Percutaneous closure of patent arterial ducts in patients from high altitude: a sub-Saharan experience.

BACKGROUND: At high altitude, patent arterial ducts tend to be larger and associated with pulmonary hypertension. Patent ductus arteriosus device closure in this background could be challenging. OBJECTIVES: We report our experience with percutaneous closure of patent arterial ducts using a variety of devices in patients residing in a high altitude. PATIENTS AND METHODS: This is a retrospective review of the case records of 145 patients (age 9 months-20 years, mean 5.6 ± 3.9 years, and weight 7-54 kg, mean 17.7 ± 9.4) with duct sizes ranging between 2 and 21 mm, (mean, 5.8 ± 2.7) who underwent percutaneous closure of patent arterial ducts. One hundred thirty-six (93.8%) of the patients were from a geographic area of 2100-2800 m above sea level. RESULTS: Successful device closure was achieved in 143 cases. It was difficult to achieve device stability in two patients with expansile ducts. Therefore, they were treated surgically. The devices used were various types of duct occluder devices in 131 patients, while atrial and ventricular septal occluders were used in eight patients. For the group, mean systolic pulmonary artery (PA) pressure decreased from 47.0 ± 16.7 mmHg before occlusion to 29.0 ± 7.4 mmHg after occlusion (P ≤ 0.001)., mean diastolic PA pressure from 25.0 ± 10.9 mmHg to 14.8 ± 6.0 mmHg and the average mean PA pressure decreased from 35.9 ± 13.5 mmHg to 21.1 ± 6.5 mmHg. Complications (4.8%) included device and coil embolization, bleeding, and pulse loss. On follow-up (mean duration of 36.1 ± 12.1 months, range 12-62 months), 137 patients were in functional class 1, 3 had residual shunt, 2 had device migration and one patient had persisting pulse loss. CONCLUSIONS: Successful duct closure was achieved in the vast majority of patients, even though the ducts were larger and significant number of them had pulmonary hypertension in this high altitude group. There was a relatively higher incidence of residual shunts and device migration in this series, generally due to the nonavailability of optimal device and surgical support. Long-term follow-up is required before we can draw conclusions with regard to the sustainability of drop in PA pressures. Septal Occluder devices may be a possible alternative for large tubular or window-type ducts with severe pulmonary hypertension, where there may be concerns about the size and stability of duct occluder devices.

Inadvertent ligation of the left pulmonary artery during intended ductal ligation.

BACKGROUND: Inadvertent ligation of the left pulmonary artery during attempted surgical closure of a Patent Ductus Arteriosus has long been recognized as one of the less common complications of this procedure. Surgical reconstruction of the left pulmonary artery was then often attempted but was difficult or impossible in some of the patients with hypoplasia of the left pulmonary artery and the left lung. CASE PRESENTATION: A 10-year-old girl presented with marked exercise intolerance and palpitations and was diagnosed to have large PDA. She had feeding difficulty, diaphoresis, failure to gain weight, recurrent chest infections during infancy and early childhood. Physical examination revealed an underweight child with wide pulse pressure and bounding peripheral pulses. She had active precordium with accentuated P2 and machinery murmur in the left 2nd intercostal space and mid diastolic rumble at the mitral area. Echocardiography showed a 12 mm patent arterial duct. She was taken for an intended surgical ligation of the duct but a control echocardiogram on the 3rd postoperative day revealed that the left pulmonary artery, instead of the duct, was ligated. Surgical reconstruction of the left pulmonary artery was undertaken 3 years later, however, this was complicated by post reconstruction left pulmonary artery stenosis. Successful percutaneous stenting of the left pulmonary artery was performed 18 months after the surgical reconstruction. CONCLUSION: The incidence of inadvertent LPA ligation may be underestimated where PDA ligation is done by less experienced surgeons and postoperative echocardiography is not routinely performed. Late correction of inadvertent LPA ligation is an important surgical challenge, especially if the duct is still patent. Percutaneous stenting as a primary option may carry significant risk, as the ligated pulmonary artery is fragile. In our case, a good result was achieved with surgical repair followed by percutaneous stenting.

Successful training of self-sufficient interventional paediatric cardiology team in a sub-Saharan setting: a multicentre collaborative model.

