Edwin Francis

Transcatheter closure of very large (≥ 25 mm) atrial septal defects using the Amplatzer septal occluder

Between June 1999 and September 2002, 45 patients (age, 34 ± 13 years; mean shunt ratio, 2.6 ± 0.6) underwent transcatheter atrial septal defect (ASD) closure at our institution with the Amplatzer septal occluder (mean device size, 31.4 ± 3 mm). Patients were selected by transesophageal echocardiography. The mean ASD dimension was 25.3 ± 3.7 mm and 33 (73%) patients had deficient anterior rim. Specific procedural details included the use of 13 or 14 Fr introducer sheaths and the right upper pulmonary vein approach if the conventional approach failed. There were two procedural failures, with device embolization in both (surgical retrieval in one, catheter retrieval in one). During follow‐up (3–30 months; median, 16 months), one patient (59 years) with previous atrial flutter had pulmonary embolism and was managed with anticoagulation. Two patients developed symptomatic atrial flutter. Fluoroscopy time was 31.6 ± 19.5 min for the first 22 cases and 19.6 ± 11.4 min for the rest (P = 0.04). Transcatheter closure of large ASDs is technically feasible but careful long‐term follow‐up is needed to document its safety. Cathet Cardiovasc Intervent 2003;59:522–527.

Transcatheter occlusion of patent ductus arteriosus in pre-term infants.

OBJECTIVES The aim of this study was to describe our institutional experience with transcatheter coil occlusion of patent ductus arteriosus (PDA) in symptomatic low birth weight pre-term infants. BACKGROUND Transcatheter treatment of PDA in very small infants (<2 kg) is technically challenging and therefore often not considered as an alternative to traditionally accepted modalities (surgical or medical treatment). METHODS Coil occlusion was offered as an option to selected infants with symptomatic PDA. Case selection for the transcatheter procedure was determined by the patients weight, PDA size, size of ampulla, and the anticipated coil mass required for complete closure (determined through echocardiography). The PDA occlusion was achieved with coils delivered with assistance of a 3-F bioptome. Arterial access and catheter manipulation within the cardiac chambers were avoided whenever feasible. RESULTS Eight pre-term infants underwent coil occlusion. Gestational age ranged from 27 to 32 weeks (28.7 +/- 1.9 weeks). The median birth weight was 1,040 g (range 700 to 1,700 g), and the median weight at the time of procedure was 1,100 g (range 930 to 1,800 g). Three patients were receiving mechanical ventilation before intervention. Duct sizes ranged between 2 and 3.5 mm. Complete occlusion of the duct was instantly achieved in 7 patients, and 1 patient had a small residual flow for 24 h. There were no major procedure or access-related complications; 4 patients were discharged within 72 h; 1 patient was discharged on Day 10. Three patients required prolonged ventilation (34 and 150 days) due to pulmonary pathology. CONCLUSIONS It is technically feasible to undertake transcatheter coil closure of PDA in carefully selected symptomatic pre-term infants, and it is a safe alternative to surgical ligation.

Transcatheter closure of fistula between the right pulmonary artery and left atrium using the Amplatzer duct occluder

A congenital fistula between the right pulmonary artery and the left atrium is a rare condition that results in cyanosis. We report a successful catheter‐based closure of such a fistula in a 12‐year‐old using an Amplatzer duct occluder. The patient also had an atrial septal defect that was closed with an Amplatzer septal occluder. Catheter Cardiovasc Interv 2004;63:83–86.

Clinical course and management strategies for hemolysis after transcatheter closure of patent arterial ducts.

Residual flows following transcatheter coil or device closure of the patent ductus arteriosus (PDA) can result in hemolysis. Of 611 patients who underwent transcatheter PDA closure at our institution, 5 patients (age, 6–63 years) developed overt hemolysis (after coil occlusion in 4 and Amplazter device closure in 1). All had ducts > 3 mm and residual flows after the procedure. In one patient, hemolysis occurred 3 months after coil occlusion following a period of uncontrolled hypertension. The occurrence of hemolysis correlated significantly with both age as well as duct size (P < 0.00001). Hemolysis was associated with a fall in hemoglobin of 3–6 g/100 ml (n = 3), jaundice (n = 2), and renal failure (n = 1). Hemolysis subsided spontaneously in one patient and four patients required flow elimination. Deploying additional coils in three patients eliminated residual flows. In one patient (after Amplatzer device closure for 12.5 mm duct with aneurysm), flow persisted after 25 additional coils, transient balloon occlusion, and gel foam instillation. Flow elimination was eventually achieved through thrombin instillation after balloon occlusion of the ampulla. All patients recovered completely and were well on follow‐up. Although hemolysis after duct occlusion is rare (0.8% in this series), residual flow at the end of the procedure merits careful monitoring. Aggressive elimination of residual flows is often necessary to control hemolysis. Cathet Cardiovasc Intervent 2003;59:538–543.

