Intra-stent aortic wall aneurysm formation after Be-graft covered stent implant

Aortic wall injuries may occur after interventional treatment of aortic coarctation (CoA), especially after balloon angioplasty. We reported on a patient who presented with an intra-stent aneurysm formation after direct stenting of a native near atretic aortic CoA by using a BeGraft Aortic stent. This evidence supports the need to maintain a strict follow-up protocol. A computed tomography scan is mandatory, after covered stent implantation as well, especially in high-risk cases and even in the absence of any immediate apparent complication.

CRISP: Catheterization RISk score for Pediatrics: A Report from the Congenital Cardiac Interventional Study Consortium (CCISC)

OBJECTIVES

We sought to develop a scoring system that predicts the risk of serious adverse events (SAE's) for individual pediatric patients undergoing cardiac catheterization procedures.

BACKGROUND

Systematic assessment of risk of SAE in pediatric catheterization can be challenging in view of a wide variation in procedure and patient complexity as well as rapidly evolving technology.

METHODS

A 10 component scoring system was originally developed based on expert consensus and review of the existing literature. Data from an international multi-institutional catheterization registry (CCISC) between 2008 and 2013 were used to validate this scoring system. In addition we used multivariate methods to further refine the original risk score to improve its predictive power of SAE's.

RESULTS

Univariate analysis confirmed the strong correlation of each of the 10 components of the original risk score with SAE attributed to a pediatric cardiac catheterization (P < 0.001 for all variables). Multivariate analysis resulted in a modified risk score (CRISP) that corresponds to an increase in value of area under a receiver operating characteristic curve (AUC) from 0.715 to 0.741.

CONCLUSION

The CRISP score predicts risk of occurrence of an SAE for individual patients undergoing pediatric cardiac catheterization procedures.

Use of local anesthetic (0.25% bupivacaine) for pain control after pediatric cardiac catheterization: A randomized controlled trial

OBJECTIVES

To investigate the effects of local infiltration of 0.25% bupivacaine on post-operative pain and analgesic use in children undergoing cardiac catheterization procedures.

BACKGROUND

In pediatric catheterization procedures performed under general anesthesia, a local anesthetic is often used prior to femoral sheath removal. There are no published reports of the impact of local anesthetic infiltration on pain after pediatric procedures, and mixed reports on its effectiveness in adults.

METHODS

A randomized controlled trial was undertaken of 140 children, aged 7-18 years undergoing cardiac catheterization under general anesthesia via the femoral vein or artery. Participants received a subcutaneous infiltration of 0.25% bupivacaine at the access site prior to sheath removal, or usual care without bupivacaine. Outcomes included patient reported pain scores and analgesic use up to 6 hr after the procedure.

RESULTS

Pain scores were similar between groups through the 6-hr post-procedure period. The proportion of children reporting a maximal pain score of ≤2/10 was higher in the bupivacaine group (64% vs. 44%, P = 0.03). A significantly higher proportion of children in the control group required IV morphine (18.8% vs. 4.5%, P = 0.02).

CONCLUSIONS

Morphine use can be reduced with the use of 0.25% bupivacaine given prior to femoral sheath removal and should be considered for post-procedural pain control for pediatric patients undergoing cardiac catheterization. This study is the first to contribute evidence to the effectiveness of 0.25% bupivacaine after pediatric cardiac catheterization.

Iatrogenic aortopulmonary communications after transcatheter interventions on the right ventricular outflow tract or pulmonary artery: Pathophysiologic, diagnostic, and management considerations

OBJECTIVES

To investigate the spectrum, etiology, and management of traumatic aortopulmonary (AP) communications after transcatheter interventions on the pulmonary circulation.

BACKGROUND

An iatrogenic AP communication is an unusual complication after balloon pulmonary artery (PA) angioplasty or stenting, or transcatheter pulmonary valve replacement (TPVR). However, with the increasing application of transcatheter therapies for postoperative PA stenosis and right ventricular outflow tract (RVOT) dysfunction, including percutaneous pulmonary valve replacement, consideration of the etiology, diagnosis, and management of this problem is important for interventional cardiologists performing such procedures.

