Congenital pulmonary lymphangiectasia in patient with pulmonary vein stenosis/atresia

No abstract Keywords.

Stenting of stenotic aortopulmonary collaterals in non-surgically treated adolescent or adult patients with pulmonary atresia, ventricular septal defect and multiple aortopulmonary collaterals

OBJECTIVES

To present our experience with stent implantations in non-surgically treated patients with pulmonary atresia, ventricular septal defect and stenotic aortopulmonary collaterals.

METHODS

Between April 2007 and June 2009, 6 stents in 4 patients were implanted into stenosed segments of MAPCAs. The median age and weight of patients at stent implantation were 24 years (range 13-34 years) and 58.5 kg (range 56-70 kg), respectively.

RESULTS

All implantations were successfully performed; there were no procedure associated complications. The median diameter increase of stenosed MAPCAs was 107%. The mean arterial blood saturation increased from mean 78% to 84%. An early increase in the median exercise duration measured by 6MWT was 36%. Neointimal in-stent fibroproliferation in 4/6 stents and stent fracture in 1/6 patients occured in mid-term follow-up.

CONCLUSION

Percutaneous catheterizational stent implantation into stenosed segments of MAPCAs is a palliative procedure, that might improve quality of life of non-surgically treated patients with PA, VSD, MAPCAs. Neointimal in-stent fibroproliferation and stent fracture can be expected as complications in mid-term follow-up. CT-angiography is recommended to confirm these complications in progressive satO2 decrease (Fig. 3, Ref. 12).

The optimal timing for magnetic resonance imaging in long-term follow-up of patients after a complete correction of the Tetralogy of Fallot

OBJECTIVES

Long-term pulmonary regurgitation (PR) leads to right ventricular (RV) dilatation and dysfunction. In patients after a complete correction of the tetralogy of Fallot (TOF) it represents the most frequent and high risk late complication. Magnetic resonance imaging (MRI) is an objective possibility for RV measurements; on the other hand MRI is complicated and not always accessible method.

BACKGROUND

We analyzed echocardiography (ECHO) and MRI parameters regarding RV dilatation and function and the correlation between these two methods with the aim to define optimal ECHO parameters indicating a necessity for further investigations.

PATIENTS AND METHODS

In 50 patients with TOF > 10 years, after a complete surgical correction, ECHO and MRI were performed.

RESULTS

ECHO finding of end-diastolic diameter (EDD) of RV > 30mm was detected in 13 patients (26%) and in 30 patients (60%) RV EDD above 4 standard deviations (SD) their normal values was present. MRI finding of end-diastolic volume (EDV) > 160 ml/m2 was present in 14 patients (28%) and end-systolic volume (ESV) > 85 ml/m2 in 17 patients (34%). Significant correlations between ECHO and MRI RV diastolic measurements were found (p=0.0001, r=0.34, resp. p=0.001, r=0.39). PR was significantly affecting diastolic RV dilatation (p=0.0001), on the other hand. RV dysfunction resulted in systolic RV dilatation (p=0.007). PR did not correlate with RV function (p=0.56).

CONCLUSIONS

MRI is a golden standard for exact RV measurements and for the indication of pulmonary valve replacement, but ECHO still can be used during long-term follow-up, defining the point for further and more exact RV measurements (Tab. 2, Fig. 11, Ref. 17). Full Text in free PDF www.bmj.sk.

Shock--manifestation of pulmonary atresia with aorto-pulmonary collaterals and single ventricle physiology in a 2-day neonate

BACKGROUND

The combination of pulmonary valve atresia and ventricular septal defect accounts for about 2% of cases of congenital heart disease. Most of the cases have intracardiac anatomy of Tetralogy Fallot and present with cyanosis in neonatal age.

OBJECTIVES

To report a case of a newborn with rare combination of pulmonary atresia, ventricular septal defect and single ventricle physiology presenting with shock very early following birth.

METHODS AND RESULTS

We describe a newborn infant who developed shock with severe metabolic acidosis and respiratory distress several hours following birth. Cardiac ultrasound showed pulmonary atresia and ventricular septal defect with single ventricle physiology. Cardiac cathetrisation revealed major aorto-pulmonary collaterals with an excessive pulmonary blood flow. Resuscitative measures resulted in hemodynamic stability. However, due to unfavorable prognosis, a decision not to undertake surgical palliation was made. Withdrawal of intensive care led to rapid demise of the patient.

