Paweł Dryżek

Interventions Complementing Surgery as Part of Multistage Treatment for Hypoplastic Left Heart Syndrome: One Center's Experience

Background Interventional procedures often are used as part of multistage treatment for hypoplastic left heart syndrome (HLHS). This study aimed to evaluate the efficacy of interventions in multistage treatment of HLHS. Methods and Results Between 1999 and 2007, 78 interventions were performed for 58 children with HLHS at different stages of surgical treatment. Group 1, involving 30 interventions for 22 patients with postoperative pulmonary arterial stenosis, showed reduced pulmonary artery pressure and increased vessel diameter. Group 2, involving 15 interventions after the Norwood operation for 12 patients with aortic arch obstruction, showed success for 11 patients. Group 3, involving eight balloon angioplasties of narrowed Glenn anastomosis for seven patients, showed abolition of the pressure gradient between the superior vena cava and the right pulmonary artery. Group 4, involving eight interventional closures of a fenestration for eight patients after a Fontan operation, showed increased oxygen saturation for all eight patients. Group 5, involving seven interventions for six patients in whom venovenous collaterals were closed percutaneously, showed improved oxygen saturation. For Group 6, uncommon miscellaneous interventions were used to stabilize the patients’ condition before the next surgical treatment. Conclusions Interventional procedures play an important role during multistage treatment of HLHS. They allow for a reduction in the number of operations or stabilization of the patients’ condition before the next surgical treatment.

The neoaortic root in children with transposition of the great arteries after an arterial switch operation

OBJECTIVES Neoaortic root changes in children with transposition of the great arteries (TGA) are reportedly risk factors for the development of neoaortic regurgitation (NeoAR). The aims of this study were to assess the neoaortic root diameter and relative proportion in children with TGA after surgical correction and to identify possible correlations with the development of neoaortic insufficiency. METHODS Of the 611 children who had the arterial switch operation performed in the Cardiology Department of the Polish Mothers Memorial Hospital, 172 consecutive patients were qualified for this study. The inclusion criteria were: anatomical correction performed during the neonatal period, more than 10 years of postoperative observation and at least two full echocardiographic examinations. RESULTS NeoAR increased during postoperative follow-up and at the end of the observation period, 76% of the patients had NeoAR (27%-trace, 42%-mild, 7%-moderate and 0.6%-severe). Among the analysed risk factors for NeoAR development, the significant ones were arterial valve discrepancy (OR = 2.05; 95% CI: 1.04-4.02; P = 0.031) and the non-facing commissures (OR = 4.05; 95% CI: 1.34-11.9; P = 0.01). The neoaortic root diameter was not statistically significantly correlated with the presence of NeoAR or with the heart defects associated with transposition. The neoaortic root was initially, on average, 37% (z-score = 1.58) bigger than the aortic root in healthy children. This disproportion increased during the follow-up evaluations to 57% (z-score = 2.09). CONCLUSIONS The neoaortic root in children after the arterial switch procedure develops differently from that in healthy children, but this is not evidently related to NeoAR development or associated heart defects.

Repair of anomalous origin of the left coronary artery from the pulmonary artery in infants.

OBJECTIVES Anatomical repair seems an ideal method for the surgical treatment of the anomalous left coronary artery arising from the pulmonary artery (ALCAPA) in infancy. The medium-term outcome has been investigated for infants with ALCAPA following the restoration of a dual-coronary arterial circulation. METHODS Between April 1995 and July 2012, 23 infants with a median age of 4 months underwent surgical repair of ALCAPA in our department. Direct implantation of the anomalous coronary artery into the ascending aorta was feasible in 16 patients. A trap door flap method was used in 5 cases and a tubular extension technique in 2. No infant underwent mitral valve repair at the time of ALCAPA surgery. Left ventricular function and the degree of mitral valve regurgitation were assessed during a 10-year follow-up. RESULTS Four patients died in the early postoperative period, without independent predictors associated with this mortality. During follow-up, improvement in myocardial function occurred in all patients both early and late. There was only one improvement in severe mitral valve regurgitation. Subsequently, 2 children needed mitral valve replacement. There were no early or late reoperations of the reimplanted coronary arteries. CONCLUSIONS Aortic reimplantation is an effective surgical treatment for ALCAPA in infants burdened with a low risk of reoperation due to coronary artery stenosis. There was good potential for myocardial recovery within the first year after surgery. Restoration of the anatomical coronary circulation did not improve mitral valve function in infants with severe preoperative mitral incompetence.

Bronchial compression as adverse effect of left pulmonary artery stenting in a patient with hypoplastic left heart syndrome.

A 5-year-old child with hypoplastic left heart syndrome (HLHS) was noted to have left pulmonary artery stenosis after Glenn shunt placement. Therefore, a stent was implanted into the left pulmonary artery to relieve stenosis. After redilatation of the pulmonary artery stent, wheezing, fatigue, asymmetric bronchial sound, and desaturation was noted. Computed tomography, bronchoscopy, and bronchography confirmed critical left main bronchus compression as a consequence of the mass effect of the dilated stent. Balloon plasty of the left bronchus successfully relieved bronchial stenosis. Tracheobronchial obstruction is a possible adverse effect of vascular stenting in children with congenital heart defects. Balloon plasty seems to be a safe and efficient therapeutic option in those cases.

