OBJECTIVE To review the outcomes of transcatheter closure of atrial septal defects using the Card... more OBJECTIVE To review the outcomes of transcatheter closure of atrial septal defects using the Cardio-Seal implant. DESIGN A prospective interventional study. SETTING Tertiary referral centre. PATIENTS The first 50 patients (median age 9.7 years) who underwent attempted percutaneous occlusion. INTERVENTIONS Procedures were done under general anaesthesia and transoesophageal guidance between December 1996 and July 1998. MAIN OUTCOME MEASURES Success of deployment, complications, and assessment of right ventricular end diastolic diameter, septal wall motion, and occlusion status by echocardiography. RESULTS The median balloon stretched diameter was 14 mm. Multiple atrial septal defects were present in 11 patients (22%) and a deficient atrial rim (< 4 mm) in 19 (38%). In four patients (8%), a second device was implanted after removal of an initially malpositioned first implant. There were no significant immediate complications. All patients except one were discharged within 24 hours. ...
The aim of this study was to assess the incidence of persistently positive results on agitated sa... more The aim of this study was to assess the incidence of persistently positive results on agitated saline contrast injection after patent foramen ovale (PFO) closure, the underlying mechanism, and management. BACKGROUND Transcatheter intervention to close a PFO is reasonable in highly selected patients younger than 60 years, after a thorough cardioneurological investigation following a cryptogenic stroke, particularly in the presence of thromboembolic disease or in patients at high risk for venous thrombosis. The U.S. Food and Drug Administration approved the Amplatzer PFO Occluder in October 2016 for such an indication. Confirmation of PFO closure is usually verified by an agitated saline contrast injection during an echocardiographic examination. The appearance of bubbles in the left atrium raises the concern of incomplete closure or other sources of shunting. METHODS The medical records and echocardiograms of patients who were treated with transcatheter closure of a PFO for cryptogenic stroke were reviewed. RESULTS From January 1998 through December 2015, 880 patients were taken to the catheter laboratory for PFO closure, of whom 568 patients, 320 men (56.3%), underwent transcatheter closure of a PFO using an Amplatzer PFO Occluder, at a mean age of 48.1 AE 12.9 years. The incidence of right-to-left shunting (RLS) was 19.5% at a mean of 4 months' follow-up, which reduced to 8.4% at 11 AE 2 months. Sources of RLS were identified in 10 (1.8%); pulmonary arteriovenous malformation (n ¼ 4) was the most common etiology, followed by leak through the device (n ¼ 3). All patients with additional sources of RLS were treated percutaneously. At 2-year follow-up, 16 patients (2.8%) persisted with only mildly positive results on agitated saline contrast injection, without an apparent additional source of shunting. CONCLUSIONS Coexistence of a PFO and an additional lesion responsible for RLS is uncommon, but not rare; the majority are amenable to transcatheter or surgical intervention.
OBJECTIVES This study reviewed a series of patients treated with transcatheter closure of septal ... more OBJECTIVES This study reviewed a series of patients treated with transcatheter closure of septal defect to treat platypnea-orthodeoxia syndrome, with specific attention to septal characteristics and device choice. BACKGROUND Platypnea-orthodeoxia syndrome is an uncommon condition characterized by positional dyspnea and hypoxemia due to intracardiac right-to-left shunting through a patent foramen ovale (PFO), an atrial septal defect, or pulmonary arteriovenous malformations. Percutaneous closure of such defects is the treatment of choice. METHODS In this single-center series, 52 patients were treated with percutaneous closure of an interatrial communication after presentation between January 1997 and July 2015. Septal morphology, clinical, procedural, and outcomes data were analyzed. RESULTS All patients had a PFO; however, nearly one-quarter required a non-PFO device (11 Amplatzer Septal Occluder and 1 post-infarct muscular VSD), as opposed to a dedicated PFO device to achieve shunt occlusion. These patients were characterized by an aneurysmal septum, shorter primum septum overlap with the secundum septum, and greater septal angulation from the midline. After closure, all demonstrated acute improvements in oxygen saturation (pre-procedure: 81 AE 8%; post-procedure: 95.1 AE 0.5% on room air). Each patient was treated with a single device and no one required re-intervention. CONCLUSIONS Patients presenting with platypnea-orthodeoxia syndrome can be treated successfully with a percutaneous intervention often requiring a variety of devices. Those requiring a non-PFO-type device had a greater prevalence of an aneurysmal septum, shorter primum septal overlap with the secundum septum, and greater septal angulation with the midline.
Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions, 2014
Pediatric and Congenital Interventional Cardiology is the practice of catheter-based techniques t... more Pediatric and Congenital Interventional Cardiology is the practice of catheter-based techniques that improve cardiac physiology and circulation through the treatment of heart disease in children and adults with congenital or acquired heart defects. Over the last decade, and since last published training guidelines for pediatric cardiac catheterization and interventional cardiology were published in 2005 [1] the field of Pediatric and Congenital Cardiac Catheterization has evolved into a predominantly interventional discipline. As there is no sub-specialty certification for interventional cardiac catheterization in pediatrics, the Congenital Heart Disease Committee of the Society of Cardiovascular Angiography and Interventions has put together this consensus statement for advanced training in pediatric and congenital interventional cardiac catheterization. The statement puts forth recommendations for program infrastructure in terms of teaching, personnel, equipment, facilities, confe...
