A case report of percutaneous MitraClip implantation in an adult with a double-outlet right ventricle.

Background: Atrioventricular valve regurgitation (AVVR) is present in up to 75% of Fontan patients, and it is associated with an increased risk of Fontan circulation failure, morbidity, and mortality. Traditional treatment options include surgical repair vs. surgical replacement. We present, to the best of our knowledge, one of the first cases of successful trans-catheter repair of severe common AVVR using the MitraClip device. Case summary: A 20-year-old male with a history of double-outlet right ventricle (DORV) with unbalanced common atrioventricular canal to the right ventricle, severely hypoplastic left ventricle, and total anomalous pulmonary venous return status post-Fontan procedure presented with progressively worsening dyspnoea on exertion. Transoesophageal echocardiogram demonstrated severe common AVVR. After discussion of the case during the adult congenital heart disease multidisciplinary conference, patient underwent successful placement of two MitraClip devices, reducing the regurgitation from torrential to moderate. Discussion: MitraClip therapy can be used to alleviate symptoms in patients deemed as high risk for surgery. However, careful attention must be paid to haemodynamics before and after clip placement, which may predict short-term clinical outcomes.

Pediatric Surgical Pulmonary Valve Replacement Outcomes After Implementation of a Clinical Pathway.

BACKGROUND: Standardization of perioperative care can reduce resource utilization while improving patient outcomes. We sought to describe our outcomes after the implementation of a perioperative clinical pathway for pediatric patients undergoing elective surgical pulmonary valve replacement and compare these results to previously published national benchmarks. METHODS: A retrospective single-center descriptive study was conducted of all pediatric patients who underwent surgical pulmonary valve replacement from 2017 through 2020, after the implementation of a clinical pathway. Outcomes included hospital length of stay and 30-day reintervention, readmission, and mortality. RESULTS: Thirty-three patients (55% female, median age 11 [7, 13] years, 32 [23, 44] kg) were included in the study. Most common diagnosis and indication for surgery was Tetralogy of Fallot (61%) with pulmonary valve insufficiency (88%). All patients had prior cardiac surgery. Median hospital length of stay was 2 [2, 2] days, and longest length of stay was three days. There were no 30-day readmissions, reinterventions, or mortalities. Median follow-up time was 19 [9, 31] months. CONCLUSIONS: Formalization of a perioperative surgical pulmonary valve replacement clinical pathway can safely promote short hospital length of stay without any short-term readmissions or reinterventions, especially when compared with previously published benchmarks. Such formalization enables the dissemination of best practices to other institutions to reduce hospital length of stay and limit costs.

Transcatheter Systemic AV Valve-in-Valve Implantation in a Patient With LTGA and Ebstein Anomaly.

We present the first in-human transcatheter systemic atrioventricular valve-in-valve implantation in a 37-year-old patient with Ebstein anomaly, levo-transposition of the great arteries, and prior systemic valve replacement. She had severe bioprosthetic valve regurgitation and reduced systolic function. She had high surgical risk and was planned for transcatheter intervention. (Level of Difficulty: Advanced.).

Uhl's Anomaly With Left Ventricular Noncompaction: Role of Multimodality Imaging in a Rare Association.

Uhl's anomaly is a rare congenital heart disease characterized by partial or complete absence of the right ventricle myocardium. We report the first case, in a 21-year-old man, of Uhl's anomaly-associated left ventricular noncompaction. This association represents a unique clinical entity and has important implications for management strategies. (Level of Difficulty: Intermediate.).

Novel Multidisciplinary Management of Acute Kidney Injury After Infant Orthotopic Heart Transplantation.

Acute kidney injury following orthotopic heart transplantation in pediatric recipients is often multifactorial, requiring balance of immune suppression, nephrotoxic medication exposure, nutrition, and fluid status. Therapeutic options are often limited by patient size and hemodynamic stability. We describe a four-month, 4.9-kg female bridged by mechanical circulatory support to transplant after failed stage 1 palliation secondary to recurrent aortic stenosis and severe ventricular dysfunction. Posttransplant, kidney injury was managed by transcatheter relief of central obstruction from an anastomotic stricture and continuous renal replacement therapy, allowing uninterrupted immune suppression, medication, and nutrition delivery until sufficient recovery of renal function.

