Nicole Nagdyman

Masked left ventricular restriction in elderly patients with atrial septal defects: A contraindication for closure?

The impact of an atrial septal defect in the elderly with reduced diastolic elasticity of the left ventricle is unclear. We studied the hemodynamic changes during balloon occlusion of atrial septal defects in patients over 60 years of age. In 18 patients (61–78 years old; median, 70), the left atrial pressure and the mitral valve inflow was measured during complete balloon occlusion of the defect and after deflation of the balloon. In seven patients, the left atrial pressure and the E/A ratio of the mitral valve inflow increased markedly (P = 0.02). Mean atrial pressures reached values of 27 mm Hg and the v‐wave peak values of 55 mm Hg. Two patients received a transcatheter device closure and developed congestive heart failure. In the elderly, an atrial septal defect can have a decompressive impact on the left ventricle. Therefore, caution appears to be warranted if atrial septal closure is planned. Cathet Cardiovasc Intervent 2001;52:177–180.

Heart transplantation in children after mechanical circulatory support with pulsatile pneumatic assist device

BACKGROUND Mechanical support with a pulsatile pneumatic ventricular assist device (VAD) is a complex rescue procedure performed in children with untreatable cardiogenic shock. Its impact on early and long-term survival after subsequent heart transplantation (HTx) remains to be determined. METHODS We reviewed retrospectively the course of 95 children (median age, 8 years; range, 8 days-17 years; body weight, 24 kg; range, 3-110 kg) who underwent HTx. Group A, the elective-HTx group, consists of 33 children who were treated as outpatients before transplantation. Group B, the emergency-HTx group, has 44 children who were critically ill and hospitalized before transplantation but without ventricular assist devices, whereas Group C, the VAD-HTx group, consists of 18 children resuscitated and supported with pulsatile pneumatic VADs for a median time of 20 days. RESULTS Overall actuarial survival after cardiac transplantation was 86% at 1 month, 82% at 1 year, and 78% at 5 years, without significant differences among the 3 sub-groups. Group A had the best long-term survival rate, 88% at 1 month, 88% at 1 year, and 80% at 5 years. Group B had a survival rate of 88% at 1 month, 82% at 1 year, and 79% at 5 years. Group C had a survival rate of 72% at 1 month, 72% at 1 year, and 72% at 5 years. We found no differences in neurologic outcome, acute cardiac rejection, or transplant failure. The survival rate was significantly better in the children with cardiomyopathy compared with those with congenital heart defects (p = 0.014). CONCLUSIONS Bridging to HTx with a pulsatile pneumatic VAD is a safe procedure in pediatric patients. After HTx, overall survival of these children is similar to that of patients who were bridged with inotropes or who were awaiting heart transplantation electively.

A modified repair technique for tricuspid incompetence in Ebstein's anomaly

OBJECTIVE A modified technique for tricuspid valve repair in Ebsteins anomaly restructures the valve mechanism at the level of the true tricuspid anulus by using the most mobile leaflet for valve closure without plication of the atrialized chamber. Midterm results of this therapeutic approach for patients with Ebsteins anomaly and tricuspid valve incompetence are reported. METHODS Between October 1988 and April 1997, the incompetent tricuspid valve was repaired with our technique in 19 patients (12 female, 7 male; 2 to 54 years, mean 21 years). The indication for operation was congestive heart failure of various degrees in all patients. Tricuspid incompetence was grade II in two patients, grade III in 14, and grade IV in three. Associated congenital malformations were simultaneously repaired (interatrial communication in 18, ventricular septal defect in two, pulmonary stenosis in two, mitral valve prolapse in one). Follow-up ranged between 10 and 103 months (median 28 months) and was complete for all patients. RESULTS There were no operative deaths. One patient with active endocarditis and pulmonary abscess died 2 months after the operation of recurrent sepsis; there were no late deaths. During follow-up, New York Heart Association functional class improved from 2.8 before the operation to 1.9 without recurrent cyanosis, and tricuspid incompetence decreased from a mean grade of 3.1 to one of 0.9, without any echocardiographic deterioration of the tricuspid valve function or right ventricular dilation. CONCLUSIONS Our technique allows tricuspid valve repair in patients with Ebsteins anomaly, even in cases usually reserved for primary valve replacement, without late functional deterioration.