The Journal of Thoracic and Cardiovascular Surgery, 2008
The development of the Amplatzer Membranous VSD Occluder (AGA Medical Corp, Plymouth, Minn) for c... more The development of the Amplatzer Membranous VSD Occluder (AGA Medical Corp, Plymouth, Minn) for closure of the perimembranous ventricular septal defect has ameliorated many of the technical difficulties of previous devices. Application of this new technology requires comparative evaluation with the current standard of surgical repair. We report our experience of complete heart block associated with device closure of a large perimembranous ventricular septal defect with unequivocal indications for intervention. Methods: We performed a retrospective review of 20 patients between January 2003 and August 2005 who underwent perimembranous ventricular septal defect device closure, 18 with hemodynamically large shunts meeting the surgical criteria for intervention. The median age was 1.6 years (range, 0.5-16.2 years), and the median weight was 9.7 kg (range, 6.2-43 kg). Results: Acute complete shunt occlusion was achieved in all patients. There were no acute procedural complications. The median follow-up time was 23.1 months (range, 1-37.8 months). Four (22%) had complete heart block at 17 days, 4.2 months, 8.8 months, and 37.5 months after implantation, respectively. No risk factors were identified for development of complete heart block, including age, weight, trisomy 21, preceding conduction abnormalities, perimembranous ventricular septal defect size related to body surface area or device size, and progressive device flattening. Conclusions: Device closure of large perimembranous ventricular septal defects in infants and children with the Amplatzer Membranous VSD Occluder resulted in excellent closure rates but an unacceptably high rate of complete heart block. From the Cardiac Diagnostic and Interventional Unit,
Objectives The goal of this study was to prospectively assess blood pressure (BP) and echocardiog... more Objectives The goal of this study was to prospectively assess blood pressure (BP) and echocardiographic parameters to delineate the incidence and nature of the hypertension burden in this cohort. Background Few data are available on the long-term outcomes of aortic stenting. Methods Thirty-one patients with successfully stented coarctation during childhood (mean age 12.4 years) underwent 24-h ambulatory BP monitoring (ABPM), exercise BP measurement, and echocardiographic assessment. Results Mean time after stent implantation was 5.3 Ϯ 4 years. Hypertension was noted on one-off right-arm BP assessment in 3 patients (10%), but on the basis of the 24-h ABPM assessment in 14 patients (45%). Twenty-four of 31 patients (80%) had an abnormally elevated exercise BP response. Peak exercise BP correlated with left ventricular mass index (r ϭ 0.51; p Ͻ 0.05), which was also significantly increased in the entire cohort (mean ϭ 91.3 g/m 2 ; p Ͻ 0.05). In patients with significant somatic growth since implantation, the indexed diameter of the stent (to aortic diameter) had significantly decreased from the 48th percentile at the implantation to the 4th percentile during the study (p Ͻ 0.05). There was no difference in any parameter between patients with native or those with recurrent coarctation. Conclusions Hypertension is endemic in patients with stented coarctation, irrespective of the absence of residual obstruction. Due to abnormal BP homeostasis, hypertension should be aggressively pursued by ABPM assessment and exercise stress testing in this population. Relative hypoplasia of the stented arch after somatic growth may contribute to this tendency and should provoke consideration of elective serial redilation of coarctation stents.
Background— All 3 palliation strategies, Norwood, Sano, and Hybrid, currently used for hypoplasti... more Background— All 3 palliation strategies, Norwood, Sano, and Hybrid, currently used for hypoplastic left heart syndrome pose a risk of myocardial injury at different times and through different mechanisms. We sought to compare these strategies to understand longitudinal differences in interstage ventricular dysfunction and their subsequent impact on transplant-free survival and atrioventricular valve regurgitation (AVVR) as well as the relationship between adverse events and ventricular function. Methods and Results— Serial echocardiographic reports and clinical data were reviewed for 138 children with hypoplastic left heart syndrome who underwent stage I surgical palliation (Sano: 11; Norwood: 73; Hybrid: 54) between 2004 and 2011. Stage II palliation was achieved in 92 (67%) patients (Sano: 7; Norwood: 51; Hybrid: 34). Interstage transplant-free survival, ventricular dysfunction, and AVVR were equivalent among palliation strategies. Patients with preserved ventricular function had ...
Catheterization and Cardiovascular Interventions, 2003
Placement of intravascular stents that can reach adult size in infants and smaller children has b... more Placement of intravascular stents that can reach adult size in infants and smaller children has been limited by the large profile and poor flexibility of currently available stents. In vitro and in vivo testing of the Genesis stent was performed to evaluate crimpability, predeployment flexibility, and radial strength. Comparisons were made to the Palmaz iliac and IntraStent (IS) LD stents. Nine physicians placed 30 Genesis stents in swine pulmonary and systemic arteries to evaluate stent deliverability/crimpability. Two swine were recovered and underwent a second catheterization 8 weeks later, where the stents (n = 8) were reexpanded to maximal size. Angiographic and intravascular ultrasound (IVUS) assessments were performed. In vitro testing revealed the Genesis stent to have superior crimpability, flexibility, and comparable radial strength to the Palmaz iliac stent, and superior crimpability and radial strength and comparable flexibility to the IS LD series. During in vivo testin...
Catheterization and Cardiovascular Interventions, 2008
Objective: To determine types of complications and risks associated with pedatric cardiac cathete... more Objective: To determine types of complications and risks associated with pedatric cardiac catheterization in the current era. Background: Pedatric cardiac catheterization is an important diagnostic and therapeutic tool. Although in the last decade, there have been significant improvements in technology and equipment, the risk for complications remains, adversely effecting outcomes. Design: The clinical records of 11,073 children undergoing cardiac catheterizations between January 1994 and March 2006 were reviewed to identify procedures associated with complications within the first 24 h after catheterization. All children's electronic and paper chart records were reviewed to obtain demographic, procedural, and treatment data. Results: A total of 858 (7.3%) complications (classified as major or minor) occurred in 816 studies (510 males, 63%), in children ranging in age from 8 h to 20 years (median 4.13 years). There were 195 major (22%) and 663 (78%) minor complications. Vascular complications represented the majority (n 5 278; 32.4%) and were major in 53 instances (P < 0.0001). Twenty-five children died within 24 h (0.23% of total case numbers). Independent risk factors for a complication included young patient age (<6 months), male gender, inpatient status, and year of catheterization. Conclusions: Complications continue to be associated with pedatric cardiac catheterization, although overall incidence appears to be decreasing. Patient age, gender, and inpatient status continue to be risk factors for morbidity and mortality. Efforts at improving equipment for flexibility and size, and developing strategies for the use of alternative methods for catheter access should be encouraged.
Journal of the American College of Cardiology, 1993
Objectives. The objectives of this study were to determine the anatomic and physiologic factors m... more Objectives. The objectives of this study were to determine the anatomic and physiologic factors most responsible for the severe symptonas and poor prognosis of infants with scimitar syndrome .
Journal of the American College of Cardiology, 2000
We sought to investigate the clinical impact of balloon angioplasty for native coarctation of the... more We sought to investigate the clinical impact of balloon angioplasty for native coarctation of the aorta (CoA) and determine predictors of outcome. BACKGROUND Balloon dilation of native CoA remains controversial and more information on its long-term impact is required. METHODS Hemodynamic, angiographic and follow-up data on 69 children who underwent balloon angioplasty of native CoA between 1988 and 1996 were reviewed. Stretch, recoil and gain of CoA circumference and area were calculated and related to outcomes. RESULTS Initial systolic gradients (mean Ϯ SD, 31 Ϯ 12 mm Hg) fell by Ϫ74 Ϯ 27% (p Ͻ 0.001), with an increase in mean CoA diameters of 128 Ϯ 128% in the left anterior oblique and 124 Ϯ 87% in the lateral views (p Ͻ 0.001). Two deaths occurred, one at the time of the procedure and one 23 months later, both as a result of an associated cardiomyopathy. Seven patients had residual gradients of Ͼ20 mm Hg. One patient developed an aneurysm, stable in follow-up, and four patients had mild dilation at the site of the angioplasty. Freedom from reintervention was 90% at one year and 87% at five years with follow-up ranging to 8.5 years. Factors significantly associated with decreased time to reintervention included: a higher gradient before dilation, a smaller percentage change in gradient after dilation, a small transverse arch and a greater stretch and gain, but not recoil. CONCLUSION Balloon dilation is a safe and efficient treatment of native CoA in children. Greater stretch and gain are factors significantly associated with reintervention, possibly related to altered elastic properties and vessel scarring.
