Luigi Ballerini

Minimally invasive or interventional repair of atrial septal defects in children : Experience in 171 cases and comparison with conventional strategies

OBJECTIVES The goal of this study was to evaluate percutaneous interventional and minimally invasive surgical closure of secundum atrial septal defect (ASD) in children. BACKGROUND Concern has surrounded abandoning conventional midline sternotomy in favor of the less invasive approaches pursuing a better cosmetic result and a more rational resource utilization. METHODS A retrospective analysis was performed on the patients treated from June 1996 to December 1998. RESULTS One hundred seventy-one children (median age 5.8 years, median weight 22.1 kg) underwent 52 device implants, 72 minimally invasive surgical operations and 50 conventional sternotomy operations. There were no deaths and no residual left to right shunt in any of the groups. The overall complication rate causing delayed discharge was 12.6% for minimally invasive surgery, 12.0% for midline sternotomy and 3.8% for transcatheter device closure (p < 0.01). The mean hospital stay was 2.8 +/- 1.0 days, 6.5 +/- 2.1 days and 2.1 +/- 0.5 days (p < 0.01); the skin-to-skin time was 196 +/- 43 min, 163 +/- 46 min and 118 +/- 58 min, respectively (p < 0.001). Extracorporeal circulation time was 49.9 +/- 10.1 min in the minithoracotomy group versus 37.2 +/- 13.8 min in the sternotomy group (p < 0.01) but without differences in aortic cross-clamping time. Sternotomy was the most expensive procedure (15,000 EUR +/- 1,050 EUR vs. 12,250 EUR +/- 472 EUR for minithoracotomy and 13,000 EUR +/- 300 EUR for percutaneous devices). CONCLUSIONS While equally effective compared with sternotomy, the cosmetic and financial appeal of the percutaneous and minimally invasive approaches must be weighed against their greater exposure to technical pitfalls. Adequate training is needed if a strategy of surgical or percutaneous minimally invasive closure of ASD in children is planned in place of conventional surgery.

Right oblique subxiphoid view for two-dimensional echocardiographic visualization of the right ventricle in congenital heart disease.

Two-dimensional echocardiography in the right oblique subxiphoid view (ROSV) was used to visualize all right ventricular components in 351 patients younger than 2 years of age (100 normal and 251 with various types of congenital heart disease). The ROSV, which is anterior and parallel to the ventricular septum, displays all right-sided cardiac components, the left atrium and the aorta. This view provided the correct diagnosis in patients with pulmonary stenosis or atresia with intact ventricular septum, Ebsteins anomaly, tricuspid atresia, infundibular ventricular septal defect, tetralogy of Fallot and truncus arteriosus. In all patients studied with the ROSV, an excellent definition of morphologic characteristics, equivalent to that in the right oblique axial angiocardiographic view, was achieved. The ROSV should be used routinely to delineate the right ventricular anatomy in all infants with congenital heart disease.

Balloon-expandable metallic stents in the management of tracheomalacia in neonates

Tracheomalacia is a challenging problem after operations for certain congenital heart malformations in neonates and infants. 1 It may often prevent the patients from being weaned from mechanical ventilation. Management of this condition remains difficult. Many surgical approaches have been suggested, although none of them is universally accepted. 2 Conversely, a major role could be played by stent implantation at the level of the malacic segment. However, both silicone stents and self-expanding metallic stents present major technical or physiologic problems in pediatric patients. 35 This article reports on our preliminary experience with the use of endovascular balloon-expandable metallic stents in the treatment of neonatal tracheomalacia after surgical repair of congenital heart malformations. Patient population. During 1993, three patients (Table I) were subjected to implantation of a balloon-expandable metallic stent at the airway level. The stent was used to treat tracheobronchial malacia that caused failure to wean from assisted ventilation after operations for congenital cardiovascular malformations. In each case, informed parental consent was obtained before stent implantation. Technique. The morphologic features of the malacic segment were evaluated by tracheography during spontaneous respiration. Peak respiratory pressure and pulmonary compliance were measured before and after stent implantation by a Capnomac Ultima monitor (Datex Medical Instrumentation, Tewksbury, Mass.). Endovascular balloon-expandable Palmaz-Schatz stents (Johnson & Johnson, New Brunswick, N.J.), 128 mm long, were used to support the tracheomalacic segment. The stent was mounted on the Lo-Bow (Mallinckrodt Medical, Inc., St. Louis, Mo.) 6 mm balloon guidewire (0.035 inch) and positioned, under fluoroscopic guidance, at the level of the malacic segment through the endotracheal tube used for mechanical ventilation. After the endotracheal tube had been withdrawn as far as possible, mechanical ventilation was briefly suspended and the balloon rapidly inflated to expand the stent. Statistical analysis. Morphologic and functional data were expressed as mean values _-2-1 standard deviation. Statistical analysis was performed by the paired Students t test. Results. Balloon-expandable stent implantation was simply, quickly, and successfully performed in all cases.