CONCLUSIONS

We report a case of a newborn with pulmonary atresia, ventricular septal defect and single ventricle physiology in whom an excessive flow through major aorto-pulmonary collaterals led to shock and death very early following birth (Fig. 1, Ref. 5). Full Text (Free, PDF) www.bmj.sk.

The first experience with the high-resolution multi-slice CT-angiography in pediatric cardiology in Slovakia

OBJECTIVES

The high-resolution multi-slice computed tomography angiography (HRMS-CTA) is a new imaging method characterized by a precise isotropic imaging of any cardiovascular system structure. The purpose of this study was to review the first experience with the high-resolution multi-slice HRMS-CTA in pediatric patients with congenital heart defects as well as with acquired cardiac diseases in the Slovak Republic.

METHODS

We retrospectively reviewed benefits of HRMS-CTA and its influence on the subsequent choice of the most appropriate management in 20 patients with pulmonary atresia with ventricular septal defect and multiple aortopulmonary collaterals (PA, VSD, MAPCAs) and in 15 patients with different diagnoses with expected benefit from HRMS-CTA in terms of an exact delineation of extra-cardiac vascular structures.

RESULTS

The delineation of the examined extra-cardiac structures was very detailed and clear in all 35 patients. All findings definitely contributed to the choice of the most appropriate management not only in PA, VSD, MAPCAs patients (20), but also in 15 patients with different diagnoses.

CONCLUSIONS

HRMS-CTA is a new complementary imaging method with the potential to replace invasive catheterization procedures in large number of patients who need extra-cardiac vascular structure imaging (Fig. 1, Ref. 18). Full Text (Free, PDF) www.bmj.sk.

Arrhythmias in congenital heart defects

AIM OF THE STUDY

Evaluation of the incidence and severity of late arrhythmias in patients with predisposing congenital heart defects--either due to the anatomy of the defect itself or as a result of a particular type of surgical intervention.

PATIENTS AND METHODS

In a retrospective long-term study authors analyzed 158 patients (divided into 5 groups) with congenital heart defects after surgical correction. Evaluated were: the incidence of rhythm disturbances, the type of arrhythmia and the need for medication or intervention.

RESULTS

The most rhythm disturbances occurred in patients after physiological correction of D-transposition of the great arteries (68.5%) and these patients also mostly needed medication or pacemaker implantation; followed were by patients with hypoplastic left heart syndrome after Fontan procedure (40%), then were patients after long-term correction of tetralogy of Fallot (31.1%), atrial septal defect sinus venosus type with partial anomalous pulmonary venous return after Warden correction (25.7%) and congenitally corrected L-transposition of the great arteries (25 %). Most of these arrhythmias were asymptomatic and there was no need to treat them. There was an increased incidence of arrhythmias with time (p < 0.05).

DISCUSSION

During childhood in patients after surgical correction late arrhythmias mostly do not represent a severe problem, but with time, when reaching adulthood, this may be an issue. It is therefore very important to understand the anatomy, physiology and the arrhythmogenic substrate of every high risk congenital heart defect (Tab. 2, Fig. 6, Ref. 10).

Neuropsychological outcome in children with hypoplastic left heart syndrome

OBJECTIVES

The purpose of this study is to review a single-institutional experience gained over one decade, to assess late neuropsychological outcome in patients as well as to determine Norwood operation risk factors that are related to patient and procedure and influence these results.

BACKGROUND

The reports of first successful staged operation of hypoplastic left heart syndrome (HLHS) and its numerous modifications have improved the early survival also in patients with complex forms. Specifically, the identification of other specific risk factors related to patient or procedure in the first stage of palliation for HLHS may play a role in cognitive deficit.

METHODS

Single-institutional, cross-sectional study of neurodevelopmental outcome. The mean age at testing was 6.9 +/- 0.3 years. There were 19 patients enrolled with completed psychological testing Standford-Binet test.

RESULTS

The mean neurocognitive results were significantly below the population normative values. The mean full-scale IQ for the entire cohort was 84.1 +/- 8.2. The predictive factors are strongly associated with severe metabolic acidosis, low birth weight, hospital stay over 35 days, prolonged duration of DHA and aortic valve diameter playing an important role in the subsequent psychological outcome, especially in differential subsections of IQ scale (Tab. 2, Ref. 15). Full Text (Free, PDF) www.bmj.sk.

