Ieda Biscegli Jatene

New transcatheter techniques for creation or enlargement of atrial septal defects in infants with complex congenital heart disease

To describe a series of 8 consecutive infants (5 with transposition of the great arteries [TGA] and 3 with hypoplastic left heart syndrome [HLHS]) who underwent nonconventional septostomy techniques.

Mid-Term Outcomes after Percutaneous Closure of the Secundum Atrial Septal Defect with the Figulla-Occlutech Device

OBJECTIVES To evaluate the mid-term outcomes after percutaneous closure of the secundum atrial septal defects (ASD) using the Figulla-Occlutech device (FOD). BACKGROUND Transcatheter closure has become the method of choice for most patients with ASD. Although the FOD may have some advantageous characteristics there is a paucity of data on later outcomes after the use of this relatively new device. METHODS Observational, single arm study including 200 non-consecutive patients who underwent ASD closure between 04/09 and 07/15 in 2 centers. Device performance, deployment technique, and immediate and mid-term outcomes were assessed. RESULTS Median age and weight were 24 years (4-72) and 58 kg (15-92), respectively. Single defects were observed in 171 patients (median size of 19 mm). The remainder had multiple or multifenestrated defects. Implantation of FOD (median size of 24 mm) was successful in all (99%), but 2 patients (1 with deficient postero-inferior rim; 1 with a large ASD for the size of the child). Embolization with device retrieval occurred in 2 (1%). Median follow-up of 36 months was obtained in 172 patients. Serial echocardiographic assessment showed complete closure in all but 2 patients, in whom an additional small non-significant posterior defect was purposely left untouched. There have been no episodes of late arrhythmias, device embolization, cardiac erosion, endocarditis, thromboembolism, wire fracture, or death. CONCLUSIONS Transcatheter closure of ASDs in older children, adolescents, and adults using the FOD was highly successful in a wide range of anatomical scenarios with high closure rates and no complications in mid-term follow-up.

Use of octreotide in the treatment of chylothorax and chyloperitoneum.

Report of three cases of chylothorax and one case of chylous ascites in children who had undergone cardiac surgery with no response to routine clinical treatment, based on fasting and long-term parenteral nutrition. Treatment with octreotide at an initial dose of 1.0 mcg/kg/h was chosen, with a gradual increase of 1.0 mcg/kg/hr/day until a maximum dose of 4.0 mcg/kg/h. All cases had a favorable response, with gradual reduction of drainage output until prognosis improvement with no significant side effects.Relato de tres casos de quilotorax y un caso de ascitis quilosa en ninos en postoperatorio de cirugia cardiaca, que evolucionaron sin respuesta al tratamiento clinico habitual, basado en ayuno y nutricion parenteral prolongada. Fue elegido tratamiento con octreotide en dosis inicial de 1,0 mcg/kg/h , con aumento progresivo de 1,0 mcg/kg/h/dia hasta la dosis maxima de 4,0 mcg/kg/h. Todos los casos tuvieron respuesta favorable, con reduccion progresiva del debito del drenaje, hasta resolucion del cuadro, sin efecto colateral significativo.

Fechamento percutâneo da comunicação interventricular muscular congênita

SUMMARYPercutaneous Closure of Congenital MuscularVentricular Septal DefectsBackground: Percutaneous treatment of muscular ventricularseptal defects (VSD) has been performed with good resultsin the last 10 years. We report our experience with thepercutaneous closure of congenital muscular VSDs withAmplatzer devices assessing the feasibility, safety andefficacy of the procedure. Methods: From 9/2002 to 12/2007, 9 procedures were performed in multiple centers in8 non-consecutive patients (median age: 6 years; medianweight: 26 kg) under general anesthesia and transesophagealechocardiographic monitoring. All VSDs were single (7 inthe trabecular region and 1 anterior) and had a meandiameter of 6.0 ± 2.1 mm. There was one device embo-lization with immediate percutaneous device retrieval.This procedure was successfully repeated after a year.The other cases were completed successfully without majorcomplications. The rate of complete closure was 100% atfollow-up. Conclusion: In this small series of patients,percutaneous closure of congenital single muscular VSDwas relatively easy to perform, safe and highly effective.