Patent ductus arteriosus occlusion using detachable coils

Occlusion of patent ductus arteriosus was performed using detachable coils in 193 cases, with 181 successful implants and a low embolization rate. This technique is safe and effective for occlusion of ductuses of various sizes, and is low cost.

Treatment of pulmonary artery stenosis after arterial switch operation: Stent implantation vs. balloon angioplasty

The development of pulmonary artery stenosis is a potential complication during the mid‐ to long‐term follow‐up after arterial switch operation (ASO) for transposition of the great arteries. Surgical results have been disappointing and conventional balloon dilation yields a fairly important incidence of failures and recurrences. We evaluated our results with implantation of balloon‐expandable stents in 5 out of 13 patients with a previously attempted unsuccessful conventional balloon dilation of pulmonary artery branch stenosis after ASO. In two more cases, stents were used as a primary procedure. Balloon angioplasty achieved a 15% increase in mean diameter of the stenosis vs. 124% with the use of stents (P < 0.01), a 10% decrease of the pressure gradient across the stenosis vs. 71% of stents (P < 0.01), and a 10% drop in RV/aorta pressure ratio vs. 43% of stents (P < 0.01). Compared to conventional balloon angioplasty in our series, stents were more effective in the treatment of patients with peripheral pulmonary artery stenosis after ASO. Balloon dilation should be considered in selected cases unsuitable for treatment with endovascular stents. Cathet. Cardiovasc. Intervent. 50:207–211, 2000.

Management of patients with patent foramen ovale and cryptogenic stroke: a collaborative, multidisciplinary, position paper: executive summary.

Objectives: To organize a common approach on the management of patent foramen ovale (PFO) and cryptogenic stroke that may be shared by different specialists. Background: The management of PFO related to cryptogenic stroke is controversial, despite an increase in interventional closure procedures. Methods: A consensus statement was developed by approaching Italian national cardiological, neurological, and hematological scientific societies. Task force members were identified by the president and/or the boards of each relevant scientific society or working group, as appropriate. Drafts were outlined by specific task force working groups. To obtain a widespread consensus, these drafts were merged and distributed to the scientific societies for local evaluation and revision by as many experts as possible. The ensuing final draft, merging all the revisions, was reviewed by the task force and finally approved by scientific societies. Results: Definitions of transient ischemic attack and both symptomatic and asymptomatic cryptogenic strokes were specified. A diagnostic workout was identified for patients with candidate event(s) and patient foramen ovale to define the probable pathogenesis of clinical events and to describe individual PFO characteristics. Further recommendations were provided regarding medical and interventional therapy considering individual risk factors of recurrence. Finally, follow‐up evaluation was appraised. Conclusions: Available data provided the basis for a shared approach to management of cryptogenic ischemic cerebral events and PFO among different Italian scientific societies. Wider international initiatives on the topic are awaited.

Indication for systemic-pulmonary artery shunts guided by two-dimensional and Doppler echocardiography: criteria for patient selection.

