Alban Baruteau

Palliative Potts shunt for the treatment of children with drug-refractory pulmonary arterial hypertension: updated data from the first 24 patients

OBJECTIVES Palliative Potts shunt has been proposed in children with suprasystemic pulmonary arterial hypertension (PAH). METHODS A retrospective multicentre study was performed to assess short- and long-term outcomes after Potts shunt. RESULTS From 2003 to 2014, 24 children underwent a Potts shunt [19 surgical, median age: 7.7 years (1.5-17 years), median weight: 19.5 kg (10.2-47 kg) and 5 transcatheter, median age: 8.1 years (2.3-9.7 years), median weight: 22 kg (12.5-31 kg)] for drug-refractory PAH. For the first time in humans, we performed an unidirectional valved Potts anastomosis in a child with infrasystemic PAH on intravenous epoprostenol who experienced repeated central line infections. Severe postoperative complications occurred in 6 patients (25.0%, all from the surgical group) including 3 early deaths (12.5%) related to low cardiac output. After a median follow-up (FU) of 2.1 years (range, 3 months to 14.3 years, ≥8 years in 7 patients), World Health Organization (WHO) functional class was dramatically improved in the 21 survivors, all being in WHO-functional class 1 or 2 (P < 0.05); none experienced syncope during the FU; none had overt right ventricular failure; mean 6-min walk distance improved from 42.3 ± 10.0% to 81.2 ± 9.7% of adjusted values for age and sex (P < 0.001), BNP/NT-proBNP levels normalized in all; and weaning of intravenous epoprostenol was obtained in all patients who received triple combination as pre-Potts anastomosis therapy. Finally, all survivors caught up to normal growth curves. Arterial oxygen saturation gradient between upper and lower limbs persisted at the last FU (94.7 ± 3.6% vs 81.6 ± 5.1%, P < 0.001). One patient required double lung transplantation 6 years after a surgical Potts shunt. CONCLUSIONS Palliative Potts shunt allows prolonged survival and dramatic, long-lasting improvement in functional capacities in children with severe, drug-refractory PAH. The Potts shunt might be considered as a first surgical or interventional step in the management of children with severe, drug-refractory PAH, leaving the door open for further lung transplantation, if needed.

Transcatheter closure of patent ductus arteriosus: Past, present and future

This review aims to describe the past history, present techniques and future directions in transcatheter treatment of patent ductus arteriosus (PDA). Transcatheter PDA closure is the standard of care in most cases and PDA closure is indicated in any patient with signs of left ventricular volume overload due to a ductus. In cases of left-to-right PDA with severe pulmonary arterial hypertension, closure may be performed under specific conditions. The management of clinically silent or very tiny PDAs remains highly controversial. Techniques have evolved and the transcatheter approach to PDA closure is now feasible and safe with current devices. Coils and the Amplatzer Duct Occluder are used most frequently for PDA closure worldwide, with a high occlusion rate and few complications. Transcatheter PDA closure in preterm or low-bodyweight infants remains a highly challenging procedure and further device and catheter design development is indicated before transcatheter closure is the treatment of choice in this delicate patient population. The evolution of transcatheter PDA closure from just 40 years ago with 18F sheaths to device delivery via a 3F sheath is remarkable and it is anticipated that further improvements will result in better safety and efficacy of transcatheter PDA closure techniques.

A standardized repair-oriented strategy for mitral insufficiency in infants and children: Midterm functional outcomes and predictors of adverse events

OBJECTIVE Surgical management of mitral regurgitation (MR) in children remains a challenge because of the heterogeneity of the anatomy, growth potential, and necessity to avoid valve replacement. Our objective was to assess the functional outcomes and prognostic factors of a standardized strategy of mitral valve (MV) repair for children with MR. METHODS Consecutive patients aged <18 years who had undergone surgery for severe MR from 2001 to 2012 were studied retrospectively. The standardized repair strategy mainly included leaflet debridement, annuloplasty, and leaflet augmentation. Multivariable risk analyses for recurrent MR (grade>II), transmitral mean echocardiographic gradient>5 mm Hg, MV reoperation, replacement, and mortality were performed. RESULTS A total of 106 patients were included (median age, 5.1 years; range, 11 days to 18 years). The mean follow-up period was 3.9±3.2 years (range, 2 months to 11 years). The proportion of congenital and left heart obstruction-related (left ventricular outflow tract obstruction) etiology was 49% (n=52) and 11% (n=12), respectively. MV repair was performed primarily in 97% of the patients. The mortality, reoperation, replacement, and MR rate at the last follow-up visit was 4.5% (n=5), 23% (n=24), 5.5% (n=6), and 17% (n=18), respectively. Actuarial survival was 93%±2% at 10 years. Freedom from MV replacement was 95%±2% and 86%±7% at 5 and 15 years, respectively. Native valve preservation was obtained in 85% of the infants and 94% beyond infancy. Independent predictors of recurrent MR, MV reoperation, and replacement included left ventricular outflow tract obstruction etiology (hazard ratio, 45; P=.004), associated preoperative mitral stenosis (hazard ratio, 21; P=.03), and young age (hazard ratio, 1.2; P=.04). CONCLUSIONS A standardized and reproducible MV repair strategy can achieve satisfactory functional results in infants and children with severe MR, allowing native valve preservation. The left ventricular outflow tract obstruction-related etiology was the main independent predictor of recurrent MR, MV reoperation, and MV replacement.

