Timing, frequency, and results of catheter intervention following recruitment of major aortopulmonary collaterals in patients with pulmonary atresia and ventricular septal defect

The condition of pulmonary atresia (PA), ventricular septal defect (VSD), and major aortopulmonary collaterals (MAPCAs) can have an extremely variable pulmonary blood supply and there are essentially three main anatomical subtypes, one with confluent native pulmonary arteries, one with intrapulmonary but nonconfluent pulmonary arteries, and one with MAPCAs and no native pulmonary arteries (1) Surgical repair can be very challenging and the results are further complicated by patchy vascular distribution to the lung parenchyma, multiple stenoses, progressive narrowing of the MAPCAs, and high pulmonary vascular resistance; despite these hurdles, surgical repair is being carried out with increasing frequency and success, but this is also creating a new population of patients who require a specific interventional strategy. These problems, some of which are not easily addressed surgically, can be helped by catheter intervention methods and the two approaches are complementary. Between 1989 and 2002, 164 patients had surgical recruitment of MAPCAs at Birmingham Children's Hospital with repair in 70%. On average, these patients require 2.3 catheter procedures up to the point of repair. The catheter interventions are technically demanding, time consuming, must be repeated, and require specific techniques due to the pathology of the vessels. The management of PA/VSD/MAPCAs involves a multidisciplinary team approach often requiring repeated procedures, especially for those at the worst end of the spectrum. A proactive approach is essential due to known disease progression. Considerable improvement in patients' quality of life and, hopefully, life expectancy makes this approach worthwhile.     

法洛四联症外科矫治手术前后的介入干预治疗

目的:评价经导管介入治疗措施对法洛四联症(tetralogy of Fallot,TOF)外科矫治术的辅助治疗价值。方法:对我科2010年10月至2013年12月住院的27例,和作者在外院完成的3例TOF经导管介入治疗进行总结分析。结果:男性20例,女性10例,年龄8个月~49岁,平均4.3岁。外科矫治术前行体-肺侧枝血管(major aorto-pulmonary collateral arteries,MAPCAs)栓塞术17例、肺动脉瓣球囊扩张术(percutaneous balloon pulmonary valvuloplasty PBPV)4例;因术后肺出血急诊行MAPCAs栓塞术4例,术后左心衰行MAPCA-肺静脉瘘瘘口封堵1例、肺动脉分支狭窄球囊扩张(percutaneous balloon pulmonary arterioplasty PBPA)3例、PBPV1例。介入治疗均达到预期效果,未发生与操作相关的并发症,1例根治术后,肺出血患者行MAPCAs栓堵术后肺出血改善,但死于感染性心内膜炎,其他病例均痊愈出院。结论:TOF外科矫治术前、术后的介入治疗,可减少TOF根治手术风险并改善预后。     

Postinfarct VSD management using 3D computer printing assisted percutaneous closure

Postinfarct VSD (PIVSD) carries a grim prognosis. The mainstay of management has been surgical repair. The advent of septal occluder devices has offered an attractive alternative to surgical repair. Most PIVSD have serpiginous tracts with necrotic tissue, which makes assessing the defect challenging. 3D computer printing has become useful in preprocedure planning of complex surgical procedures in multiple subspecialties.     

Rehabilitation of hypoplastic pulmonary arteries and anatomic correction of pulmonary atresia with interventricular communication]

Conventional treatment of pulmonary atresia with ventricular septal defect (VSD), hypoplastic pulmonary arteries (PA) and major aorto-pulmonary collaterals (MAPCAs) is controversial: from symptomatic and palliative treatment for some authors to surgery with unifocalisation of collaterals for others. These treatments never use native pulmonary arteries as only source of pulmonary flow, but create "neo-pulmonary arteries". Nine cases of pulmonary atresia with VSD, hypoplastic PA and MAPCAs were treated by rehabilitation of native PA through a staged approach: 1) surgical neonatal connection between right ventricule (RV) and hypoplastic PA, 2) evaluation and interventionnal catheterism with angioplasty of PA stenosis and closure of collaterals, 3) complete surgical correction with reconstruction of right outflow track and PA and closure of VSD. After first surgical stage of RV-PA connection at the mean age of 4.8 months (+/- 5.6 months), 8 patients were alive and underwent 22 cardiac catheterisms (mean of 2.7 per patient), with angioplasty of PA, and occlusion of MAPCAs in 6 and 2 patients respectively. Seven patients underwent complete anatomical correction at the mean age of 28.8 months (+/- 17.7 months) with one late death. The 6 remaining patients had encouraging hemodynamic status (RV pressure/LV pressure ratio at 0.6 +/- 0.26; mean left and right distal pulmonary pressure at 15.2 mmHg (+/- 9.1 mmHg)), and good functionnal status (3 in NYHA functionnal class 1, and 3 in class 2), for a mean follow-up of 79.5 months (+/- 41.4 months). One patient had reoperation on right outflow track stenosis, 6 years after correction. This small series enhances the feasibility of a staged approach with rehabilitation of small PA, allowing complete surgical correction with the native PA with good hemodynamic and functional results in pulmonary atresia, with VSD, hypoplastic PA and MAPCAs.     