BACKGROUND: Most children in the Third World do not have access to treatment for heart diseases, as the priorities of health care are different from the developed countries. MATERIALS AND METHODS: Since 2009, teams supported by the Chain of Hope and Spanish medical volunteers have travelled twice a year to help develop paediatric cardiac services in the Cardiac Center in Ethiopia, undertaking four missions each year. As of December 2012, 296 procedures were performed on 287 patients. The procedures included 128 duct occlusions, 55 pulmonary valve dilations, 25 atrial septal defect closures, 14 mitral valve dilations, and others. The local staff were trained to perform a majority of these cases. RESULTS: Procedural success was achieved in 264 (89.2%). There were three deaths, five device embolisations, and three complications in mitral valve dilation. During the visits, the local staff were trained including one cardiologist, six nurses, and two technicians. The local team performed percutaneous interventions on its own after a couple of years. The goal is also to enable the local team to perform interventions independently. CONCLUSION: Training of an interventional cardiology team in a sub-Saharan setting is challenging but achievable. It may be difficult for a single centre to commit to sending frequent missions to a developing country to make a meaningful contribution to the training of local teams. In our case, coordination between the teams from the two countries helped to achieve our goals.

Percutaneous closure of patent ductus arteriosus in interrupted inferior caval vein through femoral vein approach.

Percutaneous closure of the patent arterial duct in patients with interrupted inferior caval vein poses a technical challenge. A 12-year-old girl with a patent ductus arteriosus (PDA) and interrupted inferior caval vein is described in this report. The diagnosis of interrupted inferior caval vein and azygos continuation was made in the catheterization laboratory. A catheter was advanced and snared in the descending aorta. An exchange wire was advanced through the catheter and snared in the descending aorta. Then, an Amplatzer TorqVue 2 delivery sheath was advanced over the wire from the venous side and again snared in the descending aorta. An Amplatzer duct occluder (ADO) size 8/6 was advanced through the sheath while still holding the sheath with a snare. The device was opened. The sheath was then unsnared once the aortic disc was completely out. The sheath and the device were pulled back into the duct and the device was successfully implanted. The device was then released and it attained a stable position. An aortic angiogram was performed which showed complete occlusion.

Percutaneous balloon dilation of severe pulmonary valve stenosis in patients with cyanosis and congestive heart failure.

OBJECTIVES: This article reports outcomes of percutaneous balloon dilation in patients with severe pulmonary valve stenosis, in particular in those treated late with cyanosis, congestive heart failure, and pericardial effusion. BACKGROUND: Percutaneous balloon dilation is the treatment of choice for pulmonary valve stenosis. Although earlier intervention may produce better results, patients may present late with congestive heart failure and cyanosis. METHODS: Fifty-five patients who underwent pulmonary valve balloon dilation, were grouped into two groups, based on the presence or absence of congestive right heart failure and/or central cyanosis. Group I included 33 patients with severe pulmonary valve stenosis, but without clinical evidence of congestive right heart failure in the form of liver enlargement, raised jugular venous pressure, and peripheral edema and/or central cyanosis and group II included 22 patients with severe pulmonary valve stenosis and congestive right heart failure and/or central cyanosis. Their outcomes were compared. RESULTS: Doppler measured transvalvar pressure gradient decreased from 110.2 ± 34.0 mm Hg before to 52.5 ± 28.7 mm Hg in group I after dilation (P < 0.001), and from 138.4 ± 32.3 mm Hg to 53.9 ± 19.3 mm Hg in group II, (P < 0.001). Complications included ventricular tachycardia/fibrillation in three patients and severe bradycardia in one patient in group II. Twelve patients in group II developed clinical and radiologic evidence of reperfusion injury/pulmonary edema within the first 24 hr of intervention and needed ventilation for 2-9 days. Three of these patients died from intractable pulmonary edema. On follow up, clinical and echocardiographic improvement parameters were similar in the two groups. CONCLUSION: Those patients with severe pulmonary valve stenosis with congestive right heart failure, especially those with pericardial effusion, ascites and cyanosis, represent an important technical and clinical challenge. They are a high-risk group with or without treatment. If they survive the procedure, they may still remain at a high risk in the first few days afterward. Maintaining their ventilator and inotropic support after balloon dilation may increase survival. However, excellent results can be obtained.

