Sergio Braga

Percutaneous closure of perimembranous ventricular septal defects with the Amplatzer device: technical and morphological considerations.

Percutaneous closure of perimembranous ventricular septal defects (VSDs) has been feasible, safe, and effective with the new Amplatzer membranous septal occluder. We report further experience with this device with emphasis on morphological aspects of the VSDs and technical issues. Ten patients (median age and weight, 14 years and 34.5 kg, respectively) with volume‐overloaded left ventricles underwent closure under general anesthesia and transesophageal guidance (TEE). The VSD diameter was 7.1 ± 4.0 mm by angiography and 7.8 ± 3.7 mm by TEE. Three patients had defects associated with aneurysm‐like formations (two with multiple exit holes), four had defects shrouded by extensive tricuspid valve tissue, two had defects with little or no tricuspid valve involvement, and one had a right aortic cusp prolapse with trivial aortic regurgitation. Implantation was successful in all patients, although in two the initial device had to be changed for a larger one. Kinkings in the delivery sheath, inability to position the sheath near the left ventricular apex, and device prolapse through the VSD prompted modifications in the standard technique of implantation. Device orientation was excellent except in one case. Nine patients had complete occlusion within 1–3 months. Device‐related aortic or tricuspid insufficiency, arrhythmias, and embolization were not observed. Two patients had slight gradients across the left ventricular outflow tract, normalizing after 3 months. The Amplatzer membranous septal occluder was suitable to close a wide range of perimembranous VSD sizes and morphologies with good short‐term outcomes. Longer follow‐up is required. Catheter Cardiovasc Interv 2004;61:403–410.

Stenting vs. balloon angioplasty for discrete unoperated coarctation of the aorta in adolescents and adults

More information is needed to clarify whether stenting is superior to balloon angioplasty (BA) for unoperated coarctation of the aorta (CoA). From September 1997, 21 consecutive adolescents and adults (24 ± 11 years) with discrete CoA underwent stenting (G1). The results were compared to those achieved by BA performed in historical group of 15 patients (18 ± 10 years; P = 0.103; G2). After the procedure, systolic gradient reduction was higher (99% ± 2% vs. 87% ± 17%; P = 0.015), residual gradients lower (0.4 ± 1.4 vs. 5.9 ± 7.9 mm Hg; P = 0.019), gain at the CoA site higher (333% ± 172% vs. 190% ± 104%; P = 0.007), and CoA diameter larger (16.9 ± 2.9 vs. 12.9 ± 3.2 mm; P < 0.001) in G1. Aortic wall abnormalities were found in eight patients in G2 (53%) and in one in G1 (7%; P < 0.001). There was no major complication. Repeat catheterization (n = 33) and/or MRI (n = 2) was performed at a median follow‐up of 1.0 year for G1 and 1.5 for G2 (P = 0.005). Gradient reduction persisted in both groups, although higher late gradients were seen in G2 (median of 0 mm Hg for G1 vs. 3 for G2; P = 0.014). CoA diameter showed no late loss in G1 and a late gain in G2 with a trend to being larger in G1 (16.7 ± 2.9 vs. 14.6 ± 3.9 mm; P = 0.075). Two patients required late stenting due to aneurysm formation or stent fracture in G1. Aortic wall abnormalities did not progress and one patient required redilation in G2. Blood pressure was similar in both groups at follow‐up (126 ± 12/81 ± 11 for G1 vs. 120 ± 15/80 ± 10 mm Hg for G2; P = 0.149 and 0.975, respectively). Although satisfactory and similar clinical outcomes were observed with both techniques, stenting was a better means to relieve the stenosis and minimize the risk of developing immediate aortic wall abnormalities. Catheter Cardiovasc Interv 2005;64:495–506.

