Roland Fiszer

Transcatheter Closure of Ruptured Sinus Valsalva Aneurysms With Amplatzer Occluder

We report the transcatheter closure of six ruptured sinus of Valsalva aneurysms (RSVAs) in five patients aged 18-51 years. The RSVA extended into the right atrium in three patients, into the right ventricular outflow tract in one, and into the pulmonary artery in one. In all patients, the RSVA was entered from the aorta, an arteriovenous loop was created, and the Amplatzer occluders were implanted using a venous approach. Six procedures were performed in five patients. Five Amplatzer duct occluders and one Amplatzer atrial septal occluder were implanted. In one patient who had a left RSVA after deployment of an Amplatzer duct occluder, ST-segment depression was observed on the ECG and the procedure was abandoned. In the other four patients, complete closure of the RSVA was confirmed by color Doppler echocardiography. No complications were observed during 9-19 months of follow-up. Percutaneous closure of an RSVA is feasible and can be used as an alternative to surgery.

Transcatheter closure of atrial septal defect in children up to 10 kg of body weight with Amplatzer device

BACKGROUND Transcatheter closure of atrial septal defect (ASD) in older children and adults is currently considered the first-choice therapeutic option. This approach remains challenging in younger children. The aim of the study was to evaluate feasibility, safety and midterm efficacy of percutaneous ASD closure in symptomatic infants ≤10 kg body weight in our institution. METHODS There were 28 children up to 10 kg of body weight, who were qualified for transcatheter closure of ASD. All patients but one showed overload of right atrium and right ventricle. Mean weight of patients who underwent transcatheter closure was 9.2 ± 0.88 kg and age 1.59 ± 0.58 years, respectively. Transcatheter closure of ASD was conducted using Amplatzer occluders (ASO). RESULTS The devices were implanted successfully in 26/28 patients (93%). In 2 (7%) children the device repeatedly straddled the septum in relatively big ASD and the procedure was abandoned. Mean ASD diameter in patients, who underwent transcatheter closure, was 9.08 ± 2.9 mm (transthoracic echocardiography) and mean implant size/weight ratio was 1.07 ± 0.31. In the child with right-left shunt through ASD normalization of saturation occurred. Mean fluoroscopy time was 4.16 min. In 3 children minor complications occurred: transient arrhythmias (n = 1), fever after procedure (n = 2). The follow-up time was 6.1 (range 1.2-11) years. At follow-up, clinical condition and/or growth improved in all patients except 4 children with coexisting comorbidity. No arrhythmia nor conduction disturbances were observed during follow-up. CONCLUSIONS In selected patients weighing less or equal to 10 kg, percutaneous closure of ASD is a safe and effective procedure.

Few comments regarding transcatheter closure of congenital perimembranous and muscular ventricular septal defects

According to our previous observation application of Muscular Amplatzer Ventricular Septal Occluder (MVSDO) in the closure of perimembranous Ventricular Septal Defect (VSD) can produce less rhythm disturbances than use of asymmetric VSD device (due to longer waist of MVSDO?). Application of MVSDO in adult patients with muscular VSD should be done with precaution in the case of thicker interventricular septum because of the risk of subsequent embolization.

Cierre transcatéter de rotura de aneurismas del seno de Valsalva con oclusores Amplatzer

El objetivo fue evaluar el poder predictivo para diagnosticar hipertrofia del ventriculo izquierdo (HVI) de la concentracion urinaria del fragmento N-terminal del propeptido natriuretico tipo B (NT-proBNP) en 160 pacientes asintomaticos diagnosticados de hipertension esencial (HT). Las concentraciones urinarias de NT-proBNP/creatinina estuvieron incrementadas en pacientes con HVI al compararlos con no hipertroficos (p odds ratio = 4,074; p = 0,009). En conclusion, la concentracion de NT-proBNP en orina es un nuevo marcador que puede ser de utilidad para detectar HVI en sujetos con HT esencial.

Immediate and long-term outcomes of percutaneous transcatheter pulmonary valve implantation

BACKGROUND Transcutaneous pulmonary valve replacement (TPVR) has become an alternative to heart surgery for patients after previous right ventricular outflow tract (RVOT) or pulmonary artery (PA) surgical interventions. The objective was to present immediate and long-term outcomes of trans¬cutaneous pulmonary valve replacement. METHODS Between 06/2009 and 06/2016, 46 patients underwent TPVR. Initial diagnoses included tetralogy of Fallot, common arterial trunk, transposition of great arteries post Rastelli correction, left ventricle outflow obstruction after Ross operation, pulmonary atresia, and isolated dysplastic pulmonary valve stenosis. Thirty eight (78%) patients had previously implanted conduits in the pulmonary position, the rest had either RVOT patch reconstruction (n = 6; 13%) or biological valve implantation (n = 2; 4%). They presented primarily with pulmonary stenosis (n = 18; 39%) or regurgitation (n = 28; 60%). RESULTS All procedures were successful - 44 Melody and 2 Edwards-Sapien valves were implanted. Before each procedure exclusion of potential coronary compression and RVOT prestenting was performed. Significant RVOT systolic gradient reduction (from 35.3 ± 19.5 to 13.5 ± 7.1 mm Hg; p < 0.001) and decrease of right to left ventricle systolic pressure ratio from 0.58 ± 0.18 to mean 0.37 ± 0.1 (p < 0.001) was achieved. Also, in every patient PA-RVOT competence was restored, with minor in¬competence in only a few patients. Post procedure follow-up ranged from 2 to 86 (mean 35.2) months. Follow-up fluoroscopy or chest X-ray revealed 6 stent fractures (2 stent defragmentation - with only 1 significant valve stenosis). CONCLUSIONS Transcutaneous pulmonary valve replacement is a safe procedure with encouraging results, it also enables deferring surgical reintervention in the majority of patients.