A 10-year single-centre experience in percutaneous interventions for multi-stage treatment of hypoplastic left heart syndrome

OBJECTIVES The purpose of this paper is to report our 10 years of experience of interventional treatment of patients with hypoplastic left heart syndrome and to focus on the frequency, type, and results of percutaneous interventions during all the stages of palliation, considering the different techniques, devices, and complications. BACKGROUND Constant progress in surgical treatment of congenital heart defects in the last decade has significantly improved the prognosis for children with hypoplastic left heart syndrome. However, morbidity and mortality remain relatively high. Modern interventional procedures complement or occasionally replace surgical treatment. METHODS Between January, 2001 and December, 2010, 161 percutaneous interventions were performed in 88 patients with hypoplastic left heart syndrome. Patients were divided into four groups: (a) before the first surgical treatment including hybrid approach, (b) after first-stage Norwood operation, (c) after second-stage bidirectional Glenn operation, and (d) after third-stage Fontan operation. RESULTS Percutaneous interventions resulted in statistically significant changes in pulmonary artery pressures, vessel diameters, and O2 saturation. Complications occurred in 4.3% of interventions and were related mainly to stent implantation in stenosed pulmonary arteries. CONCLUSIONS Percutaneous interventions may result in haemodynamic stability and reduction in the number of operations. They may result in significant changes in pulmonary artery pressures, vessel diameters, O2 saturation, with a low rate of complications, which are mainly related to stent implantation in the pulmonary arteries.

Reoperations and catheter interventions in patients with transposition of the great arteries after the arterial switch operation

OBJECTIVES: Reoperations and catheter interventions after the arterial switch operation (ASO) are relatively rare, but their frequency varies among different centres. They significantly impact the postoperative course of children with transposition of the great arteries (TGA). The aim of this study was to assess the frequency of reoperations and catheter interventions in patients with TGA after the ASO and to identify the potential risk factors. METHODS: For this retrospective case review study we included all consecutive 715 patients with TGA who underwent the ASO in the Department of Cardiac Surgery between the years 1991 and 2015. All of the surgical procedures were performed by one cardiac surgery team led by J.J.M., using the same surgical technique with his own specific modifications. RESULTS: The overall early mortality after the ASO was 7.4%; late mortality occurred in 15 cases (2.3%) and the mean clinical follow-up of our cohort was 10.5 years. Early reoperations (<30 days after surgery) were performed in 37 patients (5.1%). Reoperations were performed in 31 patients (4.7% of survivors), and their risk factors were previous early reoperation and left ventricle outflow tract obstruction, while isolated TGA reduced the risk of reoperations. Catheter interventions were performed in 25 patients (3.8% of survivors). In the majority of the cases, the indications for percutaneous procedures were pulmonary stenosis and recoarctation of the aorta. The statistically significant risk factors were aortic arch anomalies associated with TGA and neopulmonary artery anastomosis with a patch, while isolated TGA decreased the risk of reintervention. Freedom from cumulative reinterventions after the ASO was 90.4% at 5 years; 88.0% at 10 years; 86.5% at 15 years and 86.5% from 20 to 25 years. CONCLUSION: The frequency of reoperations and percutaneous interventions in patients with TGA after the ASO remains low. The majority of the procedures are performed because of pulmonary stenosis and recoarctation of aorta. Cardiac anomalies associated with TGA have a significant impact on the incidence of reoperation and reintervention.

Interventional treatment of critical coarctation of the aorta in an extremely low birth weight preterm neonate.

The authors describe successful balloon angioplasty of aortic coarctation in a preterm neonate weighing 670 grams. The intervention was performed in an open incubator to ensure stable temperature comfort and to minimise the risk of hypothermia during the procedure of obtaining surgical vessel access, performing balloon angioplasty, and closure of the wound.

Novel 3-Dimensional Image Fusion Software for Live Guidance of Percutaneous Pulmonary Valve Implantation

A 7-year-old patient (28 kg) born with aortic stenosis, having undergone the Ross procedure and a repeat surgical intervention including patch plasty of the stenosed conduit and mechanical valve implantation in the mitral position, presented with recurrence of right ventricular outflow tract conduit narrowing. Transthoracic echocardiography showed obstruction of the conduit (Vmax=4 m/s) with moderate pulmonary regurgitation. Cardiac computed tomography confirmed stenosis of the graft with a minimum diameter of 12×18 mm, unobstructed pulmonary arteries, and coronary arteries sufficiently separated from the graft. The computed tomography scan was uploaded to the dedicated workstation for processing with the novel VesselNavigator (Philips Healthcare) 3-dimensional (3D) image fusion software. The automatically created 3D reconstruction was manually modified with a single-click segmentation tool (Figure [A]) to …

Use of pre-intervention imaging with a novel image fusion software for guidance of cardiac catheterisation in a patient with pulmonary atresia and major aortopulmonary collaterals.

We present a 3.5-year-old patient with tetralogy of Fallot, pulmonary atresia, and major aortopulmonary collaterals, after repeat implantation of a central shunt, in whom we successfully re-purposed previous imaging scans with a novel image fusion software to guide diagnostic heart catheterisation. The pre-registered CT scan was segmented before the procedure and subsequently manually fused with two-dimensional fluoroscopy images. The overlaid roadmap enhanced selective cannulation of all major vessels originating from the aorta, making aortography unnecessary.

Live 3D image overlay for arterial duct closure with Amplatzer Duct Occluder II additional size.

Despite several reports describing echocardiography for the guidance of ductal closure, two-dimensional angiography remains the mainstay imaging tool; three-dimensional rotational angiography has the potential to overcome some of the drawbacks of standard angiography, and reconstructed image overlay provides reliable guidance for device placement. We describe arterial duct closure solely from venous approach guided by live three-dimensional image overlay.