Endovascular Treatment of Acquired Atheromatous Postsubclavian Aortic Coarctation.

Coral reef aorta is a rare calcifying obstructive disease that involves the thoracoabdominal aorta. Similar presentations in the postsubclavian aorta may result in acquired atheromatous aortic coarctation leading to systemic hypertension and heart failure. The associated calcification makes surgical anatomic or extraanatomic bypass and thromboendarterectomy challenging. Extensive circumferential calcification often precludes endovascular intervention. We present the case of a 25-year-old man with an acquired atheromatous coarctation of the postsubclavian aorta who underwent successful endovascular treatment with use of a balloon-expandable covered stent.

Impact of COVID-19 pandemic on pediatric cardiac services in India.

BACKGROUND: COVID-19 pandemic has disrupted pediatric cardiac services across the globe. Limited data are available on the impact of COVID.19 on pediatric cardiac care in India. AIMS: The aims are to study the impact of COVID-19 pandemic on the care of children with heart disease in India in terms of number of outpatient visits, hospitalizations, catheter-based interventions, and cardiac surgeries. SETTINGS AND DESIGN: This is a retrospective, multicentric, observational study. METHODS: We collected monthly data on the number and characteristics of outpatient visits, hospitalizations, catheter-based interventions, and cardiac surgeries and major hospital statistics, over a period of 5 months (April to August 2020), which coincided with the first wave of COVID-19 pandemic in India and compared it with data from the corresponding months in 2019. RESULTS: The outpatient visits across the 24 participating pediatric cardiac centers decreased by 74.5% in 2020 (n = 13,878) as compared to the corresponding period in 2019 (n = 54,213). The reduction in the number of hospitalizations, cardiac surgeries, and catheterization procedures was 66.8%, 73.0%, and 74.3%, respectively. The reduction in hospitalization was relatively less pronounced among neonates as compared to infants/children (47.6% vs. 70.1% reduction) and for emergency surgeries as compared to elective indications (27.8% vs. 79.2%). The overall in-hospital mortality was higher in 2020 (8.1%) as compared to 2019 (4.8%), with a higher postoperative mortality (9.1% vs. 4.3%). CONCLUSIONS: The current COVID-19 pandemic significantly impacted the delivery of pediatric cardiac care across India with two-third reduction in hospitalizations and cardiac surgeries. In an already resource-constrained environment, the impact of such a massive reduction in the number of surgeries could be significant over the coming years. These findings may prove useful in formulating strategy to manage subsequent waves of ongoing COVID-19 pandemic.

Cobra-head and other shape-memory abnormalities of nitinol atrial septal occluders: incidence, predisposing factors, and outcomes.

BACKGROUND: Shape-memory abnormalities are seen in some nitinol atrial septal occluders. Variably described as cobra-head, tulip, and others, their incidence, mechanisms, clinical impact, and outcome have not been systematically analysed. METHODS: We retrospectively reviewed all consecutive device closures in the last 6 years for deformations. Type and size of the occluder, deployment technique, size, and angulation/kinking of the delivery sheath were analysed. Procedural success, duration, and other complications were studied. RESULTS: A total of 112 devices (11.8%) among 950 occluders used in 936 patients showed deformities. Fourteen of 936 received 2 devices. Deformities were transient and self-correcting in 40%. Multivariate analysis showed significant associations with oversized sheaths (p = 0.004), kinked/angulated sheaths (p < 0.001), special deployment techniques (p < 0.001), and twist in the device waist (p = 0.011). Despite more frequent deformities with Figulla (15.6%) and Amplatzer (13.9%) occluders than Cera occluders (6.6%) and larger devices (>24 mm - 14.6%) than smaller devices (less than or equal to 24 mm - 9.7%), they were not significant on multivariate analysis. In vivo manipulations corrected most deformities; nineteen needed in vitro reformations and four needed a change of device. Despite prolongation of the procedure, repeated attempts (mean 2.76 ± 1.7 attempts, with a range from 1 to 9 attempts), and supraventricular tachycardia in two patients, there were no serious adverse effects. CONCLUSIONS: Deformations were frequent in 11.8% of atrial septal occluders on a targeted search. Oversized and angulated/kinked sheaths, special techniques like pulmonary vein deployment and twist in device waist during procedure predisposed to deformities. While most deformities were corrected with manipulations, removal of the device was infrequently needed and change of device was rarely required. Long procedural time and multiple attempts for deployment did not affect procedural success.