Safety and Feasibility of Transcatheter Closure of Large Patent Ductus Arteriosus Measuring ≥4 mm in Patients Weighing ≤6 kg

OBJECTIVES The study aims to find safety of transcatheter closure of large patent ductus arteriosus (PDA) >or=4 mm in patients weighing <or=6 kg. BACKGROUND Large PDA >or=4 mm in patients <or=6 kg challenge the interventionist due to need for large delivery sheath, kink of delivery sheath, and encroachment of aorta or pulmonary artery (PA) by the device. Many institutions refer them for surgery. METHODS Preterm neonates and ducts with coarctation were excluded. All other patients were taken for catheter closure. Ducts with roomy ampulla were closed with multiple coils aided by bioptome, and others with Amplatzer duct occluders. RESULTS Twenty-eight patients aged 2-18 months (median 5.5 months) and weighing 3.8-6 kg (median 4.7 kg) had large PDA (mean diameter 6.3 +/- 2 mm) with hyperkinetic pulmonary hypertension. Four patients had bioptome-aided coil closure. Twenty-two other ducts were closed with devices. Two procedures failed due to sheath kink in one patient and device pulling through a duct in the other patient. Four infants needed blood transfusions. The mean procedural time was 42 +/- 20 minutes. On a mean follow-up of 25.5 +/- 14.8 months, there were no residual flows and no gradients across aorta or pulmonary artery. CONCLUSIONS Transcatheter closure of large ducts >or=4 mm might be considered safe and effective in infants weighing <or=6 kg also. Decision on coils versus devices depends on ductal morphology. On midterm follow-up with somatic growth, there was no occurrence of aortic or PA gradients.

Catheter closure of atrial septal defects with deficient inferior vena cava rim under transesophageal echo guidance

Objectives: To describe the case selection, imaging considerations, technique, and results of catheter closure of atrial septal defects (ASD) with deficient inferior vena cava (IVC) rim. Background: Transcatheter closure with Amplatzer septal occluder (ASO) has become standard treatment for most secundum ASDs. Defects with deficient IVC rim continue to be challenging to image and close in the catheterization laboratory. Methods: Records of 12 patients with deficient IVC rim (<5 mm), who underwent catheter closure (April 2007 to June 2008) were reviewed. General anesthesia and transesophageal echo (TEE) guidance was used in all. The IVC rim was imaged at 70°–90° with retroflexion of the TEE probe, in addition to the conventional views. Devices 1–4 mm > maximal ASD size were selected. Deployment was accomplished either from the left atrium, left upper or from the right pulmonary veins. Results: The median age was 5.5 (2.5–27) years and median weight was 19.5 (9‐65) kg. The defects measured 16–32 mm and 18–36 mm septal occluders were used. The median fluoroscopic time was 13.1 (4.2–32.7) min. Initial device selection was revised in four patients. Two patients had residual flows at IVC margin. The device embolized to right ventricular outflow tract in one patient. This was retrieved, and a larger device was deployed. No other complications were observed immediately or on follow‐up (median 6; range 1–14 months). Conclusions: Transcatheter closure of ASDs with deficient IVC rim is feasible under TEE guidance. The modified retroflexed view allows adequate imaging of IVC rim through TEE.

EMERGENCY BALLOON DILATION OR STENTING OF CRITICAL COARCTATION OF AORTA IN NEWBORNS AND INFANTS: AN EFFECTIVE INTERIM PALLIATION

Background: Management of native uncomplicated coarctation in neonates remains controversial with current evidence favoring surgery. The logistics of organizing surgical repair at short notice in sick infants with critical coarctation can be challenging. Methods and Results: We reviewed data of 10 infants (mean age of 2.9 ±1.6 weeks) who underwent catheter intervention for severe coarctation and left ventricular (LV) dysfunction between July 2003 and August 2007. Additional cardiac lesions were present in 7. Mean systolic gradient declined from 51±12 mm Hg to 8.7±6.7 mm Hg after dilation. The coarctation segment was stented in five patients. Procedural success was achieved in all patients with no mortality. Complications included brief cardiopulmonary arrest (n =1), sepsis (n = 1) and temporary pulse loss (n = 2). LV dysfunction improved in all patients. Average ICU stay was 5±3.4 days and hospital stay was 6.5±3.4 days. On follow-up (14.1±10.5 months), all developed restenosis after median period of 12 weeks (range four to 28 weeks). Three (two with stents) underwent elective coarctation repair, two underwent ventricular septal defect (VSD) closure and coarctation repair and one underwent pulmonary artery (PA) banding. Two patients who developed restenosis on follow-up were advised surgery, but did not report. Two (one with stent) underwent redilatation and are being followed with no significant residual gradients. Conclusion: Balloon dilation ± stenting is an effective interim palliation for infants and newborns with critical coarctation and LV dysfunction. Restenosis is inevitable and requires to be addressed.

