Postoperative catheter thrombaspiration to open an occluded right ventricle-to-pulmonary artery conduit in child.

We report on a 6-year-old girl (18 kg/120 cm) who was diagnosed on day 6 postoperative with an occlusive thrombosis of a right ventricle-to-pulmonary artery conduit in the setting of a Ross procedure that was performed for severe native aortic valve insufficiency secondary to late diagnosis of bacterial endocarditis. We applied the Indigo® aspiration system from Penumbra® (Alameda, USA) to mechanically dissolve and remove the thrombus, restore flow, gradually wean from extracorporeal support, and replace the conduit after 4 days. The patient experiences good surgical outcomes at 3 months of follow-up.

Systematic approach to obtain axillary arterial access for pediatric heart catheterizations.

Background: Axillary arterial access (AAA) in pediatric heart catheterizations is undervalued. Methods: We retrospectively reviewed children with congenital heart diseases (CHDs) who received trans-axillary arterial catheterizations between January 2019 and February 2023. We aimed ultrasound-guided punctures in the proximal two-thirds of axillary arteries with diameters ≥2 mm to insert 7 cm/4 Fr short introducers. We administrated intra-arterial verapamil (1.25 mg) and heparin (100 UI/kg). We infiltrated per-operatively 2% lignocaine (10 mg) for arterial spasms, long sheaths use (≥5 Fr), and ≥60 min procedures in <3 kg patients. Results: We identified 30 patients (66.7% males) with a median age of 1.1 months (IQR, 0.3-5.4), and a median weight of 3.1 kg (IQR, 2.7-3.7). 5/30 patients had six redo interventions after a median of 3.9 months (IQR, 1.7-5.1). Overall, 27/36 procedures were interventional, including 6 aortic valvuloplasties, 6 balloon angioplasties, and 15 stenting procedures. The median arterial axillary angiographic diameter was 2.6 mm (IQR, 2.4-3). Access was right-sided in 23/36 (63.9%) procedures and obtained using 21G/2.5 cm bevel needles in 25/36 (69.4%) procedures. No hemodynamical change occurred after introducing spasmolytic drugs. The median fluoroscopy time was 26.1 min (IQR, 19.2-34.8). There were two self-resolving arterial dissections, one sub-occlusive arterial thrombosis (resolved with 6 weeks of enoxaparin), and one occlusive arterial thrombosis (resolved with alteplase thrombolysis and 6 weeks of enoxaparin). Median follow-up was 11.7 months (IQR, 8-17.5). Four patients with complex univentricular hearts died from non-procedural causes at a median of 40 days (IQR, 31-161) postoperative. Conclusion: Systematic approach for AAA is the key to success and unlocks the many potentials of trans-axillary pediatric cardiology interventions.

Word of caution: silent late device embolisation after perimembranous ventricular septal defect closure in a 6-Kg infant.

We report on a 6-month-old infant (6 Kg/ 64 cm) with perimembranous ventricular septal defect (absent sub-aortic rim, 10 mm left ventricular entry, and 4 and 6 mm right ventricular exists) and successful retrograde closure using an 8x6 mm KONAR-MF™ VSD occluder (Lifetech, China). Immediate and 48 hours post-procedure ultrasounds showed an accurately positioned device and two jets of mild-to-moderate residual shunts. At the 2-week follow-up, the device did not change position and the shunt was stable and intra-prosthetic. The scheduled 3-month follow-up was skipped for familial reasons. The patient came back without alarming symptoms for the regular 6-month follow-up, and the device was found embolised to the left pulmonary artery. The device was retrieved surgically, and the defect was patch-closed with excellent outcomes. There was a pseudoaneurysm involving the tricuspid valve chordae and the device was endothelialized partially on one edge suggesting that embolization occurred somewhere between 3 months and 6 months post-operative. Defects with compromised anatomies should be closed surgically to avoid suboptimal results, especially in small infants.

Proof of Concept: A New Solution for Low-Profile Transcatheter Implantation of Optimus-L Stents in Small Children.