The Journal of thoracic and cardiovascular surgery, Jan 19, 2017
Infants with severe tetralogy of Fallot may undergo (1) early primary surgical repair (EARLY) or ... more Infants with severe tetralogy of Fallot may undergo (1) early primary surgical repair (EARLY) or (2) early transcatheter palliation (CATH) before delayed surgical repair. We compared these strategies with (3) elective single-stage tetralogy of Fallot repair (IDEAL). From 2000 to 2012, 453 children underwent tetralogy of Fallot repair (excluding systemic-pulmonary shunts), including 383 in the IDEAL (75%), 42 in the EARLY (9%), and 28 in the CATH (6%) groups. IDEAL repair at The Hospital for Sick Children occurs after 3 months. Risk-adjusted hazard analysis compared freedom from surgical or catheter reintervention. Somatic size, branch pulmonary artery size, and right ventricle systolic pressure were modeled using 2780 echocardiogram reports via mixed-model regression. CATH involved right ventricular outflow tract stent in 18 patients, right ventricular outflow tract balloon in 9 patients, and ductal-stent in 1 patient. Three patients died (1 per group). Risk-adjusted freedom from su...
Circulation. Cardiovascular interventions, Dec 1, 2016
Tetralogy of Fallot with cyanosis requiring surgical repair in early infancy reflects poor anatom... more Tetralogy of Fallot with cyanosis requiring surgical repair in early infancy reflects poor anatomy and is associated with more clinical instability and longer hospitalization than those who can be electively repaired later. We bridged symptomatic infants with risk factors for early primary repair by right ventricular outflow tract stenting (stent). Four groups of tetralogy of Fallot with confluent central pulmonary arteries were studied: stent group (n=42), primary repair (aged <3 months) with pulmonary stenosis (early-PS group; n=44), primary repair (aged <3 months) with pulmonary atresia (early-PA group; n=49), and primary repair between 3 and 11 months of age (surg>3mo group; n=45). Stent patients had the smallest pulmonary arteries with a median (95% credible intervals) Nakata index (mm(2)/m(2)) of 79 (66-85) compared with the early-PA 139 (129-154), early-PS 136 (121-153), and surg>3mo 167 (153-200) groups. Only stent infants required unifocalization of aortopulmona...
Sirolimus-eluting stents may have clinical advantages over bare-metal stents in the extremely pro... more Sirolimus-eluting stents may have clinical advantages over bare-metal stents in the extremely proliferative environment of the neonatal arterial duct. However, sirolimus has immunosuppressive actions and little is known regarding sirolimus pharmacokinetics in the newborn. This is a retrospective review of sirolimus pharmacokinetics in neonates who underwent sirolimus-eluting stent implantation in the arterial duct for pulmonary blood flow augmentation. Pharmacokinetic parameters were obtained by noncompartmental analysis and by a Bayesian one-compartment nonlinear mixed model. Nine neonates received a single sirolimus-eluting stent with a total sirolimus dose of 245 μg (n = 1), 194 μg (n = 5), or 143 μg (n = 3). Peak sirolimus concentrations were 13.6 ± 4.5 μg/L (24.8 μg/L highest) and clearance was 0.042 ± 0.03 L/hour (noncompartmental analysis) and 0.051 L/hour (95% credible intervals 0.037-0.069, nonlinear mixed model). Sirolimus remained > 5 μg/L, the trough level used in ora...
Pediatric and Congenital Cardiology, Cardiac Surgery and Intensive Care, 2013
Left ventricular outflow tract obstruction can occur below, at, or above the aortic valve or as m... more Left ventricular outflow tract obstruction can occur below, at, or above the aortic valve or as mid-muscular subvalvar obstruction. In children, the most common level of obstruction is aortic valve stenosis and comprises a heterogeneous anatomic spectrum, from an atretic valve (with or without a hypoplastic left ventricle) to an isolated lesion with normal sized but stenotic valve leaflets. Supravalvar aortic stenosis is rarely suitable for a percutaneous intervention due to its diffuse nature and there is limited experience with the discrete fibrous expression of obstruction. Efficacy of percutaneous aortic valve dilation has been clearly demonstrated in literature and is the therapeutic procedure of choice in most centers in children, however; secondary aortic valve surgery seems to be inevitable for a significant number of the patients in long-term follow-up due to acquired regurgitation. Despite advances in catheter technology and procedural techniques, aortic valve dilation continues to be associated with a higher complications risk than other standard percutaneous interventions, ranging from 10 % to 30 % in the current era. Fetal aortic valve dilation has also been shown as an alternative intervention in selected fetuses to avoid the development of hypoplastic left heart syndrome; however, experience is limited and more studies are needed.
The Journal of thoracic and cardiovascular surgery, Jan 3, 2014
Pulmonary artery growth is an important determinant of outcome in single-ventricle strategies. Hi... more Pulmonary artery growth is an important determinant of outcome in single-ventricle strategies. Higher rates of pulmonary artery intervention have been reported with hybrid-based palliation when compared with Norwood palliation. We performed a retrospective review of pulmonary artery growth and clinical outcomes in patients undergoing hybrid-based single-ventricle palliation. The stage I hybrid procedure was performed in 72 patients between 2004 and 2012, of whom 54 were on a Fontan palliative pathway. Thirty-four infants completed stage II, and 20 infants underwent the Fontan operation. The mean diameters of the right pulmonary artery (5.6 ± 1.9 mm) and left pulmonary artery (5.6 ± 2.1 mm) were similar before stage II. After stage II, the right and left pulmonary artery diameters were 8.5 ± 2.1 mm and 5.8 ± 1.3 mm, respectively (P < .001), and after the Fontan operation, these were 8.8 ± 2.0 mm and 6.4 ± 1.1 mm, respectively (P = .002). The mean right pulmonary artery z score was...