Experiences with fenestration closure in patients after the Fontan operation

BACKGROUND AND OBJECTIVES

[corrected] In this study, decision and timing of fenestration closure are discussed. We review our experiences with transcatheter occlusion of fenestration or residual baffle leak using Amplatzer occluder.

PATIENTS AND METHODS

We have retrospectively reviewed the cath lab records of 26 patients who have undergone closure of fenestration (or another baffle leak) in period of 2002 to July 2006. Patients with the previous fenestrated Fontan procedure (intracardiac lateral tunnel, extracardiac conduit) with the presence of clinically important cyanosis, arterial desaturation less than 88 %, previously described leak by echocardiography, impaired exercise capability, absence of effusions and appropriate hemodynamic parameters were included in the study.

RESULTS

The most frequent group were patients with hypoplastic left heart syndrome (HLHS) (27 %), second most common was L-transposition of great vessels (TGA), tricuspidal valve atresia (TA) and atresia of pulmonary artery (PA) (all of them 15.4 %).

CONCLUSIONS

Our results confirm that after adjusting the hemodynamical risk, transcatheter fenestration occlusion in high risk patients might be a safe and effective method to significantly increase arterial O2 saturation. The long term benefits of closure especially at exertion are yet to be shown (Tab. 2, Ref 21). Full Text (Free, PDF) www.bmj.sk.

Echocardiographic measurements of the aorta in normal children and young adults

BACKGROUND

To be able to determine aortic valve and ascending aorta pathology, especially aortic root dilatation, it is important to establish normal aortic dimensions. The aim of the study was to measure the dimensions of the aorta in normal healthy children and young adults in Slovakia.

PATIENTS AND METHODS

702 healthy subjects, from newborns to 20 years of age, were examined at our institution. The study was carried out prospectively, by a single observer, using digitized two-dimensional (2D), Doppler and M-mode echocardiography. The aorta was measured at 3 sites: 1. aortic valve annulus, 2. sinuses of Valsalva, 3. sinotubular junction. Patients were divided into 28 groups according to their body surface area (BSA)--from 0.15 to 2.0 m2. All data were statistically evaluated (mean value, 5th and 95th percentile for all BSA groups) and regression equations were calculated for each parameter.

RESULTS

All 3 measured aortic parameters correlated closely. Measures of correlation (R-squared) for aortic parameters with the square root of BSA were high: 0.89 for aortic valve annulus, 0.86 for sinuses of Valsalva and 0.86 for sinotubular junction (Tab. 3, Fig. 7, Ref 13). Full Text (Free, PDF) www.bmj.sk

Percutaneous closure of perimembranous ventricular septal defects with the eccentric Amplatzer device: multicenter follow-up study

Using an Amplatzer membranous eccentric occluder, 186 patients with an average weight of 43.5 kg (range 12.5-77) underwent attempted catheter closure of a perimembranous venricular septal defect (PMVSD). Their age ranged from 3 to 51 years, with the an average age being 15.9 years. The patients were divided into three groups according to morphology of PMVSD: 106 patients with single PMVSD, 63 patients with single PMVSD with aneurysmatic formation, and 17 patients with multiple VSD with aneurysmatic formation. Using angiography, PMVSDs were measured to be between 2.5 and 12 mm, with an average of 5.1 mm. In the third group of patients, we did not measure the size of PMVSD and a device was selected according to the size of entry to the aneurysm. The device was successfully implanted in all patients. The immediate closure rate was 90% in the first group, increasing to 100% at 1 month and remained at that level during follow-up. The immediate closure rate in the second group was 98% and remained the same during follow-up. The immediate closure rate in the third group was 89% and during 1 year of follow-up remained the same. There was no clinical evidence of hemolysis and no incidence of device embolization or bacterial endocarditis after implantation. Before the procedure, all patients showed normal electrocardiogram (ECG) or left ventricle enlargement. After the procedure (at least 3 months later) ECG showed left anterior hemiblock (LAH) in nine patients, complete right bundle branch block in eight patients, and incomplete right bundle branch block in seven patients. A complete heart block (CHB) developed in 2 patients after the procedure (1.07%). The first patient developed LAH immediately after closure and CHB within 24 hours, The heart rate was 28 beats per minute. After treatment with steroids and atropine, CHB changed to sinus rhythm with LAH within 2 months. One year later, the ECG revealed the same findings. The second patient developed CHB immediately after the procedure and was on temporary pacing for 1 week. After 1 month, the patient recovered to sinus rhythm and ECG showed LAH.