BACKGROUND: There is no stent designed or approved for use in infants. We sought to obtain in vitro and in vivo data on a new concept conceived to implant Optimus-L stents at infant vessel diameters and offer a potential long term stent solution. METHODS: Nineteen Optimus-L stents were mounted on 8 types of angioplasty balloons with diameters 6, 8, and 10 mm with the use of an injection-moulded hand crimper. We evaluated balloon-stent unit (BSU) stability before insertion and advancement through short Terumo introducers with incremental French size and possibility of side-arm contrast injections. Three types of long sheaths were tested. Stents were inflated to balloon nominal diameters and re-expanded to 18 and 23 mm. Stent recoil, foreshortening, and fracture were evaluated. In vivo implantations were performed afterward. RESULTS: In vitro: Medtronic Evercross balloons and modified Terumo Destination sheaths were the best combination: BSUs were inserted in 6 F sheaths with possible injections (for 6 and 8 mm balloons), and 7 F sheaths without injections (for the 10 mm balloon). Retrieving BSUs inside the sheath required 1 additional F-size. Boston Scientific Sterling and Balton Lovix balloons, as well as APT Braidin L guiding sheaths showed unsatisfactory performance. Dilation up to 23 mm was possible, and stent shortening was < 24% at 18 mm and < 37% at 23 mm. Recoil was limited, and no stent fractured. In vivo: Optimus-L stents were used to treat 2 infants with aortic coarctation and 2 children with pulmonary artery stenosis with the use of 8 mm balloons and low-profile access. CONCLUSIONS: Optimus-L stents can be implanted safely in small patients with a low-profile approach. These stents have the potential to achieve adult size while maintaining structural integrity.

Cerebral embolic protection during transcatheter stent expansion of restrictive extra-cardiac Fontan conduit.

We report a 20-year-old female patient (76 Kg/164 cm) with an extra-cardiac Fontan circulation who was referred to our institution for exertional dyspnoea and desaturation. The patient was diagnosed with a large calcified thrombus at the level of the Fontan fenestration, protruding inside the lumen of the conduit and reducing the diameter by half with a 3 mmHg pressure gradient. Transcatheter stent expansion of the obstructed extra-cardiac conduit was done with a 48 mm long XXL PTFE-covered Optimus-CVS® under temporary cerebral embolic protection with a TriGUARD-3™ deflection filter device (Keystone Heart). There was no procedural complication and the 3 months clinical outcomes are good.

SwiftNINJA steerable microcatheter: a new kid on the block for selective catheterization of vascular and valvular congenital lesions.

Background: SwiftNINJA (Merit Medical Systems, USA) is a novel steerable microcatheter intended for coronary and peripheral vascular interventions. We evaluate and report the first use of SwiftNINJA in pediatric catheterization of congenital heart defects (CHDs). Methods: We performed a retrospective clinical data review of children with CHDs in whom SwiftNINJA was used during cardiac catheterization between April 2022 and June 2023. Utility, application, and standard safety were described comprehensively. Results: We identified 19 patients (78.9% males) with a median age of 5.3 months (IQR, 2-13.9), and a median weight of 5.3 kg (IQR, 4-7.7). 36.8% of the catheterizations were transarterial and 78.9% were interventional. SwiftNINJA was applied upfront in 3/19 patients to cannulate precisely the right pulmonary artery and eliminate the risk of dislocating a freshly implanted left pulmonary flow restrictor. In 16/19 patients, SwiftNINJA was applied after a median of 5 (IQR, 5-7) failed catheterization attempts using various combinations of catheters, microcatheters, and wires to cannulate challenging vasculature in seven, engage the lumen of stented vessels in five, cross complex aortic valve stenosis in three, and cross an apical ventricular septal defect in one patient with Damus-Kaye-Stansel repair. After the SwiftNINJA application, catheterization was done from the first attempt in 12/16 patients and from the second attempt in 4/16 patients. The median applied tip angulation was 90 degrees (IQR, 85-95). All procedures were completed successfully. No device malfunction or adverse events occurred. Conclusions: SwiftNINJA is a valuable addition for selective catheterization of challenging vasculatures or valvular anatomies in children with CHDs.

Improvised bespoke technique for atrial septostomy in the shortage of atrioseptostomy balloon catheters.

