Simone Rolim Fernandes Fontes Pedra

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.

Fetal Cardiomyopathies Pathogenic Mechanisms, Hemodynamic Findings, and Clinical Outcome

Background—Although the prenatal diagnosis of most fetal structural heart defects and dysrhythmias has been described, there is a paucity of information about cardiomyopathies (CMs) in prenatal life. Methods and Results—-To determine the pathogenic mechanisms, hemodynamic findings, and outcome of fetal CM, we reviewed the fetal echocardiograms and perinatal histories of 55 affected fetuses. Dilated CM was diagnosed in 22 cases, including 2 with congenital infections, 5 familial cases, 6 with endocardial fibroelastosis related to maternal anti-Ro/La antibodies, and 9 idiopathic cases. Thirty-three had hypertrophic CM, 7 associated with maternal diabetes, 2 with Noonan’s syndrome, 2 with &agr;-thalassemia, 18 with twin-twin transfusion syndrome, 1 with familial hypertrophy, and 3 with idiopathic hypertrophy. Systolic dysfunction was present in all cases of dilated CM and 15 cases of hypertrophic CM. Diastolic dysfunction was present in 19 of 30 fetuses with assessment of diastolic function parameters. Significant mitral or tricuspid valve regurgitation was seen in 32 cases. Eight fetuses were hydropic and 23 had signs of early hydrops. Seven pregnancies were terminated. Of 46 continued pregnancies with follow-up, 29 (63%) died perinatally. The presence of systolic dysfunction, diastolic dysfunction, and significant atrioventricular valve regurgitation were identified as risk factors for mortality. By multiple logistic regression, diastolic dysfunction was associated with an 8-fold increased risk relative to the other parameters. Conclusions—Fetal CM has a broad spectrum of intrinsic and extrinsic causes. A poor outcome is observed in many affected fetuses. Diastolic dysfunction in fetal CM is associated with the highest risk of mortality.

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.

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.

Efetividade clínica e segurança do tratamento percutâneo da comunicação interatrial tipo ostium secundum, com a prótese Amplatzer®

OBJECTIVE: To assess the clinical efficacy and safety of the Amplatzer occluder for percutaneous closure of secundum atrial septal defect. METHODS: Forty-nine patients underwent the procedure guided by transesophageal echocardiography (TEE) while under general anesthesia, afterwards being clinically followed up for 12 months. RESULTS: The defect presented as a single orifice in 91.8% of the cases. The means of the longitudinal and transverse diameters were 14.3±5.0 mm and 14.4±4.9 mm, respectively. The means of the stretched diameters and prostheses were 19.3±5.1 mm and 20.3±4.9 mm, respectively. Technical success occurred in 97.9% of the cases. Immediate residual flow was observed in 54.1% of the patients, being minimum or small in 45.8% and moderate in 8.3%. After 24 hours, residual flow was observed in 25% of the patients (P = 0.0002). At the end of 13.1±1.3 months, the incidence of the overall residual flow decreased to 14.6%, only 4.1% being moderate. A significant reduction in the right ventricular diastolic diameter was observed in the different phases of clinical follow-up (P < 0.001). CONCLUSION: Implantation of the Amplatzer prosthesis proved to be effective and safe, constituting an option for the treatment of the secundum atrial septal defect in selected cases.

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.

O papel da ecocardiografia no tratamento percutâneo dos defeitos septais

In the last few years, percutaneous treatment of atrial and ventricular septal defects has developed signifi cantly, having been established as a feasible, safe and effective therapeutic modality. Echocardiography has a primary role in this scenario, identifying suitable candidates for the procedure, monitoring the device implantation and evaluating the rate of occlusion during follow-up. The available devices for percutaneous occlusion of septal defects have been progressively modifi ed and improved. Similarly, a great technological advancement has also occurred in the echocardiography area, such as the advent of high-resolution transesophageal multiplan probes, on and off-line three-dimensional (3-D echo) and intracardiac echocardiography. In some centers, the latter has become the proce-dure of choice for monitoring percutaneous occlusion of atrial septal defect in adult patients, as it does not require general anesthesia, thus making the procedure even simpler. In this review article, we will discuss the role of echocardiography to evaluate patients before, during and after interventional procedures for occlusion of septal defects, including the

Experiência inicial no fechamento percutâneo da comunicação interatrial com a prótese de Amplatzer

