Lee Benson

Covered stents in the management of coarctation of the aorta in the adult: Initial results and 1-year angiographic and hemodynamic follow-up

BACKGROUNDnThe purpose of this study was to determine the safety and efficacy of the Cheatham Platinum covered stent in adults with coarctation of the aorta.nnnMETHODSnAdults with native coarctations (n=14); previous coarctation surgery (n=4), stenting (n=1) or both surgery and endovascular therapy (n=3) underwent percutaneous intervention with a covered stent. Indications for stenting in those with previous intervention were recurrent coarctation (n=4), aneurysm formation at the site of previous intervention (n=2) or both recurrent coarctation and aneurysm formation (n=2).nnnRESULTSnTwenty-three covered stents were placed in 22 patients (mean age 39+/-14 years, n=11 males). Successful device deployment was achieved in all patients, although one patient required a second covered stent for aortic wall rupture. Peak systolic gradient across the coarctation site decreased from 29+/-17 to 3+/-5 mm Hg (p<0.001) immediately following implant and this was maintained (6+/-9 mm Hg, p=0.001) at invasive assessment, 12 months after the initial procedure. Right arm systolic blood pressure significantly declined (p=0.02), as did the number of antihypertensive medications per patient (p=0.03). At angiographic follow-up, post-stenotic dilatation of the aorta decreased from 32+/-8 mm to 30+/-8 mm (p=0.001), however, no stent recoil was observed.nnnCONCLUSIONSnCovered stents are safe, durable and efficacious in the management of coarctation of the aorta. Angiography and hemodynamic assessment is an effective method of screening for recurrent coarctation, and arch and vascular complications after stenting in adults.

Percutaneous Pulmonary Valve Implantation: 5 Years of Follow-Up Does Age Influence Outcomes?

Background—Percutaneous pulmonary valve implantation (PPVI) is a safe, less invasive alternative to surgical valve replacement for the congenital heart disease patient with right ventricular (RV) outflow tract dysfunction. The aim of this study was to determine whether reverse RV remodeling after PPVI was persistent in the longer term and whether timing of PPVI influenced outcomes. Methods and Results—Consecutive patients from the pediatric and adult congenital heart disease programs were enrolled. Cardiac MRI, echocardiography, metabolic exercise testing, chest radiography, and hemodynamics before intervention were compared with repeated follow-up measurements to assess changes over time. Fifty-one patients (including 23 patients <16 years old) were followed for a mean 4.5±1.9 (0.9–6.9) years after implantation, 59% of patients having available comparative cardiac MRI data. Freedom from any reintervention was 87% and 68% at 3 and 5 years, and freedom from surgery was 90% at 5 years. For every decade younger at implantation, there was an increase of 3.9%±1.0% in cardiac MRI left ventricular ejection fraction (P<0.001) and 2.4±0.9 mL/kg/min in maxVO2 (P=0.005) and a decrease of 0.7±0.2 cm in RV end-diastolic dimension (P<0.001) after intervention. Younger patients displayed an additional decline in the RV/left ventricular end-diastolic volume ratio (P=0.05) and trended toward improved RV ejection fraction in late follow-up (50%±7% versus 41%±12%, P=0.07). Conclusions—This is the largest series to show that PPVI at a younger age yields incremental improvements in RV size and maximum oxygen consumption. Early valve implantation is associated with better RV function and should be considered in management planning for this population.

Percutaneous coronary artery fistula closurein adults: Technical and procedural aspects

Coronary artery fistulae (CAF) are an uncommon congenital anomaly characterized by an abnormal connection between the coronary arteries and cardiac chambers or vessels without traversing the usual capillary network. CAF are associated with a number of well‐described symptomatic sequelae, which may necessitate treatment. With a tendency for symptoms to develop over time, symptomatic CAF may present for the first time in adulthood, with limited data existing on the technical aspects related to transcatheter fistula closure in adults.

