Balloon Atrial Septostomy by a Right Internal Jugular Venous Approach in a Newborn with Hypoplastic Left Heart Syndrome with a Restrictive Atrial Septum

Hypoplastic left heart syndrome with an intact or highly restrictive atrial septum requires urgent decompression of the left atrium. Catheter‐based interventions from the femoral or umbilical veins represent the standard method of atrial decompression. Restrictive atrial septal defects located at the superior portion of the fossa ovalis can be difficult to cross from these access sites. Here, we describe a successful R ashkind balloon atrial septostomy performed from an internal jugular approach.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/108663/1/chd12108.pd

Pulse Fluoroscopy Radiation Reduction in a Pediatric Cardiac Catheterization Laboratory

ObjectiveTo determine if lower starting pulse fluoroscopy rates lead to lower overall radiation exposure without increasing complication rates or perceived procedure length or difficulty.SettingThe pediatric cardiac catheterization laboratory at University of Michigan Mott Children's Hospital.PatientsPediatric patients with congenital heart disease.Design/InterventionsWe performed a single‐center quality improvement study where the baseline pulse fluoroscopy rate was varied between cases during pediatric cardiac catheterization procedures.Outcome MeasuresIndirect and direct radiation exposure data were collected, and the perceived impact of the fluoroscopy rate and procedural complications was recorded. These outcomes were then compared among the different set pulse fluoroscopy rates.ResultsComparing pulse fluoroscopy rates of 15, 7.5, and 5 frames per second from 61 cases, there was a significant reduction in radiation exposure between 15 and 7.5 frames per second. There was no difference in perceived case difficulty, procedural length, or procedural complications regardless of starting pulse fluoroscopy rate.ConclusionsFor pediatric cardiac catheterizations, a starting pulse fluoroscopy rate of 7.5 frames per second exposes physicians and their patients to significantly less radiation with no impact on procedural difficulty or outcomes. This quality improvement study has resulted in a significant practice change in our pediatric cardiac catheterization laboratory, and 7.5 frames per second is now the default fluoroscopy rate.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/111168/1/chd12197.pd

Use of a Pressure Guidewire to Assess Pulmonary Artery Band Adequacy in the Hybrid Stage I Procedure for High‐risk Neonates with Hypoplastic Left Heart Syndrome and Variants

Objective The hybrid stage I procedure is an alternative palliative strategy for patients with hypoplastic left heart syndrome who traditionally have undergone the N orwood operation. At our institution, the hybrid stage I procedure is employed only for patients with high operative risk. Our objective was to describe our use of a pressure guidewire during the hybrid stage I procedure to assess quantitatively pulmonary artery band adequacy. Design After reviewing the charts on all high‐risk patients who underwent a hybrid stage I procedure at our institution, we compared two groups of patients: those who underwent the standard hybrid stage I palliation (standard cohort) and those with pressure wire‐facilitated assessment of distal branch pulmonary artery pressure (pressure wire cohort) to evaluate the impact of pressure guidewire use on procedural risk, radiation time, patient outcomes, and need for reoperation for pulmonary artery band adjustment. Results The pressure guidewire was used in 8 of 14 patients at the time of hybrid stage I procedure and was successful and without complication in all attempts. In the standard cohort, 67% of patients needed reoperation for pulmonary artery band adjustment, compared to 12.5% of patients in the pressure wire cohort ( P =.09). Procedure time, radiation exposure, and survival to hospital discharge were not different between groups. Conclusions This novel use of a pressure guidewire to assess quantitatively pulmonary artery band adequacy at the time of placement is feasible, safe and may decrease the need for reoperation for pulmonary artery band adjustment.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/97511/1/chd12005.pd

Use of 3D rotational angiography to perform computational fluid dynamics and virtual interventions in aortic coarctation

Computational fluid dynamics (CFD) can be used to analyze blood flow and to predict hemodynamic outcomes after interventions for coarctation of the aorta and other cardiovascular diseases. We report the first use of cardiac 3‐dimensional rotational angiography for CFD and show not only feasibility but also validation of its hemodynamic computations with catheter‐based measurements in three patients.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/154333/1/ccd28507.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/154333/2/ccd28507_am.pd

Temporal relationship between instantaneous pressure gradients and peak‐to‐peak systolic ejection gradient in congenital aortic stenosis

ObjectiveWe sought to identify a time during cardiac ejection when the instantaneous pressure gradient (IPG) correlated best, and near unity, with peak‐to‐peak systolic ejection gradient (PPSG) in patients with congenital aortic stenosis. Noninvasive echocardiographic measurement of IPG has limited correlation with cardiac catheterization measured PPSG across the spectrum of disease severity of congenital aortic stenosis. A major contributor is the observation that these measures are inherently different with a variable relationship dependent on the degree of stenosis.DesignHemodynamic data from cardiac catheterizations utilizing simultaneous pressure measurements from the left ventricle (LV) and ascending aorta (AAo) in patients with congenital valvar aortic stenosis was retrospectively reviewed over the past 5 years. The cardiac cycle was standardized for all patients using the percentage of total LV ejection time (ET). Instantaneous gradient at 5% intervals of ET were compared to PPSG using linear regression and Bland‐Altman analysis.ResultsA total of 22 patients underwent catheterization at a median age of 13.7 years (interquartile range [IQR] 10.3‐18.0) and median weight of 51.1 kg (IQR 34.2‐71.6). The PPSG was 46.5 ± 12.6 mm Hg (mean ± SD) and correlated suboptimally with the maximum and mean IPG. The midsystolic IPG (occurring at 50% of ET) had the strongest correlation with the PPSG (PPSG = 0.97(IPG50%)–1.12, R2 = 0.88), while the IPG at 55% of ET was closest to unity (PPSG = 0.997(IPG55%)–1.17, R2 = 0.87).ConclusionsThe commonly measured maximum and mean IPG are suboptimal estimates of the PPSG in congenital aortic stenosis. Using catheter‐based data, IPG at 50%–55% of ejection correlates well with PPSG. This may allow for a more accurate estimation of PPSG via noninvasive assessment of IPG.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140042/1/chd12514.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/140042/2/chd12514_am.pd