The Journal of Thoracic and Cardiovascular Surgery, 1999
have demonstrated that percutaneous implantation of balloon expandable stents offer a safe and ef... more have demonstrated that percutaneous implantation of balloon expandable stents offer a safe and effective palliation for obstructed conduits. 6-9 In the present study, we further report our experience with this palliative strategy and its impact on clinical management. Methods Patient selection. Since 1990, the option of transcatheter endovascular stent implantation within the right ventricular outflow tract has been offered for patients with right ventricle-to-pulmonary artery conduits when surgical replacement was considered necessary for management of significant obstruction. Right ventricular pressure exceeding two thirds of systemic arterial pressure, as observed on echocardiography, was considered an indication for intervention, with or without the presence of symptoms such as effort intolerance or fatigue. Technique. The technique of implantation has been described in detail in a previous report. 6 Balloon-expandable stent implants (Palmaz type; Johnson & Johnson Interventional Systems, Warren, NJ), available in different lengths (P128 = 12 mm, P188 = 18 mm, P204 = 20 mm, P308 = 30 mm, P4014 = 40 mm, and P5015 = 50 mm), were used, depending on the diameter and length of the obstruction. T he placement of extracardiac conduits between the pulmonary ventricle and the pulmonary arteries has allowed the correction of many complex cardiac lesions. 1,2 These techniques, however, almost always commit the patient to multiple surgical reinterventions because of progressive obstruction within the conduit. 1-5 The cause for these progressive obstructive lesions include both conduit and valve deterioration, and the simple fact that small children eventually outgrow the initially placed conduit. 3,5 Previous studies Objective: Extracardiac conduits between the right ventricle and pulmonary arteries commit patients to multiple reoperations. We reviewed our experience with stent implantation in obstructed conduits. Methods: Between 1990 and 1997, stents were implanted across 43 conduits. The median age at procedure was 6 years (0.5-17 years), and the median interval between conduit insertion and stent implantation was 2.4 years (0.3-14 years). Results: Mean systolic right ventricular pressures and gradients, respectively, decreased from 71 ± 18 mm Hg and 48 ± 19 mm Hg before to 48 ± 15 mm Hg and 19 ± 13 mm Hg after stent placement. Mean percentage of predicted valve area for body surface area increased from 26% ± 12% to 48% ± 17% after stent placement. Fifteen patients underwent a second transcatheter intervention (dilation or additional stent), and 2 patients, a third, allowing further postponement of surgery in 8 patients. One sudden death occurred 2.8 years after stent placement. Surgical conduit replacement has occurred in 20 patients. Body growth was maintained during follow-up. Freedom from surgical reintervention was 86% at 1 year, 72% at 2 years, and 47% at 4 years. Higher right ventricular pressure and gradient before and after stent placement and lower percentage of predicted valve area for body surface area after stent placement were associated with shorter palliation. Conclusion: Endovascular stent placement across obstructed conduits is a safe and effective palliation that allows for normal body growth.
The Journal of Thoracic and Cardiovascular Surgery, 1995
The use of endovascular devices as an adjunct to repair of congenital heart anomalies represents ... more The use of endovascular devices as an adjunct to repair of congenital heart anomalies represents a novel but unproven therapeutic approach. Intraoperative implantation of pulmonary arterial stents (5 to 15 mm diameter) was done in 11 patients with pulmonary atresia with ventricular septal defect (n = 4), classic tetralogy of Fallot (n = 2), truncus arteriosus (n = 1), hypoplastic left heart syndrome (stage II [n = 1] and stage III In = 1] Norwood procedure), and miscellaneous pulmonary arterial stenoses (n = 3), as well as in patients with congenital (n = 1) and postoperative (n = 3) pulmonary venous osbstruction and in 1 patient with combined pulmonary arteria~ and venous obstruction. The stents were effective at achieving immediate patency in all patients. There were two early deaths, one related to acute thrombosis of a small-diameter left pulmonary artery stent. Reintervention because of stentrelated pulmonary arterial stenosis was frequently necessary. In five of seven patients who survived more than I month after implantation of stent size 8 mm or smaller severe stent-related pulmonary arterial obstruction developed. In four of the five patients with pulmonary vein stent implantation intractable obstruction developed, resulting in death in all three patients who had bilateral pulmonary vein stent implantation. Intraoperative occlusion of apical muscular ventricular septal defect with use of a clamshell device inserted from the right atrial approach was accomplished in four patients. One patient who underwent associated aortic arch reconstruction died as a result of left ventricular hypoplasia. The results in the remaining three patients were favorable on the basis of absence of significant late residual intraventricular shunting, left ventricular dysfunction, or arrhythmia. We conclude that recurrent intraluminal obstruction as a result of neointimal hyperplasia appears to be an eventual certainty in currently designed small-diameter endovascular stents. For this reason, we would recommend standard surgical techniques for repair of obstructive lesions of the pulmonary arterial confluence to maximize growth potential. Device occlusion of muscular ventricular septal defects is feasible but probably only indicated for complex cases of ventricular septal deficiency that otherwise necessitate a left ventriculotomy.
The Journal of Thoracic and Cardiovascular Surgery, 2002
Background: We evaluated stent implantation across stenotic bioprosthetic pulmonary valves in 9 p... more Background: We evaluated stent implantation across stenotic bioprosthetic pulmonary valves in 9 patients. Methods: Nine patients (6 male patients) underwent stent implantation across stenotic bioprosthetic pulmonary valves between July 1996 and July 1999 at the Hospital for Sick Children, Toronto. Catheter intervention was indicated if echocardiography revealed Doppler estimates of right ventricular pressure of more than two thirds of systemic arterial pressure (or systolic septal flattening with an estimated gradient of Ͼ60 mm Hg across the valve prosthesis). Catheterization was performed during general anesthesia at an age (mean Ϯ SD) of 9.3 Ϯ 3.5 years and a weight of 32.0 Ϯ 17.1 kg 5.9 Ϯ 1.8 years after surgical insertion of a bioprosthetic valve in the pulmonary position: 7 patients with tetralogy of Fallot, 1 patient with congenital pulmonary stenosis-insufficiency, and 1 patient after a Rastelli operation. All had systolic septal flattening and right ventricular dilatation with moderate-tosevere pulmonary insufficiency before intervention. Fluoroscopy times were 33.1 Ϯ 9.5 minutes. Seven patients received a single P4014 stent, and 2 received single P308 stents (Palmaz; Johnson & Johnson Interventional Systems, Warren, NJ) without significant complications. Results: The right ventricular systemic pressure decreased acutely from 83% Ϯ 16% to 41% Ϯ 10% (P Ͻ .001, n ϭ 9), and the transvalvular gradient decreased from 49.7 Ϯ 8.5 to 11.0 Ϯ 5.9 mm Hg (P Ͻ .001, n ϭ 8). During the follow-up period (10.9 Ϯ 8.1 months, n ϭ 8), 1 patient had an unsuccessful attempt at redilation of the stent (right ventricular pressure, 60% systemic) and underwent uneventful surgical pulmonary valve replacement. None of the remaining patients had echocardiographic evidence of systolic septal flattening, and right ventricular dimensions did not change significantly. Conclusion: Stent implantation is a safe and effective means of providing palliative relief of obstructed bioprosthetic valves in the pulmonary position and can safely delay the requirement for pulmonary valve replacement.
