The successful use of alternative routes of vascular access for performing pediatric interventional cardiac catheterization

Objective: The objective of this study is to examine the safety/efficacy of alternative routes of vascular access (ARVA) for successful performance of interventions. Background: Complex interventional catheterizations may be required in children with limited vascular access, vascular constraints relative to size, and hemodynamic instability. Our approach has been to utilize ARVA in selected cases. Methods: ARVA pertains to any vessel excluding femoral, jugular/subclavian veins, or umbilical access. A retrospective review performed on patients with an intervention utilizing ARVA between August 1995 and January 2004 was performed. Patients were divided by clinical status: critically ill/emergent (A), elective cases (B). Procedural success was based on previously published criteria. Results: Sixty‐four interventions were performed in 50 patients using 54 ARVA. ARVA utilized: radial (1), axillary (2), brachial (2), carotid arteries (25); brachial (2) hepatic (9) veins; and open chest/direct cardiac puncture (13). ARVA provided successful access to target lesions. Interventions included stents (30), valvuloplasty (16), angioplasty (14), and one each of vascular occlusion, septal occlusion, accessory pathway ablation, and septostomy. Group A patients were smaller (P < 0.0002) and younger (P < 0.004) than B. All open chest/direct cardiac and the majority (71%) of carotid arterial approaches were performed in group A. Fifty‐six (88%) inteventions were successful with no difference between groups A (88%) and B (86%). There were two complications. Neither resulted in long‐term sequelae. Conclusions: ARVA may provide a strategic advantage that may be safely applied to a variety of interventions regardless of patient size or degree of illness. These techniques may further extend the scope of successful interventions in children. © 2008 Wiley‐Liss, Inc.     

Adverse event rates in congenital cardiac catheterization — A multi‐center experience

Objectives : To describe case mix variation among institutions, and report adverse event rates in congenital cardiac catheterization by case type. Background : Reported adverse event rates for patients with congenital heart disease undergoing cardiac catheterization vary considerably, due to non‐comparable standards of data inclusion, and highly variable case mix. Methods : The Congenital Cardiac Catheterization Outcomes Project (C3PO) has been capturing case characteristics and adverse events (AE) for all cardiac catheterizations performed at six pediatric institutions. Validity and completeness of data were independently audited. Results : Between 2/1/07 and 4/30/08, 3855 cases (670 biopsy, 1037 diagnostic, and 2148 interventional) were recorded, median number of cases per site 480 (308 to 1526). General anesthesia was used in 70% of cases (28 to 99%), and 22% of cases (15 to 26%) were non‐electively or emergently performed. Three institutions performed a higher proportion of interventions during a case, 72 to 77% compared to 56 to 58%. The median rate of AE reported per institution was 16%, ranging from 5 to 18%. For interventional cases the median rate of AE reported per institution was 19% (7 to 25%) compared to 10% for diagnostic cases (6 to 16%). The incidence of AE was significantly higher for interventional compared to diagnostic cases (20% vs 10%, p<0.001), as was the incidence of higher severity AE (9% vs 5%, p<0.001). Adverse events in biopsy cases were uncommon. Conclusions : In this multi‐institutional cohort, the incidence of AE is higher among interventional compared to diagnostic cases, and is very low among biopsy cases. Equitable comparisons among institutions will require the development and application of risk adjustment methods.     

Transhepatic portal vein access for balloon dilation of right upper pulmonary vein stenosis following infradiaphragmatic total anomalous pulmonary venous drainage repair

Transhepatic cardiac catheterization is now a well‐established alternative when conventional venous routes for cardiac access have failed. Some operators prefer this route even routinely, due to the direct access that it offers to the right atrium and atrial septum. We report the case of a newborn baby previously operated on for infradiaphragmatic total anomalous pulmonary venous drainage who represented with right sided pulmonary vein stenosis. Transhepatic portal vein access, first reported here, gave direct access to the right upper pulmonary vein, through the patent descending vein, after the conventional transfemoral venous and retrograde arterial routes had failed. © 2011 Wiley‐Liss, Inc.     

Device fracture and severe tricuspid regurgitation after percutaneous closure of perimembranous ventricular septal defect: a case report.

We report a case in which fracture of an Amplatzer perimembranous ventricular septal defect (VSD) device occurred within 1 month after placement. This was associated with severe tricuspid regurgitation. Surgical removal of the device and repair of the tricuspid valve was performed with reasonable outcome. We propose a hypothesis on how this complication might have occurred and how it could be prevented.     