Atrioseptostomy balloon catheter is an essential item to have on our shelves. However, the recall and shortage in production of the commonly used balloon atrioseptostomy catheters posed an imminent threat to our patients. Herein, we present the case of a newborn with a post-natal diagnosis of simple transposition of great arteries and restrictive atrial communication where repeated static balloon atrial septostomy using a 9 mm x 20 mm Sterling balloon failed to improve his status. We had to improvise per-operatively a new bespoke technique to perform a vital pull-through balloon atrial septostomy. The distal third of a 10 mm x 20 mm semi-compliant Cristal balloon was exteriorised out the tip of a 6-Fr 55 cm Cook Flexor sheath in the left atrium, and both were simultaneously pulled back to the right atrium to create an 8 mm septal defect. The procedure was successful without any complications. The baby was weaned off prostaglandin on day 3 and surgically repaired on day 5 with excellent results.

Transcatheter Management of Pulmonary Sequestrations in Children-A Single-Center Experience.

BACKGROUND: A pulmonary sequestration (PS) is an area of bronchopulmonary tissue with aberrant arterial supply. Transcatheter occlusion of PSs is an appealing treatment option, but data on outcomes remain scarce. We aim to describe our experience with transcatheter management of PS in infants and children. METHODS: Retrospective review of clinical data of all patients with suspected PS sent for diagnostic and/or interventional cardiac catheterization at our institution between January 1999 and May 2021. Procedural considerations, techniques, standard safety, and outcomes were assessed. RESULTS: We identified 71 patients (52.1% males), with median age and weight of 4.9 months (IQR, 2.1-26.6) and 4.2 kg (IQR, 3.9-12.1), respectively. Sixty-one (86%) patients had associated congenital heart defects (CHDs). Forty-two (59%) patients had pulmonary arterial hypertension (PAH) at the time of diagnosis. Fifty-three (74.7%) patients underwent embolization of the PS feeding vessel using microcoils and/or vascular plugs, and eight (15.1%) of these were neonates who presented with severe PAH and cardiac failure. Two patients had large feeding vessels and were treated surgically. Sixteen (22.5%) patients with small feeding vessels received conservative management. At median follow-up of 36.4 months (IQR, 2.1-89.9), seven patients had died, 24 patients had CHD corrective surgeries, 26 patients had redo catheterizations, and five patients had persistent PAH. No PS surgical resection was needed, and no infection of the remaining lung tissue occurred. CONCLUSIONS: Transcatheter assessment and treatment of PSs is a safe and effective procedure. Neonates with large PSs are severely symptomatic and improve remarkably after PS closure. PS embolization and surgical repair of associated CHDs generally leads to the normalization of pulmonary pressures.

Outcomes of manually modified microvascular plugs to pulmonary flow restrictors in various congenital heart lesions.

Background: The development of microvascular plugs (MVPs) has enabled novel transcatheter deliverable endoluminal pulmonary flow restrictors (PFRs) with the potential to treat newborns and infants with life-threatening congenital heart diseases (CHDs) in a minimally invasive manner. We present our experience to evaluate the efficacy of this concept in controlling pulmonary blood flow in various CHDs. Methods: Retrospective clinical data review of patients with CHD and pulmonary over-circulation who received bilateral PFRs percutaneously. Results: Twenty-eight PFRs (7 MVP-5Q, 12 MVP-7Q, and 9 MVP-9Q) were finally implanted in 14 patients with a median age of 1.6 months (IQR, 0.9-2.3) and a median weight of 3.1 Kg (IQR, 2.7-3.6). Nine patients had large intra-cardiac left-to-right shunts (including 3 with fatal trisomy and palliative programs), 2 had borderline left ventricles, 2 had Taussig-Bing anomaly, and one had a hypoplastic left heart. Four patients had concomitant ductal stenting. Two MVP-5Qs were snare-removed and upsized to MVP-7Q. Patients experienced a significant drop in oxygen saturation and Qp/Qs. All patients were discharged from the ICU after a median of 3.5 days (IQR, 2-5.8) postoperative. Five patients had routine inter-stage catheterization and no device embolization or pulmonary branch distortion was seen. Fourteen (50%) PFRs were surgically explanted uneventfully on a median of 4.3 months (IQR, 1.2-6) post-implantation during biventricular repair in 6 patients and stage-2 palliation in one patient. The latter died 1 month post-operative from severe sepsis. Four patients are scheduled for surgical PFR removal and biventricular repair. Two patients with trisomy 18 died at 1 and 6.8 months post-procedure from non-cardiac causes. One patient with trisomy 13 is alive at 2.7 months post-procedure. Conclusion: It is feasible to bespoke MVPs and implant them as effective PFRs in various CHDs. This approach enables staged left ventricular recruitment, comprehensive stage-2 or biventricular repair with lower risk by postponing surgeries to later infancy. Device explantation is uneventful, and the outcomes afterward are promising.

