Gianpiero Gaio

Stenting of the arterial duct in newborns with duct-dependent pulmonary circulation

Objective: To evaluate the feasibility and results of stenting of the arterial duct in newborns with duct-dependent pulmonary circulation using low-profile, high-flexibility premounted coronary stents. Design: Prospective interventional and clinical follow-up study. Setting: Tertiary referral centre. Patient population: Between April 2003 and December 2006, 26 neonates (mean (SD) age 15.2 (19.9) days, mean (SD) weight 3.3 (0.8) kg) underwent attempts at stenting of the arterial duct. Main outcome measures: Procedural success and complication rates. Early and mid-term follow-up results. Results: The procedure was successfully completed in 24/26 (92.3%) cases. Minor complications occurred in 2/26 (7.7%) cases. No mortality occurred. After stenting, the ductal diameter increased from 1.2 (1.0) mm to 3.1 (0.4) mm (p<0.001) and the percutaneous O2 saturation increased from 70 (14)% to 86 (10)% (p<0.001), respectively. Over a mid-term follow-up, 2/24 patients (8.3%) needed a systemic-to-pulmonary artery shunt because of inadequate ductal flow and 4/24 patients (16.7%) underwent stent redilatation after 6.0 (4.4) months, but before corrective surgery. Cardiac catheterisation before corrective surgery in 9 patients showed an increase of the Nakata index from 112 (49) mm/mm2 to 226 (108) mm/mm2 (p<0.001), without any left-to-right imbalance of the pulmonary artery size. In the subset of 11 patients who improved without needing an additional source of pulmonary blood supply, the stented arterial duct closed uneventfully in 45.5% of cases after 4.0 (2.2) months. Conclusions: Stenting of the arterial duct is a feasible, safe and effective palliation in newborns with duct-dependent pulmonary circulation, supporting the spontaneous improvement process or promoting significant and balanced pulmonary artery growth for subsequent corrective surgery.

Redilation of e-PTFE covered CP stents

Objectives: To evaluate the possibility to redilate covered Cheatham‐Platinum stents during follow‐up, in particular in growing children with aortic coarctation. Background: There are no data in the literature about the redilation of ePTFE covered CP stents. Methods: Sixty covered CP stents were implanted in patients with aortic coarctation or recoarctation between January 2004 and October 2007. Seven patients (mean age 14.2 ± 3.7 years) needed to repeat the hemodynamic study due to somatic growth and increase of aortic gradient with the occurrence of systemic hypertension. Two had near‐atretic aortic coarctation, three had postsurgical recoarctation and aneurysm formation, one had native aortic coarctation associated with aneurysm of the arterial wall, and one had severe native aortic coarctation. Results: Procedures were performed a mean of 20 ± 5 months (range, 12–24 months) after the primary stent implantation. Fluoroscopy time ranged between 7 and 15 min (median, 10 min) whereas procedure time ranged between 60 and 75 min (median, 65 min). After redilation the gradient across the stenosis decreased from a median value of 35 mm Hg to a median value of 5 mm Hg. The stent diameter increased of 20–50% the predilation value. No complications occurred and angiographic controls showed that the stenoses have been relieved. Follow‐up: During a median follow‐up of 12 months (6–30 months) the results were stable without complications. Conclusion: Covered Cheatham‐Platinum stents can be easily redilated

Is steroid therapy enough to reverse complete atrioventricular block after percutaneous perimembranous ventricular septal defect closure

Due to the close proximity of the perimembranous ventricular septal defect to the conduction system, complete atrioventricular block may occur after transcatheter closure in around 1-5% of cases. Some authors reported on successful use of steroids and aspirin in reversing complete atrioventricular heart block early after transcatheter closure of perimembranous ventricular septal defect using the Amplatzer membranous ventricular septal defect occluder. In this paper, we report a case of reappearance of complete atrioventricular block requiring a definitive pacemaker implantation after an initial successful reversal using both steroids and aspirin.

Transcatheter closure of complex atrial septal defects: feasibility and mid-term results.