Left ventricular conditioning in the elderly patient to prevent congestive heart failure after transcatheter closure of atrial septal defect

Transcatheter closure of atrial septal defects (ASDs) is a safe and effective treatment. Over the past years, an increasing number of elderly patients (age > 60 years) have been admitted for transcatheter closure to prevent ongoing congestive heart failure from volume overload. However, recent data point to the risk of serious acute left ventricular dysfunction leading to pulmonary edema immediately after surgical or transcatheter ASD closure in some patients. In this study, we used a technique described before to recognize in advance patients at risk of left heart failure after ASD closure. Those patients at risk were then treated with preventive conditioning medication for 48–72 hr before definitive transcatheter ASD closure was performed. Fifty‐nine patients aged over 60 years (range, 60–81.8 years; median, 68 years) were admitted to our institution for transcatheter closure of an atrial septal defect. All patients received evaluation of atrial pressures before and during temporary balloon occlusion of the ASD. Patients with left ventricular restriction due to increased mean atrial pressures (> 10 mm Hg) during ASD occlusion received anticongestive conditioning medication with i.v. dopamine, milrinone, and furosemide for 48–72 hr before definitive ASD closure with an Amplatzer septal occluder was performed. In 44 patients without any signs of left ventricular restriction, ASD closure was performed within the first session. Fifteen (25%) out of 59 patients showed left ventricular restriction. In the majority of patients with LV restriction, the mean left atrial pressures with occluded ASD were significantly decreased after 48–72 hr of conditioning medication. Definitive ASD closure was then performed in a second session. Only two patients received a fenestrated 32 mm Amplatzer occluder due to persistent increased atrial pressures > 10 mm Hg even after conditioning medication. There were no significant differences in shunt, device size, or defect size between the two groups. Balloon occlusion of atrial septal defects identifies patients with left ventricular restrictive physiology before ASD closure. Intravenous anticongestive conditioning medication seems to be highly effective in preventing congestive heart failure after interventional closure of an ASD in the elderly patient with a restrictive left ventricle. Catheter Cardiovasc Interv 2005;64:333–337.

Relation of cerebral tissue oxygenation index to central venous oxygen saturation in children

ObjectiveTo evaluate the relationship between the cerebral tissue oxygenation index measured by near-infrared spectroscopy and central venous oxygen saturation (SvO2) after corrective surgery of congenital heart defects in children.DesignProspective observational clinical study.SettingA tertiary neonatal and paediatric intensive care unit for paediatric cardiology.PatientsNeonates and children consecutively admitted to the paediatric cardiology intensive care unit after corrective surgery of non-cyanotic congenital heart defects.Measurements and resultsForty-three children were studied. Cerebral tissue oxygenation index, measured non-invasively by near-infrared spectroscopy, was compared to SvO2, measured by a catheter placed in the right atrium, and to haemodynamic and respiratory parameters. Pearson’s correlation coefficients and p values were calculated. Simultaneously measured values for SvO2 (62.2±9.8%, 39.8–80.4%) and cerebral tissue oxygenation index (56.7±8.8%, 35.8–71.2%) showed a significant correlation (r=0.52, p<0.001).ConclusionCerebral tissue oxygenation index and SvO2 are not interchangeable parameters, but cerebral tissue oxygenation index reflects the haemodynamic influence on cerebral oxygenation after cardiovascular surgery. Further work is necessary to confirm the clinical role of continuous non-invasive measurement of cerebral tissue oxygenation index with regard to the variations of global systemic oxygen consumption after cardiac surgery in children.

Transcatheter therapy of long extreme subatretic aortic coarctations with covered stents

We report our experience with the transcatheter treatment of long extreme subatretic coarctations in four adult patients by the implantation of covered stents. The minimal narrowing of the stenosis was 0.014″ to 2 mm; the hypoplastic distance measured between 21 and 42 mm. Polytetrafluoroethylene‐covered stents 39–50 mm long were implanted and 6 months later redilated. Residual pressure gradients ranged from 0 to 10 mm Hg. One stent fracture required the implantation of a second stent after 6 months. The follow‐up period ranges from 18 to 4 months and has been uneventful so far. Covered stents seem to have the potential to extend the limits of interventional therapy to extreme forms of aortic coarctations. Catheter Cardiovasc Interv 2004;63:236–239.