Comparative outcomes of two competitive devices for retrograde closure of perimembranous ventricular septal defects.

Background: Retrograde closure of perimembranous ventricular septal defects (pmVSDs) is a well-established procedure. However, interventionists are still looking for the best closure device. Methods: We performed a single-center retrospective review of 5-year-experience (from July 2015 to July 2020) with retrograde closure of pmVSDs using AmplatzerTM Duct Occluder II (ADOII) and KONAR-MF™ VSD occluder (MFO). Deficient sub-aortic rim (SAR) (≤2.5 mm for MFO and ≤3 mm for ADOII) was an exclusion criterion in defects with a diameter ratio (right-side exit/left-side entry) > 0.5. Results: We identified 77 patients (57.1% males) with a median age of 4.3 years (IQR, 2.2-8.3) and a median weight of 16 kg (IQR, 11.2-24.5). 44 (57.1%) defects (22.7% with deficient SARs) with a median left-side defect diameter of 8.7 mm (IQR, 5.7-10) were closed with ADOIIs. 33 (42.9%) defects (51.5% with deficient SARs) with a median left-side defect diameter of 10.8 mm (IQR, 8.8-13.5) were closed with MFOs. One 7/5 MFO was removed before release and upsized to a 12/10 MFO. Implantation success rate was 100% with ADOII and 90.9% with MFO devices. Two MFOs were snare-recaptured after embolization, and one 9/7 MFO was snare-retrieved for a new onset of grade-2 aortic regurgitation that persisted afterward. Median follow-up was 3.3 years (IQR, 2.1-4.2) for ADOII and 2.3 years (IQR, 1.7-2.5) for MFO. No permanent heart block or death occurred. Freedom from left ventricular dilation was 94.62% at 36 months of follow-up. Freedom from residual shunt was 90.62% for MFO and 89.61% for ADOII at 24 months of follow-up. One 2.6-year-old patient with baseline mild aortic valve prolapse and trivial aortic regurgitation developed a grade-2 aortic regurgitation after 9/7 MFO implantation. He was treated surgically after two years without device extraction. One new grade-2 asymptomatic tricuspid regurgitation persisted at the last follow-up in the ADOII group. Conclusions: ADOII and MFO are complementary devices for effective retrograde closure of pmVSDs in children, including defects with absent or deficient SAR. ADOII is limited to smaller defects but offers a lower profile and a flexible left-side disk for better maneuverability over the aortic valve during retrograde implantation.

FAST technique: fast atrial sheath traction technique for device closure of atrial septal defects.

Background: Transcatheter closure of atrial septal defects (ASDs) is well-established. However, this procedure can be challenging, requiring multiple attempts and advanced implantation maneuvers. Materials and methods: From July 2019 to July 2022, patients to whom the fast atrial sheath traction (FAST) technique was applied for ASD device closure were prospectively followed up. The device was rapidly unsheathed in the middle of the left atrium (LA) to let it clamp the ASD from both sides simultaneously. This novel technique was directly applied in patients with absent aortic rims and/or ASD size-to-body weight ratio higher than 0.9 or after failed attempts of standard implantation. Results: Seventeen patients (64.7% males) were involved with a median age of 9.8 years [interquartile range (IQR), 7.6-15.1] and a median weight of 34 kg (IQR, 22-44). The median ASD size on ultrasound was 19 mm (IQR, 16-22). Five (29.4%) patients had absent aortic rims, and three (17.6%) patients had an ASD size-to-body weight ratio higher than 0.9. The median device size was 22 mm (IQR, 17-24). The median difference between device size and ASD two-dimensional static diameter was 3 mm (IQR, 1-3). All interventions were straightforward without any complications using three different occluder devices. One device was removed before release and upsized to the next size. The median fluoroscopy time was 4.1 min (IQR, 3.6-4.6). All patients were discharged the next postoperative day. On a median follow-up of 13 months (IQR, 8-13), no complications were detected. All patients achieved full clinical recovery with complete shunt closure. Conclusion: We present a new implantation technique to efficiently close simple and complex ASDs. The FAST technique can be of benefit in overcoming left disc malalignment to the septum in defects with absent aortic rims and in avoiding complex implantation maneuvers and the risks of injuring the pulmonary veins.