介入及手术联合治疗伴有体肺侧枝的法鲁氏四联症和肺动脉闭锁

目的评价介入栓堵侧枝合并手术矫治伴有体肺侧枝的重症法鲁氏四联症和肺动脉闭锁的临床结果,总结临床应用经验。方法回顾1992年至2006年我院介入加外科手术治疗25例伴有体肺侧枝的重症发鲁氏四联症和肺动脉闭锁,其中法四12例,肺动脉闭锁13例,年龄6月～17岁,体重7～55公斤,男性16例,女性9例,造影发现体肺侧枝共65支,平均2.6/例。外科根治手术23例,2例肺动脉闭锁行姑息手术,术前栓堵20例,术后栓堵5例,共栓堵侧枝53支,完全栓堵率86.8%。结果全组病例死亡6例,总死亡率24%,肺动脉闭锁根治术11例,死亡4例,死亡率36.4%,肺动脉闭锁姑息手术2例,死亡1例,法四根治术12例,死亡1例,死亡率8.3%。介入栓堵后根治术共18例,死亡3例,均为肺动脉闭锁,死亡率13%,根治术后介入栓堵5例,死亡2例,死亡率40%,其中法四4例死亡1例,肺动脉闭锁1例死亡1例。死亡原因为充血性心衰1例,低心排1例,肺出血1例,广泛肺渗出1例,肺缺血坏死1例,下腔静脉梗阻致多器官功能衰竭1例。结论介入栓堵体肺侧枝与外科手术联合治疗伴有体肺侧枝的重症法鲁氏四联症和肺动脉闭锁安全有效,可以减轻手术难度,减少术中出血,缩短手术时间,提高手术矫治成功率,减少手术创伤。术前栓堵侧枝对于手术成功尤为重要,术前明确体肺侧枝与固有肺动脉交通情况,对于单独供血的大体肺侧枝不宜拴堵,应于术中进行融合重建。与国外同期治疗结果比较我们的总死亡率较高。     

Hybrid palliation in hypoplastic left heart syndrome

PURPOSE OF REVIEW: Despite progressive improvement in surgical results, hypoplastic left heart syndrome remains one of the congenital heart abnormalities with the greatest morbidity and mortality. Hybrid approaches to management, combining surgical and interventional catheterization procedures, have been introduced to minimize exposure to cardiopulmonary bypass, and improve outcomes for these high-risk infants. RECENT FINDINGS: First-stage palliation of hypoplastic left heart syndrome has been performed as a hybrid procedure combining surgical pulmonary artery banding with catheterization stenting of the ductus arteriosus and balloon atrial septostomy, especially in high-risk patients. Additionally, several centers have performed second-stage palliation - bidirectional Glenn or hemi-Fontan procedures - in a manner that allows the subsequent 'Fontan' procedure to be completed in the catheterization laboratory with a covered stent. SUMMARY: These innovative procedures offer the potential of an alternative management strategy for hypoplastic left heart syndrome. They have been applied to a very limited number of patients and long-term results are not available. Their role in management of hypoplastic left heart syndrome remains to be defined, especially as results of conventional surgical management continue to improve.     

