Perspective Chapter: Transcatheter Interventions in the Management of Aortic Valve Stenosis

Transcatheter interventions that are useful in the management of valvar aortic stenosis will be reviewed. This chapter focuses on congenital aortic valve stenosis. The procedure of balloon aortic valvuloplasty (BAV) and the results were reviewed; BAV offers good relief of aortic valve obstruction and serves as substitute to surgery and is considered a favored option in the management of aortic stenosis in all age groups. However, BAV in elderly patients with calcific aortic stenosis offers only a temporary relief of aortic valve obstruction and BAV is not recommended for this subgroup of patients. Except for neonates, most patients are discharged home within 24-hours after BAV. While there is conclusive data for provision of pressure gradient relief both acutely and at follow-up as well as deferral of any surgery after BAV, the development of aortic insufficiency (AI) at long-term follow-up is a most important drawback. In neonates, severe AI may develop necessitating surgical intervention. Notwithstanding these drawbacks, BAV is presently believed to be a therapeutic procedure of option in the treatment of valvar aortic stenosis in pediatric and young adult patients. Methodical follow-up to identify reappearance of aortic obstruction and development of substantial AI is suggested

Fontan Operation: A Comprehensive Review

Since the first description of the Fontan operation in the early 1970s, a number of modifications have been introduced and currently staged, total cavopulmonary connection with fenestration has become the most commonly used multistage surgery in diverting the vena caval blood flow into the lungs. The existing ventricle, whether it is left or right, is utilized to supply systemic circuit. During Stage I, palliative surgery is performed, usually at presentation in the neonatal period/early infancy, on the basis of pathophysiology of the cardiac defect. During Stage II, a bidirectional Glenn procedure is undertaken in which the superior vena caval flow is diverted into the lungs at an approximate age of 6 months. During Stage IIIA, the blood flow from the inferior vena cava (IVC) is rerouted into the pulmonary arteries, typically by an extra-cardiac conduit along with a fenestration, generally around 2 years of age. During Stage IIIB, the fenestration is closed by transcatheter methodology 6–12 months after Stage IIIA. The evolution of Fontan concepts, the indications for Fontan surgery, and the results of old and current types of Fontan operation form the focus of this review

Five- to nine-year follow-up results of balloon angioplasty of native aortic coarctation in infants and children

AbstractObjectives. To evaluate the usefulness of balloon angioplasty for relief of native aortic coarctation, we reviewed our experience with this procedure, with special emphasis on follow-up results.Background. Controversy exists with regard to the role of balloon angioplasty in the treatment of native aortic coarctation.Methods. During an 8.7-year period ending September 1993, 67 neonates, infants and children underwent balloon angioplasty for native aortic coarctation. A retrospective review of this experience with emphasis on long-term follow-up forms the basis of this study.Results. Balloon angioplasty produced a reduction in the peak-to-peak coarctation gradient from 46 ± 17 (mean ± SD) to 11 ± 9 mm Hg (p < 0.001). No patient required immediate surgical intervention. At intermediate-term follow-up (14 ± 11 months), catheterization (58 patients) and blood pressure (2 patients) data revealed a residual gradient of 16 ± 15 mm Hg (p > 0.1). When individual results were scrutinized, 15 (25%) of 60 had recoarctation, defined as peak gradient >20 mm Hg. Recoarctation was higher (p < 0.01) in neonates (5 [83%] of 6) and infants (7 [39%] of 18) than in children (3 [8%] of 36), respectively. Two infants in our early experience had surgical resection with excellent results. Three patients had no discrete narrowing but had normal arm blood pressure and had no intervention. The remaining 10 patients had repeat balloon angioplasty with reduction in peak gradient from 52 ± 13 to 9 ± 8 mm Hg (p < 0.001). Reexamination 31 ± 18 months after repeat angioplasty revealed a residual gradient of 3 to 19 mm Hg (mean 11 ± 6). Three (5%) of 58 patients who underwent follow-up angiography developed an aneurysm. Detailed evaluation of the femoral artery performed in 51 (88%) of 58 patients at follow-up catheterization revealed patency of the femoral artery in 44 (86%) of 51 patients. Femoral artery occlusion, complete in three (6%) and partial in four (8%), was observed, but all had excellent collateral flow. Blood pressure, echocardiography-Doppler ultrasound and repeat angiographic or magnetic resonance imaging data 5 to 9 years after angioplasty revealed no new aneurysms and minimal (2%) late recoarctation.Conclusions. On the basis of these data, it is concluded that balloon angioplasty is safe and effective in the treatment of native aortic coarctation; significant incidence of recoarctation is seen in neonates and infants; repeat balloon angioplasty for recoarctation is feasible and effective; and the time has come to consider balloon angioplasty as a therapeutic procedure of choice for the treatment of native aortic coarctation