Effectiveness of percutaneous balloon mitral valvotomy during pregnancy

During pregnancy, medically refractory congestive heart failure due to mitral stenosis continues to present a clinical challenge and optimal management remains controversial. Thirteen women underwent balloon mitral valvotomy for control of functional class III or IV congestive heart failure due to mitral stenosis during pregnancy. The mean gestational age at the time of valvotomy was 25 +/- 6 weeks. Percutaneous balloon mitral valvotomy was performed successfully in all patients. No maternal or fetal mortality occurred. The mean mitral valve area assessed by Doppler echocardiography increased from 0.9 +/- 0.3 cm2 before to 2.1 +/- 0.3 cm2 after valvotomy. The mean mitral valve gradient decreased from 20 +/- 7 to 4 +/- 2 mm Hg. This was associated with a decrease in the pulmonary artery systolic pressure from 62 +/- 24 to 32 +/- 14 mm Hg. Currently, 12 of the 13 patients have delivered at an average gestational age of 38 +/- 0.5 weeks. Symptoms of congestive heart failure improved in all women and all were in New York Heart Association functional class I at the time of delivery. One patient is still pregnant and symptom free. Eleven singlet pregnancies resulted in the birth of full-term, healthy infants (mean birth weight 3.2 kg). The woman carrying a twin pregnancy improved from New York Heart Association class IV to class I after balloon mitral valvotomy but delivered prematurely at 32 weeks. The premature twin infants weighed 1.0 and 1.5 kg and died from respiratory failure at 48 hours. Percutaneous balloon mitral valvotomy can be performed safely during pregnancy and is effective in relieving symptoms of severe congestive heart failure.(ABSTRACT TRUNCATED AT 250 WORDS)

Initial experience in Brazil with the Helex septal occluder for percutaneous occlusion of atrial septal defects

OBJECTIVE To evaluate the initial clinical experience with the Helex septal occluder for percutaneous closure of atrial septal defects. METHODS Ten patients underwent the procedure, 7 patients with ostium secundum atrial septal defects (ASD) with hemodynamic repercussions and 3 patients with pervious foramen ovale (PFO) and a history of stroke. Mean age was 33.8 years and mean weight was 55.4 kg. Mean diameter by transesophageal echocardiography and mean stretched ASD diameter were 11.33 3.3mm, and 15.2 3.8mm, respectively. The Qp/Qs ratio was 1.9 0.3 in patients with ASD. RESULTS Eleven occluders were placed because a patient with 2 holes needed 2 devices. It was necessary to retrieve and replace 4 devices in 3 patients. We observed immediate residual shunt (< 2mm) in 4 patients with ASD, and in those with patent foramen ovale total occlusion of the defect occurred. No complications were noted, and all patients were discharged on the following day. After 1 month, 2 patients with ASD experienced trivial residual shunts (1mm). In 1 patient, we observed mild prolapse in the proximal disk in the right atrium, without consequences. CONCLUSION The Helex septal occluder was safe and effective for occluding small to moderate atrial septal defects. Because the implantation technique is demanding, it requires specific training of the operator. Even so, small technical failures may occur in the beginning of the learning curve, but they do not involve patient safety.

Short- and midterm follow-up results of valvuloplasty with balloon catheter for congenital aortic stenosis

OBJECTIVE To report short and midtem follow-up results of balloon aortic valvuloplasty to treat congenital aortic stenosis. METHODS Seventy-five patients (median age: 8 years) underwent the procedure through the retrograde femoral or carotid route. RESULTS The procedure was completed in 74 patients (98.6%). The peak-to-peak systolic gradient dropped from 79.6 27.7 to 22.3 17.8 mmHg (P<0.001), the left ventricular systolic pressure dropped from 164 39.1 to 110 24.8 mmHg (P<0.001), and the left ventricular end diastolic pressure dropped from 13.3 5.5 to 8.5 8.3 mmHg (P< 0.01). Four patients (5.3%) died due to the procedure. Aortic regurgitation (AoR) appeared or worsened in 27/71 (38%) patients, and no immediate surgical intervention was required. A mean follow-up of 50 38 months was obtained in 37 patients. Restenosis and significant AoR were observed in 16.6% of the patients. The estimates for being restenosis-free and for having significant AoR in 90 months were 60% and 50%, respectively. CONCLUSION Aortic valvuloplasty was considered the initial palliative method of choice in managing congenital aortic stenosis, with satisfactory short- and midterm results.