Accurate measurement of oxygen consumption in children undergoing cardiac catheterization

Oxygen consumption (VO₂) is an important part of hemodynamics using the direct Fick principle in children undergoing cardiac catheterization. Accurate measurement of VO₂ is vital. Obviously, any error in the measurement of VO₂ will translate directly into an equivalent percentage under‐ or overestimation of blood flows and vascular resistances. It remains common practice to estimate VO₂ values from published predictive equations. Among these, the LaFarge equation is the most commonly used equation and gives the closest estimation with the least bias and limits of agreement. However, considerable errors are introduced by the LaFarge equation, particularly in children younger than 3 years of age. Respiratory mass spectrometry remains the “state‐of‐the‐art” method, allowing highly sensitive, rapid and simultaneous measurement of multiple gas fractions. The AMIS 2000 quadrupole respiratory mass spectrometer system has been adapted to measure VO₂ in children under mechanical ventilation with pediatric ventilators during cardiac catheterization. The small sampling rate, fast response time and long tubes make the equipment a unique and powerful tool for bedside continuous measurement of VO₂ in cardiac catheterization for both clinical and research purposes. © 2012 Wiley Periodicals, Inc.     

Ischemic prevention for stent implantation via brachial artery in children

An 11‐year‐old boy received stent implantation for peripheral pulmonary stenosis through the left modified Blalock‐Taussig shunt from the left brachial approach because of the hairpin‐shaped route from a femoral or carotid approach. A temporary bypass between the left radial and the femoral arteries was established to prevent ischemic complication of the left forearm. There was no ischemic change of the left forearm in the physiological monitoring despite the long procedure (more than 4 hr) and brachial arterial spasms. No complications occurred after the procedure. The temporary bypass will support fewer complications in various catheter interventions through a brachial arterial approach in children. © 2009 Wiley‐Liss, Inc.     

Stent implantation is effective treatment of vascular stenosis in young infants with congenital heart disease: Acute implantation and long‐term follow‐up results

Background: Stents implantation in infants has been shown to be feasible, however, there are no published reports examining long‐term outcomes. Concerns exist regarding creation of fixed obstructions secondary to the stent if expansion to larger diameters over time is not possible. Methods: A retrospective analysis of the earliest consecutive series of infants who underwent stent placement at our institution between October 1995 and December 1999. Results: Implantation of 33 stents were attempted in 27 infants, median age = 10 (25–24) months, wt = 8.1 (3.4–14.5) kg. Stents used were as follows: 16 large, 13 medium, and 4 coronary. Acute implant success was 94%. There were three nonprocedure‐related deaths within 30 days of implantation, 1 patient was lost to follow‐up and 1 had acute stent thrombosis. The remaining 22 patients (26 stents) form the long‐term follow‐up study group. Nineteen stents underwent 33 redilations. Following latest redilation, 67.0 (37–113) months postimplantation, minimal luminal diameter increased from 7.0 ± 1.8 mm immediately following implantation to 8.7 ± 2.3 mm (P < 0.001). Seven stents were electively removed/ligated during a planned surgery. All 18 remaining in situ stents are patent without significant obstruction 102 (84–116) months following implantation. There was one late death 51 months after stent implantation. The remaining 21 patients are alive and well. Conclusions: Stent implantation in infants is safe and effective. Serial redilation is possible to keep pace with somatic growth; however, efforts should be made to implant stents with adult diameter potential in children who will not require further cardiac surgery. Implantation of small‐ and medium‐sized stents can provide effective palliation and should be considered in carefully selected infants who will ultimately require future surgery. © 2008 Wiley‐Liss, Inc.     