A giant left ventricular pseudoaneurysm diagnosed after double-valve replacement.

A diagnostic coronary catheter injury to the subaortic region in a 41-year-old woman with rheumatic heart disease led to a pseudoaneurysm that later caused extrinsic left coronary compression. She subsequently underwent double-valve replacement, overlooking the pseudoaneurysm that enlarged to a giant size three months later following thrombolysis for mitral prosthesis thrombosis. A thrombolysis-induced large intracerebral hemorrhage posed a significant risk for reoperation, and mechanical prosthetic valves in the aortic and mitral positions allowed a catheter option only, through percutaneous transapical access. Interventional closure of the pseudoaneurysm is discussed in this unique report.

Are early palliative procedures providing an adequate long-term benefit in young cyanotic infants from developing countries, despite advances in surgery and interventions?

OBJECTIVES: Ductal stents, right ventricular outflow tract stents, and aortopulmonary shunts are used to palliate newborns and infants with reduced pulmonary blood flow. Current long-term outcomes of these palliations from resource-restricted countries are unknown. METHODS: This single-centre, retrospective, observational study analysed the technical success, immediate and late mortality, re-interventions, and length of palliation in infants ≤5 kg who underwent aortopulmonary shunts, ductal, and pulmonary outflow stents. Patients were grouped by their anatomy. RESULTS: There were 69 infants who underwent one of the palliations. Technical success was 90% for aortopulmonary shunts (n = 10), 91% for pulmonary outflow stents (n = 11) and 100% for ductal stents (n = 48). Early mortality within 30 days in 12/69 patients was observed in 20% after shunts, 9% after pulmonary outflow stents, and 19% after ductal stents. Late mortality in 11 patients was seen in 20% after shunts, 18% after outflow stents, and 15% after ductal stents. Seven patients needed re-interventions; two following shunts, one following outflow stent, and four following ductal stents for hypoxia. Among the anatomical groups, 10/12 patients with pulmonary atresia, intact ventricular septum survived after valvotomy and ductal stenting. Survival to Glenn shunt after ductal stent for pulmonary atresia, intact ventricular septum and diminutive right ventricle was very low in two out of eight patients, but very good (100%) for other univentricular hearts. Among 35 patients with biventricular lesions, 22 survived to the next stage. CONCLUSIONS: Cyanotic infants, despite undergoing technically successful palliation had a high inter-stage mortality irrespective of the type of palliation. Duct stenting in univentricular hearts and in pulmonary atresia with an intact ventricular septum and adequate sized right ventricle tended to have low mortality and better long-term outcome. Completion of biventricular repair after palliation was achieved only in 63% of patients, reflecting unique challenges in developing countries despite advances in intensive care and interventions.

Abernethy malformation draining above the diaphragm to the coronary sinus and its embryological explanations.

Abernethy malformation connecting to a supradiaphragmatic vein may be missed due to their rarity or lack of awareness. Embryological reasons explain the involvement of the left superior caval vein in these connections.

Transcatheter reduction in size of large undesirable fenestrations following extracardiac conduit Fontan surgery with off-label use of Occlutech atrial flow regulator.

Fontan surgery streamlines the systemic venous return through the pulmonary circulation before filling the systemic ventricle in univentricular hearts. The venous congestion leads to effusions, lowers cardiac output, and affects organ perfusion. Fenestrations in the Fontan circuit improve forward flow through the ventricles, lower venous pressures, and reduce perioperative morbidity. When large fenestrations cause profound hypoxia and effort intolerance, there are no current techniques to reduce their size. Atrial flow regulators with a predetermined orifice were used off-label in three borderline patients with large undesirable fenestrations following extracardiac conduit Fontan surgeries. This resulted in improved oxygenation without marked elevation of venous pressures, while retaining the patency of the decompressive fenestration.