Is a learning curve for arterial switch operation in small countries still acceptable? Model for cooperation in Europe

OBJECTIVES

To assess the results of a cooperative arrangement between Slovakia and Slovenia for neonatal cardiac surgery. The aim of the study was to analyze the performance of this approach for complete transposition of the great arteries (D-TGA).

METHODS

Due to the overall small number of new patients with D-TGA in Slovenia a decision was made to avoid a prolonged learning curve by centralizing the experience of two countries at one center. Since 1995 the center in Slovakia has become the only referral center for Slovenia. Between February 1993 and June 2002 in this center, 147 patients with D-TGA underwent arterial switch operation (ASO). The median age at operation was 11 days, with 110 patients from Slovakia and 37 patients from Slovenia.

RESULTS

Overall hospital mortality was 4.8% (seven patients). The 1, 2, 3, 4 and 5 year survival rate was 95% with the mean follow-up of 4 years. Operation before 1997 (P=0.0001) was identified as a risk predictor for death by multivariate analysis. There are no deaths among the 90 patients operated on after 1996. All patients are without medication with normal left ventricular function. Stenosis (gradient >30 mmHg) was noted in the pulmonary artery reconstruction in seven patients (5%). More than mild aortic regurgitation was noted in five patients (4%). The incidence of redo or reintervention was 5% at 5 years of follow-up.

CONCLUSIONS

In the current era a prolonged learning curve for ASO is not acceptable to most European countries and their patients. The risk of surgery can be minimized by concentrating surgical experience as part of the quality control of congenital heart programs. If the number of new patients is small due to the birth rate and size of the population, institutions should merge activity. Such centralization amplifies the experience to the benefit of the patient.

[Transcatheter closure of ostium secundum atrial septal defects--initial experience with treatment of adult patients]

The authors present their initial experience with the use of Amplatzer septal occluder for transcatheter closure of secundum atrial septal defect. For patients where the secundum atrial septal defect type is haemodynamically significant or when paradoxical embolization via the defect is suspected, the catheterization technique is an alternative for cardiosurgical correction of the defect. The morphology of the defect which is the basic criterium for indication of a transcatheter closure is evaluated on transoesophageal echocardiographic examination. The closure takes place under skiascopic and transoesophageal echocardiographic control. The procedure in all three patients (2 women--age 58 and 62 years, 1 man--24 years) treated at our department was without complications. Consistent with formerly published data it may be concluded from our initial experience that when all indication criteria are respected the closure of secundum atrial defect by means of Amplatzer septal occluder is a safe technique and a relatively easy operation with a high rate of primary success.

The role of transesophageal echocardiography in transcatheter closure of secundum atrial septal defects by the Amplatzer septal occluder

BACKGROUND

Our purpose was to determine the role of transesophageal echocardiography (TEE) in the closure of atrial septal defects by the Amplatzer septal occluder (ASO) (AGA Medical, Golden Valley, Minn).

METHODS

A total of 240 patients with atrial septal defect (ASD) secundum were examined by transthoracic 2-dimensional echocardiography (TTE) and TEE to determine the ASD morphologic features, diameter, and rims. During transcatheter closure TEE was used for determination of the ASD diameter and guidance of the ASO implantation.

RESULTS

Sixteen (6%) patients were found not suitable for transcatheter closure with TTE, 35 (14%) with TEE, and 2 during catheterization. Twenty-eight patients (18%) had partial or total deficiency of the posterior, inferoanterior, or inferoposterior rim, 54 (27%) had a centrally positioned ASD, 92 (46%) had insufficient superoanterior rim, and 9 had multiple ASDs, whereas 8 had a septal aneurysm associated with a single defect and 4 a multiperforated aneurysm. A total of 170 patients underwent implantation of ASO. The ASO was correctly positioned in 144 at the first attempt. In the remainder TEE revealed unstable position of the left atrial disk (12), opening of both atrial disks in the left atrium (5), deployment of the device through the smaller defect in patients with multiple ASDs (3), and, in 1 patient, the device was too small and had to be replaced by a larger one.

CONCLUSIONS

Morphologic variations of the ASD are common. TEE is crucial for the determination of the ASD morphologic features, diameter, and rims, which are crucial for proper patient selection. TEE allows precise guiding and positioning of the ASO, which is essential for safe and effective transcatheter ASD closure.