OBJECTIVE To review the outcomes of transcatheter closure of atrial septal defects using the Card... more OBJECTIVE To review the outcomes of transcatheter closure of atrial septal defects using the Cardio-Seal implant. DESIGN A prospective interventional study. SETTING Tertiary referral centre. PATIENTS The first 50 patients (median age 9.7 years) who underwent attempted percutaneous occlusion. INTERVENTIONS Procedures were done under general anaesthesia and transoesophageal guidance between December 1996 and July 1998. MAIN OUTCOME MEASURES Success of deployment, complications, and assessment of right ventricular end diastolic diameter, septal wall motion, and occlusion status by echocardiography. RESULTS The median balloon stretched diameter was 14 mm. Multiple atrial septal defects were present in 11 patients (22%) and a deficient atrial rim (< 4 mm) in 19 (38%). In four patients (8%), a second device was implanted after removal of an initially malpositioned first implant. There were no significant immediate complications. All patients except one were discharged within 24 hours. ...
The aim of this study was to assess the incidence of persistently positive results on agitated sa... more The aim of this study was to assess the incidence of persistently positive results on agitated saline contrast injection after patent foramen ovale (PFO) closure, the underlying mechanism, and management. BACKGROUND Transcatheter intervention to close a PFO is reasonable in highly selected patients younger than 60 years, after a thorough cardioneurological investigation following a cryptogenic stroke, particularly in the presence of thromboembolic disease or in patients at high risk for venous thrombosis. The U.S. Food and Drug Administration approved the Amplatzer PFO Occluder in October 2016 for such an indication. Confirmation of PFO closure is usually verified by an agitated saline contrast injection during an echocardiographic examination. The appearance of bubbles in the left atrium raises the concern of incomplete closure or other sources of shunting. METHODS The medical records and echocardiograms of patients who were treated with transcatheter closure of a PFO for cryptogenic stroke were reviewed. RESULTS From January 1998 through December 2015, 880 patients were taken to the catheter laboratory for PFO closure, of whom 568 patients, 320 men (56.3%), underwent transcatheter closure of a PFO using an Amplatzer PFO Occluder, at a mean age of 48.1 AE 12.9 years. The incidence of right-to-left shunting (RLS) was 19.5% at a mean of 4 months' follow-up, which reduced to 8.4% at 11 AE 2 months. Sources of RLS were identified in 10 (1.8%); pulmonary arteriovenous malformation (n ¼ 4) was the most common etiology, followed by leak through the device (n ¼ 3). All patients with additional sources of RLS were treated percutaneously. At 2-year follow-up, 16 patients (2.8%) persisted with only mildly positive results on agitated saline contrast injection, without an apparent additional source of shunting. CONCLUSIONS Coexistence of a PFO and an additional lesion responsible for RLS is uncommon, but not rare; the majority are amenable to transcatheter or surgical intervention.
OBJECTIVES This study reviewed a series of patients treated with transcatheter closure of septal ... more OBJECTIVES This study reviewed a series of patients treated with transcatheter closure of septal defect to treat platypnea-orthodeoxia syndrome, with specific attention to septal characteristics and device choice. BACKGROUND Platypnea-orthodeoxia syndrome is an uncommon condition characterized by positional dyspnea and hypoxemia due to intracardiac right-to-left shunting through a patent foramen ovale (PFO), an atrial septal defect, or pulmonary arteriovenous malformations. Percutaneous closure of such defects is the treatment of choice. METHODS In this single-center series, 52 patients were treated with percutaneous closure of an interatrial communication after presentation between January 1997 and July 2015. Septal morphology, clinical, procedural, and outcomes data were analyzed. RESULTS All patients had a PFO; however, nearly one-quarter required a non-PFO device (11 Amplatzer Septal Occluder and 1 post-infarct muscular VSD), as opposed to a dedicated PFO device to achieve shunt occlusion. These patients were characterized by an aneurysmal septum, shorter primum septum overlap with the secundum septum, and greater septal angulation from the midline. After closure, all demonstrated acute improvements in oxygen saturation (pre-procedure: 81 AE 8%; post-procedure: 95.1 AE 0.5% on room air). Each patient was treated with a single device and no one required re-intervention. CONCLUSIONS Patients presenting with platypnea-orthodeoxia syndrome can be treated successfully with a percutaneous intervention often requiring a variety of devices. Those requiring a non-PFO-type device had a greater prevalence of an aneurysmal septum, shorter primum septal overlap with the secundum septum, and greater septal angulation with the midline.
Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions, 2014
Pediatric and Congenital Interventional Cardiology is the practice of catheter-based techniques t... more Pediatric and Congenital Interventional Cardiology is the practice of catheter-based techniques that improve cardiac physiology and circulation through the treatment of heart disease in children and adults with congenital or acquired heart defects. Over the last decade, and since last published training guidelines for pediatric cardiac catheterization and interventional cardiology were published in 2005 [1] the field of Pediatric and Congenital Cardiac Catheterization has evolved into a predominantly interventional discipline. As there is no sub-specialty certification for interventional cardiac catheterization in pediatrics, the Congenital Heart Disease Committee of the Society of Cardiovascular Angiography and Interventions has put together this consensus statement for advanced training in pediatric and congenital interventional cardiac catheterization. The statement puts forth recommendations for program infrastructure in terms of teaching, personnel, equipment, facilities, confe...
