Aorto-mesenteric and renal allograft transplant: a novel treatment for midaortic syndrome.

Midaortic syndrome (MAS) is a rare condition characterized by stenosis of the aorta and often involving renal and visceral arteries. Current therapies include medical management of associated hypertension, and interventional procedures such as angioplasty or surgical bypass. We report a 2-year-old female with severe MAS who was initially treated with angioplasty and stents in both her aorta and superior mesenteric artery (SMA). Due to the presence of long segment stenoses, her renal arteries were not amenable to surgical reconstruction and she rapidly progressed to Stage V chronic kidney disease. The patient underwent bilateral nephrectomy and renal transplantation using a donor thoracoabdominal aorta allograft to provide inflow for the kidney as well as to bypass the nearly occluded aorta. The donor SMA was used to bypass the native SMA stenosis. Postoperatively, the patient had normalization of four limb blood pressures. She weaned from five anti-hypertensive agents to monotherapy with excellent renal function. This is the first reported case of thoracoabdominal aortic bypass using allograft aorta to address MAS. This approach allowed for successful kidney transplantation with revascularization of the mesenteric, and distal aortic circulation using allograft conduit that will grow with the child, obviating the need for repeated interventional or surgical procedures.

Ventricular size and function assessed by cardiac MRI predict major adverse clinical outcomes late after tetralogy of Fallot repair.

BACKGROUND: Factors associated with impaired clinical status in a cross-sectional study of patients with repaired tetralogy of Fallot (TOF) have been reported previously. OBJECTIVES: To determine independent predictors of major adverse clinical outcomes late after TOF repair in the same cohort during follow-up evaluated by cardiac magnetic resonance (CMR). METHODS: Clinical status at latest follow-up was ascertained in 88 patients (median time from TOF repair to baseline evaluation 20.7 years; median follow-up from baseline evaluation to most recent follow-up 4.2 years). Major adverse outcomes included (a) death; (b) sustained ventricular tachycardia; and (c) increase in NYHA class to grade III or IV. RESULTS: 22 major adverse outcomes occurred in 18 patients (20.5%): death in 4, sustained ventricular tachycardia in 8, and increase in NYHA class in 10. Multivariate analysis identified right ventricular (RV) end-diastolic volume Z >or=7 (odds ratio (OR) = 4.55, 95% confidence interval (CI) 1.10 to 18.8, p = 0.037) and left ventricular (LV) ejection fraction <55% (OR = 8.05, 95% CI 2.14 to 30.2, p = 0.002) as independent predictors of outcome with an area under the receiver operator characteristic curve of 0.850. LV ejection fraction could be replaced by RV ejection fraction <45% in the multivariate model. QRS duration >or=180 ms also predicted major adverse events but correlated with RV size. CONCLUSIONS: In this cohort, severe RV dilatation and either LV or RV dysfunction assessed by CMR predicted major adverse clinical events. This information may guide risk stratification and therapeutic interventions.

Changes in left heart hemodynamics after technically successful in-utero aortic valvuloplasty.

