Diabolo Stent - Fontan Fenestration Creation, Creation of Dumbell shape

Catheter Cardiovasc Interv. 2010 Nov 15;76(6):860-4.
Novel technique to reduce the size of a Fontan Diabolo stent fenestration.
Anderson B, Bhole V, Desai T, Mehta C, Stumper O.
Source
The Birmingham Children's Hospital, Birmingham, United Kingdom.

Abstract
OBJECTIVES:
To develop an effective catheter technique to reduce the size of a Diabolo stent fenestration in the failing Fontan circulation.

BACKGROUND:
Diabolo stent fenestration is employed by many centers in the treatment of the failing Fontan patient. With subsequent recovery, exercise tolerance may be impaired by significant desaturation secondary to the right to left shunt across the fenestration. Complete fenestration closure carries the risk of recurrence of the initial symptoms and, hence, reduction of the size of fenestration should be the preferred technique.

METHODS:
Twenty-eight patients with failing Fontan circulations (16 early and 12 late) underwent Diabolo stent fenestration for relief of symptoms. Five of these patients remained very limited by severe desaturation even at rest, after complete recovery from symptoms. Further cardiac catheterization with crimping/reduction of the size of the waist of the stent was carried out using a technique whereby a snare catheter was placed over the waist of the stent aided by an arterio-venous guidewire loop and a balloon catheter placed within the stent.

RESULTS:
All 5 patients had successful stent reduction with improvement in saturations, whilst still maintaining a small residual fenestration. No complications were encountered.

ONCLUSION:
This novel technique of reduction of a diabolo stent fenestration, in a failing Fontan circulation, offers the advantages of avoidance of implanting further devices in the circulation and the ability to redilate the stent should symptoms recur.

Copyright © 2010 Wiley-Liss, Inc.

Bifurcation stenting - RVOT. Branch PA, Coarctation

Catheter Cardiovasc Interv. 2011 Sep 1;78(3):419-24. doi: 10.1002/ccd.23025. Epub 2011 Mar 30.
A novel technique for stenting pulmonary artery and conduit bifurcation stenosis.
Stumper O, Bhole V, Anderson B, Reinhardt Z, Noonan P, Mehta C.
SourceHeart Unit, Birmingham Children's Hospital, United Kingdom. oliver.stumper@bch.nhs.uk

Abstract
BACKGROUND: Distal conduit obstruction is a recognized complication after surgery for congenital heart disease requiring implantation of a conduit from the right ventricle to the pulmonary arteries. Endovascular stenting of distal conduit obstruction can be challenging due to the proximity to the pulmonary artery bifurcation.

OBJECTIVE: A technique is described, whereby a single stent is mounted onto two balloon angioplasty catheters in tandem. This ensemble was delivered to the distal conduit/pulmonary artery via a large Mullins sheath on two guidewires, one placed in each of the branch pulmonary arteries. The aim was to assess safety and efficacy of this novel technique.

MATERIALS AND RESULTS: Seven patients (mean age 13.4 (6.7-23.4) years, mean weight 44.2 (23-69) kg were treated with this method. The pressure gradient was reduced from 36 (26-52) mm Hg to 11 (8-15) mm Hg [P< 0.05]. RV/LV pressure ratio decreased from 0.85 (0.6-0.95) to 0.42 (0.35-0.5) [P < 0.05]. There were no significant complications. During follow-up over a median of 2.6 (0.3-6.7) years no patient required re-intervention or surgery.

CONCLUSION: This novel technique appears to be safe and effective for stenting stenoses just proximal to pulmonary artery bifurcation.

Copyright © 2011 Wiley-Liss, Inc.



Catheter Cardiovasc Interv. 2011 Sep 1;78(3):425-7.



Dual wire technique for aortic coarctation stent placement.
Lampropoulos K, Budts W, Gewillig M.
SourceCongenital, University Hospitals Leuven, Belgium.

