Oval stenting in left pulmonary artery stenosis: a novel double balloon technique to prevent airway compression in single ventricle.

AIMS: Left pulmonary artery (LPA) stenosis is common in patients with cavopulmonary connections. Stent implantation is the treatment of choice but may be complicated or contraindicated by left main bronchus (LMB) compression due to limited retro-aortic space after a Damus-Kaye-Stansel (DKS) or Norwood operation. This study describes a novel double balloon technique of LPA stenting in patients at risk of LMB compression. METHODS AND RESULTS: A cohort study was performed in 11 patients who underwent LPA stenting with an oval stent technique between 2015 and 2018. Retro-aortic anatomy was evaluated periprocedurally by three-dimensional rotational angiography (3DRA). Pre-existing LMB compression was demonstrated by 3DRA in seven out of eight patients who had undergone previous LPA stenting and in one patient without stenting. Primary ovalisation with immediate stent implantation on double balloons was performed in one patient. Ten patients had secondary ovalisation with single balloon stent implantation followed by the double balloon technique for ovalisation. The procedures were successful in all patients and guaranteed LMB patency without increasing pre-existing compression. CONCLUSIONS: The 3DRA-guided oval stent technique with double balloon inflation is successful in treating LPA stenosis after a DKS or Norwood operation in patients at risk of bronchial compression, guaranteeing LMB patency without increasing pre-existing compression.

Three-Dimensional Rotational Angiography in Pediatric Patients with Congenital Heart Disease: A Literature Review.

Cardiac catheterization is a commonly used form of imaging and treatment in pediatric patients with congenital heart disease. Traditionally, two-dimensional conventional angiography was the method used, but since 2000 three-dimensional rotational angiography (3DRA) is increasingly used in the field of cardiology in both adult and pediatric patients. To investigate the use and applications of 3DRA in pediatric congenital cardiology, literature was systematically reviewed and 29 eligible articles were found. Those showed that 3DRA is already a greatly valued diagnostic and therapeutic technique in pediatric cardiology. However, the literature misses well-designed clinical, homogeneous, multicenter, prospective studies recording data in a standardized manner. These studies are necessary to ensure proper data analysis and to investigate the true advantages of 3DRA and how it exactly benefits the patients.

Dramatic Dose Reduction in Three-Dimensional Rotational Angiography After Implementation of a Simple Dose Reduction Protocol.

Previously, median effective dose (ED) of 1.6 mSv per three-dimensional rotational angiography (3DRA) has been reported. This study evaluated ED and image quality in 3DRA after implementation of a simple dose reduction protocol in pediatric catheterizations. Simple conversion factors between 3DRA ED and readily available parameters at the cathlab were determined. The dose reduction protocol consisted of frame reduction (60-30 frames/s (f/s)), active collimation of the X-ray beam, usage of a readily available low dosage program, and a pre-3DRA run check. EDs were calculated with Monte Carlo PCXMC 2.0. Three observers blindly assessed 3DRA image quality of the dose reduction and normal-dose cohort. Between October 2014 and October 2015, 84 patients (median age 4.3 years) underwent 100 3DRAs with a median ED of 0.54 mSv (0.12-2.2) using the dose reduction protocol. Median ED in the normal-dose cohort (17 3DRAs) was 1.6 mSv (1.2-4.9). Image quality in the dose reduction cohort remained excellent. Correlations between ED and dose area product (DAP) and ED and skin dose were found with a ρ of 0.82 and 0.83, respectively. ED exposure of the entire catheterization was reduced to 2.64 mSv. Introduction of a simple protocol led to 66% dose reduction in 3DRA and 79% in the entire catheterization. 3DRA image quality in this group remained excellent. In 3DRA ED correlates well with DAP and skin dose, parameters readily available at the cathlab.

Additional value of three-dimensional rotational angiography in the diagnostic evaluation and percutaneous treatment of children with univentricular hearts.

AIMS: Complex single ventricle topography, changes in vessel geometry after surgical steps and subsequent stenoses are difficult to visualise with biplane conventional angiography (CA). This study aimed to investigate the additional value of three-dimensional rotational angiography (3DRA) compared to CA for diagnostic and interventional purposes in children with univentricular hearts. METHODS AND RESULTS: Demographic data, clinical data and catheterisation details of both imaging techniques were collected retrospectively. Image quality, interventional success and the additional value of 3DRA were reviewed and scored. Between January 2003 and March 2017, 140 patients underwent 183 CAs and 107 3DRAs. 3DRA image quality was superior to CA with fewer diagnostic angiographies performed (p<0.001). Intervention rate (p<0.001) and interventional success (p=0.03) were higher with 3DRA, while complication rates were similar. Mean radiation was lower in the 3DRA group, reaching significance pre-PCPC. 3DRA was considered of additional value in imaging of cardiovascular anatomy, collaterals, stenoses, and vessel-vessel and vessel-bronchi interactions. CONCLUSIONS: In univentricular hearts, 3DRA provides superior image quality when compared to CA. Furthermore, 3DRA is performed with fewer diagnostic angiographies, less radiation and higher interventional success.

Sudden Death Due to Coronary Artery Lesions Long-term After the Arterial Switch Operation: A Systematic Review.

BACKGROUND: The arterial switch operation (ASO) is the preferred procedure for children with dextrotransposition of the great arteries or Taussig-Bing anomaly. Short- as well as long-term outcome of ASO are excellent, but coronary artery stenoses are reported as a common long-term complication. It has been hypothesized that these might result in sudden cardiac death late after ASO. METHODS: A systematic search of PubMed and EMBASE was conducted to evaluate sudden cardiac death because of coronary complications late after ASO. Data on patients surviving ≥ 5 years post-ASO were collected from selected studies, corrected for duplicate data, and analyzed. RESULTS: After duplicate data correction 52 studies remained for data analysis. Among the 8798 survivors with follow-up, 27 patients died ≥ 5 years post-ASO (0.3%). Of these patients, 10 were known with relevant residual lesions. Five late deaths were sudden, possibly from a cardiac cause. None of the late sudden deaths were confirmed to be coronary-related. CONCLUSIONS: Sudden cardiac death in asymptomatic patients as a result of coronary artery stenosis or occlusion is extremely rare, with 5 possible cases and no proven cases of coronary artery-related sudden cardiac death in 8798 patients with 66,450 patient follow-up years. Therefore, routine coronary imaging of asymptomatic, single-stage ASO patients is not justified.