Akute Linksherzinsuffizienz nach interventionellem Verschluss eines Vorhofseptumdefekts

Congestive left ventricular failure after surgical closure of an atrial septal defect (ASD) has been repeatedly reported, particularly in the elderly. We present a case of left ventricular failure after a successful transcatheter closure of an ASD, which to our knowledge has not been described before.    In a 78-year-old woman (50 kg, 160 cm) with well-preserved left ventricular function (ejection fraction 65%) and without coronary artery disease or arterial hypertension, an ASD (Qp/Qs 1.6:1) was closed with an Amplatzer Septal Occluder without a residual shunt. Two hours after the procedure, she developed pulmonary edema due to left ventricular failure (increase of end-diastolic diameter from 42 mm to 54 mm, ejection fraction 20%), had to be mechanically ventilated for 24 hours and needed catecholamines for 4 days. High doses of diuretics were supplied until the ejection fraction normalized (32%). The patient could not be discharged until two weeks after intervention. A reduced preload for decades may predispose acute left ventricular failure, particularly in the elderly with compromised ventricular compliance. Eine Linksherzinsuffizienz nach Operation eines Vorhofseptumdefekts (ASD) ist – vor allem beim älteren Patienten – wiederholt beschrieben worden. Wir berichten erstmals von einer Dekompensation des linken Ventrikels nach erfolgreichem interventionellem ASD-Verschluss.    Bei einer 78-jährigen Patientin (50 kg, 160 cm) mit guter systolische Funktion des linken Ventrikels (Auswurffraktion 65%), ohne arteriellen Hypertonus und ohne koronare Herzkrankheit wurde ein Vorhofseptumdefekt (Qp/Qs=1,6:1) mit einem Amplatzer Septal Occluder restshuntfrei verschlossen. Zwei Stunden später entwickelte sie ein Lungenödem bei deutlich reduzierter linksventrikulärer Funktion (Auswurffraktion 20%, Anstieg des enddiastolischen Durchmessers von 42 auf 54 mm). Sie wurde für 24 Stunden beatmungs- und für 4 Tage katecholaminpflichtig. Die Patientin rekompensierte allmählich unter hohen Gaben von Diuretika und konnte zwei Wochen nach Intervention in einem im Vergleich zur Aufnahme leicht gebesserten Zustand entlassen werden. Die Verkürzungsfraktion des linken Ventrikels hatte sich normalisiert (32%). Eine über Jahrzehnte reduzierte Vorlast scheint insbesondere beim älteren Menschen mit reduzierter Ventrikelcompliance für die akute Insuffizienz des linken Ventrikels zu prädisponieren.

Novel growth stent for the permanent treatment of vessel stenosis in growing children: An experimental study

Stent implantation in stenotic vessels of infants and small children is problematic because there is no ideal stent model that is small enough to be easily introduced into the infant femoral vein or artery and, at the same time, large enough to be dilated during growth to adult vessel diameters. To overcome this problem, we designed a new stent, the growth stent. This growth stent is a balloon‐expandable metal stent. Two longitudinal halves are connected with bioabsorbable sutures so that a circular stent is created. It was postulated that after absorption of the sutures the stent would not impede growth. Twenty of these stents were implanted in the aorta, pulmonary arteries, and inferior vena cava of piglets (average weight 6.9 kg). After 18 weeks (14–23 weeks) and a mean weight gain of 59 kg, none of the stented vessels showed any significant stenosis or pressure gradient, documented by angiography and catheter pullback. During fluoroscopy, the two halves of the stent were clearly separated in all animals. The growth stent has the potential to be nonrestrictive during vessel growth, and thus is a promising new device for the permanent treatment of stenotic vessels in infancy and childhood. Catheter Cardiovasc Interv 2004;62:506–510.

Initial experience with bosentan (Tracleer) as treatment for pulmonary arterial hypertension (PAH) due to congenital heart disease in infants and young children.

