Geoffrey K. Lane

Transcatheter Angioplasty for Acquired Pulmonary Vein Stenosis After Radiofrequency Ablation

Background—Pulmonary vein stenosis has recently been recognized as a complication of radiofrequency ablation for atrial fibrillation. This study evaluates the presentation of affected patients and the role of transcatheter therapy for this patient population. Methods and Results—This study used a retrospective review of data from 19 patients (age, 51±13 years) with pulmonary vein stenosis who underwent catheterization and angiography between December 2000 and December 2002. Quantitative perfusion and spiral CT scans were performed for initial diagnosis and follow-up. The median duration between radiofrequency ablation and the reported onset of respiratory symptoms for 18 of 19 patients was 7.5 weeks (0.1 to 48). After the onset of symptoms, all but two patients were initially misdiagnosed with a symptoms-to-diagnosis duration of 16 weeks (2–59). At initial catheterization, 17 of 19 patients had angioplasty in 30 veins with stent placement in 5 vessels when a flap occurred. Overall vessel diameter increased from 2.6±1.6 to 6.6±2.4 mm (P <0.0001). There were 4 procedure-related adverse events but no long-term sequelae. Immediate follow-up showed improved flow to involved lung segments. At a median follow-up of 43 weeks (2–92), although repeat angioplasty for restenosis was necessary in 8 of 17 patients, 15 of 17 patients currently have no or minimal persistent symptoms. Conclusions—Pulmonary vein stenosis after radiofrequency ablation for atrial fibrillation is often misdiagnosed. Although further follow-up is necessary to determine long-term success, our data indicate better pulmonary vein flow and symptomatic improvement in the majority of patients undergoing dilation of postablation pulmonary vein stenosis.

Initial results of primary device closure of large muscular ventricular septal defects in early infancy using perventricular access

Objectives: To report our experience with the use of the Amplatzer muscular ventricular septal defect (VSD) occluder, using direct right ventricle free wall puncture for primary closure of muscular VSDs in infants. Background: Young infants with heart failure due to large or multiple muscular VSDs often require intervention at a stage when percutaneous device closure is impractical due to delivery system limitations. There are considerable benefits to avoiding bypass in these infants. Methods: Patients with suitable muscular VSDs, considered too small for transvenous closure, underwent perventricular muscular VSD closure under transesophageal echo (TEE) guidance. Results: Eight infants underwent the procedure. The median age was 14 weeks (2–41) with median weight of 4 kg (3–6.6). Four patients had additional VSDs and one patient had previous repair of coarctation. One patient had dextrocardia and severe left ventricular impairment due to an associated cardiomyopathy. The median VSD size was 8 mm (range, 4–10 mm). A single device (6–12 mm) was deployed in each patient, the size chosen being 1–2 mm larger than the TEE measurement. Two patients had subsequent pulmonary artery banding, with absorbable bands, because of moderate residual shunting through additional VSDs. The latest echo study at a median of 7.2 weeks (0.5–66) post device implantation revealed no patients with a hemodynamically significant shunt. Conclusion: Perventricular muscular VSD closure can be safely and effectively undertaken in small infants with suitable muscular defects, and this strategy can avoid the need for bypass.

Cutting balloon angioplasty for children with small-vessel pulmonary artery stenoses.

Patients with complex congenital heart disease may have pulmonary artery stenoses that are either congenital or associated with scarring following surgical procedures. This study evaluates cutting balloon angioplasty for small‐vessel pulmonary artery stenoses resistant to standard balloon angioplasty. Between October 1998 and December 1999, patients were enrolled in an FDA‐approved compassionate‐use protocol. During four catheterizations, there were seven lesions found resistant to standard balloon angioplasty (mean lesion diameter was unchanged: 1.8 mm ± 0.8 mm to 1.9 ± 0.8 mm). A cutting balloon was inflated twice in each of these lesions. Standard balloon angioplasty was then repeated. Final mean lesion diameter was increased significantly (1.9 mm ± 0.8 mm to 3.8 ± 1.3 mm; P ≤ 0.01). Follow‐up catheterizations performed a median of 14 months later showed only slight decrease in mean lesion diameter (3.2 ± 1.2 mm), still significantly greater than initial mean lesion diameter (P < 0.03). In conclusion, cutting balloon angioplasty for pulmonary artery stenoses resistant to standard balloon angioplasty improves the immediate and intermediate term results of angioplasty for these lesions. Cathet Cardiovasc Intervent 2002;55:73–77.

