Interventional Opportunities Interventional Opportunities

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Interventional Opportunities Interventional Opportunities

  1. 1. Pediatric Interventional Cardiology: Interventional Opportunities Current and New Interventions October 17, 2006 Holes: make them; close them – Atria, ventricles, arteries, veins James P. Kyser, M.D. Blockages: balloon them, stent them Interventional Pediatric Cardiology – valves, arteries, veins Children’s Cardiac Center of Oregon Arrhythmias: ablate their cause Legacy Emanuel Children’s Hospital – atrial, ventricular Surgery or Cath? The Atrial Septum: Intervention Consider best long term solution to problem 1966: William Rashkind and balloon atrial Balance risks and benefits septostomy – life-saving for newborns with Effective treatment may be a combination transposition of the great arteries. of both catheterization and surgery 2001: FDA approves Amplatzer Septal Balanced presentation to family is important Occluder for closure of secundum ASDs – when either option is safe and effective nearly 50 years after first surgical ASD closure D-TGA: 1200 gram infant Hypoplastic Left Heart Syndrome
  2. 2. Atrial Septostomy-RF Perforation Septostomy- HLHS-Restrictive Atrial Septum HLHS- Pulmonary Atresia-RF Perforation Atresia- Valvular Pulmonic Stenosis Tetralogy of Fallot, Cyanotic Fallot, 1.4 Kg, Sat = 60% RA Critical Aortic Stenosis: Stenosis: Vascular Approaches Retrograde Umbilical Antegrade (IVC-RA-LA-LV-Aao) Trans-carotid
  3. 3. Critical Aortic Stenosis Valvular Aortic Stenosis 1.9 kg male Total Anomalous Pulmonary Obstructed TAPVR Venous Return vs. Pulmonary Hypertension? Vertical Vein Stent Secundum Atrial Septal Defect
  4. 4. Transcatheter ASD Closure Amplatzer ASD device Approved by the FDA in 2001/2002 Double Umbrella design LA disc 7 mm greater radius than central disc RA disc 5 mm greater than central disc Sizes up to 38 mm (LA disc 52 mm dia.) ASD Sizing LA Disc release Pre-deployment Pre- Release
  5. 5. Amplatzer ASD ® Occluder Results ASD: Device vs. Surgery ASD size not different between groups Multicenter non-randomized study comparing – (13 mm versus 14 mm) surgical closure versus device closure, 29 Procedural success rate - immediate – 95.7 % for device group centers, 1998 – 2000 – 100 % for surgical group 442 patients device closure; 154 surgical Procedural success – 6 months closure – Device - 97.2 % – Surgery - 100 % Median age Length of Stay – 9.8 (0.6-82) yrs for device group – Device - 1.0 +/- 0.3 days – 4.1 (0.6-38) yrs for surgical group – Surgery - 3.4 +/- 1.2 days Du et al. JACC Vol 39 2002 Du et al. JACC Vol 39 2002 Device vs. Surgery: Complications Costs: Device versus surgery Device Group (n = 442) – 1.6 % Major – embolization, stroke Hughes et al. Heart 2002 – 6.1% Minor – arrhythmias, headaches – Similar procedure costs – Lower hospital costs Surgical group (n = 154) – Procedure times/LOS significantly longer in – 5 % major - tamponade, re-operation, wound surgical group complication – No ICU services/blood products required in – 19 % minor – effusions, wound infection, device group arrhythmia Du et al. JACC Vol 39 2002 PDA Coil Closure PDAs represent 10-18% of all CHD. Ivalon plug (1967) was successful in 90% of cases, however delivery apparatus (12- 27F sheaths) precluded use in small children. Gianturco coil for PDA closure first described in 1993.
  6. 6. Combining Procedures Pulmonary Atresia with IVS Pulmonary Atresia with intact ventricular septum – Surgical valvotomy – Modified BT shunt Tricuspid Atresia, with Pulmonary Atresia with IVS Fenestrated Fontan Cyanosis with saturations in the low 70’s Increasing exercise intolerance Brought to cath lab to assess for venous collaterals
  7. 7. Fenestrated Fontan with Fenestrated Fontan with Cyanosis Cyanosis Fenestrated Fontan with Fenestrated Fontan with Cyanosis Cyanosis Fenestrated Fontan with Fenestrated Fontan with Cyanosis Cyanosis: Sat = 95%
  8. 8. Vascular Plug 9 month old with Pulmonary AVM 9 month old with Pulmonary AVM Endovascular Stents Sats improved from 75% to 95% Endovascular Stents LPA stenosis, S/P BT shunt for PA/VSD stenosis, Avoid need for creating intimal tears Avoids restenosis due to vessel recoil Allows for staged dilation if desired Does not completely eliminate risks of aneurysm formation/vascular trauma Original indications for adult ileo-femoral artery and biliary duct obstructions. Currently applied to arterial as well as venous stenoses unresponsive to conventional balloon therapy
  9. 9. LPA stenosis LPA stenosis, post-stent Cutting Edge / Future Directions Coarctation Stent Remarkable imagination and innovations have removed many former limitations Percutaneous valve placement Ventricular septal defect closure Laser valvotomy of atretic valves Fetal intervention Percutaneous Fontan completion Molecular interventional therapy – Veg-F angiogenesis Fetal Aortic Stenosis Intervention Fetal Aortic Stenosis Intervention Tworetzky et al Circuation 2004; 110:2125 Tworetzky et al Circuation 2004; 110:2125
  10. 10. VSD Devices Amplatzer Closure Muscular VSD Muscular VSD devices expected to be widely available in the USA later this year Perimembranous VSD devices still with unacceptable amount of heart block, aortic valve regurgitation and procedure complications – Hybrid opportunity Piechaud Heart 2004:90:1505 New ASD Device: Percutaneous VSD Issues Cribriform Device Patient selection Designed for – Patient size fenestrated ASDs – Defect location and size – Thin central waist Potential for surgical closure – Equal sized and flat left and right atrial Adequacy of closure discs Damage to adjacent structures Stage I Norwood Hybrid Stage I Norwood Hybrid Procedure Procedure
  11. 11. Percutaneous pulmonary valve stent insertion Percutaneous Pulmonary Valve Coats, L. et al.; Eur J Cardiothorac Surg 2005;27:536-543 Andrews and Tulloh ADC 2004 89:1168 Copyright ©2005 Elsevier Science B.V. Exciting Time and Future

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