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

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

Here today, gone tomorrow: Outcomes of residual leak following secundum atrial septal defect closure with the GORE CARDIOFORM Septal Occluder.

OBJECTIVE: To assess the outcomes and potential predictors of residual leak after implantation of the GORE CARDIOFORM Septal Occluder (GSO) in secundum atrial septal defects (ASDs). BACKGROUND: The non-self-centering design of the GSO could lead to residual leak at the edge of the device. Outcomes of residual leak are poorly understood. METHODS: Retrospective, multicenter review of patients treated with the GSO for the pivotal and continued access study. Procedural, echocardiographic, and follow up data were reviewed. Multivariate analysis was performed to determine predictors of leak at implant and outcomes of these leaks. RESULTS: There were 370 total ASD device closures with the GSO, 65 (17.56%) of which were found to have residual leak at implantation. Patients with residual leak had larger defects (10.33 ± 3.05 mm vs. 9.13 ± 2.89 mm, p = .006) and smaller aortic rims (4.87 ± 3.33 mm vs. 6.17 ± 3.78 mm, p = .019), as compared to those without leak. Larger devices were implanted (p = .008) and more devices per case (p = .007) were utilized in the residual leak cohort as compared to those without leak. Overall, among patients with residual leak, there was a significant decrease in leak size over 1 year, from 1.55 ± 0.75 mm to 0.25 ± 0.74 mm (p < .001), with the majority (87.6%) disappearing by 12-month follow-up. CONCLUSIONS: Residual leak at implantation can be seen after ASD device closure with the GSO, more commonly in larger defects with smaller retroaortic rims. The vast majority of these leaks completely resolve by 1 year follow up.

Elective left pulmonary artery embolisation for pulmonary arteriovenous malformations secondary to cavopulmonary anastomoses not responsive to heart transplantation: a case report.

A 10-year-old female with heterotaxy-asplenia and complex CHD developed pulmonary arteriovenous malformations with associated cyanosis after Fontan completion. She underwent orthotopic heart transplantation, but her pulmonary arteriovenous malformations persisted with progressive worsening cyanosis. Elective transcatheter left pulmonary artery embolisation was performed 2 years post-transplant, which successfully normalised her oxygen saturation without a significant increase in pulmonary artery pressure.

Results of the combined U.S. multicenter postapproval study of the Nit-Occlud PDA device for percutaneous closure of patent ductus arteriosus.

OBJECTIVES: To report the results of the Nit-Occlud PDA prospective postapproval study (PAS) along with a comparison to the results of the pivotal and continued access trials. BACKGROUND: The Nit-Occlud PDA (PFM Medical, Cologne, Germany), a nitinol coil patent ductus arteriosus (PDA) occluder, was approved by the Food and Drug Administration in 2013. METHODS: The PAS enrolled a total of 184 subjects greater than 6 months of age, weighing at least 5 kg, with PDAs less than 4 mm by angiography at 11 centers. Patients were followed prospectively at 2 months, 12 months, and 24 months postprocedure. These outcomes were compared to the 357 subjects enrolled in the pivotal and continued access protocols. Efficacy and safety data were reported. RESULTS: Among 184 subjects enrolled for the PAS between 2014 and 2017, 180 (97.8%) had successful device implantation. After 12 months, 98.7% (150/152) had trivial or no residual shunt by echocardiography and two subjects had only small residual shunts. There were three device embolizations that were all retrieved by snare without clinical consequence. Together with the pivotal and continued access study, 97.4% (449/461) had complete echocardiographic closure at 12 months in 541 enrolled subjects. The composite success was 94.4%. There were no mortalities and no serious device-related adverse events. CONCLUSIONS: The Nit-Occlud PDA is a safe and effective device for closure of a small to moderate sized PDA. There were no serious device-related adverse events in a large cohort of three clinical trials.

Variation in Anticoagulation Practices in the Congenital Cardiac Catheterization Lab: Results of a Multinational PICES Survey.

