Carlos Augusto Cardoso Pedra

Efetividade clínica e segurança do tratamento percutâneo da comunicação interatrial tipo ostium secundum, com a prótese Amplatzer®

OBJECTIVE: To assess the clinical efficacy and safety of the Amplatzer occluder for percutaneous closure of secundum atrial septal defect. METHODS: Forty-nine patients underwent the procedure guided by transesophageal echocardiography (TEE) while under general anesthesia, afterwards being clinically followed up for 12 months. RESULTS: The defect presented as a single orifice in 91.8% of the cases. The means of the longitudinal and transverse diameters were 14.3±5.0 mm and 14.4±4.9 mm, respectively. The means of the stretched diameters and prostheses were 19.3±5.1 mm and 20.3±4.9 mm, respectively. Technical success occurred in 97.9% of the cases. Immediate residual flow was observed in 54.1% of the patients, being minimum or small in 45.8% and moderate in 8.3%. After 24 hours, residual flow was observed in 25% of the patients (P = 0.0002). At the end of 13.1±1.3 months, the incidence of the overall residual flow decreased to 14.6%, only 4.1% being moderate. A significant reduction in the right ventricular diastolic diameter was observed in the different phases of clinical follow-up (P < 0.001). CONCLUSION: Implantation of the Amplatzer prosthesis proved to be effective and safe, constituting an option for the treatment of the secundum atrial septal defect in selected cases.

Experiência global no fechamento percutâneo do canal arterial

OBJETIVO: Avaliar a experiencia global da nossa instituicao com o fechamento percutâneo do canal arterial. METODOS: Desde dezembro/92, 150 pacientes foram submetidos a 178 procedimentos (85 - tecnica de Rashkind; 87 - coils de Gianturco; 6 - coils Duct Occlud). A mediana de idade foi de 6,5 anos (1 a 57). A media do diâmetro minimo do canal foi de 3,05±1,24mm (1 a 8). Avaliacoes clinicas e ecocardiograficas foram realizadas seriadamente. RESULTADOS: Implantes adequados ocorreram em 143 (95,3%) pacientes. A prevalencia de shunt residual imediato foi de 52,1%, decrescendo para 15,9% no seguimento. Esta taxa caiu para 5,2% apos a realizacao de procedimentos adicionais. Embolizacao de coils ocorreu em 12 procedimentos e de umbrella em 1. Um paciente apresentou hemolise e outro estenose discreta da arteria pulmonar esquerda. Nao houve mortalidade. CONCLUSAO: Esta modalidade terapeutica e segura e eficaz, proporcionando bons resultados a longo prazo.

O papel da ecocardiografia no tratamento percutâneo dos defeitos septais

In the last few years, percutaneous treatment of atrial and ventricular septal defects has developed signifi cantly, having been established as a feasible, safe and effective therapeutic modality. Echocardiography has a primary role in this scenario, identifying suitable candidates for the procedure, monitoring the device implantation and evaluating the rate of occlusion during follow-up. The available devices for percutaneous occlusion of septal defects have been progressively modifi ed and improved. Similarly, a great technological advancement has also occurred in the echocardiography area, such as the advent of high-resolution transesophageal multiplan probes, on and off-line three-dimensional (3-D echo) and intracardiac echocardiography. In some centers, the latter has become the proce-dure of choice for monitoring percutaneous occlusion of atrial septal defect in adult patients, as it does not require general anesthesia, thus making the procedure even simpler. In this review article, we will discuss the role of echocardiography to evaluate patients before, during and after interventional procedures for occlusion of septal defects, including the

Oclusão Percutânea do Pequeno Canal Arterial com Molas de Gianturco: Impacto da Otimização da Seleção das Molas e dos Pacientes e da Não-Tolerância ao Fluxo Residual Significativo Imediato nos Resultados