OBJECTIVE: Severe aortic stenosis in the mid-gestation fetus can progress to hypoplastic left heart syndrome (HLHS). @ In-utero aortic valvuloplasty is an innovative therapy to promote left ventricular growth and function and potentially to prevent HLHS. This study evaluated the effects of mid-gestation fetal balloon aortic valvuloplasty on subsequent fetal left ventricular function and left heart Doppler characteristics. METHODS: We reviewed fetuses with aortic stenosis that underwent attempted in-utero aortic valvuloplasty between 2000 and 2006. Pre-intervention and the latest post-intervention fetal echocardiograms were analyzed to characterize changes in left heart function and Doppler characteristics in utero. RESULTS: Forty-two fetuses underwent attempted aortic valvuloplasty during the study period, 12 of which were excluded from analysis secondary to inadequate follow-up data, termination or fetal demise. Study fetuses (n = 30) underwent pre-intervention echocardiography at a median gestational age of 23 weeks, and were followed for a median of 66 +/- 23 days post-intervention. In 26 fetuses, aortic valvuloplasty was technically successful. Among these 26, left heart physiology was abnormal pre-intervention and improved or normalized after intervention in most cases: biphasic mitral inflow was present in 5/25 (20%) cases pre-intervention and in 21/23 (91%) post-intervention (P < 0.001); moderate or severe mitral regurgitation was present in 14/26 (54%) cases pre-intervention and in 5/23 (22%) post-intervention (P = 0.02); bidirectional flow across the patent foramen ovale was present in 0/26 cases pre-intervention and in 6/25 (24%) post-intervention (P = 0.01); antegrade flow in the transverse arch was present in 0/25 cases pre-intervention and in 17/26 (65%) post-intervention (P < 0.001). The left ventricular ejection fraction increased from 19 +/- 10% pre-intervention to 39 +/- 14% post-intervention (P < 0.001). These changes were not observed in control fetuses (n = 18). CONCLUSION: Fetal aortic valvuloplasty, when technically successful, improves left ventricular systolic function and left heart Doppler characteristics.

Factors affecting technical success of fetal aortic valve dilation.

OBJECTIVE: We have reported previously that valve dilation enhances growth of cardiac structures and may prevent hypoplastic left heart syndrome (HLHS) in fetuses with critical aortic stenosis. We aimed to investigate maternal/fetal factors which may affect the technical success of fetal valvuloplasty, and to describe perinatal complications of the procedure. METHODS: This was a descriptive series of 22 fetuses diagnosed with critical aortic stenosis developing into HLHS which underwent intervention by valvuloplasty. Initially this was attempted using a percutaneous approach; reassessment after our first five attempts, only one of which was successful, led to the introduction of the option of laparotomy. Technical success was defined as balloon inflation across the aortic annulus and a broader jet through the aortic valve as assessed by Doppler. Data collected included body mass index, demographic variables, ultrasound findings and postprocedure interventions. RESULTS: Technical success increased significantly if maternal laparotomy was an option (83.3% vs. 20.0%, P = 0.017). Laparotomy was performed in 66.6% (12/18) of cases. There was a learning curve that showed an increase in success rate and decrease in need for laparotomy over the 3-year study period. Neither the need for laparotomy nor the chances of technical success were predictable by gestational age, body mass index or placental location. Tocolysis was limited to perioperative prophylaxis; one woman experienced wound infection and fluid overload. Postoperatively, three fetuses died and two delivered prematurely, 2 and 7 weeks after intervention. CONCLUSION: Fetal aortic valvuloplasty can be performed with technical success, with low fetal loss rate and few maternal complications. While the need for laparotomy cannot be predicted, having it available as an option improves the technical success rate.

Biatrial or left atrial drainage of the right superior vena cava: anatomic, morphogenetic, and surgical considerations--report of three new cases and literature review.

Since the posterior wall of the right superior vena cava (RSVC) is contiguous with the anterior wall of the right upper pulmonary veins, a localized defect in this common wall may create a cavopulmonary venous confluence without eliminating the normal connection of the same right pulmonary veins with the left atrium (LA). Through this defect, blood of the unroofed right pulmonary veins will drain into the RSVC and right atrium (RA), and blood from the RSVC may shunt into the right pulmonary veins and LA. Hemodynamically, the RSVC will become biatrial. If the RSVC blood flows preferentially into the LA, its right atrial orifice will become stenotic or even atretic. If atretic, the normally positioned RSVC will drain entirely into the LA. In this report, we present the clinical and anatomical findings of two postmortem cases with biatrial drainage of the RSVC. We also document the clinical, echocardiographic, angiocardiographic, and surgical data of a living patient with left atrial drainage of the RSVC and tetralogy of Fallot with pulmonary atresia. The relevant literature and surgical treatment are reviewed, and the morphogenesis of the biatrial and left atrial RSVC is considered.

Balloon dilation angioplasty of peripheral pulmonary stenosis associated with Williams syndrome.

