Off-label use of the amplatzer ductal occluder II additional size for percutaneous treatment of acute aortic occlusion in a baby.

We describe the case of a 5-month-old baby with a pro-coagulative condition, referred for rapid atrial tachycardia. At echocardiography we found a large free-floating atrial thrombus that spontaneously embolized into the descending aorta and produced acute sub-renal occlusion. Aorta and iliac vessels were cleared using the ADO II additional sizes device. © 2016 Wiley Periodicals, Inc.

Interventional treatment of congenital heart disease patients.

During the last 10 years the interventional treatment of congenital and structural heart diseases has known enormous changes in techniques, methods and patients management. Lesions previously treated surgically are now approached in the catheterization laboratory. The advent of multidisciplinary approach of congenital heart disease has made possible the development of hybrid techniques, of fetal medicine and of magnetic resonance imaging (MRI)- guided cardiac catheterization. Technological innovation has introduced new concepts in treatment of congenital heart disease patients and has allowed to adapt different techniques to single patients. The knowledge of the evolution of structural heart disease has allowed to chose the best percutaneous and/ or surgical technique and the best materials to optimize long term results. Improvement in non invasive imaging modality has allowed to diminish the radiation exposure and to provide useful information to interventional cardiologists and cardiac surgeons. Absorbable, drug eluting tools will change the treatment and probably the natural history of congenital and structural cardiac and vascular diseases.

[Transfer of cardiac catheterisation from a paediatric to an adult cardiological centre: results at 3 years]. / Transfert de l'activité de cathétérisme cardiaque d'un centre pédiatrique à un centre de cardiologie de l'adulte: trois ans d'activité

The advances of surgical and interventional treatment of congenital heart diseases have allowed a large number of patients with congenital heart disease to reach adult age. This population involves almost 0.3/1000 of total population in West Europe and North America and can be estimated around 200000 patients in France. Patients with operated Tetralogy of Fallot, benign forms of pulmonary atresia with ventricular septal defect, simple or complex transposition of the great arteries usually survive beyond childhood. These patients can need repeated interventions to treat lesions of native or reconstructed pulmonary arteries and/or aortic arch, to occlude residual shunts, to treat pulmonary incompetence. More complex heart diseases such as single ventricle, rarely allow survival until the adult age. The majority of these patients undergo heart transplant, often made difficult by multiple cardiac surgeries, anomalies of pulmonary arteries, chronic cyanosis, aorto-pulmonary shunts. Patients with relatively simple or complex congenital heart diseases need to be followed-up in specialized units, like those created more than twenty years ago in the United States, Canada, and United Kingdom. Interventional cardiac catheterisation play a major role in the management of this population. The results of 3 years of activity in a new centre treating GUCH patients are illustrated.

[Percutaneous occlusion of a left superior vena cava draining into the left atrium: two case reports]. / Occlusion percutanée d'une veine cave supérieure gauche s'abouchant à l'oreillette gauche. A propos de deux observations.

Persistent left superior caval vein draining into the left atrium is responsible for a right-to-left shunt which can be source of desaturation and systemic embolism. We present 2 cases of successful percutaneous treatment in 2 patients in whom no bridging vein existed and systemic desaturation was found after repair of the underlying congenital heart.

[Utilisation of gastric ring systems for pulmonary artery banding: an animal study]. / Utilisation d'un système de cerclage gastrique comme cerclage réglable de l'artère pulmonaire: une étude chez l'animal.

OBJECTIVES: Pulmonary artery banding is often required as a first palliative procedure in infants with congenital heart disease and high pulmonary blood flow or to retrain the left ventricle. The purpose of the study was to demonstrate the safety of a gastric banding system as an adjustable pulmonary artery banding in chronic implantation. METHODS: Five ewes underwent implantation of the banding system around the main pulmonary artery through a left thoracotomy. All had functional evaluation with progressive occlusion and opening of the device every two weeks for a total period of three months. Invasive pressure measurements in the right ventricle and aorta were carried out each time. RESULTS: Devices could be implanted easily. Progressive occlusion and re-opening were possible in all animals during each time point. All animals survived throughout the protocol. Retrieval of the device was achieved in all animals. In one, it was challenging because of the presence of a fibrotic reaction around the device. It died because of pulmonary artery perforation before the sacrifice. At autopsy, microscopic examination showed no signs of myocardial fibrosis. CONCLUSIONS: In animals, gastric banding system is a safe and effective implantable device to adjust pulmonary artery diameter over a prolonged period of time. This new device may be a valuable alternative to the repeated conventional pulmonary artery banding needed for ventricular retraining in humans.