Percutaneous closure of ductus arteriosus with the amplatzer prosthesis. The Brazilian experience

OBJECTIVE - To report the results of percutaneous occlusion of persistent ductus arteriosus with the Amplatzer prosthesis in 2 Brazilian cardiological centers. METHODS - From May 1998 to July 2000, 33 patients with clinical and laboratory diagnosis of persistent ductus arteriosus underwent attempts at percutaneous implantation of the Amplatzer prosthesis. The median age was 36 months (from 6 months to 38 years), and the median weight was 14kg (from 6 to 92kg). Sixteen patients (48.5%) were under 2 years of age at the time of the procedure. All patients were followed up with periodical clinical and echocardiographic evaluations to assess the presence and degree of residual shunt and possible complications, such as pseudocoarctation of the aorta and left pulmonary artery stenosis. RESULTS - The minimum diameter of the arterial ducts ranged from 2.5 to 7.0mm (mean of 4.0+/-1.0, median of 3.9). The rate of success for implantation of the prosthesis was 100%. Femoral pulse was lost in 1 patient. The echocardiogram revealed total closure prior to hospital discharge in 30 patients, and in the follow-up visit 3 months later in the 3 remaining patients. The mean follow-up duration was 6.4+/-3.4 months. All patients were clinically well, asymptomatic, and did not need medication. No patient had narrowing of the left pulmonary artery or of the aorta. No early or late embolic events occurred, nor did infectious endarteritis. A new hospital admission was not required for any patient. CONCLUSION - The Amplatzer prosthesis for persistent ductus arteriosus is safe and highly effective for occlusion of ductus arteriosus of varied diameters, including large ones in small symptomatic infants.

New Percutaneous Techniques for Perforating the Pulmonary Valve in Pulmonary Atresia with Intact Ventricular Septum

We report new percutaneous techniques for perforating the pulmonary valve in pulmonary atresia with intact ventricular septum, in 3 newborns who had this birth defect. There was mild to moderate hypoplastic right ventricle, a patent infundibulum, and no coronary-cavitary communications. We succeeded in all cases, and no complications related to the procedure occurred. The new coaxial radiofrequency system was easy to handle, which simplified the procedure. Two patients required an additional source of pulmonary flow (Blalock-Taussig shunt) in the first week after catheterization. All patients had a satisfactory short-term clinical evolution and will undergo recatheterization within 1 year to define the next therapeutic strategy. We conclude that this technique may be safely and efficiently performed, especially when the new coaxial radiofrequency system is used, and it may become the initial treatment of choice in select neonates with pulmonary atresia and intact ventricular septum.

Experiência global no fechamento percutâneo do canal arterial

OBJETIVO: Avaliar a experiencia global da nossa instituicao com o fechamento percutâneo do canal arterial. METODOS: Desde dezembro/92, 150 pacientes foram submetidos a 178 procedimentos (85 - tecnica de Rashkind; 87 - coils de Gianturco; 6 - coils Duct Occlud). A mediana de idade foi de 6,5 anos (1 a 57). A media do diâmetro minimo do canal foi de 3,05±1,24mm (1 a 8). Avaliacoes clinicas e ecocardiograficas foram realizadas seriadamente. RESULTADOS: Implantes adequados ocorreram em 143 (95,3%) pacientes. A prevalencia de shunt residual imediato foi de 52,1%, decrescendo para 15,9% no seguimento. Esta taxa caiu para 5,2% apos a realizacao de procedimentos adicionais. Embolizacao de coils ocorreu em 12 procedimentos e de umbrella em 1. Um paciente apresentou hemolise e outro estenose discreta da arteria pulmonar esquerda. Nao houve mortalidade. CONCLUSAO: Esta modalidade terapeutica e segura e eficaz, proporcionando bons resultados a longo prazo.