Serum Sirolimus Levels After Implantation of Third Generation Drug Eluting Cobalt Chromium Coronary Stent in Ductus Arteriosus in Neonates with Duct-Dependent Pulmonary Circulation.

Ductal stenting (DS) palliates duct-dependent lesions using coronary stents. Sirolimus-eluting stents have replaced bare-metal stents in coronary interventions. Concerns exist about sirolimus levels in neonates. Therapeutic immunosuppressive sirolimus level is 5-15 ng/ml. After neonatal DS, drug levels were assessed at 24 h, 7 days and monthly thereafter till they were undetectable. Clinical course, ductal patency till their final corrective surgery was analyzed. The exact quantity of sirolimus in each stent was known. Twelve neonates with median age of 5.5 days received sirolimus-eluting stents, one stent in nine and two in the rest. The lesions were pulmonary atresia intact ventricular septum(PAIVS) in four, univentricular lesions with pulmonary atresia in four, biventricular lesions with pulmonary atresia in three and right ventricular rhabdomyoma in one neonate. If single stents up to 22 mm length, 24-h drug levels were less than 5 ng/ml. Even though 24-h levels were above 5 ng/ml in patients with single longer stent or two stents, it reduced to very low levels by seventh day. Two hospital deaths included rhabdomyoma with complete heart block and post-valvotomy cardiac failure for PAIVS. Stent patency after valvotomy for PAIVS exceeded three years. Patency was retained for 8-27 months till their elective corrective surgery in others. Sirolimus levels were acceptable at 24 h in all neonates receiving single stent under 22 mm length. In patients needing two stents, drug levels were in immunosuppressive range at 24 h but reduced rapidly within 7 days. The palliation provided by sirolimus-eluting DS was sufficiently long to provide clinical benefit.

Successful percutaneous retrieval of unusually knotted temporary pacemaker lead.

Implantation of temporary pacemaker lead is commonly performed procedure and is usually safe, but can sometimes develop rare and serious complication like intracardiac lead knotting which may require challenging retrieval techniques. We report a case of successful percutaneous retrieval of unusually knotted right internal jugular venous temporary pacing lead via left femoral transvenous approach using snare over a long sheath after cutting the electrode proximally and thus avoiding any surgical intervention.

High-precision flexible fabrication of tissue engineering scaffolds using distinct polymers.

Three-dimensional porous structures using biodegradable materials with excellent biocompatibility are critically important for tissue engineering applications. We present a multi-nozzle-based versatile deposition approach to flexibly construct porous tissue engineering scaffolds using distinct polymeric biomaterials such as thermoplastic and photo-crosslinkable polymers. We first describe the development of the deposition system and fabrication of scaffolds from two types of biodegradable polymers using this system. The thermoplastic sample is semi-crystalline poly(ε-caprolactone) (PCL) that can be processed at a temperature higher than its melting point and solidifies at room temperature. The photo-crosslinkable one is polypropylene fumarate (PPF) that has to be dissolved in a reactive solvent as a resin for being cured into solid structures. Besides the direct fabrication of thermoplastic PCL scaffolds, we specifically develop a layer molding approach for the fabrication of crosslinkable polymers, which traditionally can only be fabricated by stereolithography. In this approach, a thermoplastic supporting material (paraffin wax) is first deposited to make a mold for each specific layer, and then PPF is deposited on demand to fill the mold and cured by the UV light. The supporting material can be removed to produce a porous scaffold of crosslinked PPF. Both PCL and crosslinked PPF scaffolds fabricated using the developed system have been characterized in terms of compressive mechanical properties, morphology, pore size and porosity. Mouse MC3T3-E1 pre-osteoblastic cell studies on the fabricated scaffolds have been performed to demonstrate their capability of supporting cell proliferation and ingrowth, aiming for bone tissue engineering applications.