INTRODUCTION: Percutaneous occlusion of the patent ductus arteriosus (PDA) by non-controlled retrogade release of Gianturco coils has been frequently employed. METHODS: Since January of 2001, we have applied this technique for patients with type A, D and E PDAs with < 3 mm and have not tolerated significant immediate residual leaks, implanting additional coils. In this paper we report the outcome of this approach. RESULTS: From January 2001, 178 patients (110 females; median age and weight: 5 years and 17 kg, respectively) underwent the procedure. The mean minimal diameter of the PDA was 1.8 ± 0.6 mm (0.5 to 3.0 mm) with 157, 9 and 12 being of types A, D and E, respectively. In 3 patients, there was initial embolization with percutaneous retrieval followed by coil re-implantation in 2 (success rate: 99.4%). More than one coil was required in 32 patients with PDAs significantly larger than the remainder (2.3 ± 0.5 versus 1.6 ± 0.5 mm; p < 0.001). Immediate occlusion was observed in 160 patients with 17 (9.6%) having discrete, diffuse, low velocity residual leaks. Pulse reduction and transfusion were complications observed in 2 patients. One patient with mild residual leak was lost to follow up. On echocardiography, all 176 patients had occlusion and none had flow disturbances in the aorta or in the pulmonary artery on follow up (average 6 months). CONCLUSION: Zero tolerance for significant immediate residual leaks and optimized selection of coils and patients probably explain these excellent outcomes. The procedure is easy to perform, cost effective, safe and highly efficient.

Hypoplastic Left Heart Syndrome With Intact or Restrictive Atrial Septum: A Report From the International Fetal Cardiac Intervention Registry

Infants with hypoplastic left heart syndrome and an intact or highly restrictive atrial septum (HLHS-IAS) represent a high-risk subset. Fetal cardiac intervention (FCI) for fetuses with HLHS-IAS has been reported in single-institution series as a therapy that may improve outcomes. This study uses the International Fetal Cardiac Intervention Registry (IFCIR) to examine fetal and maternal characteristics and pregnancy and neonatal outcome data for FCI in this population. For this descriptive analysis, the IFCIR was queried for fetuses with HLHS-IAS evaluated between 2001 and March 2015 for possible FCI and felt to be candidates at the referral center by a variety of published criteria including foramen ovale (FO) size, shunt flow direction across the FO, and pulmonary venous Doppler flow patterns. It includes those who were determined not to be candidates because of other fetal noncardiac conditions, maternal conditions, or maternal preferences, or because FCI was not performed at the participating institution. Further details on the methodology of the IFCIR registry are found in the initial report.1 Participating IFCIR member sites obtained local institutional review board and ethics board approval or a waiver, as governed …

Outcomes After Transcatheter ASD Closure

Ostium secundum-type atrial septal defect closure has evolved from a surgical procedure requiring cardiopulmonary bypass to a percutaneous, catheter-based procedure usually requiring only an overnight hospital stay. The overall safety and effectiveness has compared favorably with surgical repair. Although rare, complications have been described, including erosion, device embolization, or malfunction and arrhythmias. The overall long-term clinical outcomes have been excellent: good quality of life, functional class improvement, and ventricular remodeling have been the rule after the procedure. It is mandatory to recommend indefinite follow-up of patients undergoing this procedure for potential long-term complications.

Future Directions of Fetal Interventions in Congenital Heart Disease

Fetal interventions for congenital heart disease have become important treatment modalities in the past 10 to 15 years. The basic hypothesis has been that a prenatal intervention may remodel cardiac morphology and function to such an extent that it may favorably alter the in utero natural history, resulting in improved prenatal and postnatal outcomes, including an increased likelihood of achieving biventricular circulation. This review discusses the current indications, techniques, and outcomes of fetal cardiac interventions and provides a glimpse into the future with regard to technical improvements and newer treatment modalities, such as maternal oxygenation and in utero pacemaker implantation.

