Andrew Tometzki

Balloon expandable stent implantation for native and recurrent coarctation of the aorta—prospective computed tomography assessment of stent integrity, aneurysm formation and stenosis relief

Background Stenting for aortic coarctation is known to be effective in the medium term. Aneurysm formation following stent implantation is a recognised complication. However, data regarding aortic wall injury and stent integrity following stent placement are sparse. Objectives We report comprehensive clinical, echocardiographic and prospective CT follow-up data following stenting for aortic coarctation from a single centre. Methods Full data analysis of all patients undergoing balloon expandable stent implantation and follow-up procedures in a single tertiary congenital cardiac unit. Results Between October 2002 and April 2008, we performed 102 coarctation stent procedures on 88 patients. Median age was 20.6 years (range 8.5–65) and median weight 65 kg (range 34–101). 94 stents (26 covered) were implanted. 12 procedures were re-dilatations. Stenting resulted in a reduction of the gradient across the site of coarctation, from a median of 20 mm Hg to 4 mm Hg. There were no procedure-related deaths. Four patients had immediate complications (one requiring emergency surgery). During median follow-up of 34.5 months (range 4.2–72.8), two patients had late complications requiring additional stent procedures. Follow-up CT data are available in 84 patients with MRI in one patient (96.5%). Only one patient developed a procedure-related aortic aneurysm. All stent fractures (n=7) occurred with a single stent design. Conclusions Stenting for aortic coarctation and re-coarctation is effective with low immediate complication rates. CT is useful in the longer term for assessment of stent integrity and post-procedural aneurysm formation. Overall incidence of post-procedural aneurysm is rare and stent fractures were not seen with newer generation stents.

Self‐expanding and balloon expandable covered stents in the treatment of aortic coarctation with or without aneurysm formation

Objectives: We describe our complete experience with covered stent implantation for aortic coarctation including short‐ to medium‐term outcomes. Background: Coarctation of the aorta is a heterogeneous disease process with multiple associated complications both with and without treatment. Covered stents have evolved to provide greater support to the aortic wall and a varied approach with choice of stent tailored to the anatomy of the patient is required. Methods: We retrospectively analyzed consecutive patient data from two congenital heart centers from March 2003 to October 2007. Results: We implanted 38 covered stents in 37 patients (20 female) of which three were self‐expanding stents. Median age was 29.6 years (9–65) with median weight of 71.5 kg (35–95). The indications for stent placement were native coarctation (n = 13); recurrent coarctation following surgical treatment (n = 11); aneurysm associated with previous coarctation surgery (n = 7); aorto‐bronchial fistula leading to acute hemoptysis (n = 2); stent fracture (n = 1); associated arterial duct (n = 2). One patient had a combination of acquired coarctation and false aneurysm. The median screening time was 10 min (3–22). The median systolic gradient of 26 mm Hg (10–60) was reduced to 4 mm Hg (0–20) postprocedure (P < 0.001). There were no deaths on median follow up of 11.5 months (1–56). One patient developed aortic rupture during the procedure and required emergency surgery. Conclusion: Covered stent implantation for treatment of aortic coarctation is safe and highly effective in selected patients. Self‐expanding stent grafts may be preferable to balloon expandable stents when there is aneurysm formation in the setting of aortopathy.

Early clinical experience with the new Amplatzer Ductal Occluder II for closure of the persistent arterial duct.

Objectives: To describe the early single‐center clinical experience with the Amplatzer Ductal Occluder II (ADO II). Methods: All patients undergoing attempted transcatheter closure of persistent arterial duct (PDA) with the ADO II were included. Data collected included demographic, clinical, and echocardiographic parameters. Results: From March until September 2008, 29 procedures were undertaken in 27 patients (21 female). Median age was 1.4 years (range 0.4–76 years) with median weight 9.4 kg (range 4.7–108 kg). A transarterial approach was used in 2 patients. The median minimum ductal diameter was 2.7 mm (range 1.7–5). ADO II was released in 25 patients (92.5%). Two patients had significant residual shunting following deployment of ADO II and underwent closure with Amplatzer ductal occluder (ADO I). Postprocedural echocardiography identified one occluder had changed position with development of a significant leak and one occluder had embolized to the left pulmonary artery. Both occluders were retrieved successfully at a second catheter procedure. Complete occlusion was noted predischarge in 22 of the remaining 23 occluders (96%). One patient had mild flow acceleration in the left pulmonary artery which has resolved. Conclusions: The ADO II is highly effective at providing rapid occlusion of morphologically varied PDAs. Occluder design allows closure with arterial or venous approach and delivery with 4 or 5 F delivery catheters. Stable occluder position is dependent on correct positioning of both aortic and pulmonary discs. A larger range of sizes and configurations of this occluder may be required to successfully occlude all ductal sizes and morphologies.