Experiência multicêntrica na América do Sul no fechamento perventricular da comunicação interventricular muscular congênita

BACKGROUND: Perventricular closure of muscular ventricular septal defects (VSD) has become an attractive treatment modality for infants. However, its reproducibility worldwide remains to be seen. METHOD: We report a multicenter experience in South America. From July, 2007 to May, 2009, nine non-consecutive patients (median age and weight were 6 months and 5.5 kg, respectively) underwent the procedure in the operating room under transesophageal echocardiographic guidance using Amplatzer devices. All patients but one were in congestive heart failure and had pulmonary arterial hypertension. Four patients had coarctation of the aorta and one was submitted to pulmonary artery banding at 6 months of life, which were all repaired at the same session. Eight patients had single defects (six mid-muscular, two apical) measuring 10.3 ± 3.7 mm and one patient had multiple apical defects that required two devices. RESULTS: Ten devices were implanted successfully (median size: 12 mm), and two had to be sutured to the right ventricular wall with a surgical suture. One patient developed right bundle branch block and another one developed left bundle branch block. In one patient with a 14 mm defect, the inferior portion of a 16 mm device prolapsed through the inferior rim of the defect towards the right ventricle, requiring surgical removal with patch closure of the mid-muscular VSD. After a median one year follow-up, all the eight remaining patients, including the one with multiple VSDs, had complete closure of the defects with normal left ventricular size. CONCLUSION: Perventricular closure of muscular VSDs seems to be reproducible, feasible, relatively safe and effective in this multicenter study. Large defects may require device oversizing or suture fixation for adequate stabilization. More patients and longer follow-up are needed for stronger conclusions.

Incidence and Treatment of Chylothorax in Children Undergoing Corrective Surgery for Congenital Heart Diseases

Introduction Chylothorax is a lymphatic extravasation into pleural cavity and its incidence is 0.25%-5.3% in children undergoing cardiac surgery. Objective To evaluate the incidence of chylothorax in pediatrics patients operated, linking it in each surgical intervention. Evaluate treatment types and efficiency. Methods Retrospective study using medical records of children undergoing cardiac surgery in the Hospital do Coração between 2004 and 2014. For statistical analysis, qualitative variables by absolute frequency and relative frequency; quantitative variables, by median of 25 and 75 percentiles, as they did not present normal distribution (Shapiro-Wilk, P<0.05). The Chi-square test was used for the association between type of treatment and result. The adopted confidence level was 95%. Results Incidence of chylothorax was 2.1% (0.9% in intracardiac surgery, 1.7% correction of patent ductus arteriosus and aortic coarctation, 8.3% Glenns surgery, 11.8% total cavopulmonary surgery and 3% in others). Among treatments, fasting associated with total parenteral nutrition (TPN) resolved 51% of the cases. Hypoglossal diet had failed treatment and surgical referral in 22% of the cases. Fasting with TPN associated with octreotide had success in the treatment of chylothorax in a period exceeding 15 days in 78% of cases, and 3.7% were referred for surgery. Conclusion According to the results, incidence of chylothorax was 2.18%. Treatment with fasting and TPN leads to resolutions in 86.5%, and the association with octreotide was successful in 85.1% of cases, showing an efficient option, while the treatment with hypoglossal diet had therapeutic failure in 22% of the cases in which it was used.

Double shunt technique for hybrid palliation of hypoplastic left heart syndrome: a case report

We report a technique to palliate hypoplastic left heart syndrome, with no PDA stenting, but with double polytetrafluoroethylene shunt from pulmonary artery to ascending and descending aorta by combined thoracotomies. A 30-day-old female was operated with this technique. Five months after first operation, the child was submitted to Norwood/Glenn operation. Good hemodinamic recovery and initial clinical evolution was observed. The child was extubated in 8th post operatory day and reentubated in the next day due to pulmonary infection. Despite antibiotic treatment, the child died after systemic infectious complications.