The Journal of Thoracic and Cardiovascular Surgery, 2008
The development of the Amplatzer Membranous VSD Occluder (AGA Medical Corp, Plymouth, Minn) for c... more The development of the Amplatzer Membranous VSD Occluder (AGA Medical Corp, Plymouth, Minn) for closure of the perimembranous ventricular septal defect has ameliorated many of the technical difficulties of previous devices. Application of this new technology requires comparative evaluation with the current standard of surgical repair. We report our experience of complete heart block associated with device closure of a large perimembranous ventricular septal defect with unequivocal indications for intervention. Methods: We performed a retrospective review of 20 patients between January 2003 and August 2005 who underwent perimembranous ventricular septal defect device closure, 18 with hemodynamically large shunts meeting the surgical criteria for intervention. The median age was 1.6 years (range, 0.5-16.2 years), and the median weight was 9.7 kg (range, 6.2-43 kg). Results: Acute complete shunt occlusion was achieved in all patients. There were no acute procedural complications. The median follow-up time was 23.1 months (range, 1-37.8 months). Four (22%) had complete heart block at 17 days, 4.2 months, 8.8 months, and 37.5 months after implantation, respectively. No risk factors were identified for development of complete heart block, including age, weight, trisomy 21, preceding conduction abnormalities, perimembranous ventricular septal defect size related to body surface area or device size, and progressive device flattening. Conclusions: Device closure of large perimembranous ventricular septal defects in infants and children with the Amplatzer Membranous VSD Occluder resulted in excellent closure rates but an unacceptably high rate of complete heart block. From the Cardiac Diagnostic and Interventional Unit,
Objectives The goal of this study was to prospectively assess blood pressure (BP) and echocardiog... more Objectives The goal of this study was to prospectively assess blood pressure (BP) and echocardiographic parameters to delineate the incidence and nature of the hypertension burden in this cohort. Background Few data are available on the long-term outcomes of aortic stenting. Methods Thirty-one patients with successfully stented coarctation during childhood (mean age 12.4 years) underwent 24-h ambulatory BP monitoring (ABPM), exercise BP measurement, and echocardiographic assessment. Results Mean time after stent implantation was 5.3 Ϯ 4 years. Hypertension was noted on one-off right-arm BP assessment in 3 patients (10%), but on the basis of the 24-h ABPM assessment in 14 patients (45%). Twenty-four of 31 patients (80%) had an abnormally elevated exercise BP response. Peak exercise BP correlated with left ventricular mass index (r ϭ 0.51; p Ͻ 0.05), which was also significantly increased in the entire cohort (mean ϭ 91.3 g/m 2 ; p Ͻ 0.05). In patients with significant somatic growth since implantation, the indexed diameter of the stent (to aortic diameter) had significantly decreased from the 48th percentile at the implantation to the 4th percentile during the study (p Ͻ 0.05). There was no difference in any parameter between patients with native or those with recurrent coarctation. Conclusions Hypertension is endemic in patients with stented coarctation, irrespective of the absence of residual obstruction. Due to abnormal BP homeostasis, hypertension should be aggressively pursued by ABPM assessment and exercise stress testing in this population. Relative hypoplasia of the stented arch after somatic growth may contribute to this tendency and should provoke consideration of elective serial redilation of coarctation stents.
Background— All 3 palliation strategies, Norwood, Sano, and Hybrid, currently used for hypoplasti... more Background— All 3 palliation strategies, Norwood, Sano, and Hybrid, currently used for hypoplastic left heart syndrome pose a risk of myocardial injury at different times and through different mechanisms. We sought to compare these strategies to understand longitudinal differences in interstage ventricular dysfunction and their subsequent impact on transplant-free survival and atrioventricular valve regurgitation (AVVR) as well as the relationship between adverse events and ventricular function. Methods and Results— Serial echocardiographic reports and clinical data were reviewed for 138 children with hypoplastic left heart syndrome who underwent stage I surgical palliation (Sano: 11; Norwood: 73; Hybrid: 54) between 2004 and 2011. Stage II palliation was achieved in 92 (67%) patients (Sano: 7; Norwood: 51; Hybrid: 34). Interstage transplant-free survival, ventricular dysfunction, and AVVR were equivalent among palliation strategies. Patients with preserved ventricular function had ...
Catheterization and Cardiovascular Interventions, 2003
Placement of intravascular stents that can reach adult size in infants and smaller children has b... more Placement of intravascular stents that can reach adult size in infants and smaller children has been limited by the large profile and poor flexibility of currently available stents. In vitro and in vivo testing of the Genesis stent was performed to evaluate crimpability, predeployment flexibility, and radial strength. Comparisons were made to the Palmaz iliac and IntraStent (IS) LD stents. Nine physicians placed 30 Genesis stents in swine pulmonary and systemic arteries to evaluate stent deliverability/crimpability. Two swine were recovered and underwent a second catheterization 8 weeks later, where the stents (n = 8) were reexpanded to maximal size. Angiographic and intravascular ultrasound (IVUS) assessments were performed. In vitro testing revealed the Genesis stent to have superior crimpability, flexibility, and comparable radial strength to the Palmaz iliac stent, and superior crimpability and radial strength and comparable flexibility to the IS LD series. During in vivo testin...
Catheterization and Cardiovascular Interventions, 2008
Objective: To determine types of complications and risks associated with pedatric cardiac cathete... more Objective: To determine types of complications and risks associated with pedatric cardiac catheterization in the current era. Background: Pedatric cardiac catheterization is an important diagnostic and therapeutic tool. Although in the last decade, there have been significant improvements in technology and equipment, the risk for complications remains, adversely effecting outcomes. Design: The clinical records of 11,073 children undergoing cardiac catheterizations between January 1994 and March 2006 were reviewed to identify procedures associated with complications within the first 24 h after catheterization. All children's electronic and paper chart records were reviewed to obtain demographic, procedural, and treatment data. Results: A total of 858 (7.3%) complications (classified as major or minor) occurred in 816 studies (510 males, 63%), in children ranging in age from 8 h to 20 years (median 4.13 years). There were 195 major (22%) and 663 (78%) minor complications. Vascular complications represented the majority (n 5 278; 32.4%) and were major in 53 instances (P < 0.0001). Twenty-five children died within 24 h (0.23% of total case numbers). Independent risk factors for a complication included young patient age (<6 months), male gender, inpatient status, and year of catheterization. Conclusions: Complications continue to be associated with pedatric cardiac catheterization, although overall incidence appears to be decreasing. Patient age, gender, and inpatient status continue to be risk factors for morbidity and mortality. Efforts at improving equipment for flexibility and size, and developing strategies for the use of alternative methods for catheter access should be encouraged.
Journal of the American College of Cardiology, 1993
Objectives. The objectives of this study were to determine the anatomic and physiologic factors m... more Objectives. The objectives of this study were to determine the anatomic and physiologic factors most responsible for the severe symptonas and poor prognosis of infants with scimitar syndrome .
Journal of the American College of Cardiology, 2000
We sought to investigate the clinical impact of balloon angioplasty for native coarctation of the... more We sought to investigate the clinical impact of balloon angioplasty for native coarctation of the aorta (CoA) and determine predictors of outcome. BACKGROUND Balloon dilation of native CoA remains controversial and more information on its long-term impact is required. METHODS Hemodynamic, angiographic and follow-up data on 69 children who underwent balloon angioplasty of native CoA between 1988 and 1996 were reviewed. Stretch, recoil and gain of CoA circumference and area were calculated and related to outcomes. RESULTS Initial systolic gradients (mean Ϯ SD, 31 Ϯ 12 mm Hg) fell by Ϫ74 Ϯ 27% (p Ͻ 0.001), with an increase in mean CoA diameters of 128 Ϯ 128% in the left anterior oblique and 124 Ϯ 87% in the lateral views (p Ͻ 0.001). Two deaths occurred, one at the time of the procedure and one 23 months later, both as a result of an associated cardiomyopathy. Seven patients had residual gradients of Ͼ20 mm Hg. One patient developed an aneurysm, stable in follow-up, and four patients had mild dilation at the site of the angioplasty. Freedom from reintervention was 90% at one year and 87% at five years with follow-up ranging to 8.5 years. Factors significantly associated with decreased time to reintervention included: a higher gradient before dilation, a smaller percentage change in gradient after dilation, a small transverse arch and a greater stretch and gain, but not recoil. CONCLUSION Balloon dilation is a safe and efficient treatment of native CoA in children. Greater stretch and gain are factors significantly associated with reintervention, possibly related to altered elastic properties and vessel scarring.