BACKGROUND: Experience of balloon dilation of peripheral pulmonary stenosis (PPS) in Williams syndrome (WS) is limited. METHODS AND RESULTS: Catheterizations in all patients with WS undergoing therapy for PPS from 1984 to 1999 were reviewed. Criteria for successful dilation included an increase >50% in predilation diameter and a decrease >20% in ratio of right ventricular (RV) to aortic (Ao) systolic pressure. Median age and weight were 1.5 years and 9.5 kg. There were 134 dilations during 39 procedures in 25 patients. The success rate for initial dilations was 51%. In multivariate analysis, successful dilation was more likely (1) in distal than in central pulmonary arteries (P=0.02), (2) if the balloon waist resolved with inflation (P=0.001), and (3) with larger balloon/stenosis ratio (P<0.001). RV pressure was unchanged after dilation (96+/-30 versus 97+/-31 mm Hg), primarily because of failure to enlarge central pulmonary arteries. The Ao pressure increased (102+/-14 versus 109+/-19 mm Hg, P=0.03), and the RV/Ao pressure ratio decreased (0.97+/-0.34 versus 0.91+/-0.30, P=0.05). Aneurysms developed after 24 dilations (18%) and were not related to balloon/stenosis ratio. Balloon rupture in 12 dilations produced an aneurysm in all 7 cases when rupture was in a hypoplastic segment. Three patients died, none from pulmonary artery trauma, and all before 1994. CONCLUSIONS: Mortality occurred early in our experience. Despite successful dilation of distal pulmonary arteries, there was modest initial hemodynamic improvement, mainly because of persistent central pulmonary artery obstruction. A serial approach of distal dilations followed by surgical repair of proximal obstruction may be a rational and successful therapy.

Balloon pulmonary angioplasty for treatment of chronic thromboembolic pulmonary hypertension.

BACKGROUND: Although pulmonary thromboendarterectomy is increasingly successful for the definitive treatment of chronic thromboembolic pulmonary hypertension (CTEPH), not all patients have surgically accessible disease. Others are poor surgical candidates because of comorbid illness. Therefore, for selected patients, we defined and implemented an alternative interventional strategy of balloon pulmonary angioplasty (BPA). METHODS AND RESULTS: Eighteen patients (mean age, 51.8 years; range, 14 to 75 years) with CTEPH underwent BPA; they averaged 2.6 procedures (range, 1 to 5) and 6 dilations (range, 1 to 12). Selection of pulmonary artery segments for dilation required (1) complete occlusion, (2) filling defects, or (3) signs of intravascular webs. After an average of 36 months of follow-up (range, 0.5 to 66 months), the average New York Heart Association class improved from 3.3 to 1.8 (P:<0.001), and 6-minute walking distances increased from 209 to 497 yards (P:<0.0001). Pulmonary artery mean pressures decreased from 43.0+/-12.1 to 33. 7+/-10.2 mm Hg (P:=0.007). Eleven patients developed reperfusion pulmonary edema; 3 required mechanical ventilation. CONCLUSIONS: BPA reduces pulmonary artery hypertension in patients with CTEPH and is associated with long-term improvement in New York Heart Association class and 6-minute walking distances. BPA is a promising interventional technique that warrants randomized comparison with medical therapy in CTEPH patients who are not surgical candidates.

Long-term results of the lateral tunnel Fontan operation.

