RESUMO
BACKGROUND: Recoarctation after the Norwood procedure increases risk for mortality. The Single Ventricle Reconstruction (SVR) trial randomized subjects with a single right ventricle undergoing a Norwood procedure to a modified Blalock-Taussig shunt or a right ventricle-pulmonary artery shunt. We sought to determine the incidence of recoarctation, risk factors, and outcomes in the SVR trial. METHODS AND RESULTS: Recoarctation was defined by intervention, either catheter based or surgical. Univariate analysis and multivariable Cox proportional hazard models were performed with adjustment for center. Of the 549 SVR subjects, 97 (18%) underwent 131 interventions (92 balloon aortoplasty, 39 surgical) for recoarctation at a median age of 4.9 months (range, 1.1-10.5 months). Intervention typically occurred at pre-stage II catheterization (n=71, 54%) or at stage II surgery (n=38, 29%). In multivariable analysis, recoarctation was associated with the shunt type in place at the end of the Norwood procedure (hazard ratio, 2.0 for right ventricle-pulmonary artery shunt versus modified Blalock-Taussig shunt; P=0.02), and Norwood discharge peak echo-Doppler arch gradient (hazard ratio, 1.07 per 1 mm Hg; P<0.01). Subjects with recoarctation demonstrated comorbidities at pre-stage II evaluation, including higher pulmonary arterial pressures (15.4±3.0 versus 14.5±3.5 mm Hg; P=0.05), higher pulmonary vascular resistance (2.6±1.6 versus 2.0±1.0 Wood units·m(2); P=0.04), and increased echocardiographic volumes (end-diastolic volume, 126±39 versus 112±33 mL/BSA(1.3), where BSA is body surface area; P=0.02). There was no difference in 12-month postrandomization transplantation-free survival between those with and without recoarctation (P=0.14). CONCLUSIONS: Recoarctation is common after Norwood and contributes to pre-stage II comorbidities. Although with intervention there is no associated increase in 1-year transplantation/mortality, further evaluation is warranted to evaluate the effects of associated morbidities.
Assuntos
Coartação Aórtica/epidemiologia , Coartação Aórtica/cirurgia , Procedimento de Blalock-Taussig/métodos , Procedimentos de Norwood/métodos , Coartação Aórtica/mortalidade , Criança , Pré-Escolar , Estudos de Coortes , Humanos , Incidência , Lactente , Análise Multivariada , Modelos de Riscos Proporcionais , Estudos Prospectivos , Reoperação , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida , Resultado do TratamentoRESUMO
Three-dimensional transesophageal echocardiography (3D TEE) has been used to guide the percutaneous repair of simple atrial septal defects (ASDs). There has been limited experience in using this imaging modality to guide complex ASD repair. In this report, we describe how 3D TEE was used to guide the repair of a complex, multifenestrated ASD. In a single view, 3D TEE provides a superior anatomic definition when compared to the traditional two-dimensional echocardiography. We believe that this emerging technology will play a critical role as the number and complexity of percutaneous techniques treating structural heart disease continue to rise. (Echocardiography 2010;27:590-593).