Discrete subpulmonic membrane in association with isolated severe pulmonary valvar stenosis.

BACKGROUND: Subpulmonic membrane as a cause of right ventricular outflow tract obstruction in patients with concordant ventriculoarterial connection and intact ventricular septum is considered to be rare. CASE PRESENTATION: A 7-year-old boy was referred to a tertiary care hospital with complaints of dyspnea on moderate exertion and palpitations of about 2 years duration. Physical examination revealed parasternal lift, systolic thrill and a 4/6 ejection systolic murmur, best heard over the left 2nd intercostal space. His oxygen saturation was 88% on room air. Two-dimensional echocardiography showed a thickened pulmonary valve with fused leaflets that show severe systolic doming. There was a discrete subpulmonic membrane about 1.3 cm below the pulmonary valve annulus. Continuous wave Doppler interrogation showed peak systolic pressure gradient of 185 mmHg across the pulmonary valve. Balloon dilation of the pulmonary valve was performed and the pressure gradient came down to 50 mmHg. Follow-up transthoracic echocardiography showed residual pressure gradient of about 50-60 mmHg across the pulmonary valve. The residual pressure gradient appeared to be mainly subvalvar, as seen on the continuous wave Doppler tracing. The patient reported marked improvement in terms of exercise tolerance and subjective symptoms. CONCLUSIONS: Association of subpulmonic membrane with severe pulmonary valvar stenosis, concordant ventriculoarterial connection and intact ventricular septum is rare. When it occurs, the result of percutaneous valve dilation may be suboptimal.

Patent ductus arteriosus at low and high altitudes: anatomical and haemodynamic features and their implications for transcatheter closure.

BACKGROUND: Living at high altitude increases the prevalence of patent ductus arteriosus (PDA) and may affect its morphology. AIM: To compare the anatomical and haemodynamic features of isolated PDA in patients living at low and high altitudes (1,500-4,200 metres above sea level - m.a.s.l.). METHODS: We studied retrospectively data from 1,404 consecutive patients - 708 living in lowland areas (group L) and 696 in highland areas (group H), in whom transcatheter closure of PDA was attempted. The mean age of the patients in group L was 9.9 ± 13.5 years and in group H it was 8.2 ± 19.7 years. RESULTS: The diameter of PDA in group L was 2.3 ± 1.3 mm and 4.1 ± 1.2 mm in group H (p < 0.001), while the mean pulmonary artery pressure was 17.9 ± 5.9 mm Hg and 25.5 ± 12.3 mm Hg, respectively (p < 0.001). Angiographic PDA type A was more frequently observed in highland patients. In groups L and H, self expanding nitinol occluders (mostly Amplatzer devices) were used in 25.7% vs 92.2% of patients (p < 0.001), whereas coils were used in 69.2% vs 7.5% (p < 0.001), respectively. Double umbrella systems were used in 4.8% of patients in group L. CONCLUSIONS: In catheterised patients with PDA living at high altitude, larger ductal diameter, anatomic type A and higher pulmonary artery pressure were more frequently observed. This finding has important implications for future strategy regarding transcatheter closure in populations living at different altitudes. Kardiol Pol 2011; 69, 5: 431-436.

Cardiopatías congénitas del adulto: procedimientos terapéuticos percutáneos / Percutaneous interventions in adults with congenital heart disease

Dos grandes grupos de cardiopatías congénitas se presentan al cardiólogo intervencionista: simples, que incluyen comunicación interauricular, estenosis pulmonar, ductus persistente, comunicación interventricular, estenosis aórtica, etc., y complejas, generalmente consecuencia de operaciones paliativas o correctoras en la edad pediátrica (estenosis de ramas pulmonares, obstrucciones de conductos protésicos, dehiscencias de cierres previos, neoformaciones venosas o arteriales). En ambos grupos, la cirugía es eficaz, aunque con morbimortalidad e incomodidad para el paciente, a veces operado varias veces y pendiente de más cirugías futuras. El cateterismo terapéutico en este creciente grupo de pacientes aporta soluciones que evitan un procedimiento quirúrgico. El cierre de la comunicación interauricular, ductus persistente y malformaciones venosas o arteriales evita por completo la cirugía. En otras enfermedades, como la coartación de aorta y la estenosis aórtica, retrasan la cirugía o resuelven sus complicaciones. Los stents en ramas pulmonares permiten tratar lesiones casi inaccesibles al cirujano. Múltiples dehiscencias se ocluyen con prótesis o dispositivos. La ecocardiografía, la resonancia magnética y la tomografía computarizada son herramientas imprescindibles (AU)