Failure to post-dilate BeSmooth peripheral stents to adult vessel size diameters during benchside tests.

BACKGROUND: Low-profile stent implantation remains a rescue treatment for aortic coarctation and branch pulmonary arteries stenosis in small children. Stent re-expansion to cope with vascular growth remains problematic. OBJECTIVES: To evaluate ex vivo feasibility and mechanical behaviour of over-dilating BeSmooth peripheral stents (Bentley InnoMed, Germany). METHODS: Three BeSmooth peripheral stents in diameters of 7, 8, and 10 mm were dilated to nominal pressure and then 13 atm. BeSmooth Ø7 × 23 mm was sequentially post-dilated using 12, 14, and 16 mm high-pressure balloons. BeSmooth Ø10 × 57 mm was post-dilated with a 14 mm balloon and then with a 48 mm bare-metal Optimus XXL stent hand-mounted on a 14 mm balloon (stent-in-stent). BeSmooth Ø8 × 57 mm was directly post-dilated with a 48 mm bare-metal Optimus XXL stent hand-mounted on a 16 mm balloon (stent-in-stent). The stents' diameter and length were measured. Digital inflation pressure was noted. Balloon rupture and stent fracture patterns were closely evaluated. RESULTS: At 20atm pressure, BeSmooth Ø7 × 23 mm shortened to 2 mm forming a 12 mm diameter solid ring circle and the woven balloon ruptured radially. At 10 atm pressure, BeSmooth Ø10 × 57 mm fractured longitudinally in various dispatched breaking points at a diameter of 13 mm without shortening and ruptured the balloon with multiple pinholes. At 10 atm pressure, BeSmooth Ø8 × 57 mm fractured centrally at three different points at a diameter of 11.5 mm without shortening and the balloon broke radially in half. CONCLUSIONS: In our benchmark tests, extreme shortening, severe balloon rupture, or unpredictable stent fracture patterns at small balloon diameters limits safe post-dilation of BeSmooth stents beyond 13 mm. BeSmooth stents are not ideal candidates for off-label stent interventions in smaller patients.

Transvenous retrograde thoracic duct embolization for effective treatment of recurrent plastic bronchitis after fontan palliation.

We report the case of a 5.5-year-old patient (16 kg/105 cm) who presented with plastic bronchitis (PB) refractory to conservative treatment 3 months after completion of Fontan palliation. Bi-inguinal transnodal fluoroscopy-guided lymphangiogram confirmed the chylous leak originating from the thoracic duct (TD) into the chest and did not opacify any central lymphatic vessel for direct transabdominal puncture. Retrograde transfemoral approach was adopted to catheterize the TD and selectively embolize its caudal portion using microcoils and liquid embolic adhesive. Recurrence of symptoms after 2 months indicated a redo catheterization to occlude the TD entirely using the same technique. The procedure was successful and the patient was discharged after 2 days with sustained clinical improvement at 24 months postoperative. In the context of refractory PB, end-to-end transvenous retrograde embolization of the TD appears to be an interesting alternative to more complex interventions such as transabdominal puncture, decompression, or surgical ligation of the TD.

Early spontaneous closure of large arterial ducts in two term neonates with Ebstein anomaly after failed attempts of transcatheter closure.

In neonatal Ebstein's anomaly of the tricuspid valve, prolonged ductal patency in patients without anatomic pulmonary valve atresia can be deleterious. Circular shunts may develop in patients with different degrees of pulmonary and tricuspid insufficiency. Closure of the arterial duct may result in haemodynamic improvement in particular scenarios. The transcatheter approach is a valuable closure alternative despite some technical difficulties in large-sized arterial ducts and low birth weight neonates. Herein, we report on two consecutive term newborns with Ebstein's anomaly and large arterial ducts in whom mechanical stimulus of the arterial duct during failed attempts of transcatheter closure led after two days to definitive closure followed by good clinical outcomes.

Multicentre experience with Optimus balloon-expandable cobalt-chromium stents in congenital heart disease interventions.