The complex nature of congenital heart disease (CHD) has hindered the establishment of management standards for peri-catheterization anticoagulation. We sought to describe anticoagulation practice variability among providers performing cardiac catheterization in children and adults with CHD. A web-based survey ( http://www.surveymonkey.com ) was distributed to pediatric and congenital interventional cardiologists. Respondents were queried on their training, practice setting, years in practice, and case volume. Clinical questions focused on general anticoagulation strategies and on five common clinical scenarios: two diagnostic (biventricular circulation, single ventricle physiology) and three interventional cardiac catheterizations (atrial septal defect closure, pulmonary artery stenting in Fontan circulation, stent placement for coarctation of aorta). Seventy-seven pediatric and congenital interventional cardiologists responded to the survey (81% in the United States). Twenty-six (36%) worked in a public medical institution; 57% worked in a free-standing children's hospital. Twenty-six percent had been in practice for < 5 years and 32% for > 15 years; 75% completed additional training in interventional congenital cardiology. The median number of cases performed was 200/year (IQR 110); median number of interventional cases was 100/year (IQR 100). Responses to general queries and specific clinical scenarios suggested significant variation in anticoagulation practices, including monitoring of anticoagulation during catheterization, protamine use, and outpatient anticoagulation after catheterization. Practices not only varied between providers but also between different clinical scenarios. Practice patterns did not correlate with provider experience or case volume. Management of anticoagulation in the congenital cardiac catheterization lab varies from operator to operator. Our study may provide some initial insight and context for discussion regarding anticoagulation in a field of increasingly heterogeneous interventional techniques and patient substrates. Future studies would be helpful to better define "best practices" for peri-procedural thromboprophylaxis in patients with congenital heart disease.

Subaortic Stenosis Resection in Children: Emphasis on Recurrence and the Fate of the Aortic Valve.

BACKGROUND: Recurrence after surgical resection of discrete subvalvar aortic stenosis in children often requires repeat operation. Risk factors for recurrence are poorly understood. We sought to determine potential risk factors for recurrence and postoperative comorbidities in the long term. METHODS: Retrospective chart review was performed on all pediatric patients who underwent surgical resection of discrete subaortic stenosis at our institution. Demographics, perioperative findings, and clinical data were analyzed for predisposing factors. RESULTS: From 1991 to 2015, a total of 104 patients underwent primary surgical resection of discrete subaortic stenosis. There were no postoperative deaths. Three (2.9%) patients required pacemaker implantation. Nine (8.4%) patients required repeat resection for recurrence of subaortic membrane over a median follow-up of 8.5 years (interquartile range: 5.9-13.5 years). Actuarial freedom from repeat resection was 100%, 94%, and 82% at one, five, and ten years, respectively. Repeat resection occurred more frequently in patients with genetic disease (37.5% vs 10.7%; P = .033) and preoperative mitral regurgitation (MR; 25% vs 1.2%; P < .001). Postoperative aortic insufficiency (AI) that was moderate or worse was associated with older age at the time of first resection (relative risk [RR]: 1.54, P < .05), moderate or severe preoperative AI (RR: 1.84, P = .002), and repeat resection of subaortic stenosis (RR: 1.90, P < .001). CONCLUSION: The majority of children who undergo surgical resection of subaortic stenosis will not experience recurrence in childhood and those who do require repeat resection may have a higher incidence of genetic disease and preoperative MR. Postoperative AI is associated with repeat resection, older age at the time of surgery, and degree of preoperative AI.

Serial Versus Direct Dilation of Small Diameter Stents Results in a More Predictable and Complete Intentional Transcatheter Stent Fracture: A PICES Bench Testing Study.