There are two major groups of congenital heart lesions that are often referred for percutaneous intervention: simple lesions, such as atrial or ventricular septal defects, pulmonary or aortic stenosis, and patent ductus arteriosus; and complex lesions, which generally result from palliative or corrective surgery carried out during childhood (e.g. pulmonary branch stenosis, prosthetic conduit obstruction, dehiscence following surgical closure, and arterial or venous malformations). In both groups, surgery is effective, but there is some associated morbidity and mortality and patient discomfort, repeat surgery may be necessary at times, and additional surgery can be anticipated in the future. Percutaneous intervention provides an alternative to invasive surgery in this growing group of patients. In fact, surgery can be completely avoided in the treatment of atrial septal defects, patent ductus arteriosus, and arterial and venous malformations. In other conditions, such as coarctation of the aorta and aortic stenosis, surgery can be postponed and complications can be resolved. And, it is possible to treat lesions that are almost inaccessible to the surgeon by stent placement in arterial branches. Multiple leaks can be closed using stents or occlusion devices. Echocardiography, nuclear magnetic resonance and axial computed tomography are essential diagnostic tools (AU)

Coartación de aorta: posibles soluciones a un complejo problema / Aortic coarctation: current solutions for a complex condition

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[Use of coated stents in two patients with congenital heart defects and secondary vascular aneurysms]. / Utilidad del stent recubierto en 2 casos de cardiopatía congénita complicada con aneurismas vasculares.

The formation of an aneurysm in the aorta or pulmonary artery is a dangerous potential complication of surgical and angioplasty procedures involving these vessels. Treatment using covered stents has emerged as an effective alternative to surgery and the use of conventional stents. The authors report on 2 patients who were treated successfully by the implantation of covered stents in the aorta and pulmonary artery following angioplasty and surgery, respectively. We discuss the mechanisms of aneurysm formation and the efficacy and limitations of using covered stents in such patients.

Utilidad del stent recubierto en 2 casos de cardiopatía congénita complicada con aneurismas vasculares / Use of coated stents in two patients with congenital heart defects and secondary vascular aneurysms

Una de las complicaciones más temidas del tratamiento quirúrgico o intervencionista de la coartación aórtica y de cualquier angioplastia sobre las ramas pulmonares esla aparición de un aneurisma. Los stents recubiertos han surgido como una efectiva alternativa terapéutica. Exponemos 2 casos de aneurismas en la coartación de la aorta y en la arteria pulmonar que fueron tratados efectivamente con stents recubiertos. Realizamos un comentario acerca de la formación de aneurismas y de la eficacia y las limitaciones del tratamiento con stents recubiertos

The formation of an aneurysm in the aorta or pulmonary artery is a dangerous potential complication of surgical andangioplasty procedures involving these vessels. Treatment using covered stents has emerged as an effective alternativeto surgery and the use of conventional stents. The authors report on 2 patients who were treated successfully by the implantation of covered stents in the aorta and pulmonary artery following angioplasty and surgery, respectively. We discuss the mecanisms of aneurysm formation and the efficacyand limitations of using covered stents in such patients

The prognostic value of balloon occlusion in candidates for the various types of cavo-pulmonary anastomosis.

The purpose of our paper is to assess the prognostic value of balloon occlusion as a test for patients with various types of functionally single ventricle after different palliative surgical procedures who were candidates for further modifications of a cavo-pulmonary operation. In all patients, there were at least two sources of pulmonary arterial supply. Our hypothesis was that, using balloon occlusion temporarily to produce changes in the haemodynamic situation, we could simulate the potential state subsequent to surgical palliation. We used balloon occlusion in 19 patients during diagnostic catheterisation, followed by interventional and or surgical procedures as considered necessary. This test was applied for temporary closure of the pulmonary valve in 8 patients, and a Blalock-Taussig anastomosis in 11 patients.