Preditores e impacto clínico intra-hospitalar do sangramento associado à intervenção coronária percutânea

ABSTRACT Predictors and In-hospital Clinical Impactof Post-PCI Bleeding Background: Percutaneous coronary intervention (PCI)-related bleeding is a frequent complication whose prognosisis often neglected. Several studies have shown the adverseclinical impact of bleeding, especially increased short andlong-term mortality rates. The purpose of this study was toevaluate predictors and clinical impact of this complicationin a large cohort of patients undergoing PCI. Method: Weperformed a prospective analysis of 2,892 consecutive pa-tients undergoing elective or urgent PCI from January/2008to June/2009. Patients with and without bleeding werecompared for clinical, angiographic and procedure-relatedvariables as well as in-hospital clinical outcomes. Multiplelogistic regression analysis was performed to determine theinfluence and independence of bleeding predictors. Results: Procedure-related bleeding was identified in 1.7% of thepatients. Taking in account only patients with acute coronarysyndrome (ACS) the incidence increased to 3.4%. Multi-variate analysis identified ACS [odds ratio (OR) 3.96, 95%confidence interval (95% CI) 1.45-11.42], use of glycoproteinIIb/IIa inhibitors (OR 2.55, 95% CI 1.68-3.87), chronic renalfailure (OR 2.34, 95% CI 1.11-3.49), Killip IV (OR 2.32,95% CI 1.54-3.5) and femoral access (OR 1.72, 95% CI1.19-3.14) as independent predictors of bleeding. Procedure-related bleeding was associated with in-hospital acute renalfailure (16.7% vs. 1.6%; P < 0.001) and in-hospital mortality(10.4% vs. 0.7%; P < 0.001).

Oclusão percutânea de defeitos cardíacos congênitos e estruturais com Amplatzer Duct oOccluder II TM

BACKGROUND: A new generation of Amplatzer devices with lower profile and greater flexibility has been recently developed for percutaneous occlusion of the patent ductus arteriosus (PDA). In this paper, the use of this new device, the Amplatzer Duct Occludder IITM (ADO II) for percutaneous closure of the PDA as well as for the treatment of other congenital and structural heart defects is reported, assessing its safety and efficacy. METHODS: Longitudinal and observational study of a cohort of patients with congenital and structural heart defects treated with ADO II between October 2009 and August 2011. Patients weighing less than 5 kg and PDAs > 5.5 mm and/or type B were excluded. The device was implanted using the antegrade or retrograde approach. The waist was 2 mm larger than the defect and the length of the prosthesis was 4 mm for shorter lesions (less than 6-8 mm). RESULTS: Twenty-eight patients with a median age and weight of 2 years and 11.7 kg, respectively, were included. Twenty-three had a PDA with a mean minimal diameter of 2.3 + 0.8 mm. The remainder had muscular ventricular septal defect (1), pulmonary arteriovenous fistula (1), ruptured aneurysm of the sinus of Valsalva (1), and univentricular heart in the early postoperative period of bidirectional cavopulmonary anastomosis with residual antegrade pulmonary flow (2). The device was successfully implanted in all patients, except for an infant weighing 8 kg with a long, tortuous and oblique PDA with a diameter of 2.8 mm and a shallow ampulla. There was total occlusion of the defects in all patients. One patient with univentricular heart and right isomerism died due to complications not related to the procedure. CONCLUSIONS: ADO II proved to be a flexible, safe and effective device for the percutaneous treatment of infants, children and selected adults with PDA and other congenital and structural heart defects. Its use may have limitations for some anatomical PDA configurations in smaller infants.