Shyam Sathanandam

Aortic cusp extension valvuloplasty with or without tricuspidization in children and adolescents: long-term results and freedom from aortic valve replacement.

OBJECTIVE Aortic cusp extension valvuloplasty is increasingly used in the management of children and adolescents with aortic stenosis or regurgitation. The durability of this approach and the freedom from valve replacement are not well defined. A study was undertaken to investigate outcomes. METHODS From July 1987 to November 2008, 142 patients aged less than 19 years underwent aortic cusp extension valvuloplasty in the form of pericardial cusp extension and tricuspidization (when needed). Three patients with truncus arteriosus and severe truncal valve insufficiency were excluded. From the available follow-up data of 139 patients, 50 had bicuspid aortic valves, 40 had congenital aortic valve stenosis, 41 had combined congenital aortic valve stenosis/insufficiency, and 8 had other diagnoses. Median follow-up was 14.4 years (0.1-21.4). Long-term mortality and freedom from aortic valve replacement were studied. RESULTS There were no early, intermediate, or late deaths. Z-values of left ventricular end-diastolic dimension, aortic annulus, aortic sinus diameter, and sinotubular junction diameter before aortic valve replacement were 4.2 +/- 3.11, 2.3 +/- 1.25, 4.4 +/- 1.23, and 1.84 +/- 1.28, respectively. During the follow-up period, 64 patients underwent aortic valve reinterventions. The Ross procedure was performed in 32 of 139 patients (23%) undergoing aortic cusp extension valvuloplasty. Other aortic valve replacements were undertaken after 16 aortic cusp extension valvuloplasties (11.5%). Freedom from a second aortic cusp extension valvuloplasty or aortic valve replacement at 18 years was 82.1% +/- 4.2% and 60.0% +/- 7.2%, respectively. CONCLUSION Aortic cusp extension valvuloplasty is a safe and effective surgical option with excellent survival and good long-term outcomes in children and adolescents. The procedure provides acceptable durability and satisfactory freedom from aortic valve replacement.

Bilateral Branch Pulmonary Artery Melody Valve Implantation for Treatment of Complex Right Ventricular Outflow Tract Dysfunction in a High-Risk Patient

Percutaneous pulmonary valve replacement is one of the most important advancements in the field of interventional cardiology in the past decade.1,2 However, currently available technologies are not applicable to patients with oversized right ventricular outflow tracts (RVOTs), especially when there is concomitant proximal branch pulmonary artery (PA) stenosis. This combination commonly is encountered in clinical practice. Our group has a longstanding interest in these complex patients, and we have recently published preclinical studies describing the feasibility and short-term effects of implanting 2 Melody valves—1 into each proximal branch PA—in an ovine model of postoperative pulmonary insufficiency and dilated RVOT.3 This report describes bilateral branch PA Melody valve implantation to treat complex RVOT dysfunction in a high-risk patient. At presentation, the patient was a 27-year-old woman with a complex medical history. Her cardiac condition was double-outlet RV with pulmonary stenosis and interrupted inferior vena cava with azygos continuation to a left-sided superior vena cava. She was status post-Waterston shunt as an infant, with subsequent closure of the ventricular septal defect and patch augmentation of the RVOT. Three months before catheterization, the patient presented to her cardiologist with symptoms of progressive activity intolerance over the past year. She was oxygen dependent and on long-term continuous positive airway pressure therapy. Comorbidities included VATER and Klippel-Feil syndromes, renal agenesis, Mullerian agenesis, gout, and obesity. The patient had undergone multiple spinal fusion and Harrington rod procedures as well as repair of tracheoesophageal …

Morphologic characterization of the patent ductus arteriosus in the premature infant and the choice of transcatheter occlusion device

Objectives: The aim of this study was to describe and differentiate the morphology of patent ductus arteriosus (PDA) seen in children born prematurely from other PDA types.

Unzipping of small diameter stents: An in vitro study

The purpose of this study was to determine if small‐diameter stents can be unzipped in vitro.

Mitral stenosis and aortic atresia in hypoplastic left heart syndrome: survival analysis after stage I palliation.