Assuntos
Ecocardiografia Tridimensional/métodos , Comunicação Interatrial/diagnóstico por imagem , Comunicação Interatrial/terapia , Dispositivo para Oclusão Septal , Ultrassonografia de Intervenção , Feminino , Fluoroscopia , Humanos , Pessoa de Meia-IdadeRESUMO
OBJECTIVES: Aortic arch reconstruction in children with single ventricle lesions may predispose to circulatory inefficiency and maladaptive physiology leading to increased myocardial workload. We sought to describe neoaortic anatomy and physiology, risk factors for abnormalities, and impact on right ventricular function in patients with single right ventricle lesions after arch reconstruction. METHODS: Prestage II aortic angiograms from the Pediatric Heart Network Single Ventricle Reconstruction trial were analyzed to define arch geometry (Romanesque [normal], crenel [elongated], or gothic [angular]), indexed neoaortic dimensions, and distensibility. Comparisons were made with 50 single-ventricle controls without prior arch reconstruction. Factors associated with ascending neoaortic dilation, reduced distensibility, and decreased ventricular function on the 14-month echocardiogram were evaluated using univariate and multivariable logistic regression. RESULTS: Interpretable angiograms were available for 326 of 389 subjects (84%). Compared with controls, study subjects more often demonstrated abnormal arch geometry (67% vs 22%, P < .01) and had increased ascending neoaortic dilation (Z score 3.8 ± 2.2 vs 2.6 ± 2.0, P < .01) and reduced distensibility index (2.2 ± 1.9 vs 8.0 ± 3.8, P < .01). Adjusted odds of neoaortic dilation were increased in subjects with gothic arch geometry (odds ratio [OR], 3.2 vs crenel geometry, P < .01) and a right ventricle-pulmonary artery shunt (OR, 3.4 vs Blalock-Taussig shunt, P < .01) but were decreased in subjects with aortic atresia (OR, 0.7 vs stenosis, P < .01) and those with recoarctation (OR, 0.3 vs no recoarctation, P = .04). No demographic, anatomic, or surgical factors predicted reduced distensibility. Neither dilation nor distensibility predicted reduced right ventricular function. CONCLUSIONS: After Norwood surgery, the reconstructed neoaorta demonstrates abnormal anatomy and physiology. Further study is needed to evaluate the longer-term impact of these features.
Assuntos
Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aortografia , Cardiopatias Congênitas/cirurgia , Ventrículos do Coração/cirurgia , Procedimentos de Norwood/efeitos adversos , Remodelação Vascular , Aorta Torácica/anormalidades , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/fisiopatologia , Aneurisma da Aorta Torácica/etiologia , Aneurisma da Aorta Torácica/fisiopatologia , Distribuição de Qui-Quadrado , Dilatação Patológica , Ecocardiografia , Feminino , Cardiopatias Congênitas/diagnóstico por imagem , Cardiopatias Congênitas/fisiopatologia , Ventrículos do Coração/anormalidades , Ventrículos do Coração/diagnóstico por imagem , Ventrículos do Coração/fisiopatologia , Humanos , Lactente , Modelos Logísticos , Masculino , Análise Multivariada , Razão de Chances , Valor Preditivo dos Testes , Ensaios Clínicos Controlados Aleatórios como Assunto , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoAssuntos
Angioplastia com Balão/métodos , Coartação Aórtica/terapia , Recém-Nascido Prematuro , Recém-Nascido de muito Baixo Peso , Stents , Aorta/patologia , Aortografia , Cateterismo Cardíaco , Seguimentos , Humanos , Lactente , Recém-Nascido , Cuidados Paliativos , Complicações Pós-Operatórias , Resultado do Tratamento , Túnica Íntima/patologiaAssuntos
Cateterismo Cardíaco , Artéria Femoral/fisiologia , Fluxo Pulsátil/efeitos dos fármacos , Fluxo Pulsátil/fisiologia , Terapia Trombolítica , Ativador de Plasminogênio Tecidual/uso terapêutico , Arteriopatias Oclusivas/tratamento farmacológico , Arteriopatias Oclusivas/fisiopatologia , Arteriopatias Oclusivas/cirurgia , Procedimentos Cirúrgicos Cardiovasculares , Proteção da Criança , Pré-Escolar , Artéria Femoral/diagnóstico por imagem , Artéria Femoral/cirurgia , Seguimentos , Humanos , Lactente , Bem-Estar do Lactente , Recém-Nascido , Tempo de Internação , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/etiologia , Valor Preditivo dos Testes , South Carolina , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia de Intervenção , Grau de Desobstrução Vascular/efeitos dos fármacos , Grau de Desobstrução Vascular/fisiologiaRESUMO
BACKGROUND: Prior studies suggest that patent foramen ovale (PFO) diameter >4 mm is associated with a high probability of cryptogenic ischemic stroke (CIS). METHODS: We evaluated all patients diagnosed with CIS who underwent closure of intra-atrial communication (IAC) using the Amplatzer atrial septal defect (ASD) occluder in our institution between August 1997 and March 2004. For each IAC, echocardiographic diameters and balloon-stretched diameters were recorded. Stretchability index was calculated as the ratio of stretched diameter to unstretched diameter. RESULTS: Fifty-six patients met the inclusion criteria for this study. There was an inverse logarithmic relationship between unstretched IAC diameter and stretchability index. For the 28 smaller defects, the median IAC diameter was 2 mm, and median stretchability index was 5.58 (range 2.6-15). For the 28 larger defects, median diameter was 6 mm, and median stretchability index was 2.38 (range 1.05-5). The difference in stretchability index between the two groups was significant (P < 0.0001). CONCLUSION: Our data bring into question the concept that the diameter of the defect would singularly predict the probability of stroke.
