We describe a patient with chronic thromboembolic pulmonary hypertension who presented to the pediatric cardiac catheterization laboratory for peripheral pulmonary artery recanalization and ...angioplasty. This case report outlines serial pulmonary arterial rehabilitation via a retrograde approach through intrapulmonary collateral arterial connections.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Objectives
To devise a classification scheme for ductal morphology in patients with ductal dependent pulmonary blood flow (PBF) that can be used to assess outcomes.
Background
The impact of ductal ...morphology on outcomes following patent ductus arteriosus (PDA) stenting is not well defined.
Methods
Patients <1 year of age who underwent PDA stenting for ductal dependent PBF at the four centers comprising the Congenital Catheterization Research Collaborative (CCRC) were included. A classification scheme for PDA morphology was devised based on a tortuosity index (TI)—Type I (straight), Type II (one turn), and Type III (multiple turns). A subtype classification was used based upon the ductal origin.
Results
One hundred and five patients underwent PDA stenting. TI was Type I in 58, Type II in 24, and Type III in 23 PDAs, respectively. There was a significant association between ductal origin and vascular access site (p < 0.001). Procedure times and need for >1 stent did not differ based on TI. Greater TI was associated with pulmonary artery (PA) jailing (p = 0.003). Twelve (11.4%) patients underwent unplanned reintervention, more commonly with greater TI (p = 0.022) and PA jailing (p < 0.001). At the time of subsequent surgical repair/palliative staging, PA arterioplasty was performed in 32 patients, more commonly when a PA was jailed (p = 0.048). PA jailing did not affect PA size at follow up.
Conclusions
The proposed qualitative and quantitative PDA morphology classification scheme may be helpful in anticipating outcomes in patients with ductal dependent PBF undergoing PDA stenting.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Cardiovascular disease (CVD) remains the leading cause of death in the United States. However, percutaneous interventional cardiovascular therapies are often underutilized in Blacks, Hispanics, and ...women and may contribute to excess morbidity and mortality in these vulnerable populations. The Society for Cardiovascular Angiography and Interventions (SCAI) is committed to reducing racial, ethnic, and sex‐based treatment disparities in interventional cardiology patients. Accordingly, each of the SCAI Clinical Interest Councils (coronary, peripheral, structural, and congenital heart disease CHD) participated in the development of this whitepaper addressing disparities in diagnosis, treatment, and outcomes in underserved populations. The councils were charged with summarizing the available data on prevalence, treatment, and outcomes and elucidating potential reasons for any disparities. Given the huge changes in racial and ethnic composition by age in the United States (Figure 1), it was difficult to determine disparities in rates of diagnosis and we expected to find some racial differences in prevalence of disease. For example, since the average age of patients undergoing transcatheter aortic valve replacement (TAVR) is 80 years, one may expect 80% of TAVR patients to be non‐Hispanic White. Conversely, only 50% of congenital heart interventions would be expected to be performed in non‐Hispanic Whites. Finally, we identified opportunities for SCAI to advance clinical care and equity for our patients, regardless of sex, ethnicity, or race.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Objective
The purpose of this study was to review the outcomes following the percutaneous carotid arterial (PCA) approach in infants and children with congenital heart disease.
Background
PCA access ...is becoming more commonly adopted following reports demonstrating it is a safe alternative to surgical carotid cutdown and even the femoral arterial route. However, follow‐up outcomes after PCA remain unreported.
Methods
We reviewed all cases with PCA access and follow‐up catheterizations which included carotid artery (CA) angiography between May 2012 until December 2016. We examined for evidence of CA stenosis at follow‐up angiography and assessed any other CA complications associated with vascular access.
Results
There were 61 PCA catheterizations performed in 55 unique patients. Follow‐up CA imaging with angiography was available in 43 patients (78%, 43/55). There was no vessel stenosis nor lumen irregularity in 28 (65%) patients. In 15 cases (35%), there was a mild degree of irregularity or narrowing by angiography (median 4.1%, range 2.3%–12.5%). Nine patients underwent repeat PCA catheterizations. Seven of these had no visible vascular stenosis on follow‐up angiographic imaging, including a patient who was accessed three separate times from the CA. No statistically significant risk factors for developing mild CA stenosis were identified.