BACKGROUND Mitral stenosis with aortic atresia (MS-AA) has been implicated as a risk factor for decreased survival after stage 1 palliation for hypoplastic left heart syndrome. Conflicting results were reported in the literature evaluating the association of anatomic subtypes and mortality. Our objective was to determine whether MS-AA is associated with increased mortality after stage 1 palliation. METHODS Between January 2005 and May 2009 100 consecutive neonates with hypoplastic left heart syndrome underwent stage 1 palliation. Echocardiograms were reviewed for patency of the mitral and aortic valves as well as presence of ventriculocoronary connections (VCC). Patients were divided into (1) mitral and aortic atresia (MA-AA), (2) MS-AA, and (3) mitral and aortic stenosis groups. Survival analysis was performed, and impact of MS-AA and VCC on early and midterm survival was assessed. RESULTS Of the 100 patients, 31 had MA-AA, 42 had mitral stenosis and aortic stenosis, and 27 had MS-AA (15 with VCC and 12 without). Stage 1 palliation 30-day survival was 90% for the entire cohort and 88.9% for the MS-AA subtype (not significantly different). Six-month survival was 70% overall and 70.4% for MS-AA (not significantly different). When VCC was taken into account, MS-AA with VCC reached 93% survival (versus 50% for MS-AA without VCC; p < 0.01). CONCLUSIONS Stage 1 palliation for hypoplastic left heart syndrome is associated with satisfactory hospital and midterm survival regardless of anatomic subtype. The variants MS-AA and MA-AA are associated with smaller ascending aorta. Mitral stenosis with aortic atresia or VCC did not adversely influence survival.

Hypoplastic Left Heart Syndrome: Feasibility Study for Patients Undergoing Completion Fontan at or Prior to Two Years of Age

BACKGROUND There is limited data regarding the management of children with HLHS (hypoplastic left heart syndrome) and completion Fontan (CF) at or prior to 2 years of age. A study was undertaken to investigate intermediate outcomes. METHODS From August 1999 to December 2008, 52 HLHS survivors underwent extracardiac-conduit CF (29 prior to [group A] versus 23 after 25 months of age [group B]). Mean weight and median follow-up was 9.9 +/- 1.3 kg and 79 months (2 to 112) for group A versus 12.1 +/- 2.2 kg and 87 months (1 to 97) for group B, respectively. Polytetrafluoroethylene conduits were used. Perioperative outcome variables were studied. RESULTS There was no hospital mortality and 1 late death (group B). In group A, 16 CF had 20-mm conduit (vs 18 mm in 13). Thirteen group B patients received 18-mm conduit (vs 20 mm in 10). No CF was taken down. Eight patients in each group required fenestration (p = not significant [NS]). Cardiopulmonary bypass was 78 +/- 37.3 minutes in group A versus 77 +/- 33.9 minutes in group B (p = NS). Mean pulmonary artery size, McGoon ratio, and transpulmonary gradient in group A versus group B were 7.94 +/- 0.59 mm versus 7.87 +/- 0.58 (p = NS), 1.79 +/- 0.2 versus 1.77 +/- 0.19 (p = NS), and 4.1 +/- 1.1 mm Hg versus 3.5 +/- 0.9 (p = NS), respectively. Aspirin and warfarin were used postoperatively. Mean hospital length of stay, intensive care unit length of stay, and pleural drainage duration between groups A and B were the following: 10.9 +/- 5.8 days versus 12.7 +/- 6.1 (p = NS); 5.6 +/- 2.6 days versus 6.7 +/- 2.9 (p = NS); and 7.6 +/- 3.8 days versus 8.7 +/- 4.1 (p = NS), respectively. Between groups, no difference in ventilatory support time, arrhythmia, sinus-atrioventricular node dysfunction, protein-losing-enteropathy, and thromboembolic events were noted. CONCLUSIONS In HLHS patients, extracardiac conduit CF can be performed with good intermediate results at or prior to 2 years of age. Earlier unloading of a univentricular heart by means of CF in patients with collateral accessory flow between systemic and pulmonary circulation might be advantageous for future ventricular function preservation. In addition, relief from early cyanosis might alleviate deleterious effects from a prolonged cyanotic state. Fenestration is less often required without effect in pleural drainage duration. Age at CF had no effect in preoperative pulmonary artery growth and conduit size selection.

Selective Tricuspidization and Aortic Cusp Extension Valvuloplasty: Outcome Analysis in Infants and Children

