 4 Kg) with pulmonary atresia, subaortic ventricular septal defect (VSD), and patent ductus arteriosus (PDA) was sent for ductal stenting from the femoral vein. The route to the PDA was extremely tortuous and the procedure was complicated with a stent stuck in the abdominal inferior vena cava (IVC). Transfemoral stent recapture was technically laborious and the stent was successfully recaptured across a 10-Fr right atrial appendage (RAA) hybrid access avoiding a cardiopulmonary bypass (CBP). The PDA was subsequently stented for the femoral artery with satisfactory clinical outcomes.

A Comparative Effectiveness Systematic Review and Meta-analysis of Drugs for the Prophylaxis of Junctional Ectopic Tachycardia.

BACKGROUND: Junctional Ectopic Tachycardia (JET) is an arrhythmia originating from the AV junction, which may occur following congenital heart surgery, especially when the intervention is near the atrioventricular junction. OBJECTIVE: The aim of this systematic review and meta-analysis is to compare the effectiveness of amiodarone, dexmedetomidine, and magnesium in preventing JET following congenital heart surgery. METHODS: This meta-analysis was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement, where 11 electronic databases were searched from the date of inception to August 2020. The incidence of JET was calculated with the relative risk of 95% Confidence Interval (CI). Quality assessment of the included studies was assessed using the Consolidated Standards of Reporting Trials (CONSORT) 2010 statement. RESULTS: Eleven studies met the predetermined inclusion criteria and were included in this meta-analysis. Amiodarone, dexmedetomidine, and magnesium significantly reduced the incidence of postoperative JET [Amiodarone: risk ratio 0.34; I2= 0%; Z=3.66 (P=0.0002); 95% CI 0.19-0.60. Dexmedetomidine: risk ratio 0.34; I2= 0%; Z=4.77 (P<0.00001); 95% CI 0.21-0.52. Magnesium: risk ratio 0.50; I2= 24%; Z=5.08 (P<0.00001); 95% CI 0.39-0.66]. CONCLUSION: All three drugs have shown promising results in reducing the incidence of JET. Our systematic review found that dexmedetomidine is better in reducing the length of ICU stays as well as mortality. In addition, dexmedetomidine also has the least pronounced side effects among the three. However, it should be noted that this conclusion was derived from studies with small sample sizes. Therefore, dexmedetomidine may be considered as the drug of choice for preventing JET.

Clinical outcome of renin-angiotensin-aldosterone system blockers in treatment of hypertensive patients with COVID-19: a systematic review and meta-analysis.

BACKGROUND: Novel coronavirus disease 2019 has been stated as global disease pandemic due to its rapid spread worldwide. Up to 30% of coronavirus disease 2019 patients with hypertension are more susceptible to death. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers have been used as primary line of medication for hypertension; nonetheless, conflicting data arises as numerous studies showed contradictory results. MAIN BODY: Aiming to show clinical outcome of renin-angiotensin-aldosterone system blockers in hospital treatment of hypertensive patients with coronavirus disease 2019, systematically searched literatures through five databases were intensively appraised using The Grading of Recommendations Assessment, Development and Evaluation checklists for cohort studies. Based on the result evaluation from retrospective cohorts involving more than 15,000 patients across Asia and other regions of the world, ten encompassed studies divided into two subgroups in this meta-review showed that in-hospital hypertensive coronavirus disease 2019 patients receiving antihypertensive drugs were associated with overall risk reduction in subgroup 1 (hazard ratio, HR = 0.96, 95% CI = 0.82-1.12) to no outcome association of all-cause mortalities in subgroup 2 (HR = 0.26, 95% CI = 0.19-0.34). All appraised studies in synergism showed that mortality outcomes were not augmented with the employment of either ACE inhibitor or ARB in subjects. CONCLUSION: Therefore, the results support recommendation by the American Heart Association not to discontinue angiotensin-converting enzyme inhibitor or angiotensin receptor blocker regimens in coronavirus disease 2019 patients with hypertension.