[Percutaneous catheter closure of atrial septal defect. Short-term and mid-term results]. / Cierre percutáneo de la comunicación interauricular. Resultados a corto y mediano plazo.

INTRODUCTION: Percutaneous closure of atrial septal defects (ASD) is becoming more frequent. PATIENTS AND METHOD: From October 1997 to October 2002, 209 patients, age 0.4-70 (mean 19.5) years, were catheterized to close an ASD or patent foramen ovale (PFO). Transesophageal echocardiography was performed simultaneously in all patients. Two hundred and six patients had ASD (25 multiple ASDs) and 3 had PFO. Three devices were used, the Amplatzer Atrial Septal Occluder (ASO), CardioSeal (CS), and Starflex (SF). RESULTS: Device implantation was achieved in 181 patients (87%) but had to be abandoned in 28 patients, generally because the ASD was too large. One hundred and seventy-four ASOs were implanted in 172 patients with ASD (2 ASOs were implanted in 2 patients with double ASD) and CS/SF in 9 patients (3 patients with PFO and 6 with ASD). The procedure was effective in 166/172 (96%) ASO implantations and in 8/9 (89%) CS/SF implantations. The procedure was unsuccessful in 7 patients and the device had to be removed (6 ASO and 1 SF). The occlusion rate with ASO was 88% after 24 hours, 91% after 1 month, 95% after 1 year, 97% after 2 years, and 100% after 4 and 5 years. All defects treated with SF/CS were closed successfully after 24 hours. In one case the ASO device was embolized to the aorta. In the first month after ASO implantation, supraventricular tachycardia appeared in 2 patients and transient left ventricular failure in 2 patients. No late complications were observed. CONCLUSION: Percutaneous catheter closure of selected types of ASD using the Amplatzer Atrial Septal Occluder, CardioSeal, or Starflex should be offered to patients as non-surgical alternative. The type of device used depends on the defect size and morphology as well as the surgeon's experience. The presence of multiple defects does not exclude the possibility of a successful percutaneous catheter closure.

Cierre percutáneo de la comunicación interauricular. Resultados a corto y medio plazo / Percutaneous catheter closure of atrial septal defect. Short-term and mid-term results

Introducción. El cierre percutáneo de la comunicación interauricular (CIA) es una alternativa de tratamiento cada vez más utilizada. Pacientes y método. Entre octubre de 1997 y de 2002 se realizó cateterismo cardíaco, con la intención de cierre de una comunicación interatrial (CIA) o foramen oval permeable (FOP), en 209 pacientes con edades comprendidas entre 0,4 y 70 años (media, 19,5 años). En todos los casos se realizó ecocardiografia transesofágica (ETE) simultánea. En 206 casos existía CIA (25 con defectos múltiples) y en tres un FOP. Se utilizaron 3 dispositivos: Amplatzer Atrial Septal Occluder (ASO), CardioSeal (CS) y Starflex (SF).Resultados. Se aceptó para cierre percutáneo a 181 pacientes (87 por ciento). Se rechazaron 28 casos, en su gran mayoría por el excesivo tamaño del defecto. En 172 pacientes con CIA se utilizaron 174 ASO (en 2 casos con 2 defectos alejados se implantaron 2 ASO) y en 9 pacientes (seis con CIA y tres con FOP) los dispositivos CS/SF. El implante percutáneo del ASO fue efectivo en 166/172 (96 por ciento) pacientes, y el de CS/SF en 8/9 (89 por ciento) pacientes. En 6 casos de ASO y uno de SF el cierre no se pudo realizar por posicionamiento incorrecto del dispositivo. El porcentaje de cierre completo de la CIA con ASO fue del 88 por ciento después de 24 h, del 91 por ciento al mes, del 95 por ciento a un año, del 97 por ciento a los 2 años y del 100 por ciento a los 4 y 5 años de su implante. Todos los defectos tratados con dispositivos CS/SF se cerraron completamente después de 24 h. Como complicaciones destaca un caso de embolización de ASO en la aorta, extrayéndose el dispositivo con cirugía, 2 casos con episodios de taquicardia supraventricular y otros dos con insuficiencia cardíaca izquierda transitoria durante el primer mes tras la colocación de un ASO. Conclusión. El cierre percutáneo en los pacientes portadores de CIA o FOP es una atractiva alternativa al tratamiento quirúrgico. La elección del implante depende de la anatomía del defecto y la experiencia del médico. La existencia de múltiples defectos no excluye la posibilidad de su cierre percutáneo eficaz (AU)

[Middle aortic syndrome caused by Takayasu's disease and treated by stent implantation: a report of medium-term follow-up]. / Síndrome de la aorta media causado por enfermedad de Takayasu: tratamiento con stents y seguimiento a medio plazo.