OBJECTIVES: To evaluate bare-metal Optimus and polytetrafluoroethylene (PTFE)-covered Optimus-CVS balloon-expandable, cobalt-chromium, hybrid cell-designed stents in congenital heart disease (CHD) interventions. METHODS: Retrospective multicentre review of patients with CHD receiving Optimus stents. Stent mechanical behaviour, clinical indications and outcomes were assessed. RESULTS: 183 stents (49.2% XXL/15-ZIG, 33.3% XL/12-ZIG, 17.5% L/9-ZIG) were implanted (98.9% success rate, 2.3% serious procedural complication rate) in 170 patients (57.6% men, 64.1% adults), median age 23.6 years (IQR, 15.2-39.2) and weight 63.5 kg (IQR, 47-75.7). Indications were right ventricular outflow tract stand-alone stenting or before revalvulation (62.4%), aortic coarctation treatment (15.3%), Fontan-circuit fenestration closure (12.4%) and miscellaneous (10%). 86/170 (50.6%) patients had PTFE-covered stenting (50% prophylactic). In 86/170 (50.6%) patients with stenotic lesions, median percentage of achieved stent expansion was 93.4% (IQR, 85.5%-97.7%), median gradient decreased from 28 mm Hg (IQR, 19-41) to 5 mm Hg (IQR, 1-9) (p<0.001), median vessel diameters increased from 13 mm (IQR, 7.9-17) to 18.9 mm (IQR, 15.2-22) (p<0.001) and percentage of vessel expansion was 45.2% (IQR, 19.8%-91.3%). In 30/36 (83.3%) patients with graft, median dilation of 2 mm (IQR, 2-5) above nominal diameter was achieved. Median stent shortening was 10.9% (IQR, 6.1-15.1) and was associated only with expansion diameter (OR: 0.66, 95% CI: 0.38 to 0.93). No clinically relevant fracture, stent embolisation or dysfunction occurred on a median follow-up of 9 (IQR, 4-14) months. CONCLUSIONS: Optimus stents are effective tools for transcatheter treatment of simple and complex CHD. Optimus stents' reliable mechanical behaviour and particular covering design can promote widespread use.

A word of caution: Early failure of Magmaris® bioresorbable stent after pulmonary artery stenting.

Bioresorbable scaffolds (BRS) have been advocated as the fourth revolution in interventional cardiology medical devices with promising technology to improve the treatment of coronary artery disease with an event-free future. We describe the first reported use and early collapse of the Magmaris® Resorbable Magnesium Scaffold (RMS) stent (BIOTRONIK AG, Switzerland) to relieve left pulmonary artery severe stenosis in a newborn after the Norwood procedure. The stent collapse was detected 2 weeks after implantation and urgently treated with a balloon-expandable stent. This complication raises the alarm about the need to keep implanted RMS under scrutiny. The possibility of faster scaffold resorption in small babies or lack of sufficient radial force of RMS to resist acute vessel recoil has led to ineffective relief of branch pulmonary artery stenosis and failure to enable a safe short-term bridge to Stage II palliation.

Percutaneous stent implantation for occluded central shunts in adults: A case report and review of current evidence.

Background: Patients with cyanotic complex congenital heart defects (CHDs) commonly undergo palliation with interposition of systemic-to-pulmonary shunts (SPSs). These palliative shunts are rarely found in adults with CHDs and can be complicated with progressive obstruction or total occlusion during follow-up. The best treatment option for shunt re-permeabilization is challenging and case-oriented because most patients are high risk candidates for redo surgeries. We aimed to review the current evidence on percutaneous stent implantation to treat failed SPSs. Methods: We performed a comprehensive literature review on percutaneous stent implantation to treat failed and occluded SPSs. We also reported the case of a 33-year-old man with cyanotic CHD and a occluded central aorto-pulmonary shunt, who was successfully treated with percutaneous balloon dilatation and subsequently stent implantation at our institution. Result: We identified and included 31 articles reporting on 150 patients and 165 stent implantations in failed SPSs. The age of patients at the time of stent implantation ranged from 6 days to 47 years. The time between the surgical shunt creation and transcatheter intervention ranged from 1 day to 17 years. Overall, 161/165 (97.5%) stent implantations were successful. The most common clinical presentation was cyanosis and decreased atrial oxygen saturations and the indication for stent implantation was shunt obstruction and stenosis. Conclusion: This review highlights the benefits of endovascular stenting to permeabilize failed SPSs in children and adults with complex CHD who are classified as poor candidates for re-surgical repair.

Long-term outcomes of transcatheter Potts shunt in children with suprasystemic pulmonary arterial hypertension.