OBJECTIVES: Completion of a total cavopulmonary anastomosis with an intra-atrial lateral tunnel is known to yield good early and midterm results. In this study, we sought to determine the long-term outcome (10 years) after a lateral tunnel Fontan procedure. METHODS: Between October 1987 and December 1991, 220 patients (aged 11 months to 32 years) with a wide range of underlying diagnoses underwent a fenestrated or nonfenestrated lateral tunnel Fontan procedure at our institution. Current follow-up information was available for 196 patients (94%, mean follow-up = 10.2 +/- 0.6 years). Risk factor analysis included patient-related and procedure-related variables, with death, failure, and bradyarrhythmia or tachyarrhythmia as outcome parameters. RESULTS: There were 12 early deaths (<30 days or hospital death), 7 late deaths, 4 successful takedown operations, and 4 heart transplantations. Kaplan-Meier estimated survival was 93% at 5 years and 91% at 10 years, and freedom from failure was 90% at 5 years and 87% at 10 years. Freedom from new supraventricular tachyarrhythmia was 96% at 5 years and 91% at 10 years; freedom from new bradyarrhythmia was 88% at 5 years and 79% at 10 years. Three patients had evidence of protein-losing enteropathy. Multivariable risk factors for development of supraventricular tachyarrhythmia included heterotaxy syndrome, atrioventricular valve abnormalities, and preoperative bradyarrhythmia. Risk factors for bradyarrhythmia included systemic venous anomalies. The sole risk factor for late failure was a previous coarctation repair. CONCLUSION: The lateral tunnel Fontan procedure results in excellent long-term outcome even when used in patients with diverse anatomic diagnoses. The incidence of atrial tachyarrhythmia is low and mainly depends on the underlying cardiac morphology and preoperative arrhythmia. The good long-term outcome after an intracardiac lateral tunnel Fontan procedure should serve as a basis for comparison with other surgical alternatives.

Outcome in infants with pulmonary atresia, intact ventricular septum, and right ventricle-dependent coronary circulation.

Management of all patients with pulmonary atresia, intact ventricular septum, and right ventricle-dependent coronary circulation (n = 12) with staged surgery directed toward a Fontan palliation resulted in an 83% 5-year actuarial survival. Both deaths in the study were presumably related to coronary ischemia and occurred in the first 4 months of life.

Pulmonary artery trauma due to balloon dilation: recognition, avoidance and management.

OBJECTIVES: We reviewed the management and outcome of patients experiencing pulmonary artery (PA) trauma during balloon dilation (BD). BACKGROUND: Balloon dilation of the PA is important in the management of peripheral pulmonary stenosis. Successful BD requires a controlled tear of the PA; excessive tearing can produce complications ranging from pseudoaneurysms to rupture and death. The incidence and optimum management for such complications are unreported. METHODS: All records of patients who underwent branch PA dilation between June 1984 and October 1997 were reviewed; those with a significant complication were analyzed. RESULTS: Of 1,286 catheterizations in 782 patients, PA trauma (excluding isolated pulmonary edema and PA aneurysms) was identified in 29 catheterizations in 26 patients. Tears occurred distal to the area of stenosis in most cases (62%). Intensive medical management, with and without catheter directed therapy, was employed. The damaged PA was successfully coil embolized in five patients, four of whom survived; temporary balloon occlusion did not prevent death in two patients. There were six deaths from pulmonary hemorrhage. A case control analysis demonstrated that PA trauma was significantly associated with pulmonary hypertension. CONCLUSIONS: Pulmonary artery trauma associated with BD occurs mostly distal to the site of narrowing, is associated with underlying pulmonary hypertension and is frequently (5/12 or 42%) fatal in those with unconfined tears. Intensive management strategies as well as attention to distal balloon position may reduce incidence and mortality. Coil occlusion of the damaged PA appears to be a valuable strategy to prevent fatal hemorrhage.

Clinical outcome of fenestrated Fontan patients after closure: the first 10 years.