Conclusions
PCA access for pediatric interventional catheterization appears to be safe with a very low rate of mild stenosis, and very few complications. Follow‐up outcomes in our series are excellent, with a CA patency rate of 100%, even after multiple procedures. Mild CA stenosis was not associated with patient size or sheath introducer caliber. While the acute results from percutaneous CA catheterization have proven safe in recent literature, longer‐term outcomes remain unreported. At our institution, the outcomes following percutaneous carotid access are associated with an excellent patency rate of 100%, even after multiple procedures on the same vessel. A low incidence of mild vessel stenosis can be appreciated on follow‐up angiography.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Background In infants with ductal-dependent pulmonary blood flow, the impact of palliation strategy on interstage growth and feeding regimen is unknown. Methods and Results This was a retrospective ...multicenter study of infants with ductal-dependent pulmonary blood flow palliated with patent ductus arteriosus (PDA) stent or Blalock-Taussig shunt (BTS) from 2008 to 2015. Subjects with a defined interstage, the time between initial palliation and subsequent palliation or repair, were included. Primary outcome was change in weight-for-age
-score. Secondary outcomes included % of patients on: all oral feeds, feeding-related medications, higher calorie feeds, and feeding-related readmission. Propensity score was used to account for baseline differences. Subgroup analysis was performed in 1- (1V) and 2-ventricle (2V) groups. The cohort included 66 PDA stent (43.9% 1V) and 195 BTS (54.4% 1V) subjects. Prematurity was more common in the PDA stent group (
=0.051). After adjustment, change in weight-for-age
-score did not differ between groups over the entire interstage. However, change in weight-for-age
-score favored PDA stent during the inpatient interstage (
=0.005) and BTS during the outpatient interstage (
=0.032). At initial hospital discharge, PDA stent treatment was associated with all oral feeds (
<0.001) and absence of feeding-related medications (
=0.002). Subgroup analysis revealed that 2V but not 1V patients demonstrated significant increase in weight-for-age
-score. In the 2V cohort, feeding-related readmissions were more common in the BTS group (
=0.008). Conclusions In infants with ductal-dependent pulmonary blood flow who underwent palliation with PDA stent or BTS, there was no difference in interstage growth. PDA stent was associated with a simpler feeding regimen and fewer feeding-related readmissions.
To define optimal thromboprophylaxis strategy after stent implantation in superior or total cavopulmonary connections.
Stent thrombosis is a rare complication of intravascular stenting, with a ...perceived higher risk in single-ventricle patients.
All patients who underwent stent implantation within superior or total cavopulmonary connections (caval vein, innominate vein, Fontan, or branch pulmonary arteries) were included. Cohort was divided into aspirin therapy alone versus advanced anticoagulation, including warfarin, enoxaparin, heparin, or clopidogrel. Primary endpoint was in-stent or downstream thrombus, and secondary endpoints included bleeding complications.
A total of 58 patients with single-ventricle circulation underwent 72 stent implantations. Of them 14 stents (19%) were implanted post-superior cavopulmonary connection and 58 (81%) post-total cavopulmonary connection. Indications for stenting included vessel/conduit stenosis (67%), external compression (18%), and thrombotic occlusion (15%). Advanced anticoagulation was prescribed for 32 (44%) patients and aspirin for 40 (56%) patients. Median follow up was 1.1 (25th-75th percentile, 0.5-2.6) years. Echocardiograms were available in 71 patients (99%), and advanced imaging in 44 patients (61%). Thrombosis was present in two patients on advanced anticoagulation (6.3%) and none noted in patients on aspirin (p = 0.187). Both patients with in-stent thrombus underwent initial stenting due to occlusive left pulmonary artery thrombus acutely post-superior cavopulmonary connection. There were seven (22%) significant bleeding complications for advanced anticoagulation and none for aspirin (p < 0.001).
Antithrombotic strategy does not appear to affect rates of in-stent thrombus in single-ventricle circulations. Aspirin alone may be sufficient for most patients undergoing stent implantation, while pre-existing thrombus may warrant advanced anticoagulation.