Background: Transcatheter Potts shunt (TPS) is a palliation alternative for children with severe pulmonary arterial hypertension (PAH). Debates on the long-term outcomes remain unsolved. Objectives: To evaluate long-term clinical and procedural outcomes of TPS intervention. Methods: Single-center retrospective data review of children with severe PAH who had TPS between 2009 and 2018. Patients who died per-operatively and early post-procedure were excluded. Long-term outcomes of survivors were evaluated. Results: Out of 13 identified patients (53.8% males), 7 had endovascular stenting of probe/patent arterial ducts, while 6 individuals had aorta-to-pulmonary radiofrequency perforation and covered stent placement. Compared to baseline, the overall clinical condition significantly improved at discharge (p < 0.001) and stayed better at the last visit (p < 0.05) despite frequent clinical worsening events across follow-up. Improvement in functional class across follow-up was significant (p < 0.001). There was, however, no significant improvement in other disease markers (TPASE, 6MWD z-scores, and NT-proBNP levels) or reduction in PAH medications. The median follow-up was 77.4 months (IQR, 70.7-113.4). Survival was 100% at 1 year and 92.3% at 6 years. Freedom from reinterventions was 77% at 1 year and 21% at 6 years. Nine (69.2%) patients had stent reinterventions at a median of 25 months (IQR, 9.5-56) postoperative. Balloon dilatation and restenting were performed in 53.8% and 46.2% of patients, respectively. High-pressure post-dilatation of implanted stents was performed in 53.8% of patients during TPS intervention for incomplete stent expansion and/or residual pressure gradient and was associated with higher rates of reinterventions (p = 0.021). Stent malfunctioning was present in 46.2% of patients at last follow-up. Two patients are listed for heart-lung transplantation. Conclusion: Survivors of TPS procedures experience significant improvement in functional class that can be durable. Clinical worsening and stent malfunctioning are frequent morbid events indicating recurrent transcatheter reinterventions throughout follow-up. Six-year survival is, however, satisfactory.

Three centers experience with device closure of congenital Gerbode-type perimembranous ventricular septal defects.

OBJECTIVES: We aim to evaluate our experience with interventional closure of Gerbode-type perimembranous ventricular septal defects (pmVSDs). METHODS: We performed three-center retrospective data review of patients with congenital indirect Gerbode-type pmVSDs treated percutaneously between August 2017 and May 2021. Standard safety and latest follow-up outcomes were assessed. RESULTS: Ten patients (six females) were identified with a median age of 6.8 years (range: 2.5-54) and a median weight of 26.5 kg (range: 12-88). The median left ventricular defect size was 10 mm (range: 3-15.5). On baseline ultrasound, 6 patients had absent subaortic rim , 6 patients had trivial aortic regurgitation, and 3 patients had tear-drop-type (small) aortic cusp prolapse. The tricuspid regurgitation was graded II (n = 5) and III (n = 5). Five Lifetech Konar-Multifunctional occluders, four Amplatzer duct occluders II and one Amplatzer duct occluder I were implanted. The median fluoroscopy time was 10.4 min (range: 4.3-20.2). Pre-existing aortic regurgitations remained identical. One new aortic regurgitation was identified before discharge and remained trivial after 48 months of follow-up. No heart block or tricuspid stenosis was observed on a median follow-up of 17 months (range: 3-48). All patients are symptom-free with complete shunt closure and significant regression or resolution of tricuspid regurgitation. CONCLUSIONS: Despite anatomical challenges, interventional closure of congenital indirect Gerbode-type pmVSD appears to be feasible, safe, and most importantly clinically effective using different commercially available devices. Amplatzer duct occluder II and Lifetech Konar-Multifunctional occluder offer interesting specifications to retrogradely target this specific defect with success.

Word of caution: Severe aortic valve injury linked to retrograde closure of perimembranous ventricular septal defects.

Retrograde device closure of perimembranous ventricular septal defects (pmVSDs) is an interesting procedure with several technical advantages and encouraging follow-up results. Nevertheless, aortic valve injuries may occur and require sufficient attention. Herein, we report the first two cases of severe aortic regurgitation that we have linked to the retrograde pmVSD closure with the KONAR-MF™ VSD occluder. We detail the technical aspects, comprehensively discuss procedural errors and conclude with important learning points.