Fluoroscopy‐guided Umbilical Venous Catheter Placement in Infants with Congenital Heart Disease

ObjectiveThe objective of this study was to (1) describe the technical aspects of fluoroscopy‐guided umbilical venous catheter placement (FGUVCP); and (2) determine the procedural success rate, factors contributing to procedural failure, and risks of the procedure.BackgroundUmbilical venous catheters are advantageous compared with femoral venous access, but can be difficult to place at the bedside.Materials and MethodsThis was a retrospective chart review from a single tertiary care referral institution.ResultsFGUVCP was successful in 138 of 180 patients (76.7%) over a seven‐year period. Patients in whom FGUVCP was successful were younger at the time of procedure compared with patients in whom FGUVCP was unsuccessful (median 18.2 vs. 22.2 hours, P = .03). The optimal age cutoff to predict FGUVCP success was 20 hours with a high positive predictive value (82.4%) but low negative predictive value (32.5%). No other variables were associated with procedural failure, though functional univentricular heart and older gestational age trended toward statistical significance. Median radiation time, contrast exposure, and blood loss were 3.2 minutes, 1 mL, and 1 mL, respectively. A total of 10 complications in 10 patients were associated with FGUVCP.ConclusionsFGUVCP is a safe and highly successful way to obtain central venous access in neonates with congenital heart disease. Older age at the time of procedure is associated with procedural failure, but utilization of an age cutoff may not be clinically useful.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/113170/1/chd12233.pd

Hybrid approach for pulmonary atresia with intact ventricular septum: Early single center results and comparison to the standard surgical approach

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/106725/1/ccd25181.pd

Acute and mid‐term outcomes of stent implantation for recurrent coarctation of the aorta between the Norwood operation and fontan completion: A multi‐center Pediatric Interventional Cardiology Early Career Society Investigation

ObjectivesWe sought to evaluate outcomes of stent implantation (SI) for recurrent coarctation of the aorta (RC) following the Norwood operation.BackgroundRC is common following the Norwood operation. Balloon angioplasty (BA) is standard treatment but may result in unsatisfactory relief of RC. SI may improve RC, but outcome data are limited.MethodsWe performed a multi‐center retrospective study of patients who underwent SI for RC between the Norwood operation and Fontan completion. Outcomes were examined, including procedural success, serious adverse events (SAE), and freedom from re‐intervention. A core laboratory was utilized to review angiograms. Coarctation Index (CI) was calculated before and after SI. Paired t‐test and Wilcoxon signed‐rank test were used to compare pre‐ and post‐SI variables.ResultsThirty‐three patients at 8 centers underwent SI for RC at a median age of 5 months (IQR 4.1, 13.3) and weight of 5.9 kg (5.2, 8.6). Aortic arch gradient improved from 20 (15, 24) to 0 (0, 2) mmHg following SI (P < 0.0001). The median CI improved from 0.54 (0.43, 0.62) to 0.97 (0.89, 1.06) following SI (P < 0.0001). There were no procedural deaths but SAEs occurred in 12 (36%) patients. During a median follow‐up duration of 29.7 months (6.8, 48.0), freedom from death or heart transplant was 82%, and from re‐intervention was 45%, with median time to re‐intervention of 20.1 months (11.4, 40.3).ConclusionsSI for treatment of RC in patients after the Norwood operation provides excellent acute relief of obstruction. Intraprocedural hemodynamic instability is common and re‐intervention is frequent at mid‐term follow‐up.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140022/1/ccd27231_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/140022/2/ccd27231.pd

Comprehensive comparative outcomes in children with congenital heart disease: The rationale for the Congenital Catheterization Research Collaborative

Clinical research in the treatment of patients with congenital heart disease (CHD) is limited by the wide variety of CHD manifestations and therapeutic options as well as the generally low incidence of CHD. The availability of comprehensive, contemporary outcomes studies is therefore limited. This inadequacy may result in a lack of data‐driven medical decision making. In 2013, clinician scientists at two centers began a research collaboration, the Congenital Catheterization Research Collaborative (CCRC). Over time, the CCRC has grown to include nine cardiac centers from across the United States, with a common data coordinating center. The CCRC seeks to generate high‐quality, contemporary, statistically robust, and generalizable outcomes research which can help address important clinical questions in the treatment of CHD. To date, the CCRC has reported on multicenter outcomes in: neonates with congenital aortic stenosis, infants undergoing right ventricular decompression for pulmonary atresia and intact ventricular septum, and infants with ductal‐dependent pulmonary blood flow. The CCRC has been successful at leveraging large multicenter cohorts of patients in a contemporary period to perform comparative studies. In the future, the CCRC plans to continue to perform hypothesis‐driven retrospective and prospective observational studies of CHD populations where controversy exists or where novel interventions or therapies have emerged. Quality improvement efforts including lesion‐specific registry development may be an additional potential future target.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/149494/1/chd12737.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/149494/2/chd12737_am.pd