Successful valve-in-valve transcatheter intervention to treat severe stenosis of a 38-year-old tricuspid bioprosthesis.

A 60-year-old man presented with breathlessness. Nearly four decades previously, he had required three operations for Staphylococcus aureus infective endocarditis of the tricuspid valve and had received a bioprosthetic valve. He had critical tricuspid bioprosthesis stenosis which was treated successfully by valve-in-valve transcatheter tricuspid valve replacement using a balloon-expandable transcatheter heart valve. One year after intervention, the patient is well with no tricuspid valve stenosis or regurgitation.

Percutaneous Transcatheter Valve-in-Valve Pulmonary and Tricuspid Replacement in Carcinoid Heart Disease.

Surgical valve replacement is the most effective treatment for carcinoid heart disease; however, reoperation for prosthetic valve failure is burdened by high risk. We report the first described percutaneous transcatheter pulmonary and tricuspid valve-in-valve replacement for bioprosthesis degeneration for any reason in a patient with carcinoid heart disease. (Level of Difficulty: Advanced.).

Improving growth of infants with congenital heart disease using a consensus-based nutritional pathway.

OBJECTIVE: Infants with congenital heart disease (CHD) often experience growth failure prior to surgery, which is associated with increased paediatric-intensive-care unit length of stay (PICU-LOS) and post-operative complications. This study assessed the impact of a pre-operative, consensus-based nutritional pathway (including support from a multi-disciplinary team) on growth and clinical outcome. DESIGN: Single-centre prospective pilot study. SETTING: Tertiary paediatric cardiology surgical centre. PATIENTS: Infants with CHD. INTERVENTION: Infants with CHD were followed for up to 4-months-of-age before cardiac surgery and then to 12-months-of-age following the implementation of the consensus-based nutritional-pathway (Intervention group: November 2017-August 2018), with outcomes compared to a historic control group. The nutrition pathway involved a dietitian contacting parents of infants with the highest risk of growth failure weekly; reviewing weight gain and providing feeding support. MAIN OUTCOME MEASURE: Growth (weight-for-age, WAZ, and height-for-age-z-score, HAZ) at 4 and 12 months-of-age. RESULTS: 44 infants in the intervention group were compared to 38 in the control group. Median (inter quartile range) change in WAZ from birth to 4 months-of-age (-0.9 (-1.5, 0.7)) and from birth to 12 months-of-age (-0.09 (-1.3, 1.1)) in the intervention group compared to the control group (-1.5 (-2.0, -0.4) (p = 0.04)) at 4 months-of age and at 12 months-of-age (-0.4 (1.9, 0.2) (p = 0.03)). HAZ at 4 months-of-age was -0.7 (-1.4, -0.1) vs. -1.0 (-1.9, -0.3) (p = 0.6) in the intervention and control groups respectively, and at 12 months-of-age HAZ was -0.7 (-1.9, -0.07) in the intervention group vs.-1.6 (-2.6, -0.4) in the control group (p = 0.04). Duration of PICU-LOS was 8.2 ± 11.6 days intervention vs. 18.3 ± 24.0 days control (p = 0.006). CONCLUSION: Overall weight was well maintained and growth improved in infants who followed the pre-operative nutritional-pathway. The duration of PICU-LOS was significantly lower in the intervention group, which may be due to improved nutritional status, although this requires further investigation.

Development of feeding information for infants with CHD.

INTRODUCTION: Infants with CHD often experience growth failure. Ensuring optimal growth before surgery is associated with improved outcomes and has emerged as a significant cause of parental stress. Parents have reported a perceived lack of accessible feeding information for infants with CHD. To address this gap, the aim of this study was to develop feeding information to better support parents. MATERIALS AND METHODS: A search for existing material on six electronic databases and an internet search for unpublished (grey) literature on feeding information for infants with CHD were carried out. Following the development of feeding information, semi-structured interview(s) with parents/health-care professionals were completed, focusing on whether the information was easy to understand, relevant, provided sufficient information around feeding/feeding difficulties, and whether there were any information gaps. Iterative changes were made to the information following each interview. The process was completed until thematic saturation was achieved. RESULTS: A total of 23 unique articles were identified of which 5 studies were included. From the grey literature, four web pages were reviewed. A total of 22 parents and 25 health-care professionals were interviewed. All parents/health-care professionals felt that the feeding information developed provided sufficient information; however, many wanted information on how to introduce complementary food, particularly if weaning was delayed. CONCLUSIONS: This study describes the development of feeding information for infants with CHD. From parent interviews, gaps identified focused on the introduction of complementary foods and uncertainty regarding the feeding journey beyond surgery.

The development of a consensus-based nutritional pathway for infants with CHD before surgery using a modified Delphi process.

