Transcatheter closure of ventricular septal defects: hemodynamic instability and anesthetic management

Dexmedetomidine-propofol vs ketamine-propofol anaesthesia in paediatric and young adult patients undergoing device closure procedures in cardiac catheterisation laboratory: An open label randomised trial

Background and Aims:

Several drug combinations have been tried in patients with acyanotic congenital heart disease (ACHD) undergoing transcatheter device closure in the cardiac catheterisation laboratory (CCL). Adequate sedation, analgesia, akinesia, cardiorespiratory stability, and prompt recovery are key requirements. Ketamine with propofol is used for this purpose. Dexmedetomidine carries a shorter recovery time. This study compared dexmedetomidine–propofol (DP) with ketamine–propofol (KP) in patients in the CCL.

Methods:

This was an open label randomised trial at a CCL over a 2-year period from August 2012 to August 2014. Fifty-six paediatric and 44 young adults with ACHD underwent device closure and were randomised to receive DP or KP. The primary outcome studied was time to regain full consciousness, airway and motor recovery.

Results:

Baseline characteristics were similar in the study groups. In the DP arm as compared to the KP arm, the time to recovery of consciousness (mean ± SD) was significantly faster in both paediatric patients [30 ± 15 vs. 58 ± 13 min (P < 0.001)] and in young adult patients [22 ± 10 vs. 35 ± 12 min (P < 0.001)]. There was significantly faster motor recovery also (mean ± SD) [paediatric: 25 ± 05 vs. 40 ± 14 (P < 0.001); young adult: 10 ± 05 vs. 22 ± 10 min (P < 0.001)].

Conclusion:

Procedural anaesthesia with DP in paediatric and young adult patients with ACHD undergoing device closure in the CCL resulted in faster recovery of consciousness and motor recovery compared to KP.

The role of systematic reviews in pharmacovigilance planning and Clinical Trials Authorisation application: example from the SLEEPS trial

BACKGROUND

Adequate sedation is crucial to the management of children requiring assisted ventilation on Paediatric Intensive Care Units (PICU). The evidence-base of randomised controlled trials (RCTs) in this area is small and a trial was planned to compare midazolam and clonidine, two sedatives widely used within PICUs neither of which being licensed for that use. The application to obtain a Clinical Trials Authorisation from the Medicines and Healthcare products Regulatory Agency (MHRA) required a dossier summarising the safety profiles of each drug and the pharmacovigilance plan for the trial needed to be determined by this information. A systematic review was undertaken to identify reports relating to the safety of each drug.

METHODOLOGY/PRINCIPAL FINDINGS

The Summary of Product Characteristics (SmPC) were obtained for each sedative. The MHRA were requested to provide reports relating to the use of each drug as a sedative in children under the age of 16. Medline was searched to identify RCTs, controlled clinical trials, observational studies, case reports and series. 288 abstracts were identified for midazolam and 16 for clonidine with full texts obtained for 80 and 6 articles respectively. Thirty-three studies provided data for midazolam and two for clonidine. The majority of data has come from observational studies and case reports. The MHRA provided details of 10 and 3 reports of suspected adverse drug reactions.

CONCLUSIONS/SIGNIFICANCE

No adverse reactions were identified in addition to those specified within the SmPC for the licensed use of the drugs. Based on this information and the wide spread use of both sedatives in routine practice the pharmacovigilance plan was restricted to adverse reactions. The Clinical Trials Authorisation was granted based on the data presented in the SmPC and the pharmacovigilance plan within the clinical trial protocol restricting collection and reporting to adverse reactions.

Current approaches to pediatric heart catheterizations

Sedation for pediatric cardiac catheterization is a common requirement in many institutions. As the field of cardiac catheterization has evolved, the provision of sedation for these procedures has been varied. Increasingly the demand is for dedicated personnel focused on monitoring and delivery of sedation while in the catheterization suite. This article describes the considerations one must use when undertaking these cases.

The anaesthetist and the cardiac catheterisation laboratory

Interventional cardiology is an innovative and expanding field. Anaesthetists are increasingly involved in managing complex congenital and acquired heart lesions in the cardiac catheterisation laboratory. This article provides an overview of common lesions encountered in the cardiac catheterisation laboratory, the anaesthetic management of patients with congenital and acquired heart lesions, the procedures performed and the complications encountered during such procedures.

Occlusion of congenital ventricular septal defects by the buttoned device. "Buttoned device" Clinical Trials International Register

OBJECTIVES

To study the feasibility of congenital ventricular septal defect occlusion by the buttoned device and to establish guidelines for its safe and effective application.

DESIGN

A descriptive study of all patients with a congenital ventricular septal defect undergoing transcatheter occlusion with the buttoned device, from March 1994 to May 1995. These patients were otherwise candidates for elective surgery at their institutions because they had persistence of a significant shunt (Qp:Qs = 1.5-2.1:1, median = 1.7), with left ventricular enlargement and/or symptoms, although their systolic pulmonary artery pressure was invariably normal (20-28 mm Hg, median = 25). The angiographic diameter of the defect ranged from 2.5 to 14 mm (median 6 mm).

SETTING

A multi-institutional study.

PATIENTS

Out of 25 cases attempted, 18 children and adults aged 4-35 years had devices implanted. Fifteen of these patients had membranous ventricular septal defects and three had muscular defects. All patients with a membranous ventricular septal defect had an associated aneurysm of the membranous septum.

INTERVENTIONS

The buttoned device was introduced either directly or, in the last 12 cases, over a wire bridging the femoral artery and the femoral or jugular vein; the devices were delivered through 7-9 French (F) long sheaths. A membranous defect was regarded as suitable for device closure if the distance from the centre of the defect to the insertion of the right coronary aortic valve leaflet was more than 50% of the size of the required device. The device was guided by echocardiography and fluoroscopy. All muscular defects were corrected through the right jugular vein and all membranous ones through the femoral vein.

RESULTS

All 18 patients underwent initial successful implantation of the device. In thirteen patients the shunts were completely occluded and in the remaining five there were trivial residual shunts. In two patients with membranous ventricular septal defects a change from the original position was noticed at two weeks; mild aortic regurgitation developed in one and the murmur recurred in the other; the devices had to be removed surgically. One patient developed transient third degree atrioventricular block during implantation; no tricuspid regurgitation was observed.

CONCLUSION

Clinical occlusion of congenital ventricular septal defects was achieved in 16 out of the 18 attempted cases (13 full occlusions). Membranous ventricular septal defect occlusion can be effective and safe if patients and device sizes are carefully selected.