Midterm results of sildenafil therapy in two complex patients with elevated pulmonary artery pressure after cavopulmonary connection

Two cases are presented. In the first patient (8-year-old boy) after Glenn operation without closure of pulmonary outflow from the common ventricle (SV-PA) despite transcatheter SV-PA closure increased mean pulmonary artery pressure (mPAP) (22 mm Hg) remained. After 6 months of sildenafil therapy he was catheterized again. His mPAP dropped to 10 mm Hg and a Fontan operation was subsequently performed. The second patient was a 25-year-old man, 20 years after a Fontan operation, presenting protein losing enteropathy and severe heart failure. All syndromes diminished significantly after medical therapy with sildenafil. Good clinical results of sildenafil therapy were maintained after 1 and 4 years of treatment. Chronic therapy with sildenafil can be beneficial in patients before and after the Fontan operation with elevated pulmonary artery pressure.

Use of the AndraStent XL and XXL for the treatment of coarctation of the aorta in children and adults: immediate and midterm results.

AIMS The aim of this study is to present our experience with a new type of extra-large stent, namely the AndraStent XL/XXL. METHODS AND RESULTS AndraStents were implanted in 46 patients, 38 with native coarctation of the aorta (CoA) and eight with recurrent coarctation of the aorta following previous surgery (ReCoA). All patients had arterial hypertension in the upper limbs, absent or weak femoral pulses, and continuous flow in the abdominal aorta on Doppler examination. The median age of patients was 25 years (range from nine to 65). The stents (cobalt-chromium with semi-open cell design) were manually mounted on balloon catheters and delivered through 10 to 14 Fr Mullins sheaths using a conventional femoral approach. All procedures were successful (no stent migration, proper expansion, no aorta dissection/rupture, major bleeding or major vessel injury). The systolic gradient across the aorta decreased from 40.6 mmHg before the procedure to 11.6 mmHg after the procedure (p<0.001). The mean fluoroscopy time was 5.7 minutes. Imaging examinations were scheduled and performed between six and 12 months after the initial procedure in 40 patients (angiography or angio CT or both). Procedural outcome remained favourable during a mean 2.4 years of follow-up. Neither stent fracture nor dislocation was observed in any patient at follow-up. In two patients, small aneurysm formation was observed six and eight months after the procedure -they were treated successfully with subsequent covered stent implantation. Re-dilatation of the implanted stent was performed between four and 26 months in 14 patients. CONCLUSIONS Implantation of new large cobalt-chromium stents is a good therapeutic option for the treatment of native and recurrent CoA.

Potts' shunt in a child with idiopathic pulmonary arterial hypertension - one-and-a-half year observation.

This paper presents the case of a young girl with idiopathic pulmonary hypertension, who developed signs of severe heart failure within a short period of time. Pharmacotherapy with sildenafil and bosentan (among other drugs) was ineffective. Heart catheterization revealed suprasystemic pressure in the pulmonary artery. At the age of 7.5 years, the patient underwent a surgical Potts shunt (namely, a direct side-by-side anastomosis from the left pulmonary artery to the descending aorta). The procedure resulted in a significant improvement of the clinical, echocardiographic, and biochemical parameters, which persists after one and a half years of follow-up. After the surgery, pharmacotherapy with bosentan was gradually discontinued.

Transcatheter closure of atrial septal defects type 2 in children under three years of age

BACKGROUND Atrial septal defect (ASD) type 2, according to current standards, is closed percutaneously usually after the child has reached the age of four to five years. There are limited data regarding such treatment in younger infants. AIM We sought to evaluate the feasibility, safety, and efficacy of percutaneous ASD closure in children under three years of age. METHODS The research group consisted of 157 children less than three years old with haemodynamically significant ASD, who underwent effective transcatheter ASD closure in a single tertiary centre between 1999 and 2014. The mean procedural age of the treated children was 2.2 years and mean weight was 12.5 kg. In all cases nitinol wire mesh devices were applied (mostly Amplatzer Septal Occluders). ASD was closed using standard technique (except a few cases wherein the left disc of the implant was inserted initially into the right pulmonary vein to prevent oblique position of the device). Procedure-related complications were divided into major and minor ones. RESULTS Atrial septal defect was closed in 149 children: 97 with a single ASD and 52 with double/multiple ASD. The procedure was abandoned in eight patients (three with single and five with double/multiple ASD). No death or implant embolisation occurred during the procedure or follow-up, and there was one case of major postprocedural complications. Normalisation of the right ventricular diameter occurred in all patients during one-year follow-up. In the majority of children acceleration of physical development and resolution of accompanying morbidity were observed in follow-up. CONCLUSIONS Percutaneous ASD closure can be performed safely in children under three years of age with low risk of peri- or postprocedural complications.

Hybrid muscular ventricular septal defect closure in a 4.5 kg infant followed by sildenafil treatment and transcatheter atrial septal defect occlusion

Corresponding author: Michal Galeczka MD, Department of Congenital Heart Defects and Pediatric Cardiology, SMDZ in Zabrze, Medical University of Silesia, Silesian Center for Heart Diseases, 9 Marii Curie-Sklodowskiej St, 41-800 Zabrze, Poland, phone: +48 609 345 681, e-mail: michalgaleczka@gmail.com Received: 12.11.2017, accepted: 10.12.2017. Hybrid muscular ventricular septal defect closure in a 4.5 kg infant followed by sildenafil treatment and transcatheter atrial septal defect occlusion