[Use of covered stents to occlude extracardiac Fontan fenestration]. / Utilisation de stents couverts pour la fermeture des fenestrations extracardiaques des dérivations cavopulmonaires totales.

INTRODUCTION: A fenestration is usually surgically created to improve the post-operative course of patients undergoing total cavopulmonary connection. It, however, has a potentially deleterious effect on the long-term period. Closure of these fenestrations is usually performed by interventional catheterization. No device has been specially designed and closure of extracardiac fenestration, in particular, can be challenging. We report our experience in occlusion of such fenestrations using covered stents (Numed Inc). METHODS: From July 2005 to October 2005, we attempted to occlude extracardiac Fontan fenestration using CP covered stents in 4 consecutive patients. RESULTS: All patients had a successful occlusion of the fenestration. The procedure was performed from femoral or jugular vein respectively in three and one patient. Mean central venous pressure did not increase significantly (from 11.25 to 12.75 mmHg) whereas mean oxygen saturation increased significantly from 92% to 99% (p=0.0047). Abolition of shunt was obtained immediately after insertion of the covered stent in all patients. No early complications were observed. All patients were ambulatory the day after the procedure. CONCLUSION: The insertion of a covered stent inside the extracardiac Fontan conduit allowed the exclusion of the fenestration in all patients without the need of crossing the fenestration and with no early mortality or morbidity. Long-term follow-up are needed before considering the use of such device as the device of choice in that application.

[Transcatheter exclusion of a giant aneurysm of the left pulmonary artery using covered stents]. / Exclusion d'un anévrisme géant de l'artère pulmonaire gauche par cathétérisme interventionnel: utilisation de stents couverts.

An 11 year-old boy with an Alagille syndrome was referred for an urgent echocardiography because of new onset of febrile hemoptysis. Follow-up in our institution to that point had shown severe hypoplastic pulmonary arteries. The diagnosis of tricuspid endocarditis complicated by pulmonary embolisms and aneurysm of the left pulmonary artery was done. Despite effective antiobiotics, the evolution was marked by rapid progression in size of the left pulmonary aneurysm. Since the surgery was not an option because of high risk of death, this aneurysm was treated by a trans-catheter technique using covered stents (CP stents, Numed Inc). Its exclusion allowed to stop its progression in size and to avoid its rupture.

[Closure of extrocardiac Fontan fenestration by using the Amplatzer duct occluder]. / Fermeture percutanée à l'aide de l'Amplatzer duct occluder des fenestrations extracardiaques des dérivations cavopulmonaires totales.

INTRODUCTION: A direct or tubular communication between the systemic venous system and the systemic atrium, generally called fenestration, is surgically created to improve the postoperative period of patients undergoing total cavopulmonary connection. However, a fenestration prompts a potentially deleterious right to left shunt, and is generally closed after the postoperative period. Direct fenestrations can be closed using coils, or devices designed for atrial septal defect closure. However, no devices have been designed for closure of extracardiac fenestrations. We report our experience concerning the closure of extracardiac Fontan fenestration by the Amplatzer duct occluder (ADO). METHODS: From January 2001 to December 2002, we closed extracardiac Fontan fenestrations using the ADO device in 10 consecutive patients. Indications to fenestration closure were: low velocity shunt through the fenestration, mild desaturation, and absence of effusions. RESULTS: All patients had a successful closure of the fenestration. The procedure was performed through the femoral vein in 7 cases and through the right jugular vein in 3. Mean central venous pressure increased not significantly from 12 to 13-mmHg. Mean oxygen saturation increased significantly from 90 to 97% (p<0.001). Immediate shut abolition was obtained in 9 cases. No complications were observed. At a median follow-up of 12 months (range 6-18 months), all patients are free of symptoms and have a normal oxygen saturation at rest as well as at exertion. CONCLUSION: The ADO device allowed closing the extracardiac Fontan fenestration in all patients with no mortality, no morbidity and a rate of 100% of complete closure at mid-term follow-up.

[Pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries]. / Atrésie pulmonaire à septum ouvert avec collatérales aorto-pulmonaires majeures.

INTRODUCTION: In order to establish the best strategy of treatment and predictors of outcome in infants with pulmonary atresia with ventricular septal defect and major aorto-pulmonary collateral arteries, we reviewed our institutional experience concerning 47 infants. METHODS: Inclusion criteria included an angiographic diagnosis of pulmonary atresia with ventricular septal defect and major aorto-pulmonary collateral arteries with or without central pulmonary arteries and a repair by the same surgeon. Thirty-one patients had confluent (type III) and 16 absent (type IV) central pulmonary arteries. Pulmonary arteries were considered to be adequate when they measured > or = 4 mm. RESULTS: There were 8 deaths (17%). Complete repair was performed in 24 patients (18 in group III and 6 in group IV) with 79.3% had a right/left ventricular pressure <0.5, 16; 5%<1 and 4.2%>1. Eleven patients are waiting for complete repair and 4 will be operated on pulmonary arteries. One stage complete repair was performed in 3 patients, two and third stage repair (after unifocalisation or right ventricle to pulmonary arteries conduit) was attained in 21 patients. Among patients having had a complete repair and showing a right/left ventricular pressure <0.5, 88.9% had a pulmonary atresia with ventricular septal defect type III and 50% a pulmonary atresia with ventricular septal defect type IV. Only 56% of type III patients with a right/left ventricular pressure <0.5 had adequate central pulmonary arteries. CONCLUSION: In our study, the small size and the absence of central pulmonary arteries do not prevent a positive outcome.

[Successful recanulization of superior venous vessels: a new challenge for interventional pediatric cardiology]. / Reperméabilisation des gros troncs veineux supérieurs: un nouveau défi pour la cardiologie interventionnelle pédiatrique.

UNLABELLED: The use of long-term central venous catheters is a routine in chronic pediatric diseases. Thrombotic complications progressively reduce the central venous capital and hamper the long-term management of these patients. OBSERVATION: We report two cases of obstruction of the central upper venous system and discuss of the techniques used to repermeabilize venous axes before the placement of a new central line. CONCLUSION: The control of the permeability of the central veins should be performed before any withdrawal of central catheters, repermeabilization of the venous axes being simpler when the central catheter is kept in place in the occluded vessel.

Effect of congestive heart failure on rate of atrial natriuretic factor release in response to stretch and isoprenaline.

STUDY OBJECTIVE: The aim was to investigate the pattern of release of atrial natriuretic factor induced by mechanical and adrenergic stimulation from atria of rats with or without congestive heart failure. DESIGN: Monocrotaline, a pyrrolizidine alkaloid, was given to rats to cause severe pulmonary hypertension, leading to a marked degree of right ventricular hypertrophy and failure. Measurements of noradrenaline and atrial natriuretic factor were performed in each cardiac chamber and in plasma. Right and left atria of control rats and rats with congestive heart failure were isolated and subjected to mechanical or adrenergic stimulation to study the in vitro release of atrial natriuretic factor. MATERIALS: Studies were performed on plasma, ventricles, and isolated right and left atria of 276 male Wistar rats, 80-100 g weight, with or without congestive heart failure. MEASUREMENTS AND MAIN RESULTS: In monocrotaline rats right and left ventricular concentrations of noradrenaline were significantly reduced. In the same rats concentrations of atrial natriuretic factor fell to 15.2% in the right atria and to 65.5% in the left atria. Whole heart content of atrial natriuretic factor was diminished, while plasma concentrations were increased sevenfold. Isolated hypertrophied right atria of failing hearts did not release atrial natriuretic factor in response to stretch or to isoprenaline (10(-9)M) and they were insensitive to the inotropic action of isoprenaline. On the other hand, non-hypertrophied left atria from the same animals released increased amounts of atrial natriuretic factor under basal conditions and after both stimuli, despite reduced tissue stores of the peptide. CONCLUSIONS: Heart failure may deplete cardiac stores of noradrenaline and atrial natriuretic factor, especially in hypertrophied chambers, and can result in a decrease in the release of atrial natriuretic factor from atrial tissue in response to mechanical and adrenergic stimulation.