Anomalous Systemic Arterial Supply to Normal Basal Segment of the Left Lung

BACKGROUND Anomalous systemic arterial supply to normal segments of the lung is an unusual anomaly. It represents part of a spectrum of bronchovascular abnormalities which have various anatomical and clinical manifestations. METHODS We retrospectively analysed cases from January 2007 to April 2010 from two institutions diagnosed with an anomalous systemic arterial supply to a normal lung segment. RESULTS Three infants were found to have anomalous systemic arterial supply to normal segments of the lung. One patient was from The Childrens Hospital at Westmead, Australia and two cases from Amrita Institute of Medical Sciences, Kochi, India. The mean age at diagnosis was 65 days (range 30-120 days) and mean weight was 3.05 kg (range 1.9-4.4 kg). All babies presented with tachypnoea. The diagnosis was suspected on echocardiography and confirmed by computerised tomography scan (CT scan) in one and by angiography in two cases. The preterm baby underwent ligation of the anomalous vessel by thoracotomy and other two infants had transcatheter occlusion of the collateral. There was no residual flow on echocardiography in any of the three cases and all have done well on follow up. CONCLUSION Anomalous systemic arterial supply to normal lung segments is a very rare anomaly. A high index of suspicion is needed to expedite diagnosis. Transcatheter embolisation or surgical ligation of the collateral proved effective therapeutic approaches in young infants without a need for surgical lobectomy.

Aorta to right atrial tunnel prenatal: diagnosis and transcatheter management in a neonate.

These images show an example of aorta to right atrial tunnel, a rare form of aorto-right atrial communication that was closed on the 4th day of life in the catheterization laboratory. The condition was suspected on fetal echocardiogram at 31 weeks of gestation that showed the presence of a large

Balloon pulmonary valvotomy as interim palliation for symptomatic young infants with tetralogy of Fallot

Objectives: To describe the case selection, technique and immediate and short-term results of balloon pulmonary valvotomy (BPV) in young infants with tetralogy of Fallot (TOF). Background: Symptomatic young infants with TOF can either undergo corrective surgery or Blalock-Taussig (BT) shunt. Corrective surgery in early infancy is associated with significant morbidity and is not a realistic option in many centers. BT shunt carries the risk of branch pulmonary artery distortion and shunt occlusion. Methods: Infants less than three months with a significant valvar pulmonary stenosis (with or without associated infundibular and annular component) and oxygen saturation ≤80% were offered BPV. The right ventricular outflow tract (RVOT) was crossed with 4F Judkins right coronary catheter and the valve was crossed with 0.014” coronary guide wire. Serial balloon dilatations were done with over the wire coronary balloons (3-4 mm) and Mini Tyshak balloons up to a balloon annulus ratio of 2:1, depending upon the improvement in saturation and formation of annular waist. Results: Seventeen infants less than three months of age with tetralogy of Fallot (median age: 33 days, range: 10-90 days, weight: 3.47 ± 0.87 kg, pulmonary annulus Z score: -5.59 ± 1.04) including eight neonates underwent palliative BPV between May 2004 and March 2007. The mean balloon annulus ratio was 1.4 ± 0.28 and fluoroscopy time was 26.18 ± 20.2 minutes. The mean oxygen saturation increased significantly from 73 ± 7% to 90 ± 3.68% following BPV (p = 0.0001). The only major complication was RVOT perforation and pericardial tamponade in one infant. The mean follow-up period was 23 ± 12 months. Two babies developed significant desaturation requiring surgery in the six months following BPV. There was a significant increase in pulmonary annulus. The z score for the pulmonary annulus improved from -5.59 ±1.04 before BPV to - 4.31 ± 1.9 at the time of last follow-up (p = 0.018). The mean Z score of hilar right pulmonary artery (RPA) increased significantly from -1.19 ± 1.78 before BPV to 0.7 ± 0.91 after BPV (p = 0.001). The mean Z score of hilar left pulmonary artery (LPA) increased significantly from -1.28 ± 1.41 to 0.03 ± 1.29 after BPV (p = 0.005). Eight patients underwent corrective surgery. Conclusions: Balloon pulmonary valvotomy is safe and effective. It significantly improves the growth of pulmonary annulus and branch pulmonary arteries. Thus it can be considered as an interim palliative procedure for symptomatic young infants with TOF and predominant valvar pulmonary stenosis.