Candidacy for transcatheter pulmonary valve replacement utilizing newer valve platforms is aided by industry-driven fit analyses. We report augmentation of this decision-making process by ...visualization of 4-dimensional cine imaging of patient-specific right ventricular outflow tract anatomy and a virtual valve model within a virtual reality platform.Candidacy for transcatheter pulmonary valve replacement utilizing newer valve platforms is aided by industry-driven fit analyses. We report augmentation of this decision-making process by visualization of 4-dimensional cine imaging of patient-specific right ventricular outflow tract anatomy and a virtual valve model within a virtual reality platform.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Infants with ductal-dependent pulmonary blood flow may undergo palliation with either a patent ductus arteriosus (PDA) stent or a modified Blalock-Taussig (BT) shunt. A balanced multicenter ...comparison of these 2 approaches is lacking.
Infants with ductal-dependent pulmonary blood flow palliated with either a PDA stent or a BT shunt from January 2008 to November 2015 were reviewed from the 4 member centers of the Congenital Catheterization Research Collaborative. Outcomes were compared by use of propensity score adjustment to account for baseline differences between groups.
One hundred six patients with a PDA stent and 251 patients with a BT shunt were included. The groups differed in underlying anatomy (expected 2-ventricle circulation in 60% of PDA stents versus 45% of BT shunts;
=0.001) and presence of antegrade pulmonary blood flow (61% of PDA stents versus 38% of BT shunts;
<0.001). After propensity score adjustment, there was no difference in the hazard of the primary composite outcome of death or unplanned reintervention to treat cyanosis (hazard ratio, 0.8; 95% confidence interval CI, 0.52-1.23;
=0.31). Other reinterventions were more common in the PDA stent group (hazard ratio, 29.8; 95% CI, 9.8-91.1;
<0.001). However, the PDA stent group had a lower adjusted intensive care unit length of stay (5.3 days 95% CI, 4.2-6.7 versus 9.19 days 95% CI, 7.9-10.6;
<0.001), a lower risk of diuretic use at discharge (odds ratio, 0.4; 95% CI, 0.25-0.64;
<0.001) and procedural complications (odds ratio, 0.4; 95% CI, 0.2-0.77;
=0.006), and larger (152 mm
/m
95% CI, 132-176 versus 125 mm
/m
95% CI, 113-138;
=0.029) and more symmetrical (symmetry index, 0.84 95% CI, 0.8-0.89 versus 0.77 95% CI, 0.75-0.8;
=0.008 pulmonary arteries at the time of subsequent surgical repair or last follow-up.
In this multicenter comparison of palliative PDA stent and BT shunt for infants with ductal-dependent pulmonary blood flow adjusted for differences in patient factors, there was no difference in the primary end point, death or unplanned reintervention to treat cyanosis. However, other markers of morbidity and pulmonary artery size favored the PDA stent group, supporting PDA stent as a reasonable alternative to BT shunt in select patients.
Introduction
This study aims to assess the utility of right ventricular myocardial performance index (RVMPI) as a potential echocardiographic tool to evaluate and serially follow patients with ...bronchopulmonary dysplasia (BPD) and pulmonary hypertension (PH).
Methods
We performed a retrospective chart review of all hemodynamic cardiac catheterizations performed January 2011 to December 2016 in patients born premature and with diagnosed BPD up to 4 years of age—excluding patients with significant congenital heart defects. Echocardiograms performed within 24 hours of the cardiac catheterization were reviewed, and a blinded RVMPI was calculated. The primary endpoint was correlation of invasive catheterization hemodynamics to noninvasive echocardiographic RVMPI measurement.
Results
A total of 49 individual patients met complete study criteria, and 10 of those patients underwent repeat cardiac catheterization. Median age at the time of assessment was 8 months (25%–75%, 4–18 months), and the cohort had a calculated RVMPI mean of 0.39 (±0.19), with 73% (43/59) having a RVMPI >0.28. A statistically significant correlation was found between the RVMPI and the baseline hemodynamics during catheterization with regard to the initial mean pulmonary arterial pressure (r = 0.58; P < 0.01) as well as the calculated pulmonary vascular resistance (r = 0.34; P = 0.01).
Conclusions
This study demonstrates the utility of RVMPI for evaluation of PH in patients with prematurity and BPD. An increased RVMPI by noninvasive echocardiography was found to correlate with increased mean pulmonary arterial pressure and pulmonary vascular resistance measured during invasive cardiac catheterization. Large‐scale validation of this study is being planned.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
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