Safety and efficacy of transradial aortoiliac interventions

Background : This study compares transradial approach (TRA) aortoiliac angioplasty/stenting to the transfemoral approach (TFA). Methods : We reviewed our peripheral database for aortoiliac interventions performed between 2007 and 2009. Demographics, clinical characteristics, procedural, and lesion details were collected. The efficacy endpoints included procedural success, ankle‐brachial index (ABI) improvement, and time to discharge. The safety endpoints were as follows: occurrence of intra‐/periprocedural complications, 30‐day MACE, and access‐site complications (minor/major). The subjects were divided into two groups, TRA and TFA, and compared using appropriate statistics. Results : Twenty‐seven patients had 33 lesions treated via TRA, and 41 patients had 47 lesions treated via TFA access. Baseline demographic differences between the TRA and TFA groups were similar, including mean Rutherford category (2.9 vs. 2.6, P = 0.31) and preintervention ABI (0.64 vs. 0.67, P = 0.80). There was a significantly higher percentage of total occlusions in the TRA group (27.3 vs. 8.5%, P = 0.03). Dye use (238 vs. 213 mL, P = 0.35) and fluoroscopy time (30 vs. 27 min, P = 0.60) were similar. Procedural success rate was similar (87.9 vs. 97.8%, P = 0.15), as well as the improvement in mean ABI (TRA: 0.64–0.77 and TFA: 0.67–0.85, P = 0.77). The time to discharge was significantly shorter for the TRA group (14.4 vs. 20.9 hr, P = 0.003). There were no 30‐day MACE or major access‐site complications, but minor access‐site complications were lower in the TRA group (0.0 vs. 7.3%, P = 0.28), although nonsignificant. Conclusions : The TRA to aortoiliac interventions is as safe and effective as the TFA with the advantage of a lower rate of access‐site complications and shorter hospitalization time. © 2009 Wiley‐Liss, Inc.     

Outcomes of emergent cardiac catheterization following pediatric cardiac surgery

Background: Although there is agreement of the importance of cardiac catheterization, especially interventional procedures, cardiac catheterization in postoperative critical care unit (CCU) period is often debated. The focus of this study was to explore the indications for and determinants of outcome after cardiac catheterization in this setting. Methods: Between March 2004 and October 2006, 49 children (2.8% of cardiac surgeries) underwent 62 catheterizations before discharge from the CCU. Morphological, surgical, and catheterization data were accrued and analyzed using parametric competing risks models and multivariable risk‐hazard analysis. Results: Median age at surgery was 167 days (0–13.5 years) and time to catheterization was 8.5 (0–84) days following surgery. Catheterization procedures were either interventional (n = 35) or noninterventional (n = 27). Children who required a more urgent investigation following initial surgery more often had deployment of a stent at catheterization (P = 0.01) or subsequent surgical pulmonary artery augmentation (P < 0.01). Surgical reoperation was required following 23 (37%) catheterizations and was more common following index surgery involving a cavopulmonary shunt. Overall mortality was high (43%). Delayed invasive investigation beyond 2–3 weeks (P = 0.04) or a splinted sternum (P < 0.001) were risk factors for death. In addition, reoperation after a noninterventional catheterization predicted worse survival (P < 0.001). Conclusions: The need for invasive investigation in the immediate CCU period is associated with a poor outcome, especially when the investigation is delayed or an intervention is not possible. Identification of at‐risk patients may improve outcomes. Best outcomes follow expedient catheterization with definitive management (often stent deployment or pulmonary artery augmentation). © 2009 Wiley‐Liss, Inc.     

Complications of pediatric cardiac catheterization: A review in the current era

Objective: To determine types of complications and risks associated with pedatric cardiac catheterization in the current era. Background: Pedatric cardiac catheterization is an important diagnostic and therapeutic tool. Although in the last decade, there have been significant improvements in technology and equipment, the risk for complications remains, adversely effecting outcomes. Design: The clinical records of 11,073 children undergoing cardiac catheterizations between January 1994 and March 2006 were reviewed to identify procedures associated with complications within the first 24 h after catheterization. All children's electronic and paper chart records were reviewed to obtain demographic, procedural, and treatment data. Results: A total of 858 (7.3%) complications (classified as major or minor) occurred in 816 studies (510 males, 63%), in children ranging in age from 8 h to 20 years (median 4.13 years). There were 195 major (22%) and 663 (78%) minor complications. Vascular complications represented the majority (n = 278; 32.4%) and were major in 53 instances (P < 0.0001). Twenty‐five children died within 24 h (0.23% of total case numbers). Independent risk factors for a complication included young patient age (<6 months), male gender, inpatient status, and year of catheterization. Conclusions: Complications continue to be associated with pedatric cardiac catheterization, although overall incidence appears to be decreasing. Patient age, gender, and inpatient status continue to be risk factors for morbidity and mortality. Efforts at improving equipment for flexibility and size, and developing strategies for the use of alternative methods for catheter access should be encouraged. © 2008 Wiley‐Liss, Inc.     