A 13-year-old girl with middle aortic syndrome caused by Takayasu's disease was treated by balloon angioplasty of the right renal artery stenosis and the implantation of 3 stents, 2 in the stenosed thoracic segment and 1 in the abdominal segment of the aorta. Spiral computed tomography one and two years after the stents were inserted showed that the disease had progressed despite treatment with immunosuppressants.

Síndrome de la aorta media causado por enfermedad de Takayasu: tratamiento con stents y seguimiento a medio plazo / Middle aortic syndrome caused by Takayasu's disease and treated by stent implantation: a report of medium-term follow-up

Se presenta el caso de una niña de 13 años de edad con síndrome de aorta media causado por enfermedad de Takayasu. Fue tratada con angioplastia con balón de la arteria renal derecha e implante de 3 stents: dos en el segmento estenótico torácico y uno en la aorta abdominal. Después de 1 y 2 años de la implantación de los stents se realizó una TC heliocoidal, que puso de manifiesto una progresión de la enfermedad a pesar del tratamiento con inmunodepresores (AU)

Valvuloplastia pulmonar con balón en el período neonatal. Efectos clínicos y ecocardiográficos / Balloon Pulmonary Valvuloplasty in the Neonatal Period. Clinical and Echocardiographic Consequences

Objetivo. Evaluar la eficacia de la valvuloplastia pulmonar con balón (VPB) en el período neonatal. Material y métodos. Se evaluó el resultado de la VPB practicada en 29 neonatos (18 ñ 12 días) portadores de estenosis valvular pulmonar (EVP) analizando diferentes variables hemodinámicas y ecocardiográficas 2-D Doppler-color. El resultado de la VPB se tipificó como satisfactorio cuando el gradiente VD-AP residual registrado fue < 40 mmHg y no fue necesaria intervención alguna para favorecer el flujo pulmonar; se consideró como no satisfactorio cuando se registró mortalidad, fue necesaria reintervención o el gradiente persistió 40 mmHg. El estudio se desarrolló en tres fases: pre-VBP, post-VPB inmediato (hospitalización; 14 ñ 11 días), y post-VPB tardío entre 8 y 96 meses de seguimiento (51 ñ 31).Resultados. No se registró mortalidad con la VPB. Como consecuencia de la dilatación, la relación de presiones de los ventrículos derecho/izquierdo se redujo de 1,4 ñ 0,3 a 0,8 ñ 0,3 (p < 0,01) y la saturación de oxígeno ascendió de 85 ñ 12 a 92 ñ 6 por ciento (p < 0,01). El gradiente Doppler pre-VPB fue de 86 ñ 18 mmHg, descendió a 28 ñ 16 postVPB inmediato (p < 0,01) y se registró de 13 ñ 6 mmHg en el seguimiento (n = 24). El valor Z pulmonar se incrementó desde -1,25 ñ 0,9 pre-VPB a -0,51 ñ 0,7 (p < 0,01) en el estudio tardío, y no se detectaron cambios en el diámetro tricuspídeo entre ambos períodos. Cinco neonatos tuvieron resultado no satisfactorio: 4 en el período inmediato (fístula sistémico-pulmonar 2, ampliación de la unión VD-AP 2) y 1 en el tardío (valvectomía y parche transanular). La curva actuarial refleja que el 82,7 por ciento de los enfermos está libre de intervención hasta un período de 8 años. Conclusiones. La EVP puede ser tratada de manera segura y efectiva mediante la VPB. Cuando el resultado es satisfactorio, la intervención puede considerarse curativa. La eco 2-D Doppler-color es indispensable para evaluar la EVP, decidir el momento para intentar la VPB y determinar los efectos que produce. (AU)