Bosentan, ein dualer Endothelin-Rezeptor-Antagonist, ist bei der Behandlung der idiopatischen (primären) Form der pulmonalarteriellen Hypertonie (PAH) als effektive Therapieform eingesetzt worden. Wir haben Bosentan im Rahmen eines Heilversuches bei Säuglingen und Kleinkindern eingesetzt, welche bereits präoperativ einen erhöhten Lungengefäßwiderstand und damit eine Kontraindikation zur operativen Korrektur entwickelt hatten, oder bei schwerer persistierender postoperative pulmonal-arterieller Hypertension Zeichen der Rechtsherz-Insuffizienz mit Minderung der körperlichen Belastbarkeit zeigten. Sieben Kinder mit PAH und angeborenem Herzfehlern (mittleres Alter 3,8 Jahre, Bereich 1,5 bis 6,4 Jahre) erhielten 3 mg/kg/d Bosentan (Tracleer®) oral. Klinische, echokardiographische und hämodynamische Daten sowie übliche Laborparameter wurden vor und unter Behandlung gemessen. Leberzell-Enzyme wurden routinemäßig monatlich bestimmt. Die mittlere Behandlungsdauer mit Bosentan war 8,6±5 Monate. Während dieser Zeit ereigneten sich keine signifikanten Nebenwirkungen. Der klinische Zustand blieb stabil oder verbesserte sich bei allen Patienten: die NYHA-Klasse erholte sich von 2,6±0,6 auf 1,7±0,6 (p<0,05). Der rechtsventrikuläre systolische Druck (RVSP) fiel von 96±11 mmHg auf 71±26 mmHg ab (p<0,05). Die Behandlung mit Bosentan wurde bei Säuglingen und Kleinkindern mit PAH bei angeborenen Herzfehlern gut vertragen ohne wesentliche Nebenwirkungen und bewirkte eine Stabilisierung des klinischen Zustandes. Eine deutliche Verminderung des rechtsventrikulären Druckes konnte gezeigt werden. Das Dosis-Regime erscheint somit adäquat und sicher für die Behandlung von Patienten in diesem Alter und scheint in einer Senkung des pathologisch erhöhten Lungengefäßwiderstandes zu resultieren. Bosentan, a dual endothelin-receptor antagonist, has been shown to be an effective treatment option in patients with the idiopathic form of pulmonary arterial hypertension (PAH). We used bosentan as compassionate treatment in infants and young children with congenital heart disease (CHD) who had a) PAH preoperatively representing a contraindication to corrective surgery or b) persisting PAH after corrective surgery causing right heart failure and reduced exercise tolerance. Seven children with PAH due to CHD (median age 3.8 years; range 1.5 to 6.4 years) received 3 mg/kg/d bosentan (Tracleer®) orally. Clinical, echocardiographic and hemodynamic parameters were measured and laboratory tests performed before treatment and during steady state while on treatment. Routine liver function parameters were monitored monthly. Mean bosentan treatment time was 8.6±5 months. During bosentan therapy there were no significant adverse events. The clinical status remained stable or improved in all patients: NYHA class decreased from 2.6±0.6 to 1.7±0.6 (p<0.05). This was associated with a mean reduction of the right ventricular systolic pressure (RVSP) from 96±11 mmHg to 71±26 mmHg (p<0.05). Treatment with bosentan in infants and young children with PAH due to congenital heart disease was tolerated without significant side effects and resulted in stabilization of clinical status. A significant reduction in right ventricular systolic pressure (RVSP) could be demonstrated. These results suggest that the dose regimen used is appropriate and safe for the treatment of infants and children with PAH, resulting in a reduction of pathologically increased pulmonary vascular resistance.

Comparison of cardiac output measurement using the CardioQP oesophageal Doppler with cardiac output measurement using thermodilution technique in children during heart catheterisation

The minimally invasive CardioQPTM oesophageal Doppler probe estimates cardiac output by measuring blood flow velocity in the descending aorta. Individual variables to enter are patient’s age, weight and height. We measured cardiac output simultaneously with CardioQP and pulmonary artery catheter thermodilution techniques during heart catheterisation in 40 paediatric patients with congenital heart defects. Median [range] age was 8.2 years [0.5–16.7 years], cardiac output values measured by thermodilution and CardioQP were 3.6 l.min−1 [1.2–7.1 l.min−1] and 3.0 l.min−1 [0.7–6.7 l.min−1], respectively. These values showed only moderate correlation (r = 0.809; p < 0.0001). Bias and precision were 0.66 l.min−1 and 1.79 l.min−1 (95% limits of agreement: −1.13 to +2.45 l.min−1). Based on our preliminary experience, cardiac output values measured by CardioQP in children do not reliably represent cardiac output values compared with the thermodilution technique. We suggest measurement of individual aortic diameter to improve performance of the CardioQP.