This document discusses nonsurgical cardiac interventions for children with congenital heart disease in India. It estimates that 130,000-270,000 children are born with CHD in India each year, with 80,000 requiring intervention as infants. While early correction is ideal, many children previously died untreated. Now, catheter-based interventions can treat conditions like PDA, ASD, and VSD without surgery. The document reviews the history, techniques, and current scope of these procedures. It concludes that 20-30% of children with CHD can now be treated in the cath lab, and future innovations may allow treating more complex cases nonsurgically.

1. Nonsurgical Cardiac Interventions
in Children
Dr Anil S.R
Consultant Pediatric Cardiologist
MIMS, Calicut

2. Estimates of Congenital Heart Disease
(CHD) Prevalence Among Live-born
Infants in India*
• Total CHD at birth ~130-270,000
• Critical CHD (requiring intervention in infancy):
~ 80,000
• Infant mortality: India- 63/ 1000
Kerala- 13/ 1000
Andhrapradesh-33/1000
• CHD mortality as a fraction of infant mortality:
3-20% (10-12% in AP?)
*Based on available data of CHD prevalence at birth in developed
countries and present birth rates in India

3. Timing for CHD
• Early correction of congenital heart disease is
desirable because it avoids a number of
adverse cardiac, neurodevelopment and
other consequences
• Early correction of a variety of congenital
heart lesions is feasible and realistic with
excellent results in most of the developed
nations and selected Indian centers

4. What Happens if Congenital
Heart Disease is Untreated?
• Majority of them succumb to
death in infancy and early
childhood
• The rest live a turbulent and
truncated life

5. Timing of Intervention in CHD
• Surgical intervention
• Trans-catheter intervention

6. Congenital Heart Disease:

7. RV LV
PA

9. MPA
Ao
Ao
PA

10. Pediatric Cardiac Interventions
1960s: Rashkind Balloon
Septostomy
1970s: King and Mills ASD
Device, Rashkind PDA
occluder
1980s: Balloon valvotomy
1990s: Devices, coils and
stents, RF wire
2000…: Implantable valves,
Percutaneous PA band,
Percutaneous shunts,
Transcatheter Fontan,
transcatheter gene therapy
60s
80s
90s
2000
…

11. Interventions in CHD: Well
Accepted
• Coil and device closure of PDA*
• ASD device closure*
• Coil / device closure of coronary cameral
fistulas
• Balloon dilation / stenting of native
coarctation in older children and adults
• Balloon dilation / stenting of baffle obstruction
• Static balloon dilation of atrial septum

12. Interventions in CHD: Performed
in Few Selected Centers
• VSD device closure
• Recanalization (laser/RF assisted) of
valvar pulmonary atresia
• RVOT dilation for TOF
• Stenting of PDA
• Balloon dilation and stenting of conduits
• Closure of paravalvar leaks

13. Transcatheter PDA Closure

14. Patent Arterial Duct: Transcatheter
Closure
Ao
LPA
Ampulla

15. The High Parasternal or “Ductal View”
MPA
Ao
The two small white arrows indicate the points where the duct is
measured at its PA insertion. The white line indicates the ampulla.

16. Methods: Echo Assessment
Duct diameter at PA insertion defined by echo in the
high parasternal view
MPA

18. PDA Coil Closure; Closure of Large Ducts Using Coils
AortaPulmonary
Artery
Coil Closure of a Patent Arterial Duct

19. Bioptome-assisted Single Coil Delivery

20. The Amplatzer PDA Occluder
• Greater ease, better
control and precision
during deployment
• Size of the duct and
shape of the duct is less
of an issue (as against
coils)
• Concerns regarding
protrusion of parts of
the device in the aorta
or PA
• Some reluctance to use
the device < 4-5 kg

21. 5.4mm PDA: Device
10mm/8mm

24. PDA Closure
• Most PDAs can potentially be closed in
the catheterization lab
• The role of surgery is now essentially
limited to large ducts with short
ampullae in small infants
• There is scope for further improvements
in the coil / device technology

25. Case Scenario DAY-2
Deep Cyanosis
Critical PS
Stabilized on
PGE1
Underwent BPV

26. Case Scenario DAY-3
•Persisting Cyanosis
•On Ventilator-
•ABG-pO2 23mmHg
• PGE1-Max Dose
•Echo
No residual PS
PDA, L-R
ASD, R-L
What Next ???

27. Day 5

28. Day 5

29. Day 5

30. Day 5

31. Day 5

33. Transcatheter ASD Closure

34. TEE, horizontal
plane
TEE, vertical plane

35. The STARFlex
Device
The Amplatzer
Device

36. The Gore Helex Device

39. • All fossa ovalis type defects < 30 –35
mm with at least 5 mm margin all
around (except anterior margin which
can be absent altogether): 40-60% of all
fossa ovalis ASDs
• Stricter criteria for younger children
• “Safe” distance from mitral valve,
pulmonary vein, coronary sinus, SVC
Transcatheter ASD Closure:
Scope (Amplatzer ASD
occluder)

40. Transcatheter VSD Closure

48. nishant

51. Chenna raja

52. Sai teja

53. Sai teja

54. Conclusions
• Today, by just stretching, tearing and
plugging alone 20-30% of children with CHD
can be treated in the cath lab
• The future is exciting because we are the
threshold of going beyond the paradigm of
“stretching, tearing and plugging”
– Creation of new channels: covered stents, special
devices
– Transcatheter gene therapy, biodegradable
devices