Morphological variations of secundum-type atrial septal defects: feasibility for percutaneous closure using Amplatzer septal occluders

The aim of the study was to assess the morphology of secundum-type atrial septal defects (ASD) with a view to percutaneous closure using Amplatzer septal occluders (ASO). One hundred and ninety patients who underwent closure of isolated secundum-type ASD between September 1995 and January 2000 were included. The morphology of the defects was studied using transthoracic and transesophageal echocardiography. Patients with defects of suitable morphology and size underwent percutaneous closure using ASO. The remaining patients underwent surgical closure. Centrally placed defects were observed in 46 patients (24.2%). Morphological variations of secundum-type ASD were detected in 144 patients (75.8%). One hundred and fifty-one patients (79.5%) underwent percutaneous closure using ASO. Thirty-nine patients (20.5%) underwent surgical closure. Centrally placed defects, defects with deficient superior anterior rim, multiple defects, and perforated aneurysms of the interatrial septum are morphological variations of secundum-type ASD suitable for percutaneous closure using ASO. Cathet Cardiovasc Intervent 2001;53:386-391.

"Cobra-like" deformation of an Amplatzer septal occluder

Transcatheter occlusion of secundum atrial septal defects using Amplatzer septal occluders (ASOs) is a safe, simple, and effective alternative to surgical closure. We present the first report of a "cobra-like" shape deformation of the device encountered during inappropriate positioning. The complication is reversible and is easily avoidable.

Early experience with the Amplatzer ductal occluder for closure of the persistently patent ductus arteriosus

Using an Amplatzer duct occluder, 106 patients (weight 21 +/- 18 kg) underwent an attempt at catheter closure of a persistently patent ductus arteriosus (PDA). Their age ranged from 22 days to 48 years. The PDA measured between 1.2 to 8.1 mm at its narrowest diameter. The device was successfully implanted in 105 patients. The immediate closure rate was 70% and gradually increased to 100% at 1-month follow-up. There was no clinical evidence of hemolysis and no incidence of device embolization or bacterial arteritis. Doppler evaluation showed no evidence of aortic arch or pulmonary artery obstruction. The device, which is currently undergoing multicenter clinical trial in the United States, is proving to be a safe and effective device for closure of the persistently PDA.

Percutaneous closure of patent ductus arteriosus: complementary use of detachable Cook patent ductus arteriosus coils and Amplatzer duct occluders

Several different devices were evaluated for the percutaneous closure of patent ductus arteriosus (PDA), and important drawbacks were found in all of them. To overcome these drawbacks, both detachable Cook PDA coils and Amplatzer duct occluders (ADO) were used for the percutaneous closure of PDA. A total of 54 patients underwent transcatheter occlusion of PDA at a median age of 4.5 years (range 0.5-29 years) and at a median weight of 19.5 kg (range 6-69 kg). Three patients were adults. Detachable Cook PDA coils were used in 26 patients with a median PDA diameter of 1.7 mm (range 1.1-2.2 mm) and ADO were used in 28 patients with a median PDA diameter of 3.8 mm (range 1.9-7.5 mm). Devices were successfully implanted in all 54 patients. Complete closure was achieved in 53 of 54 patients (98% closure rate). Median fluoroscopy time was 12 min (range 4-47 min).

CONCLUSION

According to our experience, the complementary use of detachable Cook patent ductus arteriosus coils and Amplatzer duct occluders for the percutaneous closure of PDA can be recommended.

Transcatheter occlusion of residual patent ductus arteriosus after surgical ligation

The reported frequency of residual leaks after surgical ligation of patent ductus arteriosus (PDA) varies from 6% to 23%. Reports on percutaneous closure of PDA also involve patients with residual PDA after ligation, but specific data regarding this type of PDA are rare. Our objective was to assess retrospectively the characteristics of residual PDA relevant to transcatheter closure and occlusion results using three types of occluders. Twelve consecutive patients underwent transcatheter occlusion of residual PDA after surgical ligation at a median age of 4.6 years (range 3. 2-44.6 years) and median weight 16.5 kg (range 13-62 kg). Three types of occluder were used: Gianturco coils, detachable Cook PDA coils, and the new Amplatzer duct occluder. The median diameter of residual PDA after ligation was 1.5 mm (range 0.9-4.2 mm). All PDAs were of type A morphology. Thirteen devices were successfully placed in the 12 patients, without embolization. There were no complications. At 1 month and 1 year follow-up all residual shunts were completely closed. Coils are particularly suitable for complete closure of residual leaks after surgical ligation of PDA. A 100% closure rate was achieved with a low number of implanted coils.