Assuntos
Oclusão com Balão/métodos , Cateterismo Cardíaco/métodos , Comunicação Interatrial/complicações , Comunicação Interatrial/terapia , Acidente Vascular Cerebral/complicações , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Átrios do Coração/diagnóstico por imagem , Septos Cardíacos/anatomia & histologia , Humanos , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Fatores de Risco , Acidente Vascular Cerebral/prevenção & controle , UltrassonografiaRESUMO
Angiographic diameters of 36 pulmonary artery stenoses (26 patients; median age, 3.3 years) before and after balloon angioplasty and at repeat angiography after 2-64 months were compared to diameters of 31 untreated pulmonary artery stenoses (20 patients) at a median age of 3.6 years and after 4-76 months. In the treatment group, an acute diameter gain of > 50% was achieved in 58%. On follow-up, 16 lesions remained unchanged, 6 lesions had > 20% late loss, and 12 lesions had > 20% late gain. The three patterns of vascular response were confirmed when compared to the control group. In the late gain group, overall diameter increase was 125% compared to 41% initial increase. The net result was a long-term success rate of 57%. Patterns of late diameter change appear to suggest vascular remodeling after balloon angioplasty of pulmonary arteries.
Assuntos
Angioplastia com Balão , Artéria Pulmonar , Angiografia , Estudos de Casos e Controles , Pré-Escolar , Constrição Patológica/diagnóstico por imagem , Constrição Patológica/terapia , Seguimentos , Humanos , Artéria Pulmonar/diagnóstico por imagem , Estudos Retrospectivos , Fatores de TempoRESUMO
OBJECTIVES: This study was designed to identify predictors of residual defects following deployment of the Amplatzer device to close septal defects within the oval fossa. METHODS: Between February 1997 and February 2000, we used the Amplatzer device to close defects in the oval fossa in 89 patients. Of these patients, 18 (20%) had residual defects. At 6 or 12 months following placement of the device, 13 defects (14.6%) had persisted. We evaluated several variables derived from clinical features, transesophageal echocardiography and catheterization to establish predictors for residual shunting. RESULTS: Multivariate analysis identified a shorter superior rim of less than 8 mm (Odds ratio = 10.1; 95% confidence intervals = 2.64-38.72; p = 0.001), and a smaller interatrial septum in the 30-degree transesophageal echocardiographic plane of less than 30 mm (Odds ratio = 5.5; 95% confidence intervals = 1.17-26.14; p = 0.03) as independent predictors of residual defects. When the analysis was repeated defining only those 13 patients with persisting residual defects at 6 or 12 months as failures, a short superior rim (p = 0.004) remained a predictor for residual shunting. CONCLUSIONS: Defects with a short superior rim and smaller interatrial septum in the 30-degree transesophageal echocardiographic plane independently and additively predict an increased probability of residual shunting following closure of defects in the oval fossa using the Amplatzer device.