Balloon-expandable stents, implanted in infants and children with congenital heart disease (CHD), often require redilation to match somatic growth. Small diameter stents may eventually require longitudinal surgical transection to prevent iatrogenic vascular stenosis. Intentional transcatheter stent fracture (TSF) is an emerging alternative approach to stent transection, but little is known about the optimal stent substrate and best protocol to improve the likelihood of successful TSF. Bench testing was performed with a stent dilation protocol. After recording baseline characteristics, stents were serially or directly dilated using ultra-high-pressure balloons (UHPB) until fracture occurred or further stent dilation was not possible. Stent characteristics recorded were as follows: cell design, metallurgy, mechanism, and uniformity of fracture. Stents tested included bare-metal coronary stents, premounted small diameter stents, and ePTFE-covered small diameter premounted stents. Ninety-four stents representing 9 distinct models were maximally dilated, with 80 (85%) demonstrating evidence of fracture. Comprehensive fracture details were recorded in 64 stents: linear and complete in 34/64 stents (53.1%), linear and incomplete in 9/64 stents (14.1%), transverse/complex and complete in 6/64 stents (9.4%), and transverse/complex and incomplete in 15/64 stents (23.4%). Stent fracture was not accomplished in some stent models secondary to significant shortening, i.e., "napkin-ring" formation. Serial dilation resulted in evidence of fracture in 62/67 (92.5%) stents compared with 18/27 (66.7%) stents in the direct dilation group (p = 0.003). Intentional TSF is feasible in an ex vivo model. Serial dilation more reliably expanded the stent and allowed for ultimate stent fracture, whereas direct large diameter dilation of stents was more likely to generate a "napkin-ring" configuration, which may be more resistant to fracture. In vivo animal and human testing is necessary to better understand the response to attempted TSF for newly developed stents as well as those currently in use.

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

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

Functional assessment of anomalous right coronary artery using fractional flow reserve: An Innovative Modality to Guide Patient Management.

Anomalous origin of a coronary artery is a recognized cause of sudden cardiac death (SCD). To date, there is no standard test to predict which patients are at increased risk for SCD. Fractional flow reserve (FFR) is an invasive technique used to qualify focal obstructive coronary lesions. We present a case where FFR was used to guide therapy in a young patient with anomalous right coronary artery (ARCA) when standard noninvasive testing showed ischemic discrepancy. © 2016 Wiley Periodicals, Inc.

Expansion Characteristics of Stents Used in Congenital Heart Disease: Serial Dilation Offers Improved Expansion Potential Compared to Direct Dilation: Results from a Pediatric Interventional Cardiology Early Career Society (PICES) Investigation.

OBJECTIVE: Intravascular stents are now routinely used to treat young patients with vascular stenoses. Future stent redilations are often necessary to account for somatic growth. The purpose of this study was to compile a database of characteristics for stents commonly used in the treatment of congenital heart disease patients, and compare serial dilation to direct dilation to the maximal diameter. DESIGN: A standardized bench testing protocol was established and utilized in the assessment of all stents. Ultra high pressure balloons were used to serially dilate each stent by set increments until the stent reached at least 24 mm in diameter, developed a napkin-ring configuration, or fractured. Length and diameter of each stent were measured at baseline and following each stage of dilation. Maximal stent diameters, foreshortening properties, and ability to fracture were reported. Stents were then tested for direct dilation from the primary diameter to the maximal diameter, and the same data was obtained. RESULTS: A total of 127 stents were bench-tested, 80 of which were serially dilated and 47 directly dilated. Most premounted stents could be serially dilated to approximately twice their stated nominal diameter. All tested unmounted stents could be serially dilated to ≥20 mm. Foreshortening occurred at larger diameters, but varied significantly among different stent types. Serial dilation offered more consistent results with significantly less foreshortening and more symmetric expansion when compared with direct dilation. Most premounted stents could be fractured when serially dilated. CONCLUSIONS: All tested vascular stents can be dilated beyond their nominal implantation diameter. Serial dilation offers a much more reliable response with uniform expansion, less foreshortening, greater maximal diameter, and improved intentional fracture potential, as compared to direct dilation from the nominal to maximal diameter. In vivo studies are necessary to corroborate these findings in the congenital heart disease population.

Use of Smart Technology for Remote Consultation in the Pediatric Cardiac Catheterization Laboratory.