Undetected cardiogenic shock in patients with congestive heart failure presenting to the emergency department

The purpose of this study was to examine the use of lactic acid levels and continuous central venous oxygen saturation (central venous oximetry) to stratify and treat patients with acutely decompensated end-stage chronic congestive heart failure (CHF) presenting to the emergency department. This prospective, convenience, non-outcome study was performed at an urban tertiary care hospital. Patients with end-stage CHF with an ejection fraction <30% presenting in decompensated CHF were eligible for the study. Patients were assessed using the Killip classification and New York Heart Association criteria. After lactic acid levels were obtained, patients were managed according to a standardized protocol guided by central venous oximetry. The patients were divided into high lactic acid (n = 22), low lactic acid (n = 5), and control groups (stable patients presenting to a cardiology clinic, n = 17) for comparison. There was no statistical difference in vital signs, or Killip and New York Heart Association criteria among the 3 groups. Central venous oxygen saturation was significantly lower in the high lactic acid group (32 +/- 12%) than in the normal lactic acid (51 +/- 13%) and control groups (60 +/- 6%) (p < 0.001). After treatment there was a significant decrease in lactic acid (-3.65 +/- 3.65 mM/L) and an increase in central venous oxygen saturation (32 +/- 13%) in the high lactic acid group compared with the normal lactic acid group (p < 0.001). A significant subset of patients with decompensated end-stage CHF present to the emergency department in occult shock and are clinically indistinguishable from patients with mildly decompensated CHF and stable CHF. Once identified, these patients require aggressive alternative management and disposition. Further study is necessary to identify whether this intervention impacts morbidity, mortality, and health care resource consumption.

Catheter closure of moderate- to large-sized patent ductus arteriosus using the new Amplatzer duct occluder: immediate and short-term results

OBJECTIVES

The aim of this study was to assess the immediate and short-term results of anterograde catheter closure of a moderate- to large-sized patent ductus arteriosus (PDA) using the new self-expandable, respositionable Amplatzer duct occluder (ADO) device.

BACKGROUND

Transcatheter closure of a PDA using devices or coils is technically challenging and may be accompanied by a 38% incidence of residual shunts.

METHODS

Twenty-four patients (6 male, 18 female) underwent attempted transcatheter closure of a PDA using the ADO at a median age of 3.8 years (range 0.4 to 48) and a median weight of 15.5 kg (range 6 to 70). The mean PDA diameter at its narrowest segment was 3.7+/-1.5 mm. A 6F long sheath was used for delivery of the ADO. Follow-up evaluation was performed with color flow mapping of the main pulmonary artery within 24 h and at 1 and 3 months after closure.

RESULTS

Twenty three of the 24 patients had successful device placement. Angiography showed that 7 patients had complete immediate closure, 14 had a trace shunt (foaming through the device with no jet), and 2 had a small residual shunt (with a jet). Within 24 h, color Doppler revealed complete closure in all patients. The unsuccessful attempt was during an initial trial with a prototype that has been modified. The median fluoroscopy time was 13.5 min (range 6.3 to 47). All patients were discharged home the next day. There were no complications. Of the 23 patients, 21 completed the 1-month follow-up, all (95% confidence interval [CI] 86% to 100%) with complete closure, and 18 of 23 patients completed the 3-month follow-up, also all (95% CI 83% to 100%) with complete closure.

CONCLUSIONS

Anterograde transcatheter closure using the new ADO is an effective therapy for patients with a PDA diameter up to 6 mm. Further clinical trials are underway.

Transcatheter closure of secundum atrial septal defects using the new self-centering amplatzer septal occluder: initial human experience