Clinical characteristics of coronary artery disease in adults with congenital heart defects

BACKGROUNDnThere are now more adults with congenital heart disease than children. This aging cohort is at risk for acquired heart diseases such as coronary artery disease (CAD). The purpose of the study was to examine the clinical features of the CAD in adults with congenital heart disease.nnnMETHODSnA retrospective chart review was performed. The clinical characteristics of adults with congenital heart disease and angiographically confirmed atherosclerotic CAD were examined.nnnRESULTSnOne hundred and forty-one adults with CAD (69% male) were identified from a total of 12,124 patients (1%) seen in our congenital cardiac clinic. The most common cardiac diagnoses were atrial septal defect, bicuspid aortic valve disease, tetralogy of Fallot and coarctation of the aorta. We identified 7 adults with Eisenmenger physiology and CAD. The mean age of diagnosis of CAD was 56 ±13years. Twenty patients had premature CAD (14%) presenting before age 40years. Traditional risk factors of patients with CAD were common and were present in the majority (82%) of patients. While many adults had symptoms of angina or myocardial infarction, a significant proportion (38%) were asymptomatic. The age at diagnosis in patients with coarctation of the aorta was younger than other subgroups (48±13years). Seventy-seven percent (109/141) underwent percutaneous or surgical coronary interventions.nnnCONCLUSIONnAtherosclerotic coronary artery disease may coexist with congenital heart disease. Coronary artery disease in adults with congenital heart disease typically occurs later in adulthood and in patients with traditional cardiovascular risk factors. This study highlights the need for cardiovascular risk factor screening and therapy when indicated.

Creation of a functional tricuspid valve: novel use of percutaneously implanted valve in right atrial to right ventricular conduit in a patient with tricuspid atresia.

We report the first use of a stented pulmonic valve within the right atrial to right ventricular conduit of a patient who underwent a Björk modification Fontan for tricuspid atresia. In effect, a functional tricuspid valve was created. This case report demonstrates the feasibility of transcatheter valve replacement in positions other than the pulmonic or aortic valve and that future revision of conduits in the Björk modification Fontan can be performed percutaneously.

Role of routine radial artery access during aortic coarctation interventions

We read with interest the review article by Dr. Golden and Dr. Hillenbrand entitled Coarctation of the aorta: stenting in children and adults [1]. We agree with the conclusion that in adult sized adolescents and adult patients, stent deployment is the treatment of choice for coarctation assuming appropriate anatomy and lack of other indications for cardiovascular surgery. The authors appropriately emphasize the importance of awareness of the potential for complications and the need for early identification and treatment when such events occur. As such, we routinely use radial artery access in adult patients undergoing aortic coarctation stenting. This allows prompt recognition of complications, as well as immediate hemodynamic assessment during the procedure. Radial artery access is a simple and safe technique that compliments various diagnostic and therapeutic elements of aortic coarctation stenting. Our current practice is to perform aortic stenting under general anesthesia, each patient having access from both the femoral (8 French) and radial artery (6 French) (Fig. 1). After radial artery sheath placement, a combination of intraarterial verapamil (1 mg) and nitroglycerin (100 mcg) is given in to the sheath to prevent spasm. A 6 Fr. pigtail catheter is positioned from the radial artery into the descending aorta proximal to the coarctation. The coarctation site is then crossed using an 8 Fr. Gensini (Cordis/Johnson and Johnson, Warren, NJ) catheter from the femoral artery. We have found that simultaneous radial artery monitoring confers several advantages. In preparing for stent delivery, it allows for accurate assessment of the gradient across the coarctation site. Performing aortography through the pigtail catheter from radial artery is useful in defining the position of the stent before deployment and clarifying the origin of the left subclavian during implantation. Continuous invasive monitoring during and immediately after stent deployment permits accurate assessment of systemic blood pressure, assisting prompt recognition of hemodynamic instability because of aortic disruption. During assessment of such complications, the radial artery access obviates the need for catheter exchange of the stent balloon after deployment and nullifies the associated delay in defining the origin of the instability. Additionally, in cases where crossing the coarctation site is difficult, an alternative method is exchanging the pigtail catheter from the radial artery with a 4 Fr. multipurpose catheter. This in turn allows placement of a 0.035@ extra stiff exchange guide wire, which can be advanced across the lesion. The wire can then be snared in the descending aorta and exteriorized through the right Fig. 1. Two pigtails can be seen: one in descending aorta through the femoral sheath; the other in the ascending aorta through the right radial artery.

Chronic pulmonary thromboembolism in a patient with a fontan circulation: percutaneous management.

