Tiow Hoe Goh

Transcatheter closure of perimembranous ventricular septal defects using the amplatzer membranous VSD occluder: Immediate and midterm results of an international registry

Objective: To report the immediate and midterm results of transcatheter closure of perimembranous ventricular septal defect (PmVSD) using the Amplatzer membranous VSD occluder (AMVSD). Methods: Between April 2002 and August 2004, 100 patients underwent an attempt of percutaneous device closure of PmVSD using the AMVSD in 24 international centers. The median age was 9.0 years (0.7–58 years) and the median weight was 27.5 kg (7–121 kg). Results: A device was successfully deployed in 93/100 (93%) patients. Reasons for procedural failure were an increased gradient across the left ventricle outflow tract in one patient, aortic regurgitation in 2 patients, and inability to securely position the device in 4 patients. The median VSD size by TEE was 7.0 mm (1.5–13 mm), median device size 10 mm (4–16 mm) and median fluoroscopy time 22.1 min (8.9–96.0 min). Weight below 10 kg (P = 0.0392), inlet extension of the VSD (P = 0.0139) and aortic cusp prolapse into the VSD (P = 0.0084) were significantly associated with a lower procedural success. Patients have been followed up for a median of 182 days (1–763 days). There were no procedure‐related deaths. Complications were encountered in 29/100 (29%) patients, including rhythm or conduction anomalies in 13 patients (two with complete heart block requiring permanent pacemaker implantation), new or increased aortic (9 patients) or tricuspid (9 patients) regurgitation, most of which were classified as trivial or mild. Patients with a weight below 10 kg had a significantly higher incidence of adverse events than patients with a weight above 10 kg (58.3% versus 25.0%, P = 0.0285). Immediately after device release complete closure of the defect was present in 54/93 (58.1%) patients, increasing to 46/55 (83.6%) patients at 6‐months follow‐up (P = 0.0012). Left ventricle end‐diastolic diameter decreased from a median of 44 mm prior to device closure to a median of 39 mm at 6‐months postprocedure (P = 0.0015). Conclusion: Closure of PmVSDs using the AMVSD occluder is safe and effective. However, longer follow‐up period is warranted prior to the wide spread use of this device.

Early clinical experience with use of the 'Amplatzer Septal Occluder' device for atrial septal defect

Device closure of oval fossa atrial septal defects with the Amplatzer Septal Occluder was performed in 26 patients ranging in age from 0.89 to 60.44 years. In eight additional patients no device implant was performed because of the presence of multiple defects or because the defect was of a size unsuitable for closure with the devices currently available. The stretched diameter of the defects that were closed ranged from 4 to 23 mm (mean 14+/-5.4 mm) and device sizes ranged from 4 to 24 mm. Two devices were unstable, of which one embolized to the right atrium after release. Both devices were retrieved at the same procedure. One of these patients subsequently underwent a successful device closure of his defect using a larger (24-mm) device. Three patients had multiple defects, which were successfully closed with a single device. At 1-month follow-up 23/26 (88%) and at 3-month follow-up 22/24 (92%) patients had complete closure of their defects, while two had residual shunts. One further patient who had complete closure of his defect at 1-month post-implant had his device removed and his atrial septal defect patched surgically 8 weeks after device closure. This was done as a result of the development of a vegetation affecting the device after an episode of septicaemia, which was not related to the cardiac problems. There was no procedure-related morbidity or mortality and all patients remain well at the present time.

Treatment of critical pulmonary valve stenosis by balloon dilatation in the neonate

Critical pulmonary valve stenosis represents an emergency, and immediate treatment is mandatory. The purpose of this study was to evaluate the immediate and medium-term results of pulmonary valve dilatation. We report 18 neonates in whom pulmonary valvuloplasty was attempted. The procedure could be accomplished in 14 patients. The angiographically determined diameters of the pulmonary and tricuspid valve at the time of procedure were 5.6 +/- 1.5 mm and 14.0 +/- 5.4 mm. The mean Doppler gradient decreased from 71 +/- 27 mm Hg to 27 +/- 14 mm Hg. Perforation of the right ventricular outflow tract was the major complication in three patients with one fatal event. Infusion of prostaglandin E1 could be discontinued 1 to 5 days after the procedure. On follow-up three children required a second balloon dilatation with good results. Seven patients monitored for more than 9 months with a mean follow-up time of 34.4 +/- 16 months had a residual gradient of 11.6 +/- 6.7 mm Hg. In spite of a hypoplastic pulmonary valve annulus in seven of the patients, results were good and surgery could be avoided.