Transcatheter closure of secundum atrial septal defect (ASD) using clamshell or buttoned devices is accompanied by a high incidence of residual shunt. Recently, a new self-centering device, the Amplatzer septal occluder (ASO), has been evaluated in an animal model with very good results. Therefore, our purpose is to report on our initial clinical experience with this device. Thirty patients underwent an attempt at catheter closure of their ASDs at a median age of 6.1 yr (range, 2.9-62.4 yr) and median weight of 22 kg (range, 13-69 kg) using the ASO. The median ASD diameter measured by transesophageal echocardiography (TEE) was 12.5 mm (range, 5-21 mm), and the median ASD balloon stretched diameter was 14 mm (range, 7-19 mm). All patients had right atrial and ventricular volume overload with a mean +/- SD Qp/Qs of 2.3 +/- 0.6. A 7F catheter was used for delivery of the device in all patients. The device was placed correctly in all patients. There was immediate and complete closure (C) in 17/30 patients, 10 patients had trivial residual shunt (TS), and 3 had moderate residual shunt (MS). The median fluoroscopy time was 15 min (range, 8-35 min), and the median total procedure time was 92.5 min (range, 40-135 min). There was no episode of device embolization or any other complication. Follow-up was performed using transthoracic echocardiography (TTE) 1 day, 1 mo, 3 mo, and yearly thereafter. At 1 day, there was C of the ASD in 24/30 patients, 3 had TS, 1 had small shunt (SS), and 2 had MS. At a median follow-up interval of 6 mo, there have been no episodes of endocarditis, thromboembolism, or wire fracture. We conclude that the use of the new ASO is safe and effective in complete closure of secundum ASDs up to a diameter of 21 mm in the majority of patients. Further clinical trials are underway.

Percutaneous closure of patent ductus arteriosus using special screwing detachable coils

Jackson screwing detachable coils, developed for arterial and venous embolization, have been successfully employed recently for the percutaneous occlusion of patent ductus arteriosus (PDA). Special screwing detachable coils were designed for closure of the PDA, and the experience gained by their use is described in this report. Occlusion was attempted in 29 patients with a minimal ductal diameter of 0.9-4.2 mm. Coils were successfully placed in all 29 patients. One coil, which embolized 10 min after detachment, was retrieved. In 26 patients (89%), complete closure was achieved. Only 35 coils were placed in 29 patients. Residual shunts in three patients are minimal, detectable only on color-flow mapping. Screwing detachable coils for closure of PDA are safe and effective for occlusion of PDA with a minimal diameter < 4.2 mm. Embolization of the coil is very rare. A high closure rate is achieved with a low number of placed coils.

Effects of warfarin on markers of hypercoagulability in patients with heart failure

Heart failure is associated with a hypercoagulable state. A single-center, randomized, double-blind, placebo-controlled trial was performed to test the hypothesis that warfarin will modify a hypercoagulable state in heart failure. This study included 76 patients with heart failure. At baseline, patients had evidence for a hypercoagulable state with elevated plasma levels of thrombin/antithrombin III (TAT) complexes (3.4 +/- 2.0 ng/ml), prothrombin fragment F1 + 2 (1.5 +/- 0.9 nmol/L), and D-dimers (630 +/- 401 ng/ml). Warfarin therapy (international normalized ratio [INR] 2.7 +/- 1.3) significantly decreased plasma levels of TAT complexes (p < 0.002), F1 + 2 (p < 0.001), and D-dimers (p < 0.001) when compared with baseline values at 1, 2, and 3 months of therapy. In contrast, patients receiving placebo had persistent elevation of TAT complexes (p = not significant [NS]), F1 + 2 (p = NS), and D-dimers (p = NS) during follow-up at 1, 2, and 3 months. The two treatment groups followed different trends over time for all three markers (p < 0.001). The effect of low-intensity warfarin (INR 1.3 +/- 0.08) versus moderate-intensity warfarin (INR 2.3 +/- 1.1 ) on markers of hypercoagulability was evaluated in 14 patients. When compared with baseline, low-intensity warfarin administration decreased plasma levels of TAT complexes (p = NS), F1 + 2 (p = 0.05), and D-dimers (p = 0.04). In these patients F1 + 2 was further reduced with moderate-intensity warfarin (p < 0.001). Our findings suggest that a hypercoagulable state in heart failure can be modified by warfarin therapy.

Five-year follow-up after balloon pulmonary valvuloplasty

OBJECTIVES

The aim of this study was to assess results 5 years after balloon pulmonary valvuloplasty.

BACKGROUND

Since the technique of balloon pulmonary valvuloplasty was first reported in 1982, it has become the treatment of choice for pulmonary valve stenosis. In contrast to surgical valvotomy, the long-term outcome after balloon pulmonary valvuloplasty is unknown.

METHODS

We reviewed the findings in 34 patients 5.2 +/- 0.8 (mean +/- SD) years after balloon pulmonary valvuloplasty: 27 with isolated pulmonary stenosis, 5 with Noonan syndrome and 2 with previous surgical valvotomy. In eight patients (three with Noonan syndrome), a second balloon valvuloplasty was the index procedure for analysis.

