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To reflect new developments in imaging, indications, and techniques in catheterisation of patients with CHD, the training recommendations of the Association for European Paediatric and Congenital Cardiology (AEPC) for the training in interventional catheterisation for CHD have been reviewed and updated after more than 7 years. They include detailed information about knowledge, skills, and approach to clinical practice expected from trainees at basic, intermediate, and advanced level.
CHDs are one of the most frequent congenital malformations, affecting one in hundred live births. In total, 70% will require treatment in the first year of life, but over 90% of cases in low- and middle-income countries receive no treatment or suboptimal treatment. As a result, CHDs are responsible for 66% of preventable deaths due to congenital malformations in low- and middle-income countries. This study examines the unmet need of congenital cardiac care around the world based on the global burden of disease.
Materials and methods:
CHD morbidity and mortality data for 2006, 2011, and 2016 were collected from the Institute for Health Metrics and Evaluation Global Burden of Disease Results Tool and analysed longitudinally to assess trends in excess morbidity and mortality.
Between 2006 and 2016, a 20.7% reduction in excess disability-adjusted life years and 20.6% reduction in excess deaths due to CHDs were observed for children under 15. In 2016, excess global morbidity and mortality due to CHDs remained high with 14,788,418.7 disability-adjusted life years and 171,761.8 paediatric deaths, respectively. In total, 90.2% of disability-adjusted life years and 91.2% of deaths were considered excess.
This study illustrates the unmet need of congenital cardiac care around the world. Progress has been made to reduce morbidity and mortality due to CHDs but remains high and largely treatable around the world. Limited academic attention for global paediatric cardiac care magnifies the lack of progress in this area.
Background: Most children in the Third World do not have access to treatment for heart diseases, as the priorities of health care are different from the developed countries. Materials and methods: Since 2009, teams supported by the Chain of Hope and Spanish medical volunteers have travelled twice a year to help develop paediatric cardiac services in the Cardiac Center in Ethiopia, undertaking four missions each year. As of December 2012, 296 procedures were performed on 287 patients. The procedures included 128 duct occlusions, 55 pulmonary valve dilations, 25 atrial septal defect closures, 14 mitral valve dilations, and others. The local staff were trained to perform a majority of these cases. Results: Procedural success was achieved in 264 (89.2%). There were three deaths, five device embolisations, and three complications in mitral valve dilation. During the visits, the local staff were trained including one cardiologist, six nurses, and two technicians. The local team performed percutaneous interventions on its own after a couple of years. The goal is also to enable the local team to perform interventions independently. Conclusion: Training of an interventional cardiology team in a sub-Saharan setting is challenging but achievable. It may be difficult for a single centre to commit to sending frequent missions to a developing country to make a meaningful contribution to the training of local teams. In our case, coordination between the teams from the two countries helped to achieve our goals.
To assess the cardiac catheterisation findings of all children in whom cardiac magnetic resonance imaging found great artery stenosis.
We conducted a retrospective analysis of all 45 consecutive children with congenital cardiac disease who were undergoing cardiac catheterisation for intervention on cardiac magnetic resonance-defined great vessel stenosis, between January, 2006 and August, 2008.
Following cardiac magnetic resonance, 60 significant great vessel stenoses were identified and referred to cardiac catheterisation for intervention. All patients were catheterised within a median and interquartile range of 84 and 4–149 days, respectively, of cardiac magnetic resonance. At cardiac catheterisation, the children were aged 11.5 years – with an interquartile range of 3.8–16.9 years – and weighed 34 kilograms – with an interquartile range of 15–56 kilograms. Comparing cardiac magnetic resonance and cardiac catheterisation findings, 53 (88%) findings were concordant and seven were discordant. In six of seven (86%) discordant observations, cardiac magnetic resonance defined moderate–severe great vessel stenosis – involving three branch pulmonary arteries and three aortas. This was not confirmed by cardiac catheterisation, which revealed mild stenoses and haemodynamic gradients insufficient for intervention. In one patient, a mild, proximal right pulmonary artery narrowing was found at cardiac catheterisation, which was not mentioned in the cardiac magnetic resonance report. There was no difference between discordant and concordant groups on the basis of patient age, weight, interval between cardiac magnetic resonance and cardiac catheterisation, or type of lesion.