OBJECTIVES: To evaluate the use of smartphone and tablet technology ("smart technology" or ST) in remote consultation for pediatric and congenital cardiac catheterization. DESIGN: Two online surveys, to early-career (Mentees) and senior (Mentors) pediatric interventional cardiologists, designed to assess the current use and attitudes toward ST for remote consultation. In addition, the current literature is reviewed for use of remote consultations and potential legal and patient privacy concerns. RESULTS: Forty-six (40%) Mentees and 19 (48%) Mentors responded. 74% of Mentees report using ST for remote consultation, 26% for nearly every case, with 45% of communication occurring during a procedure. Over one-third of Mentees report they have performed an intervention for the first time based on ST consultation. Of Mentors that reported receiving ST consultation, 58% were comfortable providing advice via this method, but 42% felt that the imaging sent was inadequate to provide appropriate advice for at least one case. Both groups felt the speed of consultation was much faster using ST. Privacy measures were reportedly used in up to 85% of consultations, while only 12% of respondents obtained informed consent for the consultation. The most common barrier identified by Mentees for use of ST for consultations was patient privacy concerns. CONCLUSIONS: ST use is prevalent among early-career pediatric and congenital interventional cardiologists for consultation regarding catheterization procedures. There are many technologic, legal, and patient privacy concerns that will need to be addressed as the use of ST for remote consultation grows.

Utility of preprocedure checklists in the congenital cardiac catheterization laboratory.

OBJECTIVE: Preprocedure meetings have become more commonplace in medicine but are not performed routinely in the cardiac catheterization laboratory. We sought to create, implement, and evaluate a preprocedural meeting in the form of a checklist for the cardiac catheterization laboratory. Staff attitudes and perceptions toward safety and sense of teamwork were also analyzed. DESIGN: All procedures performed in the cardiac catheterization laboratory on patients with structural heart disease from January 2010 to February 2012 were retrospectively reviewed for demographics, procedural details, and reported complications. A checklist was introduced to the preprocedure protocol at the halfway point, and patients were divided into pre- and postchecklist cohorts. Anesthesia and cardiac catheterization laboratory staff were surveyed at the beginning and end of the study period regarding attitude toward safety, team climate, and the impact of errors. RESULTS: Total number of procedures (prechecklist, n = 371; postchecklist, n = 370) and demographics were similar among groups. Complication rates were equivalent pre- and postchecklist, but there was a greater proportion of interventional cases and higher median complication level in the postchecklist group. Cardiac catheterization laboratory staff reported improved awareness of being briefed with the checklist. Anesthesia differed from cardiac catheterization staff in perception of communication as well as team and safety climate. CONCLUSIONS: A preprocedure checklist for congenital cardiac catheterization cases is easy to perform and serves to update cardiac catheterization laboratory staff. Anesthesia and cardiac catheterization staff had different perceptions of safety and teamwork climate. Further studies are needed to determine if this briefing could lead to better communication among services and ultimately reduce complications.

Blake drains: a novel method of chest drainage after extracardiac fontan operation with autologous pericardium.

BACKGROUND: Pleural effusions after Fontan palliation remain a cause of increased length of stay, cost, and morbidity. We report our experience with Blake drains (BDs) and the outpatient pediatric pleural drain pathway after Fontan operation. METHODS: A retrospective chart review was performed on all patients who underwent extracardiac lateral tunnel (ECLT) Fontan operation with pedicled autologous pericardium. Patients with prolonged pleural drainage were analyzed for predisposing factors. RESULTS: From March 1995 to December 2009, 162 patients (92 male, 56.8%) underwent ECLT Fontan operation. The median age at the time of Fontan operation was 30.9 months; the median weight was 12.9 kg. The median hospital stay was 4 days, and the median pleural drain requirement was 13 days. Prolonged pleural effusions occurred in 59 patients (36.4%), with prolonged cardiopulmonary bypass time identified as the only significant risk factor (p=0.04). Sixty patients (37%) were readmitted within 30 days of operation, with effusion requiring additional pleural drainage (n=41, 68.3%), infection (n=8, 13.3%), or a combination of the two (n=3, 5%) being the most common reason. There were two early deaths, neither of which was associated with BD malfunction. The BD clinical pathway for ECLT Fontan operation reduced our institutional cost to about $38,000 per patient, which represents a significant savings compared with traditional management with extended hospital stay after Fontan operation. CONCLUSIONS: Silicone BDs are safe and effective after ECLT Fontan operation. Hospital length of stay and cost can be significantly decreased when these drains are used with appropriate family involvement and close outpatient surveillance.