Imaging for Native Mitral Valve Surgical and Transcatheter Interventions

There has been rapid progress in transcatheter therapies for mitral regurgitation. These developments have elevated the need for the imager to have a core understanding of the functional mitral valve anatomy. Pre- and intraoperative echocardiography for surgical mitral valve repair for mitral regurgitation has defined contemporary interventional imaging in many ways. The central tenets of these principles apply to interventional imaging of transcatheter mitral valve interventions. However, the heightened emphasis on procedural planning and procedural imaging is one of the new challenges posed by transcatheter interventions. This need for accurate and reliable information has required the imager to be agnostic to the imaging modality. Cardiac computed tomography has become critical in procedural planning in this new paradigm. The expanded use of pre-procedural cardiac magnetic resonance to quantify mitral regurgitation and characterize the left ventricle is another illustration of this newer approach. Other illustrations of the new world of interventional imaging include the expanded use of 3-dimensional (3D) transesophageal echocardiography and real-time fusion of echocardiography and fluoroscopy images. Imaging data are also the basis for computational modeling, 3D printing, and artificial intelligence. These technologies are being increasingly explored to improve therapy selection and prediction of procedural outcomes. This review provides an update of the essentials in present interventional imaging for surgical and transcatheter interventions for mitral regurgitation.     

3D打印技术在瓣膜性心脏病手术中的应用

心血管3D打印技术是指根据超声心动图、计算机断层扫描或磁共振成像获得的容积成像数据集,制作患者特定的心脏解剖模型。它能够实现解剖结构的可视化,甚至有助于理解血流动力学,制定手术计划及术前模拟。鉴于患者解剖结构的高度变异性和复杂性,3D打印技术率先在先天性心脏病的治疗中得到广泛应用。随着技术与器械的进步,瓣膜性心脏病病的手术治疗方式发生了巨大的变革。对于如经导管主动脉瓣置换术、经导管二尖瓣成形术等术式,外科医师在术前需要深入了解主动脉根部的解剖结构及钙化程度等个体化信息。因而3D打印技术也被进一步推广应用于瓣膜性心脏病外科手术中,本文就此进行综述。     

Hybrid技术治疗合并体肺侧支的法洛四联症

目的:总结应用Hybrid技术治疗合并较大体肺侧支的法洛四联症的临床结果,分析该联合术式的临床疗效。方法:回顾分析阜外医院1996年1月至2008年12月手术联合栓堵治疗的46例伴有体肺侧支的法洛四联症的临床资料:2007年6月前主要采取手术前、后联合介入栓堵13例(分期组),2007年6月后采用Hybrid技术行术中栓堵33例(同期组)。全组造影发现体肺侧支共89支,成功栓堵70支。结果:同期手术组在体外循环时间、升主动脉阻断时间、呼吸机使用时间、ICU时间及住院时间方面均明显小于分期手术组。同期手术组病死率(6.1%)较分期手术组(31%)低。结论:应用Hy-brid技术治疗合并较大体肺侧枝的法洛氏四联症可降低手术难度,减轻手术创伤,提高手术矫治成功率;术中联合栓堵安全有效,优于术前或术后联合栓堵。     

Balloon Debanding the Pulmonary Artery: In Vitro Studies and Early Clinical Experience

Despite increasing corrective procedures for children with congenital heart disease, there remains a place for surgical banding of the main pulmonary artery (PA). In the vast majority of cases, these bands eventually need to be removed. We examined three cases of percutaneous disruption of PA bands using balloon catheters at our institution. We also performed an in vitro study of PA band disruption mechanism and disruption pressure. Our in vitro study suggested a predictable burst pressure for PA bands over the range of diameters routinely used in pediatric practice. Of three patients who underwent interventional debanding, two patients had successful disruption of their PA bands with no reintervention at 19 months and 23 months follow up. Balloon disruption of surgical PA bands may offer a less invasive alternative to surgical band removal. In vitro analysis suggests that the burst pressure required and mechanism of disruption are predictable.     

Routine use of transesophageal echocardiography and color flow imaging in the evaluation and treatment of children with congenital heart disease

We reviewed our experience with transesophageal echocardiography (TEE) and color flow imaging in 157 consecutive patients with known or suspected heart disease to ascertain the impact of this technology on patient care. TEE was performed for diagnostic purposes (22/157), during interventional cardiac catheterizations (13/157), and during operative procedures (122/157). Diagnostic studies were performed after transthoracic echocardiography (TTE) in 21 of 22 patients. TEE was performed because TTE was inconclusive (15/21) or failed to provide sufficient detail of an abnormality (6/21). TEE detected an abnormality in 6 of 15 inconclusive TTEs. TEE was helpful during interventional cardiac catheterizations, particularly during umbrella closure of septal defects and in patients with complex venous and atrial anatomy undergoing transseptal puncture. TEE studies performed before cardiac operations significantly changed the diagnosis in only 5 of 122 (4%) patients, but the information changed the surgical approach in 4 of 5 of these patients. Postoperative TEE assessment more frequently changed care and resulted in further surgical management in 9 of 122 (7%) or a change in medical management in 6 of 122 (5%) patients. TEE was discontinued because of complications before studies were completed in only 4 of 157 (3%) patients. TEE and color flow imaging is a useful adjunct to care of children with known or suspected congenital heart disease.     