RESULTS

The transpulmonary gradient (mm Hg) was 74 +/- 34 before balloon pulmonary valvuloplasty, 36 +/- 26 immediately after, 22 +/- 9 at cardiac catheterization in 29 patients 6 +/- 0.6 months later and 19 +/- 10 by Doppler study at 5 years. At 5 years 26 patients (group A) had a residual gradient of < or = 20 mm Hg; the remaining 8 (group B) had a gradient of > 20 mm Hg. Four group B patients had Noonan syndrome (p = 0.01). Balloon/pulmonary valve diameter ratio was larger for group A patients than for group B patients with isolated pulmonary stenosis (1.20 +/- 0.10 vs. 1.00 +/- 0.07, p = 0.005); larger balloons were used in group B patients with Noonan syndrome (1.30 +/- 0.10). Group A patients were more likely than group B patients to have significant pulmonary incompetence (6 of 24 vs. 0 of 8) and had a greater right ventricle/left ventricle long-axis diastolic dimension ratio (0.47 +/- 0.10 vs. 0.35 +/- 0.04, p = 0.05). In the subgroup of five patients with Noonan syndrome and two with prior surgical valvotomy, the transpulmonary gradient was reduced from 74 +/- 24 mm Hg before balloon valvuloplasty to 23 +/- 12 mm Hg at 5 years. In addition, two patients with isolated pulmonary valve stenosis had pulmonary valve dysplasia by angiographic criteria: transpulmonary gradients of 85 and 56 mm Hg were reduced to 20 and 11 mm Hg, respectively, at 5 years.

CONCLUSIONS

Relief of obstruction persists at 5 years especially if oversized balloons are used. Acceptable results can be obtained in patients with a dysplastic valve. More complete relief of right ventricular outflow gradient is associated with increased right ventricular dimension, probably because more pulmonary incompetence is induced. This is well tolerated at 5 years but may be important in the longer term.

[Familial supravalvular aortic stenosis]

By means of two dimensional echocardiography supravalvular aortic stenosis was diagnosed in two siblings and their cousin. Autosomal dominant transmission with incomplete penetrance or even non-penetrance is assumed to be involved. Somatic stigmatization, typical for Williams' syndrome, failed to be present in the affected children. The reported family provides further evidence that familial supravalvular aortic stenosis and Williams' syndrome are two distinct clinical entities. (Tab. 1, Fig. 3, Ref. 23.)

[How can the Williams-Beuren syndrome be recognized?]

In a girl with Williams-Beuren's syndrome psychological examination revealed mental retardation with a special mental profile, angiography revealed peripheral pulmonary stenoses, echocardiography a slight stenosis in the supravalvular aortal area and anthropometry typical facial signs. Indirect signs of hypercalcaemia were clinical signs of poor progress during infancy. The authors emphasize that accurate analysis of basic clinical signs and the natural development of the disease are the key to its diagnosis.

[Diagnosis of supravalvular aortic stenosis using 2-dimensional echocardiography]

In 13 children supravalvular aortic stenosis was diagnosed by two-dimensional echocardiography on the basis of a diminished inner diameter of the aorta in the supravalvular region "d2" compared with the inner diameter of the aortic annulus "d1". The differences in the values of "d2" and "d1" were only on the border of statistical significance. The difference in the d2/d1 ratio between the group of patients and healthy controls was statistically significant (p less than 0.001). Two-dimensional echocardiography is a very sensitive method for diagnosing supravalvular aortic stenosis. This sensitivity has been confirmed also by detecting the diminished inner diameter of the aorta in the supravalvular region in children with Williams-Beuren syndrome without clinical signs of a heart defect.

[Myocarditis in childhood]

In a group of 82 children followed up for prolonged periods the authors draw attention to some problems of virus myocarditis. They focused attention on the diagnosis of Coxsackie myocarditis for which they elaborated a scoring system. Based on this system they separated the prognostically most adverse group where cardiac decompensation was the dominant sign from the very beginning. They confirmed the theoretical assumption that in some children virus myocarditis develops into cardiomyopathy. This was proved in six children by histological examination and in 19 children by means of echocardiography.

Post-traumatic coronary occlusion and its consequences in a young child

A 250-kg metal plate fell on a six-year-old boy. The resulting internal, nonpenetrating trauma caused multiple coronary arterial occlusions leading to complete heart block and ischemic changes in the electrocardiogram. Later two left ventricular aneurysms developed that were resected.