BACKGROUND Encouraging early outcomes of emerging aortic cusp extension valvuloplasty techniques have redirected attention to nonreplacement strategies in the management of younger patients with aortic insufficiency or aortic stenosis. Outcome analysis after aortic cusp extension valvuloplasty in infants and children was undertaken. METHODS From July 1987 to December 2008, 78 patients younger than 10 years of age underwent aortic cusp extension valvuloplasty in the form of pericardial cusp extension and selective use of tricuspidization. Sixteen (20.5%) patients were younger than 1 year of age. Twenty-seven had bicuspid aortic valve, 34, congenital aortic valve stenosis, and 17, congenital or acquired aortic insufficiency or aortic stenosis. Forty-two patients had balloon valvuloplasty or surgical valvotomy before aortic cusp extension valvuloplasty. Median follow-up was 12.4 years (range, 0.1 to 21.6 years). Freedom from aortic valve replacement (AVR) and determinants of outcome were analyzed. RESULTS There were no early or late deaths. During the follow-up period, 23 patients (29.5%) had Ross operation and 8 patients (10.2%) had other AVR. The z values of left ventricular end-diastolic dimension, aortic annulus, aortic sinus diameter, sinotubular junction diameter, and left ventricular wall thickness before AVR were 3.8 +/- 2.95, 2.1 +/- 1.15, 4.2 +/- 1.22, 1.78 +/- 1.24, and 2.92 +/- 1.31, respectively. Actuarial freedom from AVR at 1, 5, and 10 years was 97.3 +/- 2.0%, 71.3 +/- 5.8%, and 55.6 +/- 6.9%, respectively. CONCLUSIONS Aortic cusp extension valvuloplasty with tricuspidization allows left ventricular reverse remodeling with satisfactory long-term durability and freedom from AVR. Used selectively, it represents a reliable and effective approach in infants and children with congenital or acquired abnormal aortic valve.

Initial clinical experience with the Medtronic Micro Vascular Plug™ in transcatheter occlusion of PDAs in extremely premature infants

To describe the early multicenter, clinical experience with the Medtronic Micro Vascular Plug™ (MVP) for the occlusion of patent ductus arteriosus (PDA) in premature infants.

Radiation Protocol for Three‐Dimensional Rotational Angiography to Limit Procedural Radiation Exposure in the Pediatric Cardiac Catheterization Lab

BACKGROUND Three-dimensional rotational angiography (3DRA) offers more detailed anatomic information than 2D digital acquisition (2DDA). Concerns over potentially higher contrast and radiation doses have limited its routine use. OBJECTIVE The primary objective of this study was to compare radiation doses required to obtain 3DRA using a customized low dose radiation protocol with 2DDA. The secondary objective was to compare total procedural radiation in pediatric cardiac catheterization procedures utilizing 3DRA to those that do not. STUDY DESIGN Phantom studies were conducted to establish customized 3DRA protocols for radiation reduction. Comparison of 3DRA and non-3DRA procedures in age-, size- and diagnosis-matched controls was performed. Radiation doses were indexed to body surface area (BSA) to account for differing body habitus as validated from the phantom study. RESULTS Study (n = 100) and control (n = 100) groups were matched for age (10.2 vs. 9.98 years; P = .239) and BSA (1.23 vs. 1.09 m2 ; P = .103). The dose area product (DAP) to acquire a 3DRA was similar to a 5 s, 15 frames/second 2DDA (278 vs. 241 cGy/cm2 ; P = .14). Despite the 3DRA group consisting of more complex interventions, no difference was found in the total procedural Air Kerma and DAP indexed to BSA (244 vs. 249 mGy/m2 ; P = .79 and 3348 vs. 3176 cGy/cm2 /m2 ; P = .48, respectively). The contrast volume to acquire a 3DRA compared to a 2DDA was greater (1.59 vs. 1.01 mL/kg; P < .001). However, no difference was found for the entire procedure (3.8 vs. 4 mL/kg, P = .494). This could have resulted from the need to obtain multiple 2DDAs to achieve the detail of a single 3DRA (11 vs. 7 per study; P < .001). CONCLUSIONS When 3DRA, using the proposed protocols is employed, total procedural contrast and radiation doses are comparable with the sole use of biplane cine-angiograms. These protocols may allow for routine use of 3DRA for congenital cardiac catheterizations.

Coronary Ostioplasty for Congenital Atresia of the Left Main Coronary Artery Ostium

BACKGROUND Coronary ostial atresia is a rare anomaly, most frequently managed with coronary artery bypass grafting. This condition is often misdiagnosed as anomalous left coronary artery from the pulmonary artery until the time of surgical intervention, leaving the surgeon little time to contemplate the best operative technique. METHODS In this single-center experience, three cases of congenital atresia of the left main coronary artery presenting during childhood were surgically managed with homograft patch ostioplasty. RESULTS Antegrade left coronary artery blood flow was successfully established in all three cases without the use of a bypass graft. Two children survived and are clinically well; the third had visibly necrotic myocardium at the time of surgical ostioplasty and did not survive to hospital discharge. CONCLUSIONS Surgical ostioplasty with a homograft patch should be considered as an alternative to bypass grafting for coronary ostial atresia in children.