Echocardiographic estimation of balloon-stretched diameter of secundum atrial septal defect for transcatheter occlusion

Stretched diameter of the atrial septal defect (ASD), determined by balloon sizing at cardiac catheterization, is commonly used to select the sizes of the devices used for transcatheter closure of the secundum ASD. We have previously evaluated the utility of pulmonary/systemic flow ratio and angiographic and echocardiographic (echo) sizes of the ASD in estimating stretched ASD diameter in a group of 16 patients and determined that echo diameter had the best correlation with stretched diameter (r = 0.82; p p &gt; 0.1) from the measured stretched diameter. The correlation between predicted and measured stretched ASD sizes was excellent (r = 0.9; p &lt; 0.001). The mean squared error was 2.4. The differences between measured and predicted values were within 2 mm in all but three patients. It is concluded that stretched ASD diameter can be estimated accurately by two-dimensional subcostal echo measurements, which in turn could be used for selection of device size for occlusion of the ASD.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/29960/1/0000322.pd

International experience with secundum atrial septal defect occlusion by the buttoned device

Several devices are available for transcatheter occlusion of atrial septal defect. This report describes the international experience with the buttoned device. During a 4.5-year period ending in February 1993, 180 transcatheter atrial septal defect occlusions were performed with the buttoned device. Patient age varied between 0.6 and 76 years and stretched atrial defect diameter between 5 and 25 mm. The defects were closed with 25 to 50 mm devices delivered through 8F (148 patients) or 9F (32 patients) sheaths. Twelve patients were adults whose defects were closed to prevent recurrence of cerebrovascular accidents caused by presumed paradoxic embolism. In the remaining patients the atrial defect was closed to treat the left-to-right shunt. The atrial septal defects were effectively occluded as demonstrated by (1) decrease in pulmonary-to-systemic flow ratio from 2.1 +/- 0.6 (mean +/- SD) to 1.05 +/- 0.1 (p 2 and disappearance of the diastolic murmur by auscultation; and (3) improvement in right ventricular volume overloading by echocardiogram. However, trivial to small shunts could be detected by color Doppler studies in 76 (45%) of 168 patients in whom such data are available. Complications included unbuttoning in 13 and whole-device embolization in 1. All patients remained stable, and retrieval of the device and surgical closure of the atrial septal defect were accomplished in 10 patients. Transcatheter retrieval was used in the remaining 4 patients. The incidence of unbuttoning, a major complication of the procedure, appeared to decrease with the increasing experience of the investigators and with device modification (third-generation). The follow-up duration varied between 1 month and 4 years. Six patients required surgery during the follow-up period. In the remaining patients (n = 160), clinical examination did not reveal signs of atrial shunts. Color Doppler studies revealed either complete disappearance of the previously demonstrated shunts or further diminution of their size. The results indicate that transcatheter occlusion of the atrial septal defects with buttoned devices is feasible, relatively safe, and effective, and it appears to be a viable alternative to surgery for some patients with secundum atrial septal defect. Complications are infrequent and should improve with experience.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/31234/1/0000139.pd