Transcatheter interventions across an inferior vena cava filter

Patients who suffer from an embolic event often undergo placement of an inferior vena caval filter. Few data are available regarding treatment of this patient population with concurrent right‐to‐left shunting across an atrial communication. We report four cases of transcatheter device closure of an atrial communication across an inferior vena cava filter. Cathet Cardiovasc Intervent 2003;59:333–337.

Cardiac cirrhosis and hepatocellular carcinoma in a 13-year-old treated with doxorubicin microbead transarterial chemoembolization

Increasing numbers of children are surviving into adulthood following surgery to correct or palliate congenital heart disease. This surgery can occasionally result in long‐standing elevated right heart pressures and chronic hepatic venous congestion leading to cardiac cirrhosis. We report the first paediatric case of hepatocellular carcinoma in the setting of cardiac cirrhosis. A 13‐year‐old girl developed inoperable hepatocellular carcinoma and was treated with transarterial embolization with lipiodol and doxorubicin eluting microbeads. Promoting awareness of this association, even in younger patients, will hopefully result in better surveillance and screening of hepatic complications in survivors of complex cardiac surgery.

Intravascular stent implantation for the management of pulmonary artery stenosis

Pulmonary artery stenosis is a challenging problem in the management of congenital heart disease. Untreated pulmonary artery stenosis may contribute to increased mortality and morbidity, and lead to suboptimal results following surgical repair of congenital heart disease. Intravascular stent implantation has emerged as one of the preferred treatment options for pulmonary artery stenosis. However, issues regarding the effectiveness and complications of stent implantation for pulmonary artery stenosis need to be identified. In addition, difficulties of stent implantation in the paediatric setting, as a consequence of small vessel size and subsequent vessel growth, are also important considerations. This review will evaluate the short and long-term effectiveness, the outcomes and complications, and discuss the potential problems of stent implantation for pulmonary artery stenosis.

Original Surgical Procedure for the Treatment of Protein-Losing Enteropathy in Fontan Patients: Report of Two Midterm Successes.

The surgical connection of the vena cava to the pulmonary arteries creates a circulation in series and defines the Fontan operation for univentricular hearts. The central venous pressure is elevated (≈15 mm Hg) and drives the blood into the pulmonary vessels. This elevated venous pressure overwhelms the postsinusoidal regulatory mechanism normally responsible for maintaining portal pressure at ≈10 mm Hg. The elevated venous pressure is transmitted to the sinusoids, portal vein, and gut capillaries. Protein-losing enteropathy (PLE) is a complication of this hemodynamic state, where proteins leach into the gut from submucosal lymphangiectasis. PLE occurs in ≈5% of patients undergoing the Fontan procedure and is often fatal within 5 years of onset. We performed a novel surgical procedure to restore a gradient similar to the physiological one between the portal vein and the inferior vena cava (IVC) in 2 Fontan patients with PLE. Hospital Human Ethics Committee’s approval and informed consent were obtained. Under cardiopulmonary bypass, the 3 major hepatic veins (right, middle, and left) were separated and connected to the common atrium. An extracardiac conduit without fenestration, placed in the hepatic portion of the IVC, completed the Fontan circuit. The other …

Intra-annular mitral valve replacement in neonates and infants

FIGURE 1. Schematic representation of the suspension of the valve, during im pended by the artificial chordae is opposite to the left ventricular posterior wal From the Cardiac Surgery Department, Royal Children’s Hospital, Melbourne, Parkville, Australia; the Murdoch Childrens Research Institute, Parkville, Australia; the Department of Pediatrics, University of Melbourne, Parkville, Australia; and the Cardiology Department, Royal Children’s Hospital, Melbourne, Parkville, Australia. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication Aug 2, 2014; revisions received Sept 16, 2014; accepted for publication Sept 20, 2014; available ahead of print Oct 24, 2014. Address for reprints: Christian P. Brizard, MD, MS, Cardiac Surgery Department, Royal Children’s Hospital, Parkville, 3052 Victoria, Australia (E-mail: christian. brizard@rch.org.au). J Thorac Cardiovasc Surg 2015;149:390-2 0022-5223/

Invasive echocardiography: The use of catheter imaging by the interventional cardiologist

36.00 Copyright 2015 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2014.09.067

Intracardiac echocardiography during transcatheter interventions for congenital heart disease

Ultrasound imaging is frequently used for diagnostic purposes or guidance during procedures in the pediatric and congenital cardiac catheterization laboratory. As new imaging modalities emerged, many interventional cardiologists rather than noninvasive specialists are now performing the ultrasound imaging as part of the catheterization. The focus of this discussion will be to detail the technique and application of echocardiography by the interventional cardiologist. Cathet Cardiovasc Intervent 2003;59:277–290.