Invasive assessment confirmed cardiac magnetic resonance-diagnosed great vessel stenosis in the majority of this cohort. The predominant discordant finding was lower catherisation gradient than predicted by morphologic and functional cardiac magnetic resonance assessment. Flow volume diversion – for example, unilateral pulmonary artery stenosis – and anaesthetic effects may account for some differences. Prospective refinement of cardiac magnetic resonance and interventional data may further improve the validity of non-invasive imaging thresholds for intervention.
We describe our experience with the closure of a synthetic Blalock–Taussig shunt using an Amplatzer vascular occluding device placed with the aid an exteriorised guidewire loop in an infant with congenital cardiac disease. The technique used in a neonate and the physiological benefits of this approach are discussed. We highlight the extended use of the Amplatzer vascular plug in this clinical setting and the advantages of using and the exteriorised guidewire loop for its placement.
We report our experience in a 12 year old boy referred with suspected myocardial infarction. He has previously been diagnosed with systemic lupus erythematosus, and was being treated with steroids. Echocardiographic examination revealed a thrombus in the left aortic coronary sinus of Valsalva partially occluding the orifice of the left coronary artery. The thrombosis was successfully treated by venous thrombolysis using recombinant tissue plasminogen activator.
We report our experience from 1996 through 1999, representing our initial experience with use of the Amplatzer device to close atrial septal defects. Of 46 patients taken to the catheter laboratory with the intention to close the defect, the device was permanently implanted in 40 (87%). They were aged between 1.4 and 71.8 years, with weights ranging from 7.8 to 90 kg. Both age and weight distributed into two peaks, demonstrating two different populations. The size of the devices, taking the biggest device if two were inserted, was between 9 and 30 mm. We underwent a short learning curve, but the time required for fluoroscopy, or the number of difficulties experienced, showed no connection with the size or age of the patient, nor the size of the defect itself. A suspicion that young age and small size would increase the risk and difficulties, and result in more interrupted procedures, could not be substantiated. In children no interruption was procedural. Our early experience, therefore, demonstrates that an experienced interventional team can use the Amplatzer occluder successfully to close atrial septal defects in patients of all ages and sizes, at least from 7.8 kg and up.
Objective: To evaluate immediate and midterm results with percutaneous aortic valvoplasty. Material and Methods: We reviewed the records of 141 patients undergoing percutaneous aortic valvopasty over a period of 13 years. Results: The patients were aged from 2 months to 40 years, with a mean of 10.9 ± 9.9 years. Of the total, 90 (63%) were male. The initial systolic peak-to-peak gradient decreased from 163 ± 52 mmHg to 32 ± 18 mmHg (p > 0.01) after valvoplasty in all 141 patients, while the proportional reduction ranged from 0 to 100%, with a mean of 72 ± 27%. The index of the size of the balloon to the diameter of the valvar orifice was 0.88 ± 0.19 in 128 patients. The follow-up ranged from 6 to 168 months, with a mean 51 ± 48 months in 70 patients. A significant difference was found in those failing after dilation when the initial evaluation was compared to the final evaluation of patients with follow-up. In those failing, the number of patients rose from 12 (17%) to 21 (30%) (p > 0.01). In contrast, in those in whom we achieved success, there was not such a great difference between the initial and final evaluation: 58 (83%) versus 49 (70%) (p > 0.1). The actuarial freedom curve of patients not needing new percutaneous aortic valvoplasty or surgery, by 182 months, was at 87% and 82% respectively. Conclusion: We have reviewed the largest series of patients in Latin-America reported thus far after undergoing percutaneous aortic valvoplasty, concentrating on mid term follow-up and limitations. New prospective and multicentric studies are needed from our region.
A neonate weighing 2.8 kilograms underwent the staged hybrid procedure for palliation of hypoplastic left heart syndrome. Within 6 hours following placement of a stent to retain patency of the interatrial communication, the infant developed second degree atrioventricular block, which resolved within 24 hours. Four days later, the patient developed complete atrioventricular dissociation. Removal of the stent was followed by recovery of atrioventricular conduction.
