Catheter Intervention for Congenital Heart Disease at Risk of Circulatory Failure

Cardiac catheterization addressing early post-operative complications in congenital heart surgery-a single-center experience

BACKGROUND

Cardiac catheterization after congenital heart surgery may play an important role in the diagnosis and management of patients with a complicated or unusual post-operative course. The main objective of this study was to evaluate the safety, efficacy, and outcome of cardiac catheterization performed in the early post-operative period following congenital heart surgery. All patients who underwent cardiac catheterization after congenital heart surgery during the same admission of cardiac surgery from November 2015 to May 2018 were included in the study.

RESULTS

Thirty procedures were performed for 27 patients (20 interventional and 10 diagnostic). The median age of the patients was 15 months (15 days to 20 years), median weight was 8.2 kg (3.4 to 53 kg), and median time from surgery was 3 days (0-32 days). Eleven procedures were performed for 11 patients on extracorporeal membrane oxygenation (ECMO) support. The main indications for catheterization included the inability to wean from ECMO (10 procedures) and cyanosis (10 procedures). Interventional procedures included angioplasty using stents (10 procedures, success rate of 90%), angioplasty using only balloons (2 procedures, success rate of 50%), and occlusion for residual shunts (8 procedures, success rate of 100%). No mortality was recorded during any procedure. Vasoactive-inotropic score had significantly decreased 48 h after catheterization when compared to pre-catheterization scores (p = 0.0001). Moreover, 72% of patients connected to ECMO support were successfully weaned from ECMO after catheterization. Procedural complications were recorded in 3 interventional procedures. Survival to hospital discharge was 55.5% and overall survival was 52%. Patients on ECMO support had a higher mortality than other patients.

CONCLUSION

Cardiac catheterization can be performed safely in the early post-operative period, and it could improve the outcome of the patient (depending on the complexity of the cardiac lesions involved).

Single-centre experience in stenting arterial shunts for adult CHD patients with single-ventricle physiology and pulmonary blood flow dependent on arterial shunts

OBJECTIVES

The objectives of this study were to describe the approach to stenting arterial shunts in adult congenital patients with single-ventricle physiology and to assess the medium-term clinical and haemodynamic outcomes following stent insertion.

BACKGROUND

Adult patients with single-ventricle physiology and pulmonary blood flow dependent on a surgically placed arterial shunt who did not progress to venous palliation are extremely challenging to manage. Progressive cyanosis secondary to narrowing of the shunt has a marked impact on exercise tolerance and results in intolerable well-being for these patients. Stenting arterial shunts in adult patients is one method that can help improve pulmonary blood flow. There is very limited information in the literature about this patient.

METHODS

This is a retrospective study for arterial shunts stenting conducted between 2008 and 2016. The peripheral oxygen saturations, the NYHA status, the haemoglobin, and the degree of atrio-ventricular valve regurgitation as assessed on transthoracic echo were compared before and 6-12 months after procedures.

RESULTS

There was a short-term improvement in oxygen saturations; the pre-procedure mean was 75.8 (SD 2.55)% (range 70-85%) and post-procedure mean was 83 (SD 2.52)% (range 78-87%), with a p value of 0.04. Haemoglobin level decreased from a pre-procedure mean of 22.06-20.28 g/L 6 months post procedure (range 18.1-24.4 to 13-23.3 g/L), with a p value of 0.44. NYHA class decreased from a mean of 3.2-2.2 post procedure. Left atrial volume for four of the cases did not change (22.6-76.6 ml [mean 48.4 ml] to 29.6-72.9 ml [mean 52 ml], p value: 0.83).

CONCLUSIONS

Stenting stenotic arterial shunts is a useful method to gain a medium-term improvement on the oxygen saturation and clinical symptoms, and may act as a useful intermediate step for further management plans.

Transcatheter cardiac interventions in neonates with congenital heart disease: A single centre experience

Objective

Percutaneous cardiac catheterization has been used as a diagnostic tool and as a therapeutic option in neonates with congenital heart disease (CHD). This study aimed to evaluate the procedural and short-term follow-up data of newborns who underwent cardiac catheterization procedures.

Methods

This retrospective study reviewed demographic, diagnostic and clinical data from the medical records of newborns who underwent percutaneous transcatheter interventions to treat CHD.