Early clinical experience with a modified amplatzer ductal occluder for transcatheter arterial duct occlusion in infants and small children

To describe early clinical experience with the amplatzer ductal occluder II additional sizes (ADO II AS) for percutaneous arterial duct occlusion in infants and small children.

Transcatheter closure of long tubular patent arterial ducts: The Amplatzer Duct Occluder II-A new and valuable tool.

Despite the wide variety of occlusion devices available for closing the patent ductus arteriosus; some defects with unusual morphology still remain a challenge. The drive for increasingly user friendly and lower caliber delivery systems is also ongoing. The new amplatzer ductal occluder II may prove to be a useful additional tool in these circumstances. We describe our initial experiences with this new device in three patients with long tubular (Type C) ducts.

Axillary artery approach for balloon valvoplasty in young infants with severe aortic valve stenosis : Medium-term results

Objectives: To assess the feasibility and results of trans‐axillary approach for balloon aortic valvoplasty (BAV) in early infancy. Background: Severe aortic valve stenosis (SAVS) is rare but serious condition in infancy, which may be promptly treated either by surgical aortic valvotomy or BAV. BAV is usually performed via the femoral artery route, which is associated with significant vascular complications and long procedure times. Methods: BAV via the trans‐axillary approach was performed on twenty‐seven sequential infants with SAVS presenting to a single tertiary referral center over an 11‐year period. Maximum inflated balloon size was less than or equal to the aortic valve diameter. Results: Twenty‐seven infants aged 1–77 days underwent BAV. Weight at time of procedure was 2.0–4.42 kgs. The median procedure and screening times were 82 and 7.9 minutes, respectively. Mean instantaneous Doppler gradient across the aortic valve reduced from 68 ± 33 to 37 ± 14 mmHg ( p < 0.0001). Three infants developed at least moderate aortic regurgitation. Right arm pulse volume was decreased in 12 infants; 5 received an intravenous heparin infusion. Longer‐term follow‐up demonstrated reduced or absent peripheral pulse in 5 infants. Transection of the axillary artery occurred in one infant requiring emergency microvascular repair. There was one post‐procedural and one late death due to non‐cardiac causes. Conclusions: In early infancy balloon aortic valvoplasty via the axillary artery approach for severe aortic stenosis is an acceptable and safe alternative to the femoral arterial approach and results in short procedure and screening times. Longer‐term vascular follow‐up is required.

Use of the Amplatzer vascular occluder to occlude large venous vessels in adults and children with congenital heart disease: A case series

We describe the use of a new vascular occlusion device to embolize vessels whose flow is detrimental to cardiac function in a variety of clinical situations in both adults and children with congenital cardiac disease. Our series includes four cases in which we have successfully occluded large venous vessels, to produce a beneficial effect on oxygen saturations and cardiac function. There were no adverse events because of the devices in our series, which provides evidence that the Amplatzer vascular plug is a safe and effective method of embolizing large venous vessels.

Longer-term outcome of perventricular device closure of muscular ventricular septal defects in children

To describe the longer‐term clinical experience and follow‐up with perventricular device closure of ventricular septal defects (VSD) in children.

Significant aortic regurgitation associated with transcatheter closure of perimembranous ventricular septal defects with a deficient aortic rim

We report on two patients who developed significant aortic regurgitation during transcatheter closure of a perimembranous ventricular septal defect, both requiring further surgical intervention. Both patients were noted prior to the procedure to have limited subaortic margins to the defect. The potential mechanisms for development of aortic regurgitation in this setting are discussed.

Long‐term clinical experience with amplatzer ductal occluder II for closure of the persistent arterial duct in children

To describe the long‐term clinical experience and follow‐up with the Amplatzer Ductal Occluder II (ADO II) in children.