Experiência clínica com a utilização de plugs vasculares Amplatzer

BACKGROUND: The Amplatzer® vascular plugs I and II (AVPs I and II) are low profile self-expandable devices made of nitinol, designed for vascular occlusions. We report our experience with these devices in two tertiary referral hospitals. METHODS: Retrospective study of patients undergoing vascular occlusion procedures with AVPs since 2005. The devices were 30%-50% larger than the target vessel, deployed under general anesthesia via femoral and internal jugular vein or femoral and brachial artery, and delivered through guiding catheters or 5 F to 8 F long sheaths. RESULTS: Fourteen patients (50% male) at a median age of 5 years (11 months to 70 years) and a median weight of 15 kg (8 kg to 67 kg) were identified. Seventeen AVPs were used: 2 AVPs II and 15 AVPs I, with a diameter ranging from 4 mm to 16 mm. In 3 patients with more than one vessel to occlude, 2 AVPs were implanted in each vessel. In 3 patients with coronary fistula total occlusion of the vessels occurred after 24 hours. In 2 patients with modified Blalock-Taussig shunts, there was total occlusion of the anastomosis, with the use of additional coils in one. In 3 patients with venovenous fistulas after Glenn or Fontan operations, there was complete occlusion of the vessels and improved saturation, with the use of additional coils in one. Another patient with venovenous fistula had mild residual shunt in the lab and total occlusion observed at echocardiographic monitoring within 24 hours. Two patients with multiple pulmonary arteriovenous malformations underwent closure using the AVP, other Amplatzer devices and Gianturcos coils, with minimal residual shunts in all cases. In 2 patients with systemic-pulmonary collaterals in the postoperative period of pulmonary atresia and VSD repair, there was complete occlusion with the aid of additional coils, one immediately after the procedure and the other within 24 hours. In one patient with scimitar syndrome the systemic collateral vessel was totally occluded. There was no embolization or death. CONCLUSIONS: The AVPs were appropriate and flexible devices for occlusion of different vascular sites, with easy deployment and good occlusion rates. Additional coils were required in some cases. In these cases, AVPs worked well to anchor the coils.

Percutaneous closure of atrial septal defects. The role of transesophageal echocardiography

PURPOSE Evaluation of the role of transesophageal echocardiography in percutaneous closure of atrial septal defects (ASD) with the Amplatzer septal occluder. METHODS Patients were selected for percutaneous closure of ASD by transesophageal echocardiography (TEE), which was also used to monitor the procedure, helping to select the appropriate size of the Amplatzer device, to verify its position, and to access the immediate results of the procedure. During the follow-up, TEE was used to evaluate the presence and magnitude of residual shunt (RS), device position, and right cardiac chamber diameters. RESULTS Twenty-two (40%) of a total of 55 studied patients were selected. Thirteen underwent Amplatzer device implantation, eight are still waiting for it, and one preferred the conventional surgical treatment. All procedures were successful, which was mainly due to proper patient selection. Six (23%) patients acutely developed RS, which spontaneously disappeared at the three-month follow-up examination in three patients. There was a significant reduction in the right ventricle diastolic diameter, from 27 mm (average) to 24 mm and 20 mm, one and three months after the procedure, respectively (p < 0.0076). CONCLUSION With the aid of TEE, percutaneous closure of ASD can be successfully, safely, and effectively performed.

Chylothorax after surgery for congenital heart disease in children

We reviewed retrospectively the clinical and surgical data from 9 children with postoperative chylothorax secondary to cardiac surgery for congenital heart disease seen over a 3 year period. Mean age was 26 months and 6 patients were female. The procedures performed were 2 Blalock-Taussig shunts, 6 Bidirectional Glenn anastomoses and 1 modified Fontan procedure. Diagnosis of chylothorax was made by classical means. The overall incidence of chylothorax was 0.8%, with the relative incidences being 2.5% for Blalock-Taussig, 2.7% for Fontan, and 11.7% for the Glenn procedures. All patients were initially treated conservatively with chest tube drainage and hypercaloric diet suplemented with medium chain triglycerides. Parenteral nutrition was needed in 2 patients, one because of sepsis and the other because of progressive malnourishment. High output fistulas and long periods of drainage were noted after cavo-pulmonary procedures. Up to 12% weight loss was observed in 6 patients, one patient was successfully treated of pneumonia and another died of Pseudomonas aeruginosa sepsis. Two patients required chemical pleurodesis because of unabated drainage, with the others being successfully treated conservatively. Chylothorax is a common complication after bidirectional Glenn procedures, and is associated with considerable morbidity and mortality. Earlier operative intervention may be required in these patients. Pleurodesis is a simple, safe, and effective procedure to stop chylous flow.