Abstract
A young adult presented for percutaneous treatment of a narrow aortic coarctation. A very large left subclavian artery originated immediately proximal to the coarctation. In order not to exclude or jail the left subclavian artery with a stent, a double wire technique was used. From a femoral approach, two guide wires were positioned, one in the aortic arch and another in the subclavian artery. A stent crimped over a 16-mm balloon and a 4-Fr catheter was advanced over the two wires within a 14-Fr long introducer sheath. The stent was successfully deployed and molded within the bifurcation by a kissing balloon technique, relieving the obstruction and leaving a guaranteed passage to the subclavian artery. The double wire technique is an elegant way to deliver a stent safely across a narrowing with guaranteed access to important side branches.

Copyright © 2010 Wiley-Liss, Inc.

Figure-8 stitch - For Hemostasis of femoral vein access

Catheter Cardiovasc Interv. 2011 Jul 1;78(1):155-60.

Technique of temporary subcutaneous "Figure-of-Eight" sutures to achieve hemostasis after removal of large-caliber femoral venous sheaths.

Cilingiroglu M, Salinger M, Zhao D, Feldman T.
SourceNorthShore University HealthSystem, Evanston, Illinois, USA.

Abstract
Over the last decade, significant advances have been made in percutaneous treatment of structural heart diseases. Many of these interventions require insertion of large caliber sheaths in the femoral veins. Manual compression, compression devices, and various closure devices have been used for removal of large-sized venous sheaths. Here, we describe the use of a temporary subcutaneous "Figure-of-Eight" suture technique for venous access site closure after removal of large-caliber sheaths.

Copyright © 2011 Wiley-Liss, Inc.

Patient-centered, "Medical Home" Concept

Click here for a link to the article from Boston Children's Hospital newsletter.

Troponin from skeletal muscle

J Am Coll Cardiol, doi:10.1016/j.jacc.2011.08.026 (Published online 28 September 2011)

Diseased Skeletal Muscle

A Noncardiac Source of Increased Circulating Concentrations of Cardiac Troponin T

Allan S. Jaffe, MD*,,*, Vlad C. Vasile, MD, PhD*,, Margherita Milone, MD, PhD, Amy K. Saenger, PhD*, Kalen N. Olson, PhD and Fred S. Apple, PhD

Dr. Allan S. Jaffe, Cardiovascular Division, Gonda 5, Mayo Clinic and Medical School, 200 First Street SW, Rochester, Minnesota 55905 (Email: Jaffe.Allan@Mayo.edu).

Objectives: The purpose of this study was to determine whether there is immunoreactive cardiac troponin T (cTnT) expression in diseased skeletal muscle that might cause possible false-positive increases in cTnT.

Background: Cardiac troponin (I or T) is the biomarker of choice for the diagnosis of cardiac injury. Recently, we were presented with a case that challenged the specificity of cTnT.
Methods: Patients with myopathies seen in the Neuromuscular Clinic at the Mayo Clinic were screened for increases in cTnT. If present, an assay for cTnI was performed. If normal, skeletal biopsy tissue was obtained for Western blot analysis using the capture and detection antibodies from both the fourth-generation and high-sensitivity cTnT assays. Results were compared with findings in normal cardiac tissue.

Results: Sixteen patients had increases in cTnT but not cTnI. All had a myopathy by clinical evaluation, clinical testing, and biopsy. Four residual biopsy samples were obtained. All 3 antibodies used in the cTnT (M11.7, M7) and high-sensitivity cTnT (5D8, M7) assays were immunoreactive with a 37- to 39-kDa protein in all 4 diseased skeletal muscle biopsy specimens and in cardiac tissue. A second immunoreactive isoform (34 to 36 kDa) was also found in 1 patient. None of the noncardiac control tissues expressed immunoreactive protein.

Conclusions: These results document that there are forms in diseased skeletal muscle that could cause increases in circulating levels of cTnT. These increases could reflect re-expressed isoforms. Clinicians need to be aware of the possibility that noncardiac increases in cTnT may occur and lead to a possible false-positive diagnosis of cardiac injury when skeletal muscle pathology is present.

Echo, Fetal echo: Predicting need for balloon atrial septostomy in d-TGA

J Am Soc Echocardiogr. 2011 Apr;24(4):425-30. Epub 2011 Feb 15.