From June, 1983, to February, 1987, 91 patients with pulmonary outflow tract obstruction underwent a systemic-to-pulmonary artery shunt without an invasive study. The surgical indication was based on two-dimensional (2-D) and Doppler echocardiography only. In 82 patients (90.1%), 2-D and Doppler echocardiography allowed correct assessment of the intracardiac anatomy and of the morphology of the pulmonary arteries, pulmonary veins, and aortic arch. The aortic arch anatomy was misdiagnosed in 6 patients (6.6%) who underwent a modified instead of a classic Blalock-Taussig shunt. In 3 patients (3.3%), the indication for the systemic-pulmonary artery shunt was inappropriate; in 1, operative death resulted from the incomplete diagnosis. After the preselection of patients based on knowledge of the anatomical patterns, a systemic-pulmonary artery shunt may be performed without cardiac catheterization if these rules for definitive patient selection are followed: (1) accurate clinical assessment to identify the patients with restricted pulmonary blood flow; (2) precise intracardiac diagnosis by 2-D and Doppler echocardiography; and (3) definitive 2-D echocardiographic visualization of the pulmonary venous connection and the confluence of the pulmonary arteries.

Complete transposition of the great arteries: Visualization of left and right outflow tract obstruction by oblique subcostal two-dimensional echocardiography

Subcostal oblique 2-dimensional echocardiography was performed in 64 infants younger than 2 years with complete transposition of the great arteries (TGA) (situs solitus, concordant atrioventricular and discordant ventriculoarterial connections). All patients examined before cardiac catheterization had a correct diagnosis by 2-dimensional echocardiography using the subcostal oblique views. Twelve patients had associated left ventricular (LV) outflow tract obstruction and 7 had right ventricular (RV) outflow obstruction. The standard parasternal views failed to diagnose obstruction in 1 patients with LV outflow obstruction and 5 with RV outflow obstruction; the subcostal left oblique cut and long axis of the left ventricle visualized all left-sided obstructions, and right-sided obstructions were correctly displayed in 5 of 7 cases using a combination of left oblique and right oblique cuts. Two-dimensional echocardiographic subcostal oblique views allow an excellent definition of the morphologic characteristics of RV and LV outflow tracts in patients with TGA and improve the diagnosis of the outflow obstruction in these malformations.

Patent foramen ovale and cryptogenic stroke. A critical review.

The underlying causes of ischemic stroke in young patients are often difficult to find, despite systematic investigations concerning heart, coagulation system or any other type of vascular disease, thus the definition of ‘cryptogenic’. In patients with cryptogenic stroke, the prevalence of a patent foramen ovale is about 45%, versus 25% of the general healthy population, leading to many speculations about a potential role of intracardiac right-to-left shunts in determining ischemic cerebral disease. Since a possible mechanism has been thought to be paradoxical embolism, percutaneous closure of the foramen ovale is currently discussed, at least until the appearance of data from the ongoing randomized trials. However, recurrent paradoxical embolism in patients with an aneurysmal atrial septum and a patent foramen ovale is currently the only unequivocal indication for percutaneous closure. Professional divers may benefit from the procedure as well, whereas migraine is still not considered an indication. In the pediatric population, closure of the patent foramen ovale seems to be safe and effective to prevent recurrent stroke. As the complication rate for device implantation decreases, the threshold for percutaneous closure is likely to decline.

Management of patients with patent foramen ovale and cryptogenic stroke: A collaborative, multidisciplinary, position paper

Objectives: To organize a common approach on the management of patent foramen ovale (PFO) and cryptogenic stroke that may be shared by different specialists. Background: The management of PFO related to cryptogenic stroke is controversial, despite an increase in interventional closure procedures. Methods: A consensus statement was developed by approaching Italian national cardiological, neurological, and hematological scientific societies. Task force members were identified by the president and/or the boards of each relevant scientific society or working group, as appropriate. Drafts were outlined by specific task force working groups. To obtain a widespread consensus, these drafts were merged and distributed to the scientific societies for local evaluation and revision by as many experts as possible. The ensuing final draft, merging all the revisions, was reviewed by the task force and finally approved by scientific societies. Results: Definitions of transient ischemic attack and both symptomatic and asymptomatic cryptogenic strokes were specified. A diagnostic workout was identified for patients with candidate event(s) and patient foramen ovale to define the probable pathogenesis of clinical events and to describe individual PFO characteristics. Further recommendations were provided regarding medical and interventional therapy considering individual risk factors of recurrence. Finally, follow‐up evaluation was appraised. Conclusions: Available data provided the basis for a shared approach to management of cryptogenic ischemic cerebral events and PFO among different Italian scientific societies. Wider international initiatives on the topic are awaited.