The Journal of thoracic and cardiovascular surgery, Jan 19, 2017
Infants with severe tetralogy of Fallot may undergo (1) early primary surgical repair (EARLY) or ... more Infants with severe tetralogy of Fallot may undergo (1) early primary surgical repair (EARLY) or (2) early transcatheter palliation (CATH) before delayed surgical repair. We compared these strategies with (3) elective single-stage tetralogy of Fallot repair (IDEAL). From 2000 to 2012, 453 children underwent tetralogy of Fallot repair (excluding systemic-pulmonary shunts), including 383 in the IDEAL (75%), 42 in the EARLY (9%), and 28 in the CATH (6%) groups. IDEAL repair at The Hospital for Sick Children occurs after 3 months. Risk-adjusted hazard analysis compared freedom from surgical or catheter reintervention. Somatic size, branch pulmonary artery size, and right ventricle systolic pressure were modeled using 2780 echocardiogram reports via mixed-model regression. CATH involved right ventricular outflow tract stent in 18 patients, right ventricular outflow tract balloon in 9 patients, and ductal-stent in 1 patient. Three patients died (1 per group). Risk-adjusted freedom from su...
Circulation. Cardiovascular interventions, Dec 1, 2016
Tetralogy of Fallot with cyanosis requiring surgical repair in early infancy reflects poor anatom... more Tetralogy of Fallot with cyanosis requiring surgical repair in early infancy reflects poor anatomy and is associated with more clinical instability and longer hospitalization than those who can be electively repaired later. We bridged symptomatic infants with risk factors for early primary repair by right ventricular outflow tract stenting (stent). Four groups of tetralogy of Fallot with confluent central pulmonary arteries were studied: stent group (n=42), primary repair (aged <3 months) with pulmonary stenosis (early-PS group; n=44), primary repair (aged <3 months) with pulmonary atresia (early-PA group; n=49), and primary repair between 3 and 11 months of age (surg>3mo group; n=45). Stent patients had the smallest pulmonary arteries with a median (95% credible intervals) Nakata index (mm(2)/m(2)) of 79 (66-85) compared with the early-PA 139 (129-154), early-PS 136 (121-153), and surg>3mo 167 (153-200) groups. Only stent infants required unifocalization of aortopulmona...
Sirolimus-eluting stents may have clinical advantages over bare-metal stents in the extremely pro... more Sirolimus-eluting stents may have clinical advantages over bare-metal stents in the extremely proliferative environment of the neonatal arterial duct. However, sirolimus has immunosuppressive actions and little is known regarding sirolimus pharmacokinetics in the newborn. This is a retrospective review of sirolimus pharmacokinetics in neonates who underwent sirolimus-eluting stent implantation in the arterial duct for pulmonary blood flow augmentation. Pharmacokinetic parameters were obtained by noncompartmental analysis and by a Bayesian one-compartment nonlinear mixed model. Nine neonates received a single sirolimus-eluting stent with a total sirolimus dose of 245 μg (n = 1), 194 μg (n = 5), or 143 μg (n = 3). Peak sirolimus concentrations were 13.6 ± 4.5 μg/L (24.8 μg/L highest) and clearance was 0.042 ± 0.03 L/hour (noncompartmental analysis) and 0.051 L/hour (95% credible intervals 0.037-0.069, nonlinear mixed model). Sirolimus remained > 5 μg/L, the trough level used in ora...
Pediatric and Congenital Cardiology, Cardiac Surgery and Intensive Care, 2013
Left ventricular outflow tract obstruction can occur below, at, or above the aortic valve or as m... more Left ventricular outflow tract obstruction can occur below, at, or above the aortic valve or as mid-muscular subvalvar obstruction. In children, the most common level of obstruction is aortic valve stenosis and comprises a heterogeneous anatomic spectrum, from an atretic valve (with or without a hypoplastic left ventricle) to an isolated lesion with normal sized but stenotic valve leaflets. Supravalvar aortic stenosis is rarely suitable for a percutaneous intervention due to its diffuse nature and there is limited experience with the discrete fibrous expression of obstruction. Efficacy of percutaneous aortic valve dilation has been clearly demonstrated in literature and is the therapeutic procedure of choice in most centers in children, however; secondary aortic valve surgery seems to be inevitable for a significant number of the patients in long-term follow-up due to acquired regurgitation. Despite advances in catheter technology and procedural techniques, aortic valve dilation continues to be associated with a higher complications risk than other standard percutaneous interventions, ranging from 10 % to 30 % in the current era. Fetal aortic valve dilation has also been shown as an alternative intervention in selected fetuses to avoid the development of hypoplastic left heart syndrome; however, experience is limited and more studies are needed.
The Journal of thoracic and cardiovascular surgery, Jan 3, 2014
Pulmonary artery growth is an important determinant of outcome in single-ventricle strategies. Hi... more Pulmonary artery growth is an important determinant of outcome in single-ventricle strategies. Higher rates of pulmonary artery intervention have been reported with hybrid-based palliation when compared with Norwood palliation. We performed a retrospective review of pulmonary artery growth and clinical outcomes in patients undergoing hybrid-based single-ventricle palliation. The stage I hybrid procedure was performed in 72 patients between 2004 and 2012, of whom 54 were on a Fontan palliative pathway. Thirty-four infants completed stage II, and 20 infants underwent the Fontan operation. The mean diameters of the right pulmonary artery (5.6 ± 1.9 mm) and left pulmonary artery (5.6 ± 2.1 mm) were similar before stage II. After stage II, the right and left pulmonary artery diameters were 8.5 ± 2.1 mm and 5.8 ± 1.3 mm, respectively (P < .001), and after the Fontan operation, these were 8.8 ± 2.0 mm and 6.4 ± 1.1 mm, respectively (P = .002). The mean right pulmonary artery z score was...