PURPOSE: To evaluate our initial experience with percutaneous closure of secundum type atrial septal defects (ASD) with the Amplatzer septal occluder. METHODS: Seven patients underwent occlusion by anterograde approach, under general anesthesia and transesophageal echocardiography (TEE) guidance. One child had 2 ASD and a patent ductus arteriosus (PDA). The ASD size ranged from 8,7 to 20mm as measured by TEE. A transthoracic echocardiogram was performed in the morning after the procedure. RESULTS: Eight devices were successfully implanted in 7 patients and the PDA was occluded with a Gianturco coil at the same session. In this patient, there was an episode of supraventricular tachycardia during the occlusion of one ASD which was reverted with adenosin. All patients were discharged the day after, with complete occlusion of all defects. CONCLUSION: The procedure is safe, effective and versatile. It can be applied as an initial alternative to the treatment of selected patients with ASD.PURPOSE To evaluate our initial experience with percutaneous closure of secundum type atrial septal defects (ASD) with the Amplatzer septal occluder. METHODS Seven patients underwent occlusion by anterograde approach, under general anesthesia and transesophageal echocardiography (TEE) guidance. One child had 2 ASD and a patent ductus arteriosus (PDA). The ASD size ranged from 8.7 to 20 mm as measured by TEE. A transthoracic echocardiogram was performed in the morning after the procedure. RESULTS Eight devices were successfully implanted in 7 patients and the PDA was occluded with a Gianturco coil at the same session. In this patient, there was an episode of supraventricular tachycardia during the occlusion of one ASD which was reverted with adenosin. All patients were discharged the day after, with complete occlusion of all defects. CONCLUSION The procedure is safe, effective and versatile. It can be applied as an initial alternative to the treatment of selected patients with ASD.

Hypoplastic Left Heart Syndrome With Intact or Restrictive Atrial Septum: A Report From the International Fetal Cardiac Intervention Registry

Infants with hypoplastic left heart syndrome and an intact or highly restrictive atrial septum (HLHS-IAS) represent a high-risk subset. Fetal cardiac intervention (FCI) for fetuses with HLHS-IAS has been reported in single-institution series as a therapy that may improve outcomes. This study uses the International Fetal Cardiac Intervention Registry (IFCIR) to examine fetal and maternal characteristics and pregnancy and neonatal outcome data for FCI in this population. For this descriptive analysis, the IFCIR was queried for fetuses with HLHS-IAS evaluated between 2001 and March 2015 for possible FCI and felt to be candidates at the referral center by a variety of published criteria including foramen ovale (FO) size, shunt flow direction across the FO, and pulmonary venous Doppler flow patterns. It includes those who were determined not to be candidates because of other fetal noncardiac conditions, maternal conditions, or maternal preferences, or because FCI was not performed at the participating institution. Further details on the methodology of the IFCIR registry are found in the initial report.1 Participating IFCIR member sites obtained local institutional review board and ethics board approval or a waiver, as governed …

Double balloon pulmonary valvuloplasty : Multi-track system versus conventional technique

Objectives: To evaluate whether double balloon pulmonary valvuloplasty (DBPV) with the Multi‐Track system (MTS) may help to simplify the procedure. Background: DBPV is usually required for patients with pulmonary valve stenosis with large annulus. However, it needs two venous accesses and can be technically demanding. Methods: From 07/03, 20 consecutive patients (19 ± 10 yrs) with typical pulmonary valve stenosis underwent DBPV using the MTS (G1). The results were compared with those achieved by conventional DBPV performed in a matched historical group of 28 patients (21 ± 11 yrs; P = NS) (G2). Results: MTS balloons were easily advanced through the skin and inflated across the valve. Similar results were observed in regards to residual gradients (12 ± 11 vs 14 ± 10 mm Hg; P = NS) and right ventricular to systemic pressures (0.35 ± 0.22 vs 0.37 ± 0.26; P = NS). Procedure and fluoroscopic times were significant lower in G1 (78 ± 24 vs 126 ± 28; 15 ± 12 vs 25 ± 8 min, respectively; both P < 0.001). There was no major complication. Median follow‐up was 1.8 yr for G1 and 5 yr for G2 (P = 0.037). At the last visit, peak instantaneous gradient across the right ventricular outflow tract by echocardiography was a mean 22 ± 10 mm Hg for G1 and 25 ± 9 mm Hg for G2 (P = NS). No patient had severe pulmonary insufficiency or required reintervention. Conclusions: The use of the MTS helped to expedite the procedure providing satisfactory midterm clinical outcomes, similar to those observed with the conventional DBPV technique.