Long-term follow-up after two coronary repair of anomalous left coronary artery from the pulmonary artery.

Abstract A retrospective analysis of ten patients with anomalous left coronary artery arising from the pulmonary artery operated between 1979 and 1990 was undertaken. All presented with evidence of left ventricular dysfunction and “ischemic” mitral regurgitation. Surgical repair consisted of an aortopulmonary tunnel (Takeuchi) procedure in eight and direct left coronary artery reimplantation in two. Two patients required postoperative support with a left ventricular assist device. There were no operative or late deaths (CL 0% to 17%) for a follow‐up of over 670 patient months. All patients are in New York Heart Association Class I or II, though two patients are still receiving anticongestive medications. One patient has required further surgery for pulmonary artery stenosis, and another has had a mitral valve replacement because of severe mitral regurgitation. One additional patient has moderate‐to‐severe residual mitral regurgitation and two have a trivial left coronary to main pulmonary artery fistula. All have a patent, nonstenotic left coronary artery and much improved left ventricular function and perfusion as assessed by echocardiography, thallium scan, gated blood pool scan, and angiography. There have been no documented arrhythmias, clinically or on Hotter monitoring. The ECGs have shown resolution or improvement of the initial changes of ischemia/infarction in all patients. Chest X‐rays have shown normalization of cardiothoracic ratio in eight of ten patients. Excellent early and late results can be achieved following timely surgical repair. Marked improvement in left ventricular function has been observed in patients with poor preoperative left ventricular function, even in the presence of extensive ischemia/infarction.

New interventional therapeutic approach for dual drainage of the scimitar vein.

A patient with scimitar syndrome and dual drainage of a right‐sided scimitar vein into the inferior vena cava and the left atrium underwent coil occlusion of the right aortopulmonary collateral artery and device occlusion of the lower scimitar vein drainage, leaving it flowing solely into the left atrium. Cathet. Cardiovasc. Intervent. 51:192–195, 2000.

Management of pulmonary sequestration and scimitar syndrome presenting in infancy

Anomalous systemic arterial supply to the lung, either isolated or in association with partial anomalous pulmonary venous drainage (scimitar syndrome, SS), is uncommon in infancy. Traditionally the management has been surgical, but more recently the technique of arterial embolisation (AE) has been used. We report 11 infants seen over 11 years with anomalous systemic arterial supply to the lung. All patients presented by 10 months of age, 10 with persisting tachypnoea and 1 with pneumonia. Seven had isolated anomalous vascular supply to the lung and 4 associated SS. Six had pulmonary hypertension (PH) at presentation and all of these had associated cardiac defects. Five patients were managed surgically (ligation 3, resection 2) and 5 by AE. All infants managed by AE and 1 of the 3 with ligation have had excellent outcomes; 2 patients with SS had reduction of PH following AE. Three patients with isolated anomalous systemic vascular supply to the lung are now asymptomatic. Two patients with anomalous arterial supply to the lung and significant cardiac lesions had cardiac surgery performed but had persistant cardiac failure. Ligation of the anomalous vessel was then undertaken, but both died. AE is an effective means of initial management of anomalous systemic arterial supply to the lung. It precludes the immediate need for surgery and may lead to control of cardiac failure and PH. In patients with associated cardiac anomalies, AE of the anomalous systemic arterial supply should be considered prior cardiac surgery. Reduction in PH following embolisation of the anomalous systemic arterial connection to the lung occurs in SS, and AE should be considered early in the management of these patients.