METHODS AND RESULTS

We present three new cases, as well as gross anatomy and histopathology data, related to AP communications after PA interventions. We also review the literature relevant to this topic. Including these new cases, there have been 18 reported cases of iatrogenic AP communication after transcatheter interventions on the PAs or RVOT, primarily patients with transposition of the great arteries who underwent PA angioplasty after an arterial switch operation, or after TPVR in patients who had undergone a Ross procedure. The likely cause of such defects is PA trauma plus distortion of the neo-aortic anastomosis resulting from angioplasty or stenting of the RVOT or central PAs, with subsequent dissection through the extravascular connective tissue and into the closely adjacent vessel through the devitalized tissue at the anastomosis.

CONCLUSIONS

Cardiologists performing PA or RVOT interventions should be aware of the possibility of a traumatic AP communication and consider this diagnosis when confronted with suggestive signs and symptoms.

Self-repositioning of an embolized patent ductus arteriosus device--a nightmare turned into sweet dreams

A 7-month-old boy was admitted for the device closure of symptomatic patent ductus arteriosus (PDA) with moderate pulmonary hypertension. The PDA measured 4.2 mm with adequate ampulla. It was closed with an 8-6 mm Heart R device from pulmonary artery (PA) end. Post extubation, the device embolized to proximal descending thoracic aorta just distal to PDA ampulla. While attempting to snare from the venous side, the device self-repositioned to PDA. It was stable thereafter and patient was discharged after 2 days. We report a complication, which got self-corrected.

Device therapy for atrial septal defects in a multicenter cohort: acute outcomes and adverse events

BACKGROUND

Secundum atrial septal defect (ASD) closure devices were granted approval based on industry-sponsored, prospective, nonrandomized, single device studies, demonstrating acceptable efficacy and safety in selected patients. We sought to report community practice and outcomes.

METHODS AND RESULTS

Procedure specific data was collected on cases considered for ASD closure in the congenital cardiac catheterization project on outcomes (C3PO) between February 1, 2007 and June 31, 2010. Eight centers contributed data during this time period. All adverse events (AE) were independently reviewed and classified by a five level severity scale. In 40 months (2/07-6/10), 653 of 688 ASDs were occluded with a single device using an AMPLATZER(®) Septal Occluder (ASO) in 566 (87%), GORE(®) HELEX(®) Septal Occluder (HSO) in 33 (5%), and a CardioSEAL(®) or STARFlex™ device (CSD) in 54 (8%). Most patients had an isolated ASD (93%). 85% were >2 years of age. The ASD median diameter was 12 mm [8,16] for ASO, with smaller diameters in HSO 8 mm [7,10] and CSD 8 mm [5,10] (P < 0.001). AE (n = 82) were recorded in 76 cases, 11.5% (95% CI 9.2%, 14.1%) and classified as high severity in 4.7% (95% CI 3.2%, 6.5%), with no mortality. A new conduction abnormality was detected during 15 cases and did not resolve in one. Transcatheter device retrieval was possible in 7 of 10 device embolizations. Device erosion occurred in 3 of 566, 0.5% (95% CI 0.1%, 1.5%), ASO implants.

CONCLUSION

Although device closure of ASDs is associated with low morbidity and rare mortality, ongoing assessment of device safety profiles are warranted, and registries offer opportunities to facilitate the required surveillance.

Iatrogenic left pulmonary artery to left atrium fistula

Trans-catheter balloon angioplasty is a well-established treatment modality for pulmonary artery (PA) stenosis in children with congenital heart disease. We report a case of an unusual complication where a fistula developed between the left PA and the left atrium during balloon angioplasty in a patient with history of tetralogy of Fallot. This was successfully treated with placement of a covered stent.