Intermittent functional closure of a patent duct has been reported both clinically and echocardio-graphically. We describe the case of a 6-year-old with intermittent complete closure of a patent duct occurring during attempted transcatheter closure. Recurrence of clinical and echocardiographic signs prompted restudy. A patent duct of moderate size was demonstrated and successfully occluded by coil embolization. The interventional aspects of this unusual condition are discussed.
Closure of atrial septal defects be means of intravenous catheterisation has been undertaken using a variety of devices as an alternative to surgical closure.1–5 We describe the first case, to the best of our knowledge, of infective endocarditis complicating a successful transcatheter closure. This highlights the potential risk of this procedure, and emphasises the need for appropriate antibiotic prophylaxis until complete endothelialization of the device has occurred.
We report the multicentric French experience with transcatheter closure in children weighing 15 kilograms or less, with the aim of assessing the efficacy of the procedure in this age group.
We included all children weighing 15 kilograms or less, and seen between January, 1997, and June, 2004, who had successful transcatheter closure of an interatrial communication within the oval fossa.
Transcatheter closure was performed in 35 patients weighing 15 kilograms or less, of whom 14 were male and 21 female. The procedures were undertaken in 8 different centres, the patients having a median age of 3 years, with a range from zero to 6.2 years, and a mean weight of 13 kilograms, with a range from 3.6 to 15 kilograms. All the patients were symptomatic, with associated cardiac malformations present in 4 cases, and extracardiac anomalies in 4 patients, including Down’s syndrome in 3, and Adams Oliver syndrome in the other case. In 1 patient, emergency cardiac surgery was needed 24 h after the procedure to correct a previously undiagnosed divided right atrium. No other complication occurred. After a median follow-up of 2 years, with a range from 0.5 to 5.2 years, all the patients are asymptomatic, except for one long-standing patient with bronchodysplasia. In 1 other patient, a small residual bidirectional shunt was detected by echocardiography. No patient presented significant arrhythmia. In the patients followed-up for more than 12 months, we found a significant gain in weight gain.
Transcatheter closure of an interatrial communication within the oval fossa is efficient in children weighing 15 kilograms or less, and can be proposed as a first line of treatment in symptomatic patients. Children with retarded growth tend to have complete recovery within one year of closure.
We report the successful use of a cutting-balloon catheter in dilating stenoses in major systemic-to-pulmonary collateral arteries which had been resistant to high pressure balloons. After dilation using the cutting balloon, we implanted stents to produce a marked improvement in both pulmonary blood flow and arterial saturation. The technique provides useful palliation for patients having such stenotic collateral arteries.
We successfully performed percutaneous transluminal angioplasty to treat severe renovascular hypertension with left ventricular failure in a 5-month-old infant. Using the transcarotid approach, we dilated the stenotic left renal artery without any difficulties, using progressively larger balloons designed for dilation of coronary arteries.
Since June 1998, we have used an Amplatzer device whenever considered appropriate in patients with isolated defects within the oval fossa. The aim of this study was to define the total cohort of patients with isolated defects in the oval fossa seen at this hospital, so as to assess the impact of this policy on contemporary management. In the two-year period commencing 1st June 1998, 116 patients older than 6 months were seen with an isolated septal defect within the oval fossa. Mean age at closure or last review was 5.8 years, with a range from 0.5 to 20 years. In total, 42 (36%) patients were assigned to surgical closure, 25 (22%) to closure using an Amplatzer device, and 49 (42%) remained under clinical follow up. Direct referral for surgical closure occurred in 24 (21%) patients, in whom transcatheter closure was considered not appropriate after transthoracic echocardiography. Transoesophageal echocardiography was performed in 45 (39%) patients to assess suitability for closure using the Amplatzer device. Of these, 20 (44% of the group undergoing transoesophageal echocardiography) were considered unsuitable for closure in this fashion. Of these, 8 were referred for surgery and 2 with small defects were considered not to require closure. Patients undergoing closure with the device were older than the group referred for surgical closure, having a median age of 7.8 versus 3.6 years, and stayed for a shorter period in hospital. Those closed using the device stayed for 2 days, as opposed to a median of 5 days, with a range from 4 to 10 days for those undergoing surgical closure. Closure was complete as assessed by echocardiography after follow up of 1–3 months in both groups. There were no recognised complications related to insertion of the device, whereas transient postoperative morbidity occurred in 38% of those closed surgically. Insertion of an Amplatzer device was considered to be appropriate in 37% of patients older than 6 months requiring closure of an atrial septal defect in the oval fossa.