BACKGROUND: The late clinical status of Fontan patients after fenestration closure is unknown. Data are now available on all patients who underwent closure from 1989 to 1999. METHODS AND RESULTS: All patients who underwent catheter closure of a Fontan fenestration were enrolled in either the Clamshell (1989 to 1994) or CardioSEAL (1996 to 1999) regulatory trials. Physiological values obtained at catheterization helped assess the hemodynamic effects of fenestration occlusion. In addition to survival, outcomes assessed included O(2) saturations, medication use, significant clinical findings (eg, heart failure, protein-losing enteropathy, or new arrhythmias), and somatic growth. Of 181 patients who underwent closure, 27 had additional significant leaks. The remaining 154 patients constituted the study group. Median time from closure to latest follow-up was 3.4 years (range 0.4 to 10.3 years). Fenestration closure increased O(2) saturation 9.4% on average (P:<0. 001). The numbers of patients receiving digoxin or diuretics decreased at the most recent follow-up compared with baseline (P:<0. 001), but use of antiarrhythmic agents increased marginally (P:=0. 05). Height and weight percentiles rose (medians of 2 and 4, respectively; P:<0.001). Clinical decompensation during follow-up of 154 patients was rare (4.5%), with 2 deaths, 3 Fontan revisions, and 1 patient each with protein-losing enteropathy and ascites. No other patient developed chronic congestive symptoms; 21 patients developed new arrhythmias, and 2 had a stroke or transient ischemic attack. CONCLUSIONS: Fenestration closure in Fontan patients was followed by improved oxygenation, reduced need for anticongestive medication, and improved somatic growth at latest follow-up. Death (1.3%) or chronic decompensation (3.2%) was rare.

Structural and compliant anatomy of the patent foramen ovale in patients undergoing transcatheter closure.

BACKGROUND: Most current intracardiac closure devices target the atrial septal defect. However, defects such as the patent foramen ovale (PFO) have unique structural features that may influence rational device design. With mounting interest in transcatheter techniques for closure of PFO in patients with cryptogenic stroke, a clearer understanding of these features is warranted. METHODS: Retrospectively, we reviewed angiograms obtained at the time of transcatheter closure of PFOs with a non-self-centering device in a group of 21 patients with a history of stroke. RESULTS: The PFO appeared as a tunnel of varying length (2.4 to 19.5 mm, mean 9.1 +/- 4.7 mm) bounded by septum secundum and septum primum. The potential area of the defect was as small as 12.2 mm(2) and as large as 121.1 mm(2). With device placement, the tunnel length shortened or disappeared (0.5 +/- 1.6 mm) by inferior displacement of the more compliant septum primum. CONCLUSIONS: In patients with PFO referred for transcatheter closure, the defect most commonly appeared as a tunnel-like defect between a thicker, less compliant septum secundum and a thinner, more compliant septum primum. Although the length of the undisturbed tunnel varied widely, the tunnel was shortened or eliminated by placement of a non-self-centering device. The observation that PFO anatomy can be predictably altered by some devices may have an impact on device design or implantation technique.

Early results and medium-term follow-up of stent implantation for mild residual or recurrent aortic coarctation.

BACKGROUND: Optimal timing and mode of treatment for patients with aortic coarctation remains controversial, particularly when the degree of obstruction is mild. Surgery, balloon dilatation, and stent implantation have all proven effective in the treatment of moderate or severe obstruction. In this report, we describe the use of stents to treat coarctation in a heterogeneous population, including patients with relatively mild obstruction. METHODS: Retrospectively, we studied the results of stent implantation in 33 patients, children and young adults, who underwent catheterization for treatment of coarctation. Patients with isolated coarctation, as well as those with associated cardiac defects, were included. The median systolic pressure gradient of our patients was 25 mm Hg. RESULTS: Patients had an acute decrease in systolic blood pressure gradient (25 mm Hg to 5 mm Hg, P <.001) and an increase in lumen diameter (8 mm to 13 mm, P <.001). When 16 patients were recatheterized during the follow-up period, gradients remained decreased (30 mm Hg to 14 mm Hg, P <.001) compared with prestent values. Ventricular end-diastolic pressure, which was increased in 82% of patients at the time of initial catheterization, decreased from 17 mm Hg to 14 mm Hg (P =.002). Although the procedure was generally safe, serious complications did occur. CONCLUSIONS: Stent implantation represents a therapeutic option that can safely and effectively reduce gradient in challenging patients with mild postoperative coarctation. Furthermore, our data suggest that aortic obstruction often coexists with ventricular diastolic dysfunction in these patients and that relief of obstruction may play a role in improvement of function.

