Suhair O. Shebani

Closure of Secundum Atrial Septal Defects by Using the Occlutech Occluder Devices in More Than 1300 Patients: The IRFACODE Project: A Retrospective Case Series.

The Occlutech Figulla ASD device series (OFSO) shows an improved device design for interventional ASD closure, larger follow‐up series are missing.

Closure of Secundum Atrial Septal Defects by Using the Occlutech Occluder Devices in More Than 1300 Patients

The Occlutech Figulla ASD device series (OFSO) shows an improved device design for interventional ASD closure, larger follow‐up series are missing.

Rapid Ventricular Pacing for Catheter Interventions in Congenital Aortic Stenosis and Coarctation: Effectiveness, Safety, and Rate Titration for Optimal Results

INTRODUCTION Infants and children with congenital aortic stenosis and coarctation of the aorta can be treated by catheter intervention. There are several pharmacological and mechanical techniques described to overcome the balloon movement; none, however, have proved entirely satisfactory. An alternative method to achieve balloon stability is the use of rapid ventricular pacing. We describe our experience with titrating the pacing rate and the use of this technique. METHODS A retrospective review of database was performed, to identify patients who underwent transcatheter intervention with rapid ventricular pacing. Invasive systemic pressures were documented with a catheter in the aorta. Rapid ventricular pacing was initiated at the rate of 180 per minute and increased by increments of 20 per minute to a rate required to achieve a drop in systemic pressure by 50% and a drop in pulse pressure by 25%. The balloon was inflated only after the desired pacing rate was reached. Pacing was continued until the balloon was completely deflated. RESULTS Thirty patients were identified, 29 of whom had interventions with rapid ventricular pacing. Balloon valvuloplasty of aortic valve was performed on 25 patients while 4 patients had stenting for coarctation by this technique. The rate of ventricular pacing required ranged from 200 to 260 per minute with a median rate of 240. Balloon stability at the time of intervention was achieved in 27 patients. CONCLUSION Rapid ventricular pacing is a safe and effective method to provide transient decrease in cardiac output at the time of transcatheter interventions to achieve balloon stability.

A congenital fistula between the descending aorta and the right pulmonary vein in a neonate presenting with heart failure.

We report a large congenital fistula connecting the descending thoracic aorta to the right upper pulmonary vein in a newborn baby presenting on the seventh day of life with cardiac failure and a continuous murmur heard posteriorly. The fistula was detected echocardiographically, and shown at cardiac catheterisation not to be suitable for percutaneous occlusion. The anatomy of the fistula was confirmed at surgery, when it was ligated successfully.

Techniques for Transcatheter Retrieval of the Occlutech ASD Device United Kingdom- European Multicenter Report

To gather current experience in Occlutech ASD device retrieval, to determine whether snaring is an effective technique and to highlight alternative retrieval techniques;

Trifecta St. Jude medical® aortic valve in pulmonary position

ABSTRACT Introduction: To evaluate an aortic pericardial valve for pulmonary valve (PV) regurgitation after repair of congenital heart defects. Methods: From July 2012 to June 2016 71 patients, mean age 24 ± 13 years (four to years) underwent PV implantation of aortic pericardial valve, mean interval after previous repair = 21 ± 10 years (two to 47 years). Previous surgery at mean age 3.2 ± 7.2 years (one day to 49 years): tetralogy of Fallot repair in 83% (59/71), pulmonary valvotomy in 11% (8/71), relief of right ventricular outflow tract (RVOT) obstruction in 6% (4/71). Pre-operative echocardiography and MRI showed severe PV regurgitation in 97% (69/71), moderate in 3% (2/71) with associated RVOT obstruction. MRI and knowledge-based reconstruction 3D volumetry (KBR-3D-volumetry) showed mean PV regurgitation = 42 ± 9% (20–58%), mean indexed RV end-diastolic volume = 169 ± 33 (130–265) ml m–2 BSA and mean ejection fraction (EF) = 46 ± 8% (33–61%). Cardio-pulmonary exercise showed mean peak O2/uptake = 24 ± 8 ml kg–1 min–1 (14–45 ml kg–1 min–1), predicted max O2/uptake 66 ± 17% (26–97%). Pre-operative NYHA class was I in 17% (12/71) patients, II in 70% (50/71) and III in 13% (9/71). Results: Mean cardio-pulmonary bypass duration was 95 ± 30ʹ (38–190ʹ), mean aortic cross-clamp in 23% (16/71) 46 ± 31ʹ (8–95ʹ), with 77% (55/71) implantations without aortic cross-clamp. Size of implanted PV: 21 mm in seven patients, 23 mm in 33, 25 mm in 23, and 27 mm in eight. The z-score of the implanted PV was −0.16 ± 0.80 (−1.6 to 2.5), effective orifice area indexed (for BSA) of native PV was 1.5 ± 0.2 (1.2 to –2.1) vs. implanted PV 1.2 ± 0.3 (0.76 to –2.5) (p = ns). In 76% (54/71) patients surgical RV modelling was associated. Mean duration of mechanical ventilation was 6 ± 5 h (0–26 h), mean ICU stay 21 ± 11 h (12–64 h), mean hospital stay 6 ± 3 days (three to 19 days). In mean follow-up = 25 ± 14 months (six to 53 months) there were no early/late deaths, no need for cardiac intervention/re-operation, no valve-related complications, thrombosis or endocarditis. Last echocardiography showed absent PV regurgitation in 87.3% (62/71) patients, trivial/mild degree in 11.3% (8/71), moderate degree in 1.45% (1/71), mean max peak velocity through RVOT 1.6 ± 0.4 (1.0–2.4) m s–1. Mean indexed RV end-diastolic volume at MRI/KBR-3D-volumetry was 96 ± 20 (63–151) ml m–2 BSA, lower than pre-operatively (p < 0.001), and mean EF = 55 ± 4% (49–61%), higher than pre-operatively (p < 0.05). Almost all patients (99% = 70/71) remain in NYHA class I, 1.45% = 1/71 in class II. Conclusion: (a) Aortic pericardial valve is implantable in PV position with an easy and reproducible surgical technique; (b) valve size adequate for patient BSA can be implanted with simultaneous RV remodelling; (c) medium-term outcomes are good with maintained PV function, RV dimensions significantly reduced and EF significantly improved; (d) adequate valve size will allow later percutaneous valve-in-valve implantation.