Transcatheter closure of coronary artery fistulas in infants and children: A French multicenter study.

The short‐term efficacy and safety of transcatheter closure (TCC) for the management of coronary artery fistulas (CAFs) was investigated in pediatric patients.

Transcatheter : A French multicenter study

The short‐term efficacy and safety of transcatheter closure (TCC) for the management of coronary artery fistulas (CAFs) was investigated in pediatric patients.

Atrial septal defect closure: indications and contra-indications

Transcatheter closure has become an accepted alternative to surgical repair for ostium secundum atrial septal defects (ASD). However, large ASDs (>38 mm) and defects with deficient rims are usually not offered transcatheter closure but are referred for surgical closure. Transcatheter closure also remains controversial for other complicated ASDs with comorbidities, additional cardiac features and in small children. This article not only provides a comprehensive, up-to-date description of the current indications and contra-indications for ASD device closure, but also further explores the current limits for transcatheter closure in controversial cases. With the devices and technology currently available, several cohort studies have reported successful percutaneous closure in the above-mentioned complex cases. However the feasibility and safety of transcatheter technique needs to be confirmed through larger studies and longer follow-up.

0378: Stents in pediatric and adult congenital cardiac catheterization in France in 2013

Stents have contributed to the development of the interventional catheterization of congenital heart diseases (CHD). The aim of this study was to describe current indications and results. Methods Participation to this study was proposed to all catheterization laboratories specialized in CHD in France (M3C network). All cases with stents implantation in 2013 in pediatric and adult CHD were retrospectively included. Adverse events were assessed using the Bergersen classification. Risk markers were searched using univariate and multivariate analysis. Results 174 stents were implanted in 127 patients. Patients were aged 15.7±15.1 year old (min 5 day-old - max 70 year-old). Main indications were transcatheter pulmonary valve replacement (prestenting and revalvulation; n=29 patients, 23.0%), pulmonary artery branches angioplasty (n=34, 27.0%), aortic coarctation or recoarctation stenting (n=37, 29.4%) and ductus arteriosus stenting (n=11, 8.7%). 18 Patients (14.3%) were under one-year old and 35 (27.8%) were over 18 year-old. Main pathologies were tetralogy of Fallot and variants (ACC-CHD 8.3, n=45, 35.7%), and aortic coarctation (ACCCHD 9.2, n=36, 28.6%). More than one stent was implanted in 32 procedures (24.4%, max. 5 stents). Main stents implanted were the CP stent (33.0%), EV3 LD max (22.0%), Valeo (16.2%) and valved stents (15.0%). 98.5% Procedures were considered as successful. Adverse events were observed in 16.7% procedures (stent related in 12.1% procedures). Serious adverse events were observed in 12.9%. After uni- and multivariate adjustment, only procedure type was related to the risk of total adverse events but not to stent related adverse events. Age, weight, center, type of stents, genetic disorder and type of CHD were not significantly related to the risk of adverse events. Conclusion Stents are used in various CHD catheterization procedures, from infancy to adult age. Adverse events rate is significant and seems related to the type of procedure.

Abstract 15403: Percutaneous Atrioseptostomy is a Safe and Efficient Strategy for Left Heart Discharge Under Veno-Arterial Peripheral Extracorporeal Membrane Oxygenation

Background: Veno-arterial Extracorporeal Membrane Oxygenation (VA-ECMO) is a life-saving mechanical support in case of intractable heart failure. It is widely used in both children and adult patients, as a bridge to recovery or heart transplantation. It can lead to increased left atrial pressure, resulting in haemoptysis and severe acute pulmonary oedema. We assessed the hypothesis that percutaneous atrioseptostomy is a safe and efficient alternative for left heart discharge under VA-ECMO. Methods and Results: A monocenter retrospective study was conducted at our tertiary center. From April 2008 to April 2013, 160 patients were assisted with peripheral VA-ECMO. Twenty-three of them (1 month to 72 years old, median age: 34 years, 6 children and 17 adults) needed left heart discharge and had a percutaneous atrioseptostomy. The procedure was done in the catheterization laboratory under fluoroscopic guidance via the femoral vein and a transseptal puncture using a Brockenbrough needle. For adult patients, a 28...