Late Follow-up of Patients Submitted to Total CavopulmonaryDerivation: Clinical Aspects, Reinterventions, and Complications Interfering inMorbidity and Mortality

Objective To identify main complications in outpatient follow-up, as well as factors before or during operation that may interfere in patients evolution. Methods Retrospective study of patients submitted to total cavopulmonary shunt with extracardiac conduit from 2000 to 2014 at the Hospital do Coração (São Paulo, Brazil) and who underwent clinical follow-up at this institution. Results One hundred and fifty surgeries were performed and 59 patients maintained outpatient follow-up. The mean age of these patients at the time of surgery was 4.45 years (median of 45 months) and 70.2% of them were males. Among the patients undergoing outpatient follow-up, postoperative time at evaluation ranged from 10 days to 145 months; 30 (50.8%) patients had single left ventricle and 29 (49.2%) had single right ventricle (48.2% of these presented with hypoplastic left heart syndrome [HLHS]). Patients with single left ventricle had a higher percentage of reintervention-free survival, but without statistically significant difference. 40% of the patients had no complications and 35% of them presented with thrombosis at some point in the follow-up period, with ventricular dysfunction being the second most frequently found complication (15% of cases), mainly among patients with single right ventricle morphology (P=0.04). Between the patients currently under follow-up, 20 (35%) of them had been evaluated by ultrasonography and had some degree of hepatic congestion and/or hepatomegaly. 16.7% of the patients with such alteration had HLHS (P=0.057). Conclusion Except for the right ventricular morphology, no other factor has been shown to interfere in late evolution after total cavopulmonary shunt.

Comparative trial of the use of antiplatelet and oral anticoagulant in thrombosis prophylaxis in patients undergoing total cavopulmonary operation with extracardiac conduit: echocardiographic, tomographic, scintigraphic, clinical and laboratory analysis

OBJECTIVE To compare the efficacy of aspirin and warfarin for prophylaxis of thrombosis in patients undergoing total cavopulmonary anastomosis. Evaluate whether coagulation factors (VII, VIII and protein C), clinical data, fenestration or hemodynamic factors, interfere with postoperative thrombosis. METHODS A prospective, randomized study of 30 patients, randomized into Group I (Warfarin) and Group II (AAS), underwent total cavopulmonary shunt with extracardiac conduit, between 2008 and 2011, with follow-up by clinical visits to evaluate side effects and adhesion. Performed transesophageal echocardiography in post operatory time, 3, 6,12 and 24 months; angiotomography at 6, 12 and 24 months to evaluate changes in the internal tube wall or thrombi and pulmonary scintigraphy to evaluate possible PTE. RESULTS Two deaths in group I; 33.3% of patients had thrombus (46.7% in Group II). The previous occurrence of thrombus and low levels of coagulation protein C were the only factors that influenced the time free of thrombus (P=0.035 and 0.047). Angiotomographic evaluation: 35.7% in group II presented material accumulation greater than 2 mm (P=0.082). Scintigraphy: two patients had PTE in group II. Five patients had difficulty to comply with the treatment, 4 in group I with INR ranging from 1 to 6.4. CONCLUSION The previous occurrence of thrombus is a risk factor for thrombosis in the postoperative period. Patients using AAS tend to deposit material in the tube wall. The small sample size did not allow to conclude which is the most effective drug in the prevention of thrombosis in this population.

TCT-429 Fetal Pulmonary Valvuloplasty. In-Utero and Post-Natal Outcomes

There is a paucity of data regarding the feasibility, safety and efficacy of fetal pulmonary valvuloplasty (FPV) for pulmonary atresia or stenosis with intact interventricular septum (PA/PS/IVS) and evolving hypoplastic right heart syndrome (HRHS) diagnosed in-utero. We report in-utero and post