Three-dimensional modeling in complex liver surgery and liver transplantation

Liver resection and transplantation are the most effective therapies for many hepatobiliary tumors and diseases. However, these surgical procedures are challenging due to the anatomic complexity and many anatomical variations of the vascular and biliary structures. Three-dimensional (3D) printing models can clearly locate and describe blood vessels, bile ducts and tumors, calculate both liver and residual liver volumes, and finally predict the functional status of the liver after resection surgery. The 3D printing models may be particularly helpful in the preoperative evaluation and surgical planning of especially complex liver resection and transplantation, allowing to possibly increase resectability rates and reduce postoperative complications. With the continuous developments of imaging techniques, such models are expected to become widely applied in clinical practice.     

Real-time vascular interventional magnetic resonance imaging

Endovascular stent-graft placement is emerging as a promising alternative to medical and surgical treatment of patients with diseases of the descending thoracic and abdominal aorta. Precise placement of the stentgraft, which is currently performed under x-ray control, remains, however, challenging as there are several shortcomings to fluoroscopic guidance beyond that related to the harmful effect of radiation exposure and nephrotoxic contrast media. While transesophageal echocardiography and intravascular ultrasound have been used as adjunct imaging modalities during endovascular stent-graft procedures to overcome the limitations of angiography, these techniques have not mitigated the need for fluoroscopy.Magnetic resonance imaging (MRI) guidance of vascular interventional procedures offers several potential advantages over fluoroscopy-guided techniques, including image acquisition in any desired orientation, superior 3D soft-tissue contrast with simultaneous visualization of the interventional device, absence of ionizing radiation, and avoidance of nephrotoxic contrast media. Magnetic resonance imaging is often used for pre-operative diagnosis of aortic disease and can provide all relevant information for the planning of endovascular stent-graft procedures as well as for accurate and immediate post-interventional evaluation. However, visualization of interventional instruments by MRI has proven to be the chief obstacle. This article will review current approaches that have been developed for depicting vascular instruments by MRI and will also discuss the first experimental experiences with MRI-guided endovascular stent-graft placement in a swine model of aortic dissection.     

Off-pump coronary artery bypass grafting versus optimal medical therapy alone: effectiveness of incomplete revascularization in high risk patients

Background Geriatric patients with multivessel coronary artery disease (CAD) are a challenging group to treat; these cases elicit discussion within heart teams regarding the actual benefit of undertaking major surgery on these patients and often lead to abandon the surgical option. Percutaneous procedures represent an important option, but coronary anatomy may be unfavorable. Off-pump coronary artery bypass (OPCAB) provides good quality graft on left anterior descending (LAD) without exposing the patient to cardiopulmonary bypass, and might be the ideal choice in patients with multiple comorbidities, not eligible to percutaneous or on-pump procedures. The objective of this study was to compare survival during a mid-term follow-up in high-risk patients with no percutaneous alternative, either treated with OPCAB or discharged in medical therapy. Methods We retrospectively evaluated from June 2008 to June 2013, 83 high-risk patients with multivessel CAD were included: 42 were treated with incomplete off-pump revascularization using left internal mammary artery (LIMA) on LAD; 41 were discharged in optimal medical therapy (OMT), having refused surgery. Follow-up ended in March 2015, with a telephonic interview. Primary endpoint was survival from all-cause mortality; secondary endpoints were survival from cardiac-related mortality and freedom from non-fatal major adverse cardiac events (MACEs). Results During follow up, 11 deaths in OPCAB group and 27 deaths in OMT group occurred. Death was due to cardiac factors in 6 and 15 patients, respectively. MACEs were observed in 6 patients in OPCAB group and in 4 patients in OMT group. With regards to survival from all-cause mortality, patients who underwent OPCAB survived more than those discharged in OMT (Log Rank < 0.001), and OMT group carries a propensity score-adjusted hazard ratio of 3.862 (P < 0.001). With regards to survival from cardiac-related events, patients who underwent OPCAB survived more than those discharged in OMT (Log Rank = 0.002), and OMT group carries a propensity score-adjusted hazard ratio of 3.663 (P = 0.010). There is no statistically significant difference concerning freedom from MACEs (Log Rank = 0.273). Conclusions For high-risk patients with multivessel CAD, not eligible to on-pump complete revascularization surgery or percutaneous procedures, incomplete revascularization with OPCAB LIMA-on-LAD offers benefits in survival when compared to OMT alone.     

