David Shim

Transhepatic therapeutic cardiac catheterization: a new option for the pediatric interventionalist.

We evaluate the efficacy and safety of percutaneous transhepatic (TH) venous access for interventional cardiac catheterization. A retrospective review of all TH therapeutic catheterizations between January 1994 and September 1998 was performed. Patient demographics, pre‐ and postcatheterization hemoglobin and liver function studies, and complications were evaluated. TH access was performed for 30 interventional catheterizations in 25 patients with a median age of 39 months (range, 1 day to 41 years) and weight of 13.2 kg (3.1–87.0 kg). Indications for TH access were bilateral obstructed femoral veins (n = 15), obstructed femoral veins and superior vena cava (n = 3), Greenfield filter (n = 2), and presumptive improved route for intervention via TH access (n = 5). TH interventions were successful in 29/30 procedures (97%). Interventions via TH sheath sizes of 4–14 Fr included pulmonary angioplasty ± stent (n = 11), radiofrequency ablation (n = 4), atrial septal defect device occlusion (n = 2), coil occlusion of pulmonary artery pseduoaneurysm (n = 2), Fontan fenestration device occlusion (n = 2), pulmonary valvuloplasty (n = 2), stent dilation of the superior vena cava (n = 2), and one each of device retrieval, Fontan baffle stent placement and subsequent redilation, Fontan fenestration dilation, transseptal mitral valvuloplasty, and cardiac biopsy. There were no changes in pre‐ and post‐TH hemoglobin levels (mean ± SD, 12.9 ± 2.2 vs. 11.9 ± 1.9 gm/dL; P = NS) or alanine transferase (34.0 ± 27.5 vs. 43.4 ± 18.2 IU/L; P = NS). One patient developed important intraperitoneal bleeding and required exploratory laporatomy. Percutaneous TH access is safe and effective as a route for interventional catheter procedures for patients with limited venous access. Cathet. Cardiovasc. Intervent. 47:41–45, 1999.

Intraperitoneal hemorrhage associated with transhepatic cardiac catheterization : A report of two cases

Transhepatic cardiac catheterization has gained increased interest as a novel technique for venous vascular access with few complications. We report important intra-abdominal bleeding encountered in two patients during transhepatic cardiac catheterization. We describe their management and suggest possible nonoperative strategies.

Radiation exposure to children during coil occlusion of the patent ductus arteriosus

The risks of excessive exposure to ionizing radiation are well described and measures are routinely taken to limit such exposure to both patient and personnel in the catheterization laboratory. Coil occlusion of the patent ductus arteriosus (PDA) as well as other more complex pediatric interventions has raised concern regarding radiation exposure, particularly as minimally invasive surgical techniques are being developed which lack such exposure risk. In eight consecutive patients, aged 0.7–7 years (median, 2.3 years), coil occlusion of a PDA was performed and surface entrance radiation dose determined by thermoluminescent dosimetry (TD). Total cumulative doses (PA + lateral dose) were also calculated for each patient. Entrance and cumulative dose was likewise measured in 12 patients undergoing standard diagnostic catheterization (DC) and in 5 consecutive patients undergoing pulmonary balloon valvuloplasty (PBV). The groups were comparable in age, weight, and body surface area (BSA). Total cumulative dose in the PDA patients was 97 ± 25 mGy (mean ± SE). There was no significant difference between the three groups in entrance dose absorbed at each location or in total cumulative dose. The mean total fluoroscopy time in the PDA occlusion group was significantly less than that of the PBV group (10.1 ± 1.81 min vs. 19.3 ± 2.29 min, P < 0.05) but was comparable to the DC group (13.2 ± 1.5 min, P = NS). When the subjects were analyzed collectively, no correlation between fluoroscopy time and measured entrance dose was observed. The strongest correlates of total cumulative dose were patient weight (r = 0.67, P < 0.001) and BSA (r = 0.62, P = 0.001). Patients undergoing coil occlusion of a PDA are not exposed to increased radiation entrance dose compared to those undergoing standard DC and PBV. Furthermore, surface entrance radiation dose as determined by TD varies according to patient size for a given fluoroscopy time. Cathet. Cardiovasc. Intervent. 47:449–454, 1999.