Chronic pulmonary embolism is a common complication in patients with Fontan circulations. When anticoagulation is ineffective and surgery is contraindicated, percutaneous techniques may be considered. The authors report the first case of successful catheter intervention in a 30‐year‐old woman with a Fontan circulation who presented with NYHA class IV symptoms and chronic and complete obstruction of her left pulmonary artery.

Transbaffle multielectrode mapping of atrial flutter post double switch operation.

A 26-year-old woman with congenitally corrected transposition of the great arteries (ccTGA) had undergone a doubleswitch corrective surgery consisting of a Mustard procedure (bovine pericardial baffles and hemashield grafts) and arterial switch (Jatene technique). She subsequently developed drug refractory atrial flutter and underwent ablation. An Agilis sheath (St. Jude Medical, St. Paul, MN, USA) and a long BRK 1 needle were used for the transbaffle puncture guided by transoesophageal echocardiography. Activation maps of the systemic venous antrum (SVA) and then the PVA (Fig. 1A) were created with a 20-pole PentaRay R

Sheath stabilizing technique for balloon sizing of large atrial septal defects response to article by Dr. Zahid Amin entitled "Transcatheter closure of secundum atrial septal defects".

We read with interest the article by Dr. Amin regarding transcatheter closure of secundum atrial septal defects (ASD) [1]. We agree with his comments of the importance of balloon sizing of the defect and acknowledge the difficulties that may be encountered in patients with deficient rims, and those with large defects. A common cause of the inability to balloon size such defects is the lack of a stable position of the sizing balloon. While relying solely on echocardiographic measurements was suggested in such problematic cases, we feel additional methods of optimizing balloon sizing can be used. We describe a novel ‘‘sheath-stabilizing’’ technique that we have used in two cases where balloon sizing was difficult. The first patient was a 34-year-old woman with an ASD measuring 27 mm on transesophageal echocardiography (TEE), the second was a 32-year-old woman with a 20 mm defect on TEE. Both patients had evidence of right ventricular enlargement in the absence of significant pulmonary hypertension. As described in Dr. Amin’s article, we follow standard techniques for ASD closure. After the defect is crossed with an 8-Fr Gensini catheter, an Amplatzer exchange length wire (Cook, Bloomingtion IN) is advanced to the left upper pulmonary vein, and an AGA sizing balloon (AGA Medical, Golden Valley, MN) positioned across the defect. In both patients, a combination of the large size of the defect and insufficient rims did not allow a stable position of the balloon (Figs. 1 and 2). It would have been standard practice to abort the procedure, deem the defects unsuitable for percutaneous closure, or rely purely on echocardiographic measurement as recommended by Dr. Amin. In these cases we chose to attempt to stabilize the balloon. The proximal end (20 cm) of a 12-Fr AGA Fig. 1. LAO CRA View. The balloon has prolapsed from the defect and no waste is identified.

Caveat Emptor Self-Expanding Stents in the Management of Arch Coarctation in the Adult

Coarctation of the aorta, a narrowing or occlusion of the aorta, occurs generally in the region of the ligamentum arteriosum and represents 5% to 8% of all congenital heart lesions. Although most often diagnosed in infancy, a small proportion present in adolescence or adulthood during evaluation for a heart murmur, reduced peripheral pulses, or therapy-resistant hypertension. It represents one of the first congenital lesions to be successfully addressed surgically1 and has a 7-decade long history as a therapeutic treatment. However, even after successful repair, survival is reduced when compared with the general population if repair takes place later life (>5 years of age).2 Repair is nonetheless advocated in the older patient to reduce the cardiovascular event risk and improve survival.3 Several surgical approaches have evolved during the years, with percutaneous treatment options only becoming available in the 1980s, first with balloon angioplasty and balloon expandable stent implantation in the late 1990s.4,5 Although clinical acceptance of percutaneous approaches was initially slow, improved techniques, operator experience, and balloon and stent technology have resulted in an enhanced clinical acceptance with improved safety profiles and success rates, although not without controversy.6 There remains a scarcity, however, of long-term follow-up studies after endovascular repair in regards to the development of aneurysm formation, recurrent obstruction, and general cardiovascular mortality and morbidity.nnSee …