Objective Transcatheter closure of atrial septal defects (ASDs) is currently a reliable alternative to surgery, even though challenging in the case of complex septal anatomy. The aim of this study was to evaluate the feasibility and mid-term results of percutaneous closure of complex ASDs in a tertiary referral centre compared with simple ASD closure. Methods Between April 2000 and November 2004, 209 patients were submitted to transcatheter ASD closure; 83 patients (39.7%) presented with a complex defect (large ASDs with a deficient rim or a multifenestrated/aneurysmal septum) and were treated using different devices tailored to the atrial septal anatomy. Results The transcatheter procedure was successful in 72 patients (86.8%), using a single device in 69 patients and two devices in the remaining three patients. Overall, 71 Amplatzer septal occluders, two multifenestrated Amplatzer septal occluders and two Cardioseal/Starflex devices were used. Procedural and fluoroscopy times were 141 ± 45 min and 28 ± 22 min, respectively (P < 0.0001 vs. simple ASD closure for both comparisons). Procedure-related complications were recorded in nine patients (12.5%) (P < 0.01 vs. simple ASD closure). One patient required surgical repair of a femoral arteriovenous fistula and another developed mitral valve dysfunction. Immediate ASD occlusion was recorded in 59.7% of patients, reaching 95.9% at the last follow-up control (P = NS vs. simple ASD closure for both comparisons). Conclusions Percutaneous closure of complex ASDs may be considered technically feasible, relatively safe and highly effective, although the procedure is still significantly more demanding than transcatheter closure of simple ASDs.

Transcatheter treatment of unroofed coronary sinus.

Unroofed coronary sinus (coronary sinus‐type atrial septal defect) is a rare congenital anomaly resulting from imperfect development of left atrio‐venous fold. This malformation is not considered suitable for percutaneous treatment due to complex anatomy and risk of coronary sinus obstruction. This article reports on the first successful treatment of partially unroofed coronary sinus by implantation of an Amplatzer® Septal Occluder device (AGA Medical Co., Golden Valley, MN). In this patient, the malformation was deemed favorable for device closure due to the local anatomy and the association with persistent left superior vena cava draining in coronary sinus.

Ten‐years, single‐center experience with arterial duct stenting in duct‐dependent pulmonary circulation: Early results, learning‐curve changes, and mid‐term outcome

To evaluate early results, learning‐curve changes, and mid‐term outcome of arterial duct (AD) stenting in congenital heart disease with duct‐dependent pulmonary circulation (CHD‐DPC) in a high‐volume, tertiary referral center.

Arterial duct stenting in low‐weight newborns with duct‐dependent pulmonary circulation

Objectives: To evaluate feasibility and results of arterial duct (AD) stenting in low‐weight newborns with congenital heart disease and duct‐dependent pulmonary circulation (CHD‐DPC). Background: AD stenting is nowadays considered a cost‐effective alternative to surgical shunt in CHD‐DPC. This option might be even more advisable in low‐weight neonates (<2.5 kg), who are at higher surgical risk and in whom stent redilation might adapt shunt magnitude to patients growth. Methods: Between April 2003 and September 2010, 76 neonates with CHD‐DPC underwent AD stenting at our institution, as lower‐risk palliation with respect to surgical shunt. Procedural and follow‐up data of the 15 low‐weight newborns (2.0 ± 0.3 kg, median 2.2) (group I) were compared with the remaining normal‐weight newborns (3.5 ± 0.7 kg, median 3.2) (group II). Results: Feasibility, complication rate, and need for surgical shunt did not significantly differ between groups. Global X‐ray exposure was significantly higher in the low‐weight group (82 ± 108 vs. 30 ± 33 Gray/cm2, P < 0.002), which maybe due to a longer angiographic presenting work‐up. In‐hospital mortality rate was 14.3% (vs. 1.9% in the group II, P = NS), although none of the fatalities was procedure‐related. During follow‐up, five patients (35.7% vs. 15.7% in the group II, P = NS) underwent stent redilation before surgical repair. At control angiography, the Nakata and McGoon indexes had significantly increased (P < 0.05 for both comparisons), without any significant difference with the group II (162 ± 52% vs. 144 ± 158% and 40 ± 17% vs. 42 ± 38%, P = NS). Conclusions: AD stenting is also feasible and effective in low‐weight newborns with CHD‐DPC, supporting the spontaneous improvement process or promoting a significant pulmonary artery growth.