Sudden death in patients after transcatheter device implantation for congenital heart disease.

To explore whether transcatheter intracardiac devices increase risk for sudden death, we analyzed patient and device-related variables with a case-control design. Sudden death was defined as unexpected death with abrupt onset and rapid deterioration. Cases included all patients known to have died suddenly after device closure at our institution, using 3 large databases. Controls (2:1), matched on year of procedure, were chosen randomly from the same databases. Data were obtained from medical record review. Of 777 patients who received implants between February 1989 and February 1999, 9 were known to have died suddenly (1.2%). In 27 cases and controls, diverse defects were occluded: atrial (n = 16), ventricular (n = 4), Fontan fenestration (n = 4), or other (n = 3). Cases were more likely to have had a history of serious arrhythmias (p = 0.008), severe valve regurgitation (p = 0.03), > or =1 cardiac surgery (p = 0.009), and multiple devices (p = 0.03). Cases were somewhat more likely to have pulmonary hypertension (p = 0.09), ventricular dysfunction (p = 0.09), and nonatrial septal defects (p = 0.10). Patients were less likely to have device arm fractures (p = 0.05). The following were not related to sudden death: age, weight, gender, low systemic cardiac index, end-diastolic pressure, major noncardiac disease, serious adverse events, maximum device size, malposition, and residual leak. This study suggests that sudden death was more likely to occur in device-implanted patients who had severe underlying cardiac disease and/or multiple devices. No other device-related variables were associated with sudden death.

Closure of patent foramen ovale for paradoxical emboli: intermediate-term risk of recurrent neurological events following transcatheter device placement.

OBJECTIVES: We report the largest and the longest follow-up to date of patients who underwent transcatheter patent foramen ovale (PFO) closure for paradoxical embolism. BACKGROUND: Closure of a PFO has been proposed as an alternative to anticoagulation in patients with presumed paradoxical emboli. METHODS: Data were collected for patients following PFO closure with the Clamshell, CardioSEAL or Buttoned Devices at two institutions. RESULTS: There were 63 patients (46 +/- 18 years) with a follow-up of 2.6 +/- 2.4 years. Fifty-four (86%) had effective closure of the foramen ovale (trivial or no residual shunt by echocardiography) while seven (11%) had mild and two (3%) had moderate residual shunting. There were four deaths (leukemia, pulmonary embolism, sepsis following a hip fracture and lung cancer). There were four recurrent embolic neurological events following device placement: one stroke and three transient events. The stroke occurred in a 56-year-old patient six months following device placement. A follow-up transesophageal echocardiogram showed a well seated device without residual shunting. Two of the four events were associated with suboptimal device performance (one patient had a significant residual shunt and a second patient had a "friction lesion" in the left atrial wall associated with a displaced fractured device arm). The risk of recurrent stroke or transient neurological event following device placement was 3.2% per year for all patients. CONCLUSION: Transcatheter closure of PFO is an alternative therapy for paradoxical emboli in selected patients. Improved device performance may reduce the risk of recurrent neurological events. Further studies are needed to identify patients most likely to benefit from this intervention.

Acute animal studies of the STARFlex system: a new self-centering cardioSEAL septal occluder.

The STARFlex system is a modified CardioSEAL device with a flexible self-centering mechanism comprised of nitinol springs strung between opposing arms, a connecting ball (sleeve joint that allows the device to pivot prerelease), and a front-loading delivery system. It was designed to allow a smaller device/defect sizing ratio and delivery profile, provide centering capability, and improve closure rates. To test this system, 13 devices (23, 28, and 33 mm) were deployed in six sheep within created atrial septal defects (12- to 22-mm diameter; n = 10), in the left atrium (n = 2), and in inferior vena cava (n = 1). All implantations in atrial septal defects were successful, with device/defect ratio ranging from 1.3 to 1.9 (median, 1.3), with no residual leak by angiography or echocardiography in seven (3/10 had