Results

Forty-six newborns were included in the study. The median gestational week and weight were 35.0 weeks and 2723 g, respectively. The median time to the procedure was 7.6 days. Aortic and pulmonary balloon valvuloplasty, ductal stenting, atrial balloon/blade septostomy and coronary fistula embolization procedures were used. The overall success rate was 73.9% (34 of 46 patients) with a complication rate of 28.3% (13 of 46 patients). Eleven patients (23.9%) underwent reinterventions after initial catheterization. Five patients (10.9%) died in the first 48 h after their procedures.

Conclusions

Interventional cardiological procedures applied during the neonatal period provide alternative life-saving methods to surgery, especially in developing countries where surgical outcomes are poor and newborn mortality rates are high.

State of the art of the Fontan strategy for treatment of univentricular heart disease

In patients with a functionally univentricular heart, the Fontan strategy achieves separation of the systemic and pulmonary circulation and reduction of ventricular volume overload. Contemporary modifications of surgical techniques have significantly improved survival. However, the resulting Fontan physiology is associated with high morbidity. In this review, we discuss the state of the art of the Fontan strategy by assessing survival and risk factors for mortality. Complications of the Fontan circulation, such as cardiac arrhythmia, thromboembolism, and protein-losing enteropathy, are discussed. Common surgical and catheter-based interventions following Fontan completion are outlined. We describe functional status measurements such as quality of life and developmental outcomes in the contemporary Fontan patient. The current role of drug therapy in the Fontan patient is explored. Furthermore, we assess the current use and outcomes of mechanical circulatory support in the Fontan circulation and novel surgical innovations. Despite large improvements in outcomes for contemporary Fontan patients, a large burden of disease exists in this patient population. Continued efforts to improve outcomes are warranted. Several remaining challenges in the Fontan field are outlined.

Toxicity of nickel ions and comprehensive analysis of nickel ion-associated gene expression profiles in THP-1 cells

The aim of the present study was to explore the toxic effects and underlying mechanisms of nickel ions during therapeutic nickel‑based alloy‑treatment in congenital heart disease by investigating the metal‑induced cytotoxicity to the human monocyte‑derived macrophage cell line THP‑1. THP‑1 cells were treated with NiCl2·6H2O (25, 50, 100, 200, 400 and 800 µM) for 24, 48 and 72 h, respectively. MTT was applied to detect THP‑1 cell proliferation following NiCl2 treatment. Apoptosis of THP‑1 cells was quantified using flow cytometry. Illumina sequencing was used for screening the associated genes, whose mRNA expression levels were further confirmed by quantitative real‑time polymerase chain reaction. High concentrations of nickel ions had a significant suppressive effect on cell proliferation at the three concentrations investigated (200, 400 and 800 µM). Treatment with nickel ions (25‑400 µM) for 48 h reduced cell viability in a dose‑dependent manner. The mRNA expression levels of RELB, FIGF, SPI‑1, CXCL16 and CRLF2 were significantly increased following nickel treatment. The results of the present study suggested that nickel ions exert toxic effects on THP‑1 cell growth, which may indicate toxicity of the nickel ion during treatment of congenital heart disease. The identification of genes modified by the toxic effects of nickel on THP‑1 cells (EPOR, RELB, FIGF, SPI‑1, TGF‑β1, CXCL16 and CRLF2) may aid in the development of interventional measures for the treatment/prevention of nickel ion‑associated toxic effects during the treatment of congenital heart disease.

Evolving trends in interventional cardiology: endovascular options for congenital disease in adults

As increasing numbers of patients with congenital heart disease enter adulthood, there is a growing need for minimally invasive percutaneous interventions, primarily to minimize the number of repeated surgeries required by these patients. The use of percutaneous devices is commonplace for the treatment of simple lesions, such as atrial septal defect, patent foramen ovale, patent duct arteriosus, and abnormal vascular connections. There is also substantial experience with device closure of membranous and muscular ventricular septal defects, as well as more complex shunts such as baffle leaks after atrial switch repair and ventricular pseudoaneurysms. An increasing use of covered stents has improved the safety of aortic coarctation, conduit, and branch pulmonary stenosis interventions. Percutaneous pulmonary valve implantation now has an established role in the setting of dysfunctional right ventricle-pulmonary artery conduits or failing bioprosthetic pulmonary valves. Many patients remain unsuitable for percutaneous pulmonary valve implantation because of large diameter "native" outflow tracts, however, various techniques have emerged and multiple devices are in development to provide solutions for these unique anatomic challenges. Hybrid approaches involving use of surgical and transcatheter techniques are increasingly common, serving to optimize efficacy and safety of certain procedures; they depend on a collaborative and collegial relationship between cardiac surgeons and interventionalists that is primarily patient-centred.