The Journal of Thoracic and Cardiovascular Surgery, 1999
have demonstrated that percutaneous implantation of balloon expandable stents offer a safe and ef... more have demonstrated that percutaneous implantation of balloon expandable stents offer a safe and effective palliation for obstructed conduits. 6-9 In the present study, we further report our experience with this palliative strategy and its impact on clinical management. Methods Patient selection. Since 1990, the option of transcatheter endovascular stent implantation within the right ventricular outflow tract has been offered for patients with right ventricle-to-pulmonary artery conduits when surgical replacement was considered necessary for management of significant obstruction. Right ventricular pressure exceeding two thirds of systemic arterial pressure, as observed on echocardiography, was considered an indication for intervention, with or without the presence of symptoms such as effort intolerance or fatigue. Technique. The technique of implantation has been described in detail in a previous report. 6 Balloon-expandable stent implants (Palmaz type; Johnson & Johnson Interventional Systems, Warren, NJ), available in different lengths (P128 = 12 mm, P188 = 18 mm, P204 = 20 mm, P308 = 30 mm, P4014 = 40 mm, and P5015 = 50 mm), were used, depending on the diameter and length of the obstruction. T he placement of extracardiac conduits between the pulmonary ventricle and the pulmonary arteries has allowed the correction of many complex cardiac lesions. 1,2 These techniques, however, almost always commit the patient to multiple surgical reinterventions because of progressive obstruction within the conduit. 1-5 The cause for these progressive obstructive lesions include both conduit and valve deterioration, and the simple fact that small children eventually outgrow the initially placed conduit. 3,5 Previous studies Objective: Extracardiac conduits between the right ventricle and pulmonary arteries commit patients to multiple reoperations. We reviewed our experience with stent implantation in obstructed conduits. Methods: Between 1990 and 1997, stents were implanted across 43 conduits. The median age at procedure was 6 years (0.5-17 years), and the median interval between conduit insertion and stent implantation was 2.4 years (0.3-14 years). Results: Mean systolic right ventricular pressures and gradients, respectively, decreased from 71 ± 18 mm Hg and 48 ± 19 mm Hg before to 48 ± 15 mm Hg and 19 ± 13 mm Hg after stent placement. Mean percentage of predicted valve area for body surface area increased from 26% ± 12% to 48% ± 17% after stent placement. Fifteen patients underwent a second transcatheter intervention (dilation or additional stent), and 2 patients, a third, allowing further postponement of surgery in 8 patients. One sudden death occurred 2.8 years after stent placement. Surgical conduit replacement has occurred in 20 patients. Body growth was maintained during follow-up. Freedom from surgical reintervention was 86% at 1 year, 72% at 2 years, and 47% at 4 years. Higher right ventricular pressure and gradient before and after stent placement and lower percentage of predicted valve area for body surface area after stent placement were associated with shorter palliation. Conclusion: Endovascular stent placement across obstructed conduits is a safe and effective palliation that allows for normal body growth.
The Journal of Thoracic and Cardiovascular Surgery, 1995
The use of endovascular devices as an adjunct to repair of congenital heart anomalies represents ... more The use of endovascular devices as an adjunct to repair of congenital heart anomalies represents a novel but unproven therapeutic approach. Intraoperative implantation of pulmonary arterial stents (5 to 15 mm diameter) was done in 11 patients with pulmonary atresia with ventricular septal defect (n = 4), classic tetralogy of Fallot (n = 2), truncus arteriosus (n = 1), hypoplastic left heart syndrome (stage II [n = 1] and stage III In = 1] Norwood procedure), and miscellaneous pulmonary arterial stenoses (n = 3), as well as in patients with congenital (n = 1) and postoperative (n = 3) pulmonary venous osbstruction and in 1 patient with combined pulmonary arteria~ and venous obstruction. The stents were effective at achieving immediate patency in all patients. There were two early deaths, one related to acute thrombosis of a small-diameter left pulmonary artery stent. Reintervention because of stentrelated pulmonary arterial stenosis was frequently necessary. In five of seven patients who survived more than I month after implantation of stent size 8 mm or smaller severe stent-related pulmonary arterial obstruction developed. In four of the five patients with pulmonary vein stent implantation intractable obstruction developed, resulting in death in all three patients who had bilateral pulmonary vein stent implantation. Intraoperative occlusion of apical muscular ventricular septal defect with use of a clamshell device inserted from the right atrial approach was accomplished in four patients. One patient who underwent associated aortic arch reconstruction died as a result of left ventricular hypoplasia. The results in the remaining three patients were favorable on the basis of absence of significant late residual intraventricular shunting, left ventricular dysfunction, or arrhythmia. We conclude that recurrent intraluminal obstruction as a result of neointimal hyperplasia appears to be an eventual certainty in currently designed small-diameter endovascular stents. For this reason, we would recommend standard surgical techniques for repair of obstructive lesions of the pulmonary arterial confluence to maximize growth potential. Device occlusion of muscular ventricular septal defects is feasible but probably only indicated for complex cases of ventricular septal deficiency that otherwise necessitate a left ventriculotomy.
The Journal of Thoracic and Cardiovascular Surgery, 2002
Background: We evaluated stent implantation across stenotic bioprosthetic pulmonary valves in 9 p... more Background: We evaluated stent implantation across stenotic bioprosthetic pulmonary valves in 9 patients. Methods: Nine patients (6 male patients) underwent stent implantation across stenotic bioprosthetic pulmonary valves between July 1996 and July 1999 at the Hospital for Sick Children, Toronto. Catheter intervention was indicated if echocardiography revealed Doppler estimates of right ventricular pressure of more than two thirds of systemic arterial pressure (or systolic septal flattening with an estimated gradient of Ͼ60 mm Hg across the valve prosthesis). Catheterization was performed during general anesthesia at an age (mean Ϯ SD) of 9.3 Ϯ 3.5 years and a weight of 32.0 Ϯ 17.1 kg 5.9 Ϯ 1.8 years after surgical insertion of a bioprosthetic valve in the pulmonary position: 7 patients with tetralogy of Fallot, 1 patient with congenital pulmonary stenosis-insufficiency, and 1 patient after a Rastelli operation. All had systolic septal flattening and right ventricular dilatation with moderate-tosevere pulmonary insufficiency before intervention. Fluoroscopy times were 33.1 Ϯ 9.5 minutes. Seven patients received a single P4014 stent, and 2 received single P308 stents (Palmaz; Johnson & Johnson Interventional Systems, Warren, NJ) without significant complications. Results: The right ventricular systemic pressure decreased acutely from 83% Ϯ 16% to 41% Ϯ 10% (P Ͻ .001, n ϭ 9), and the transvalvular gradient decreased from 49.7 Ϯ 8.5 to 11.0 Ϯ 5.9 mm Hg (P Ͻ .001, n ϭ 8). During the follow-up period (10.9 Ϯ 8.1 months, n ϭ 8), 1 patient had an unsuccessful attempt at redilation of the stent (right ventricular pressure, 60% systemic) and underwent uneventful surgical pulmonary valve replacement. None of the remaining patients had echocardiographic evidence of systolic septal flattening, and right ventricular dimensions did not change significantly. Conclusion: Stent implantation is a safe and effective means of providing palliative relief of obstructed bioprosthetic valves in the pulmonary position and can safely delay the requirement for pulmonary valve replacement.
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Papers by Lee Benson