Usefulness of Repeat Balloon Aortic Valvuloplasty in Children

This retrospective study examines all 15 patients who underwent a second balloon dilation procedure for congenital aortic stenosis to determine its safety and efficacy. The recurrent gradient was significantly reduced, but 4 patients had unsatisfactory gradient relief, 3 of whom had previous surgical valvotomies; therefore, we conclude that repeat balloon aortic valvuloplasty is worthwhile, although third balloon dilations may not be beneficial.

Neonatal Cardiac Catheterization: A 10-Year Transition from Diagnosis to Therapy

To assess the changing role of cardiac catheterization in the care of the neonate, a retrospective review of all catheterizations between January 1984 to December 1985 (group I) and January 1994 to December 1995 (group II) at C.S. Mott Childrens Hospital was performed. Neonatal cardiac catheterization was performed more frequently (p= 0.02) in group I, comprising 14% (110 of 772) of all catheterizations versus 11% (93 of 880) in group II. Access was performed by cutdown in 15 patients (13 venous and 2 arterial), all in group I. In group I, 20 of 110 patients (18%) had balloon atrial septostomies; no other catheter interventions were performed. Interventions were more frequent (p= 0.003) and varied in group II, including 15 septostomies, 17 balloon valvuloplasties (13 pulmonary and 4 aortic), 2 coil embolizations of collaterals, and 1 cardiac biopsy. Despite the higher prevalence and complexity of interventions in group II, fluoroscopy times (median; range: 16 min; 2–55 vs 16 min; 1–107) were similar in both groups (p= not significant) as well as the prevalence of complications. Neonatal cardiac catheterizations are performed less frequently than they were a decade ago at our institution, and therapeutic interventions have become more common. Despite these changes, fluoroscopy time and the rate of complications have not increased.

One-Year Follow-Up of the Amplatzer Device to Close Atrial Septal Defects

The early and 1-year follow-up of a single United States center using the Amplatzer atrial septal defect closure device is reported. Complete closure was documented in all patients by 1 year after device implantation.

Exposure to ionizing radiation in children undergoing amplatzer device placement to close atrial septal defects

To evaluate exposure to ionizing radiation during Amplatzer device occlusion, a prospective study was performed to measure surface entrance radiation dose by thermoluminescent dosimetry (TLD). Between June 1998 and April 1999, dosimetry was carried out on 12 patients with Amplatzer device occlusion of atrial septal defects (n = 10) or Fontan fenestration (n =) and 12 age‐matched patients who underwent diagnostic catherization. TLD chips were placed at the posterior (PA) and right lateral (LA) chest wall as well as the thyroid (TH) and gonadal (GN) regions. The Amplatzer group had a median age of 6.4 yr (2.4–12.4 yr) and a median weight of 23.7 kg (15.6–28.9 kg), which were similar (p = NS) to those of the control group, who had a median age of 7.9 yr (3.3–16.2 yr) and a median weight of 29.9 kg (10.6–58.0 kg). Device placement was successful in 11 of 12 patients; one device was removed owing to partial obstruction of the right‐upper pulmonary vein. Fluoroscopy times were also similar in the Amplatzer group (23.5 ± 2.1 min) and the control group (16.4 ± 3.1 min; P = NS). The measured surface entrance doses of the Amplatzer group was similar (p = NS) to those of the control group in all four regions: PA (4.96 ± 1.88 vs. 6.07 ± 2.16 cGy), LA (5.22 ± 1.68 vs. 3.13 ± 1.25 cGy), TH (0.92 ± 0.14 vs. 0.69 ± 0.09 cGy), and GN (0.20 ± 0.00 vs. 0.22 ± 0.01cGy). Fluoroscopy times and measured surface entrance doses of ionizing radiation in patients undergoing Amplatzer device occlusion are similar to those in patients undergoing routine diagnostic catheterization. Cathet. Cardiovasc. Intervent. 51:451–454, 2000.