Radiofrequency ablation on veno-arterial extracorporeal life support in treatment of very sick infants with incessant tachymyopathy.

AIMS To evaluate the use of extracorporeal membrane oxygenation (ECMO) in supporting infants who require radiofrequency ablation (RFA) for incessant tachyarrhythmias, with particular emphasis on modifications required to standard ablation techniques. METHODS AND RESULTS Three cases of RFA carried out in infancy on ECMO support were reviewed retrospectively. Two infants with permanent junctional reciprocating tachycardia (PJRT) and one with ventricular tachycardia (VT) presented in a low cardiac output state, owing to cardiomyopathy caused by incessant tachycardia. In each case antiarrhythmic drug therapy caused haemodynamic collapse, requiring emergency ECMO support. Drug therapy on ECMO was not successful. In one patient, the tachycardia was controlled on ECMO with antiarrhythmic drugs, but recurred following ECMO decannulation. Each patient had a successful RFA on ECMO support. Power delivery was low during ablation lesions. In the PJRT cases power as low as 3-5 Watts was effective. In the VT ablation, an irrigated tip RFA catheter was required when cooling remained poor even after temporarily stopping ECMO flow. CONCLUSION Extracorporeal membrane oxygenation provides a haemodynamically stable and safe platform for antiarrhythmic drug therapy and RFA in infants with incessant tachyarrhythmias. Once ECMO has been commenced, if the tachyarrhythmia remains difficult to control with antiarrhythmic drugs, RFA should be strongly considered, to avoid the risk of tachycardia recurrence following ECMO decannulation. Power delivery during ablation lesions may be low because of inadequate cooling of the catheter tip. Reducing or stopping flow in the ECMO circuit may not provide adequate cooling and an irrigated tip catheter may be required.

Usefulness of Four-Dimensional Trans-Oesophageal Echocardiography in Device Closure of An Unusual Post Myocardial Infarction Ventricular Septal Defect

Presentation of the transoesophageal echocardiogram for a patient undergoing transcatheter closure of a post infarction ventricular septal defect through a pseudoaneurysm at the basal rather than the apical part of the septum, posing a diagnostic and interventional planning challenge. Four dimensional imaging clarified the complex anatomy of the pseudoaneurysm, aiding device closure.

21 Decision-making using multimodality imaging in complex muscular ventricular septal defects post pulmonary artery banding

Large muscular ventricular septal defects below the moderator band are an interesting entity as these lesions can be surgical challenging. The conventional approach is to do pulmonary artery banding to control heart failure and allow child to grow with view to close later using interventional approach if the lesion remains significant. Hybrid approach with pulmonary artery debanding and per-ventricular VSD closure has been attempted in few centres. Current advances in multimodality imaging helps us to understand the anatomy better and help us to plan the interventional and surgical procedure well. We present 3 cases of muscular ventricular septal defects post pulmonary artery banding. The VSDs in these patients had multiple exits in right ventricle aspect extending above and below the moderator band. Assessment of ventricular septal defect using transthoracic echocardiography, 3D echocardiography, conventional angiogram and CT angiogram added more information. However along with 3D modelling and printing in these selected cases helped to preempt challenges and plan according to avoid complications. We demonstrate the use of multimodality imaging and 3D modelling in these case series.

22 Single centre experience of incorporating knowledge-based reconstruction for right ventricular volumetry into clinical practice

Knowledge-based reconstruction (KBR) is a new technique for calculating the volume of cardiac chambers accurately. The technique can be applied to 3D datasets (eg, MRI scans), but can also be used with conventional 2D echocardiography by tracking the probe position and orientation in 3D space. It is particularly useful for assessing the volume of the right ventricle without having to undergo an MRI scan. We acquired a KBR system in March 2015, and have been putting it into practice. We have performed 69 studies in 45 patients over an 18 month period, ages between 5 and 70 years average 18.9 years, 28 patients (62%) were between 5–12 years and 37 patients (82%) were below 18 years of age. Indications mainly for post surgical Tetralogy of Fallot variants or post pulmonary valve dilation resulting in free pulmonary regurgitation or mixed valve disease with resulting significant right ventricular volume loading . In a subset we have performed analysis on 13 patients who underwent pulmonary valve replacement, giving pre- and post- surgical RV volume and function analysis, all 13 patients had Cardiac MRI pre surgery, that was comparable to the pre-surgical KBR analysis. Conclusion Knowledge based reconstruction of right and left ventricle volumetric data can be preformed with good reliability and good alternative to MRI.Abstract 22 Figure 1 A,B,CAbstract 22 Figure 2 Our institute inter-observational variability