Background: Multiple perforations in the floor of the oval fossa may be an obstacle for transcatheter closure. Thus, we analyzed the interventions in 33 patients with more than one interatrial communication in comparison with 370 procedures with a single defect. Methods and Results: A diagnostic catheterization, which included a balloon-sizing maneuver, was performed. We implanted a total of 46 occluders, made up of 42 Amplatzers and 4 CardioSEALs. In 20 patients, the defects were closed with a single occluder, namely 18 Amplatzer and 2 CardioSEAL devices. Complete closure was achieved in 15 patients, while a tiny residual shunt remained in 5 patients. In 13 patients, two devices were implanted, without any residual shunt being found immediately after implantation. In 3 patients, the occluders did not touch each other. In 10 patients, their rims overlapped. In comparison with the control group, the group with multiple defects did not differ in the distribution of age, gender, and indications for device closure. The mean time of the procedure, and the time required for fluoroscopy, however, were significant longer (P< 0.001). These times ranged from 45 to 250 minutes with a median of 140 minutes, and from 0.0 to 39.2 minutes, with a median of 12.0 minutes, respectively. Also, the association with an atrial septal aneurysm was significantly more frequent 61 vs. 17%; P< 0.001). The times taken during insertion of double devices were also significantly longer than those needed for insertion of a single device (P< 0.001). Conclusions: Transcatheter closure of multiple defects within the oval fossa is feasible with currently available occluders, albeit than, in selected cases it is necessary to implant two devices.
Atrioventricular nodal reentrant tachycardia was proven during electrophysiologic study in 41 children, aged from 3.7 to 16 years, who were referred for catheter ablation of symptomatic supraventricular tachycardia. Using an abbreviated combined anatomical and electrogram-guided approach for selective ablation of the slow pathway, a steerable ablation catheter was placed at the inferior region of the vestibule of the tricuspid valve close to the orifice of the coronary sinus, with the intention of recording a multicomponent local atrial electrogramm during sinus rhythm. If application of radiofrequency current of 500 kHz at 70°C at this site did not result in a slowly accelerated junctional rhythm, at a rate of less than 120 beats per minute, the catheter was stepwise advanced up to a position midway towards the apex of the triangle of Koch for additional applications of energy. Ablation was achieved in 35 of the patients. In 6 patients, the slow pathway was modulated such that the tachycardia could no longer be induced. The number of applications of energy ranged from 1 to 19, with a median of 6 applications. The mean period of fluoroscopy was reduced to 15.6 (4.3 to 39.8) minutes, while the overall duration of the catheterization procedures ranged from 88 to 280 (mean 173.2) minutes. In none of the patients did we observe permanent high grade atrioventricular block. During follow-up over a mean of 4.1 years, two patients had recurrence of tachycardia, corresponding to a 95% rate of success in the midterm. We conclude that selective radiofrequency ablation of the slow pathway using the abbreviated anatomical and electrophysiological approach is a safe and curative therapeutic approach in children with atrioventricular nodal reentrant tachycardia. Periods required for fluoroscopy can be significantly reduced, and mid-term results are excellent.
Cardiac tamponade occurring late after interventional closure of defects within the oval fossa is a very rare but life-threatening complication. We describe such an occurrence after use of a Cardioseal device to close an interatrial communication. Two arms of the device had perforated left atrial wall. The device was removed at surgery, and the defect closed uneventfully. All available means should be used to identify this complication.