Regression of pulmonary fistulas in congenital heart disease after redirection of hepatic venous flow to the lungs.

Although the etiology of pulmonary fistulas in congenital heart disease remains unknown, several hemodynamic factors are thought to play a role. Recently it was postulated that hepatic venous effluent might protect the pulmonary bed from development of pulmonary fistulas. However, there are no experimental data supporting this hypothesis. Here, we present the cases of 2 patients in whom pulmonary fistulas developed after unintentional surgical exclusion of the hepatic venous flow from the pulmonary circulation. In both patients, symptoms resolved after rerouting of the hepatic venous blood to the lungs.

Levels of atrial natriuretic factor in the plasma and urine of patients with and without heart failure.

We assayed the concentrations of atrial natriuretic factor and guanosine 3',5'-phosphate in the plasma and urine of six healthy subjects, 12 patients with coronary artery disease and 11 patients with congestive heart failure. Patients with coronary artery disease had normal levels of atrial natriuretic factor in the plasma and urine and a normal excretion of guanosine 3',5'-phosphate, while those with congestive heart failure had a raised level of atrial natriuretic factor in the plasma, an increased excretion of 3',5'-guanosine phosphate and normal excretion of atrial natriuretic factor. Thus, measurement of atrial natriuretic factor in the urine can not replace the assay of the peptide in plasma.

Plasma levels of atrial natriuretic factor (ANF) and urinary excretion of ANF, arginine vasopressin and catecholamines in children with congenital heart disease: effect of cardiac surgery.

We studied the changes in the plasma concentration of atrial natriuretic factor (ANF) and the urinary excretion of ANF, arginine vasopressin (AVP) and catecholamines in 22 children with congenital heart disease, divided into two groups. Group 1 included 11 children with congestive heart failure (CHF), treated with digitalis and diuretics. Group 2 included 11 children without CHF and without medical treatment. Each group was compared with a control group of 15 healthy, age-matched children. The plasma concentration of ANF was raised in both groups, but it was significantly higher in group 1 (235.5 +/- 82.9 pg/ml), compared to group 2 (48.4 +/- 29.4 pg/ml, P < 0.002). Urinary excretion of ANF was measurable in both groups and higher in group 1 (185.9 +/- 116.2 pg/kg per h) than in group 2 (48.5 +/- 30.7 pg/kg per h), but not significantly so. Urinary excretion of AVP and catecholamines was not different in children with congenital heart disease and healthy children. Twenty-four hours after surgery, plasma ANF diminished in group 1 (from 235.5 +/- 82.9 to 93.4 +/- 53.8 pg/ml, P < 0.003), but did not change in group 2. The urinary excretion of ANF was unchanged in both groups. In contrast, urinary excretion of AVP and catecholamines rose significantly in both groups. These data show that plasma ANF is increased in children with congenital heart disease, even in the absence of CHF. The measurement of urinary ANF is less reliable than a plasma assay. The postoperative increases in AVP and catecholamine urinary excretions could be responsible for the vasoconstriction and water retention typical of the postoperative period.

[Atrial septal defect calibration: comparison of methods using balloons and 3D-transesophageal echocardiography]. / Calibrage des communications interauriculaires: comparaison des méthodes du ballon et de l'échocardiographie transoesophagienne 3D.