Multiple Migrated Superior Vena Cava Stents With Cardiac Injury - A Stepwise Open Cardiotomy Strategy to Mitigate Potential Fatality

Iatrogenic injuries with migrated interventional stents can sometimes be life-threatening. The interventional retrieval management is generally the treatment of choice, as surgical procedures carry a high mortality risk with only a few cases reported. We report a patient with two stents migrated into the right atrium from superior vena cava resulting in cardiac perforation. She was successfully treated using pericardiocentesis followed by surgical intervention with rapid post-operative resolution of symptoms. The technique presented here substantiates the steps for a safe and effective removal of these multiple displaced stents with minimal postprocedural complications.     

Efectos de la impresión 3D en la planificación quirúrgica de las cardiopatías congénitas

Introduction:

Congenital heart disease makes up for 30% of all congenital anomalies. The prevalence is 8/1,000 live newborns, without predominance of gender. Imaging methods such as echocardiography, angiography, computed tomography or magnetic resonance imaging must be routinely used in congenital heart disease. The mentioned methods can provide virtual reconstructions in volumetric reconstruction or in three dimensional (3D), but only 3D-printed heart models can provide real 3D tactile replicas of cardiac anatomy.

Objective:

To make 3D printed heart models in order to provide real 3D tactile replicas of the cardiac anatomy that allow a detailed visualization from all possible perspectives, either of extracardiac or intracardiac structures.

Methods:

This information is useful for surgical decision making, especially in patients with complex cardiac defects. DICOM, edited in a software package “3D slicer 4.3” and exported for printing in file format (.stl).

Results and conclusions:

With 3D printing, the intracardiac and extracardiac anatomy can be evaluated in detail with real-scale cardiac models of the patient, avoiding unexpected findings. This technique is very useful especially in complex congenital heart defects, since it allows precise planning of the surgical procedure.Key words: Congenital heart disease, Cardiac imaging, Three dimensional printing, Surgical planning     

Additive Manufacturing for Neurosurgery: Digital Light Processing of Individualized Patient-Specific Cerebral Aneurysms

This study aims at demonstrating the feasibility of reproducing individualized patient-specific three-dimensional models of cerebral aneurysms by using the direct light processing (DLP) 3D printing technique in a low-time and inexpensive way. Such models were used to help neurosurgeons understand the anatomy of the aneurysms together with the surrounding vessels and their relationships, providing, therefore, a tangible supporting tool with which to train and plan surgical operations. The starting 3D models were obtained by processing the computed tomography angiographies and the digital subtraction angiographies of three patients. Then, a 3D DLP printer was used to print the models, and, if acceptable, on the basis of the neurosurgeon’s opinion, they were used for the planning of the neurosurgery operation and patient information. All the models were printed within three hours, providing a comprehensive representation of the cerebral aneurysms and the surrounding structures and improving the understanding of their anatomy and simplifying the planning of the surgical operation.     

COURAGE under fire: on the management of stable coronary disease

The COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial showed that coronary interventional procedures added little to optimal medical therapy with respect to the long-term outcome of patients with stable coronary disease when used as initial therapy. Detractors opine that: 1) the trial was unrealistic in design and the findings were not unexpected; 2) the use of coronary interventional procedures was suboptimal; and 3) the results of COURAGE are not applicable to current clinical practice. We herein reevaluate the evidence with regard to each of these points, and conclude that COURAGE indeed provides relevant new information to assist the practitioner in the appropriate management of patients with stable coronary disease.     

COURAGE under fire: on the management of stable coronary disease.

The COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial showed that coronary interventional procedures added little to optimal medical therapy with respect to the long-term outcome of patients with stable coronary disease when used as initial therapy. Detractors opine that: 1) the trial was unrealistic in design and the findings were not unexpected; 2) the use of coronary interventional procedures was suboptimal; and 3) the results of COURAGE are not applicable to current clinical practice. We herein reevaluate the evidence with regard to each of these points, and conclude that COURAGE indeed provides relevant new information to assist the practitioner in the appropriate management of patients with stable coronary disease.