IntroductionDespite improvements in the medical and surgical management of infants with CHD, growth failure before surgery in many infants continues to be a significant concern. A nutritional pathway was developed, the aim of which was to provide a structured approach to nutritional care for infants with CHD awaiting surgery.Materials and methodsThe modified Delphi process was development of a nutritional pathway; initial stakeholder meeting to finalise draft guidelines and develop questions; round 1 anonymous online survey; round 2 online survey; regional cardiac conference and pathway revision; and final expert meeting and pathway finalisation. RESULTS: Paediatric Dietitians from all 11 of the paediatric cardiology surgical centres in the United Kingdom contributed to the guideline development. In all, 33% of participants had 9 or more years of experience working with infants with CHD. By the end of rounds 1 and 2, 76 and 96% of participants, respectively, were in agreement with the statements. Three statements where consensus was not achieved by the end of round 2 were discussed and agreed at the final expert group meeting. CONCLUSIONS: Nutrition guidelines were developed for infants with CHD awaiting surgery, using a modified Delphi process, incorporating the best available evidence and expert opinion with regard to nutritional support in this group.

Outcome after transcatheter occlusion of patent ductus arteriosus in infants less than 6 kg: A national study from United Kingdom and Ireland.

OBJECTIVES: This study aimed to report our national experience with transcatheter patent ductus arteriosus (PDA) occlusion in infants weighing <6 kg. BACKGROUND: The technique of transcatheter PDA closure has evolved in the past two decades and is increasingly used in smaller patients but data on safety and efficacy are limited. METHODS: Patients weighing < 6 kg in whom transcatheter PDA occlusion was attempted in 13 tertiary paediatric cardiology units in the United Kingdom and Ireland were retrospectively analyzed to review the outcome and complications. RESULTS: A total of 408 patients underwent attempted transcatheter PDA closure between January 2004 and December 2014. The mean weight at catheterization was 4.9 ± 1.0 kg and mean age was 5.7 ± 3.0 months. Successful device implantation was achieved in 374 (92%) patients without major complication and of these, complete occlusion was achieved in 356 (95%) patients at last available follow-up. Device embolization occurred in 20 cases (5%). The incidence of device related obstruction to the left pulmonary artery or aorta and access related peripheral vascular injury were low. There were no deaths related to the procedure. CONCLUSIONS: Transcatheter closure of PDA can be accomplished in selected infants weighing <6 kg despite the manufacturer's recommended weight limit of 6 kg for most ductal occluders. The embolization rate is higher than previously reported in larger patients. Retrievability of the occluder and duct morphology needs careful consideration before deciding whether surgical ligation or transcatheter therapy is the better treatment option.

Heart failure in the new born; vein of Galen aneurysmal malformation.

We narrate the case of a term baby who presented at 30 h of age in congestive cardiac failure due to vein of Galen aneurysmal malformation. A successful interventional radiology embolisation of the feeding vessels to the aneurysm was performed on day 5. Twenty hours following the procedure, the baby developed significant intraventricular haemorrhage with extension into the brain parenchyma; care was reoriented on day 7 of life after discussion with the parents. Vein of Galen aneurysmal malformation is a rare congenital vascular malformation. It usually manifests in the newborn period with high-output cardiac failure. The death rate is higher in those who present early in the neonatal period. The management of this condition requires a multidisciplinary approach.

Midterm follow-up of percutaneous closure of secundum atrial septal defect with Helex Septal Occluder.

INTRODUCTION: The Helex Septal Occluder (HSO) is a relatively new device used in the percutaneous closure of atrial septal defects (ASDs). The immediate and short-term results of its deployment have been reported, but the medium-term results have not been described. The objective was to describe the midterm efficacy and safety of percutaneous closure of ASD with the HSO. METHODS: The HSO was used in 33 children to close secundum ASDs between July 1999 and November 2000. Detailed data were collected at implantation and 31 children have been followed clinically and investigated with electrocardiogram (ECG) (n = 30), echocardiogram, and fluoroscopy (n = 30) at a mean of 63 (range 55-74) months after implantation. RESULTS: The ages and body weights at implantation ranged from 13 to 220 months and 7.6 to 57.6 kg. The ASD diameter ranged from 7 to 17 mm. All sizes of HSO were deployed. The range of device to defect ratio was 1.4 to 3.3. Of the 21 residual shunts noted early after implantation, only four persisted, all small, at latest follow-up. There were no new shunts. There were no new ECG abnormalities. There was a pronounced change in the configuration of one HSO without sequelae. In two patients in whom the locking loop missed the right atrial eyelet at deployment, there were no sequelae or residual shunts. There were no cases of frame fracture or explantation. There has been no death or long-term morbidity. CONCLUSIONS: At midterm follow-up the HSO is durable and effective, with a low incidence of adverse sequelae even in the small subgroup with imperfect configuration.