The atrial septal defects (ASDs) occlusion by cardiac catheterization is an alternative to the surgical technique. The use of stretching by balloon is considered as the gold-standard for the ASDs calibration. Three dimensional transesophageral echocardiography (3D-TEE) brings an imaging of the ASD surface and allows the measurement of its maximal diameter. With the goal of a percutaneous ASD occlusion, seventy patients had a simultaneous calibration of the ASDs by 3D-TEE and the balloon method. The mean maximal diameter measured by 3D-TEE was at 20 + 15 mm (range 10-28 mm) compared to the mean balloon-stretched diameter at 22 + 5 mm (range 9-31 mm). The correlation between both methods is good (y = 3.15 + 0.77x, r = 0.8, p < 0.0001). The mean difference between the diameters measured by both methods was 1.85 + 3.17 mm. The ASD visualized by 3D-TEE was single in 54 cases and multiple in 16 cases. The correlation between both methods was excellent in those with a single ASD (y = 1.74 + 0.84x; r = 0.85. p < 0.0001) but it was poor in those with multiple ASD (y = 12.4 + 0.4x; r = 0.45). The calibration by the balloon method which tests the septum resistance is an additive method to 3D-TEE which measures the anatomic diameter of ASD.

[Multicentre study of percutaneous closure of interventricular muscular defects with the aid of an Amplatzer duct occluder prosthesis]. / Etude multicentrique de la fermeture percutanée des communications interventriculaires musculaires à l'aide d'une prothèse Amplatzer duct occluder.

Percutaneous closure of interventricular defects is an alternative or adjunct to surgery with the disadvantage of a sometimes prolonged and difficult catheterisation only during which the choice of prosthesis can be determined. Despite the existence of an occlusion prosthesis, the Amplatzer Septal Defect Occluder, specifically conceived for this purpose, an arterial canal occlusion prosthesis such as the Amplatzer Duct Occluder is sometimes better suited for the occlusion of certain interventricular defects. Since 1999, 11 Amplatzer Duct Occluders were used for the closure of interventricular muscular defects, during 10 catheterisations in 9 patients with a median age of 2.5 (0.1 to 43.9) years. In 5 cases there were residual septal defects after failure of initial surgery. 10 were successful with prostheses of 6/4 mm to 12/10 mm while in one patient the interventricular communication had to be closed surgically because the 14/12 mm prosthesis could not be positioned due to a tortuous introduction route. The only complication was a pericardial effusion requiring surgical drainage in one infant. After a median follow up of 2.1 (0.3 to 4.2) years, all of the patients had a satisfactory functional status, with minimal residual shunt on echocardiography in 2 cases. The Amplatzer Duct Occluder therefore seems better adapted for the closure of post-operative residual interventricular communications, with a thickened interventricular septum or even when the tricuspid valve is very close to the right ventricular side of the orifice.

[Use of 3 French catheters for diagnostic and interventional procedures in newborns and small infants]. / Utilisation d'introducteurs 3 French pour le cathétérisme diagnostique et interventionnel chez le nouveau-né et le jeune enfant.

Miniaturisation of diagnostic and interventional tools is of main interest for cardiac catheterization of newborns and small infants, due to the limited vascular access of these patients. Since January 2001 to November 2002, we performed 11 diagnostic and 5 interventional procedures in 15 infants, utilising custom-made 3 F sheaths and catheters. The median age and weight of the patients were 7 days (range 1-180) and 2.8 kg (range 2-4), respectively. Diagnostic catheterizations gave the required information in all cases. Angiography was performed following the results of in vitro pressure to volume tests. Blood sampling was possible by using gentle aspiration. Pressure measurement, although showing some dumping, allowed the evaluation of peak to peak gradient through right and left ventricular outflow tracts. It was always possible to perform an interventional procedure, when required. No procedural complications occurred. The price for a diagnostic or interventional procedure performed with 3 F sheath and catheters exceeded of 23 euros that of a procedure performed with material measuring 4 F or more. Patients underwent echographic examination of femoral vessels at a median follow-up of 6.3 months (range 2-10 months). All vessels of the examined patients were patent, without stenosis nor collateral circulation. In conclusion, preliminary results utilising 3 F sheaths and catheters are encouraging, in terms of feasibility of diagnostic and interventional procedures, absence of procedural complications and preservation of vascular access. Financial implications are not of major concern.

[Coronary fistula in tetralogy of Fallot: a rare complication of embolisation]. / Embolisation d'une fistule coronaire chez une patiente opérée d'une tétralogie de Fallot: survenue d'une complication rare.

