Marianna Carrozza

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.

The impact of interventional cardiology for the management of adults with congenital heart defects

The objective of this study is to assess the impact of interventional cardiology procedures for the management of ACHD. The interventional approach to the management of CHD in the adult population is becoming increasingly recognized as the preferred treatment option for a wide number of congenital cardiac conditions. The files of all consecutive patients over 18 years of age who were hospitalized in our department from January 2000 to December 2004 were reviewed. Over the study period, 1,115 ACHD (583 women; mean age 41 ± 13.8, years, range 18–72 years) were hospitalized in our department; 752 patients underwent cardiac catheterization and 82.4% of them had an interventional procedure carried out. ASD (329/620) and PFO (159/620) closure account for 78% of all the procedures carried out, with a 2.7% of major complications incidence (all of them closing ASDs). Other procedures such as stenting aortic coarctation (40/620), ventricular septal defect closure (33/620), patent ductus arteriosus embolization (30/620), pulmonary valvuloplasty (12/620), stenting pulmonary artery branches (8/620), etc (5/620) were carried out. The most important complication was one death, which occurred in the case of a 22‐year‐old woman after stent implantation for a recurrent aortic coarctation. A trivial residual shunt was detected in only 5% of the patients who had a 6‐month follow‐up after VSD closure; no residual shunt was found after PDA embolization during the 12‐month follow‐up. In conclusion, we believe that the interventional approach is a safe and successful treatment option for a wide number of congenital cardiac conditions. The increasing use of catheter interventions for these patients will be responsible for an increase of complex cases in surgery.

Symptomatic aorto-pulmonary collaterals early after arterial switch operation.

Enlarged bronchial arteries and/or systemic-to-pulmonary collaterals have been frequently demonstrated in association with transposition of the great arteries. They are usually clinically silent, although they might be large enough to cause accelerated pulmonary vascular obstructive disease or symptomatic cardiac volume overload after surgical repair. We report on a low-weight neonate with transposition of the great arteries and intact ventricular septum who showed a stormy postoperative course because of multiple aorto-pulmonary collaterals early after a successful arterial switch operation. Percutaneous coil embolization of these anomalous vessels resulted in sudden weaning from mechanical ventilation and hospital discharge in a few weeks.

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.

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.

One‐step treatment of patent ductus arteriosus and pulmonary artery stenosis by cardiac catheterization

Coexistence of pulmonary artery (PA) stenosis and patent ductus arteriosus (PDA) may lead to overestimating the relative importance of these malformations. This article reports on a patient with a trivial PDA and severe PA stenosis erroneously diagnosed as moderate PDA. He was successfully submitted to simultaneous PA stenting and PDA embolization. Cathet Cardiovasc Intervent 2003;59:271–275.

Transcatheter palliation of 'complex' tetralogy of Fallot.

Tetralogy of Fallot with restrictive ventricular septal defect (VSD) and suprasystemic right ventricular pressure is an uncommon anomaly resulting in a high mortality rate [1,2]. Ideally, it should deserve an aggressive surgical corrective approach at neonatal age. Clinical stabilization of very sick patients might be achieved, however, by a minimally invasive and cost-effective percutaneous approach [3,4], in view of lower-risk corrective surgery at an older age.

Bilateral arterial duct 'stenting' in a low-weight neonate with complex congenital heart defect.

Bilateral arterial ducts feeding discontinuous pulmonary arteries are a very rare anatomic arrangement in complex heart malformations with pulmonary atresia. In this setting, neonatal ductal closure may result in abrupt pulmonary hypoperfusion and life-threatening systemic hypoxia. In high-risk patients, percutaneous arterial duct stenting might be an engaging and cost-effective alternative to surgery. This paper reports on a critical low-weight neonate with complex heart disease and discontinuous pulmonary arteries dependent on bilateral arterial ducts who underwent successful transcatheter ductal stenting as an alternative to a high-risk surgical palliation.

Hybrid transcatheter-surgical palliation of 'high-risk' hypoplastic left heart syndrome.

(a) Right pulmonary artery banding (arrows) has been performed through a midline sternotomy using an expanded polytetrafluoroethylene shunt ring longitudinally opened and wrapped around the pulmonary artery. The ring lips have been stitched with a 8-0 monofilament suture. (b) A standard 11-cm long 6-Fr introducer is placed into the pulmonary artery trunk through a stab incision and purse string suture. MPA, main pulmonary artery; RAA, right atrial appendage; RPA, pulmonary artery. Journal of Cardiovascular Medicine 2008, 9:639–640