John P. Cheatham

Percutaneous translumbar cardiac catheterization and central venous line insertion: An alternative approach in children with congenital heart disease

Children with congenital heart disease present major problems with venous access, eliminating conventional routes for cardiac catheterization. Although the transhepatic approach has recently gained popularity, we describe here an alternative approach using percutaneous translumbar approach for cardiac catheterization and/or in‐dwelling central line insertion in three children with congenital heart disease. Diagnostic hemodynamic studies, transcatheter delivery of an intravascular stent for left pulmonary artery (LPA) stenosis, and chronic central venous line insertion were performed using this technique. Disadvantages include interventionalists unfamiliarity with technique, awkward patient positioning, technically more difficult than transhepatic, and potential injury to kidney and bowel. Advantages include avoidance of vascular‐rich hepatic parenchyma, thus reducing risk of hemorrhage; providing an alternative where transhepatic entry may be contraindicated; avoidance of bile duct, portal vein, and hepatic artery injury; and providing another alternative for not only transvenous, but also transarterial access that may be required for intravascular aortic stent delivery. The interventional radiologist should be utilized as a valuable resource to the cardiologist to help teach and supervise this technique in selected infants and children with limited vascular access. Cathet. Cardiovasc. Intervent. 46:187–192, 1999.

Children With Heart Murmurs: Can Ventricular Septal Defect Be Diagnosed Reliably Without an Echocardiogram?

OBJECTIVES This study was undertaken to determine the accuracy of expert examination for ventricular septal defect (VSD) among children with a heart murmur. BACKGROUND Because the frequency and nature of errors that might be made by reliance solely on expert examination for diagnosis of VSD are speculative, the role of echocardiography in such diagnosis is controversial. METHODS Two hundred eighty-seven consecutive previously unevaluated pediatric subjects were enrolled in the study. For each child, the pediatric cardiologists prospectively recorded a working diagnosis and their level of confidence in the diagnosis, categorizing any VSD diagnosed as small or moderate to large. After echocardiography, VSDs were subcategorized by location and requirement for treatment as minor, intermediate or major. Receiver-operating characteristic (ROC) curves described the accuracy of the clinical examination. RESULTS Seventy-three subjects had a VSD (minor in 52, intermediate in 10 and major in 11). ROC areas (1.0 = perfect discrimination, 0.5 = indiscriminate) were minor VSD 0.92 +/- 0.02 and major/intermediate VSD 0.69 +/- 0.07 (p = 0.0016). Four of 52 minor VSDs were not identified at any level of suspicion; the clinical diagnoses were moderate to large VSD in two patients and atrial septal defect and unlimited differential diagnosis in one patient each. Fourteen of 235 patients without a minor VSD were believed with confidence to have a small VSD, but the final diagnosis was intermediate VSD in 4, innocent murmur in 3, major VSD in 2, pulmonary stenosis in 2 and subaortic membrane, atrial septal defect and mitral regurgitation in 1 patient each. CONCLUSIONS Almost all minor VSDs are recognized without echocardiography; however, errors can occur even when an expert examiner is confident. Clinical recognition of an intermediate or major VSD is less accurate than clinical recognition of a minor VSD. Failure to distinguish VSDs of major or intermediate importance from minor VSDs is a weakness of the expert clinical examination.

Successful transcatheter perforation of the atretic pulmonary valve membrane in a newborn using the new Coe radiofrequency end hole catheter

The new 2 French Coe radiofrequency (RF) end hole catheter was first used to successfully perforate the atretic pulmonary valve membrane using an antegrade approach in a newborn with intact ventricular septum (IVS). Nine watts of energy for 8 sec was required with simultaneous delivery of a 0.014 in. coronary guidewire coaxially through the end hole RF catheter for balloon valvuloplasty. This new ringed-tip end hole RF catheter offers considerable advantages to the pediatric interventionalist in the transcatheter therapy in neonates with pulmonary atresia (PA) and IVS.

Balloon atrial septostomy using a new low‐profile balloon catheter: Initial clinical results

Balloon atrial septostomy remains an important interventional procedure in the pediatric age group. The incidence of potential complications using the conventional balloon ranges from 0-11%. The purpose of this study was to evaluate a new low-profile end-hole septostomy balloon catheter with dual lumen, inserted via a 5F or 6F sheath. Seventeen neonates and infants with various forms of congenital heart disease requiring palliation underwent septostomy using the new catheter at a median age of 19 days (with a range of 1-593 days), and a median weight of 3.4 kg (a range of 2.5-8.4 kg). The aortic saturation increased from 72 +/- 20% to 87 +/- 7%, p < .001; and the gradient across the atrial septum decreased (a-wave gradient from 11.2 +/- 10.3 to 2.1 +/- 3.6 mm Hg; v-wave from 10.4 +/- 7.7 to 1.2 +/- 1.2 mm Hg; and mean gradient from 8.5 +/- 6.9 to 0.9 +/- 1.3 mm Hg, p < .002). The diameter of the defect increased from 2.7 +/- 1.7 mm to 8 +/- 2.3 mm, p < .001. There were no complications. We conclude that this new low-profile septostomy catheter is safe and effective in creating a large defect size between the atria. Because of the smaller inflation size of the balloon and smaller introducer sheath compared with the conventional catheter, this new septostomy catheter should be especially useful in small neonates.

Primary transcatheter treatment of congenital pulmonary arteriovenous malformation causing cyanosis of the newborn.

We report on successful transcatheter therapy of congenital pulmonary arteriovenous malformation resolving persistent cyanosis and obviating the need for surgical pneumonectomy or lobectomy. Cathet. Cardiovasc. Intervent. 50:48–51, 2000.

Continuous Assessment of a Stented Coronary Artery Using a Pressure Wire During Percutaneous Pulmonary Valve Implantation

* Corresponding Author: Brian Boe, MD The Heart Center Nationwide Children’s Hospital 700 Children’s Drive Columbus, OH 43205-2664, USA Tel.: +1 614 722 2459; Fax: +1 614 722 5030; E-Mail: brian.boe@nationwidechildrens.org Fax +1 203 785 3346 E-Mail: jshd@scienceinternational.org http://structuralheartdisease.org/