The authors report the spontaneous detachment of a coil during embolisation of a coronary fistula in a 34 old year woman with operated tetralogy of Fallot. The fistula originated from an isolated circumflex artery and drained into the infundibulum. By retrograde approach, a microcatheter was successfully advanced into the distal part of the fistula, one coil loop was fixed through the fistula mouth and two in its distal portion. During positioning of the proximal part of the coil, it suddenly detached into the microcatheter. Coaxial snaring of the coil was attempted, however this manoeuvre produced progressive elongation and repeated ruptures of the coil. Finally, the procedure was abandoned; surgical extraction of the coil and suture of the fistula were successfully performed. Percutaneous transcatheter closure of coronary fistulae, although generally feasible is burdened by complications due to tortuous anatomy, poor stabilisation of catheters and lack of specific materials.

[Experience of implantation of prefitted Palmaz Corinthian stents]. / Expérience de l'implantation de stents Palmaz Corinthian prémontés chez l'enfant.

We report our recent experience with the Palmaz Corinthian stent in children. Since 1/10/01 to 1/11/02 we implanted 18 Palmaz Corinthian stents in 12 children. Median age and weight of patients were 5.6 years (range 0.25-13) and 17.9 kg (range 3-36), respectively. Primary diagnosis were: pulmonary atresia with ventricular septal defect (n = 7), complex transposition of the great arteries (n = 2) and others (n = 3). Indications to stent implantation were: pulmonary branches stenosis (n = 9), stenosis of the ductus arteriosus (n = 1), stenosis of systemic veins (n = 2). All stents were pre-mounted and co-axially advanced over a standard guidewire across the stenotic site, using a 6F short introducer. Stent deployment was performed by hand inflation of the balloon. Final angiography confirmed correct positioning and ruled out complications. Median fluoroscopy time was 18 minutes (range 12-56). All stents reached their nominal diameter; 2 were post-dilated to 125 and 150%. No procedural complications occurred. Despite the impossibility of distal injection, stent positioning was always correct. In conclusion, due to the availability of pre-mounted stents, and the need of short 6F sheaths, the use of the Palmaz Corinthian stent in children is relatively simple. Primary results are generally good in terms of adequate delivery and absence of complications. However, the impossibility of distal injection makes more difficult the choice of the deployment site. Due to the limited possibility of over-dilation, the use of this stent has to be limited to the stenosis of peripheral pulmonary branches or to lesions that can be surgically treated during further surgical procedures.

[Early complications of stenting in children and young adults with congenital heart disease]. / Complications précoces de l'implantation de stents chez l'enfant et le jeune adulte ayant une cardiopathie congénitale.

We report the early complications of stent implantation. Since 1/1/97 to 1/12/02, we implanted 91 stents in 76 patients. Median age and weight were 15 years (range 0.3-43) and 49 kg (range 3-96). Primary diagnosis were: pulmonary atresia with ventricular septal defect (n = 17), tetralogy of Fallot (n = 13), aortic coarctation (n = 15), transposition of the great arteries (n = 3), truncus arteriosus (n = 6), univentricular heart (n = 7), other anomalies (n = 28). Indications to stent implantation were: stenosis of the pulmonary outflow and/or pulmonary branches (n = 44), aortic recoarctation (n = 14), native aortic coarctation (n = 1), systemic venous channels obstruction (n = 14), other (n = 3). The stents were: Palmaz (n = 57), non premounted CP (n = 8), premounted CP (n = 3), Palmaz Corinthian (n = 19), self-expanding (n = 4). Procedural complications occurred in 24 patients (31%) and included: 11 balloon bursting, 8 stent slipping, 1 stent migration, 4 wall dissections. Five patients (21%) needed urgent surgery. Sixty three percent of complications occurred during pulmonary outflow or pulmonary branches stenting, 25% during stenting of the aortic arch, 12% during other procedures. All but 2 complications were observed with non premounted stents. In conclusion, the use of not premounted stents, although widely diffuse, has a not negligible incidence of complications, leading to longer procedures, to the use of a large variety of materials and needing more than occasionally a surgical solution. A larger use of premounted stents, when possible, is recommended.