The hybrid cardiac catheterization laboratory for congenital heart disease: From conception to completion

There has been a recent trend toward hybrid cardiac catheterization procedures for the treatment of patients with various forms of congenital heart disease. Hybrid procedures offer the combined advantages of outstanding imaging in a full operating room environment, allowing direct access onto the heart or the great vessels for access or procedure completion, or complementary imaging before, during, or after surgical correction when necessary. With the increase in frequency of hybrid procedures, more medical centers are contemplating the conversion of standard cardiac catheterization rooms to hybrid facilities, or de novo construction. In this report, we detail a single‐center experience of conversion from a standard catheterization facility into a hybrid suite. The strategic planning, design, system integration, and the challenges inherent to this project are discussed. Many of the solutions to these challenges are likely to be applicable to other institutions planning on similar hybrid conversion or construction. © 2007 Wiley‐Liss, Inc.     

Transcatheter closure of acquired left ventricle to right atrium shunts

We describe transcatheter closure of an acquired Gerbode defect (left ventricle to right atrium shunt) in four patients, ranging in age from 8 to 75 years. All of them had undergone previous surgery (VSD closure in 3, aortic valve replacement in 1), and either had persistent symptoms of heart failure, or developed new symptoms several months or years later. The diagnosis was made by one of several imaging modalities (transthoracic or transesophageal echocardiography, or MRI), and confirmed at cardiac catheterization. Device closure using a variety of devices was successful in all, with resolution of symptoms. One patient developed complete heart block, requiring permanent pacemaker implantation. Transcatheter closure is effective, and may replace surgery in the management of these defects. © 2013 Wiley Periodicals, Inc.     

A case of late‐onset sustained ventricular tachycardia following deployment of amplatzer‐type perimembranous VSD occluder

Transcatheter closure of ventricular septal defect (VSD) has been widely used worldwide. Despite high success rate and minimal operative mortality, arrhythmia during and post‐operation has been frequently observed. However, sustained ventricular tachycardia following deployment of occluder has not been reported. In this present case, we present one rare case of late‐onset sustained ventricular tachycardia, which developed 71 hr after deployment of an Amplatzer‐type occluder for perimembranous VSD (PmVSD) in a 3‐year and 5‐month‐old boy. The sustained ventricular tachycardia was successfully corrected with the administration of lidocaine, amiodarone, and dexamethasone. The reoccurrence of ventricular tachycardia was not observed in the most recent follow‐up at 6 month. In summary, the current case indicated that sustained ventricular tachycardia could occur following deployment of Amplatzer‐type occluder for PmVSD, which could be corrected with antiarrhythmic drugs. © 2012 Wiley Periodicals, Inc.     

Determinants of immediate and follow-up results of pulmonary balloon valvuloplasty

The data of 93 patients (age 11.4 ± 9.4 years, range 8 months - 56 years) who underwent pulmonary balloon valvuloplasty (PBV) for valvular pulmonic stenosis (PS) in our institution are reviewed. The patients were classified into three groups: Group I (34 patients) had a right ventricular (RV) to aortic systolic pressure ratio of < 1, Group II (39 patients) had suprasystemic RV systolic pressures, and Group III (20 patients) included patients with elevated mean right atrial (RA) pressures irrespective of the RV systolic pressures. The percentage drop in immediate postdilatation peak systolic gradients (PSG) and the follow-up PSG were similar in the three groups and were not influenced by any predilatation patient characteristics. A balloon-annulus ratio < 1 predicted a poorer follow-up outcome. Nine patients, eight of Group III and one of Group II, experienced difficult procedures requiring sequential use of progressively larger balloon catheters. Eleven patients, six of Group II and five of Group III, experienced procedure-related events (hypotension, bradycardia/asystole, hypoxia, apnea, tachyarrhythmias, and seizures) and one patient (Group II) died. Although changes in immediate and follow-up gradients after PBV are not influenced by the severity of PS, difficult procedures and procedure-related events are particularly common in patients with severe PS and elevated RA pressures. A cautious and planned approach is therefore indicated in these patients.     

采用不同球囊行肺动脉瓣成形术

对２５例肺动脉瓣狭窄患者行经皮球囊扩张术，探讨（Ｍａｎｓｆｉｅｌｄ球囊和Ｉｎｏｕｅ球囊对手术效果的影响及其优缺点。结果表明：Ｉｎｏｕｅ球囊导管进行经皮肺动脉瓣扩张术可取得与Ｍａｎｓｆｉｅｌｄ球囊导管法相似的疗效，但比Ｍａｎｓｆｉｅｌｄ球囊导管法具有更多的优点，如操作简便、可顺序扩张，并发症少等。