Transcatheter ductal stenting in critical neonatal Ebsteinʼs anomaly

Background Symptomatic neonatal Ebsteins anomaly shows a very poor outcome, most frequently due to duct-dependent pulmonary circulation caused by functional pulmonary valve atresia. In this setting, percutaneous ductal stenting using high-flexibility coronary stents might be a highly cost-effective alternative to systemic-to-pulmonary shunt. Methods Three newborns (age 4.7 ± 2.9 days; weight 3.0 ± 0.3 kg) with critical, duct-dependent tricuspid valve Ebsteins anomaly and functional pulmonary atresia unresponsive to prostaglandin infusion and multidrug vasodilator therapy, underwent duct stabilization with high-flexibility, open-cell stents as an alternative to surgical palliation. Their echocardiographic picture predicted a very high mortality rate. In two cases, the ductus arteriosus was recanalized using a combined pharmacological (local prostaglandin infusion) and mechanical (hydrophilic coronary guide-wire manipulation) approach. Results Stent implantation increased duct diameter from 0.5 ± 0.7 to 3.2 ± 0.2 mm (P < 0.0001), resulting in a significant rise in oxygen saturation from 67 ± 9 to 92 ± 4% (P < 0.00001). After the procedure, the patients were quickly weaned from mechanical ventilation and discharged after 16 ± 7 days. Uneventful spontaneous ductal closure ensued in two patients in a few months, and percutaneous oxygen saturation was 87 ± 3% at the last follow-up session (12 ± 10 months). Conclusions In critical newborns with severe, duct-dependent Ebsteins anomaly unresponsive to medical therapy, ductal stenting could be a reliable, safe and cost-effective alternative to either long-term prostaglandin treatment or surgical palliation, in view of lower-risk corrective surgery at older age. This option may also be attempted successfully within a few days of spontaneous ductal closure using a combined pharmacological and mechanical approach.

Pulmonary artery growth after arterial duct stenting in completely duct-dependent pulmonary circulation.

Objective Significant and balanced pulmonary artery (PA) growth following arterial duct (AD) stenting has already been reported in literature. However, no data are so far available about the role of this percutaneous approach in promoting PA growth in the case of congenital heart disease (CHD) with completely duct-dependent pulmonary blood flow (CDD-PBF). Aim of this study was to evaluate the effect of AD stenting in this pathophysiological setting. Methods PA growth was evaluated as Nakata index and McGoon ratio as well as individual PA z-score changes in 49 patients submitted to neonatal AD stenting according to their pathophysiology (CDD-PBF (n=15) versus multiple PBF sources (n=34)). Results Control angiography was performed 7.2±6.4 months (range 1–8, median 6) after AD stenting. In the whole population, significant and balanced PA growth was recorded (Nakata index+122±117%; left pulmonary artery (LPA) z-score +84±52%; right pulmonary artery (RPA) z-score +92±53% versus preprocedure, p<0.0001 for all comparisons). Percentage increase of global and branch vessel size was not significantly different in patients with CDD-PBF compared with those with multiple PBF sources (Nakata index 89±90% vs 144±124%; LPA z-score 63±40% vs 89±58%; RPA z-score 74±35% vs 100±57%, p=NS for all comparisons) as was final absolute PA size (Nakata index 237±90 vs 289±80 mm2/m2, p=NS). Conclusions Percutaneous AD stenting was associated with significant and balanced PA growth in CHD with completely duct-dependent pulmonary circulation over a short-term follow-up. Thus, it may be considered as an alternative to surgical palliation in this subset of patients.

Short-term electrogeometric atrial remodelling after percutaneous atrial septal defect closure.

Background Atrial arrhythmias are well known long-term complications of atrial septal defect (ASD), presumably due to chronic atrial enlargement and stretch. Surgical repair often fails to revert the arrhythmic risk despite atrial volumetric unloading, maybe as a consequence of atriotomic scar. Avoiding atrial incision, percutaneous ASD closure should result in atrial unloading and arrhythmic risk decrease. This study evaluated the atrial short-term electrogeometric effects of percutaneous ASD closure. Methods Fifteen asymptomatic patients (age 23 ± 5 years) submitted to percutaneous closure of large ASD (QP/QS 2.4 ± 0.3) using the Amplatzer Septal Occluder device (24 ± 2 mm) underwent atrial echocardiographic (indexed right atrial size and left atrial size as well as right atrial/left atrial volume ratio) and electrocardiographic (P-wave duration and dispersion, PR conduction time and dispersion) evaluation at 1 and 6 months after ASD closure. Results After 6 months, the indexed right atrial volume and the right atrial/left atrial volume ratio had significantly decreased (from 39 ± 5 to 20 ± 2 ml/m2, P < 0.001 and from 2.0 ± 0.2 to 1.0 ± 0.1, P < 0.0001, respectively) as did the P-wave dispersion (from 32 ± 2 to 28 ± 1 ms, P = 0.03) despite a significant increase of both P-wave maximal (from 75 ± 3 to 81 ± 3 ms, P < 0.01) and minimal (from 42 ± 3 to 53 ± 3 ms, P < 0.005) duration. Conclusion Percutaneous ASD closure causes a short-term positive atrial electrogeometric remodelling. The electrocardiographic predictors of atrial arrhythmias, however, tend to worsen early after device implantation despite a marked volumetric unloading, possibly due to a ‘foreign body’ effect of the occluding device. This might warrant a closer follow-up during the first few weeks after device implantation.