Fetal predictors of urgent balloon atrial septostomy in neonates with complete transposition.

Punn R, Silverman NH.

Source

Stanford University, Lucile Packard Children's Hospital, Palo Alto, California, USA.

Abstract

BACKGROUND:

In complete transposition of the great vessels, a restrictive patent foramen ovale leads to inadequate circulatory mixing and severe cyanosis. Urgent balloon atrialseptostomy (BAS) improves mixing and bridges neonates to surgery. Several studies have determined risk factors in utero for poor postnatal outcomes in complete transposition of the great vessels, particularly a restrictive patent foramen ovale and ductus arteriosus. In addition to these risk factors, we studied two new features, a hypermobile septum and reverse diastolic patent ductus arteriosus shunt, to determine which patients will require an urgent BAS.

METHODS:

We reviewed all 26 fetuses from 2001 to 2010 with complete transposition of the great vessels and closely examined the patent foramen ovale and septum primum for hypermobility, restriction, flat appearance, or redundancy. We defined hypermobility as a septum primum flap that oscillates between both atria. We also examined the ductus size and shunting pattern to evaluate whether these features contributed to urgent BAS.

RESULTS:

In total, 14 of 26 fetuses required urgent BAS with improved cyanosis. Nine fetuses had an urgent BAS and a hypermobile septum, and 12 fetuses had no urgent BAS or hypermobile septum. Eight fetuses had an urgent BAS and a reverse diastolic patent ductus arteriosus, and 11 fetuses had no urgent BAS or reverse diastolic patent ductus arteriosus. A hypermobile septum and reverse diastolic patent ductus arteriosus had a significant association with urgent BAS (P < .01, sensitivity = 0.64 and 0.57, specificity = 1.0 and 0.92, positive predictive value = 1.0 and 0.89, negative predictive value = 0.71 and 0.65). No fetus had a restrictive patent foramen ovale/ductus arteriosus.

CONCLUSION:

A hypermobile septum and reverse diastolic patent ductus arteriosus are new prenatal findings to help predict the need for an urgent BAS postnatally in patients with complete transposition of the great vessels.

MRI: Delayed enhancement in LVNC

Figure 1 Comparison of In Vivo CE-MRI and Histological Sections in LVNC
(A) Contrast-enhanced magnetic resonance imaging (CE-MRI) in short-axis view demonstrated that diffuse delayed enhancement occurred in the interventricular septum, left ventricular free wall, and the trabecular meshwork region of the left ventricle. (B) The histological section in isolated left ventricular noncompaction (LVNC) from the apical segment of the left ventricle demonstrated that fibrosis presented within trabeculations (arrow) as well as in compacted myocardium (arrowhead). In addition, mucoid degeneration (asterisk) was identified in endocardium. (Masson's Trichrome stain, original magnification x1).

J Am Coll Cardiol, 2011; 58:311-312,
© 2011 by the American College of Cardiology Foundation

RESEARCH CORRESPONDENCE

Histopathological Features of Delayed Enhancement Cardiovascular Magnetic Resonance in Isolated Left Ventricular Noncompaction

Yan Chaowu, PhD, MD*, Li Li, PhD and Zhao Shihua, PhD, MD

Contrast-enhanced magnetic resonance imaging (CE-MRI) is an important imaging modality for the evaluation of isolated left ventricular noncompaction (LVNC). The delayed gadolinium enhancement has been identified in both compacted and noncompacted myocardium, and it may correlate with the clinical severity of LVNC (1–3). However, little is known about the histological basis of myocardial delayed enhancement in LVNC patients, especially in the noncompacted myocardium. In this study, we made a comparison between the myocardial delayed enhancement and histological findings in a patient with LVNC who underwent heart transplantation.

A 27-year-old man was admitted with exertional dyspnea. Chest roentgenogram showed cardiomegaly with pulmonary venous congestion, and the cardiothoracic ratio was 72%. The LVNC was diagnosed by echocardiography, and the ratio of the noncompacted to compacted myocardium was 3.2. The left ventricular end-diastolic dimension was 63 mm, and left ventricular ejection fraction was 18%. Contrast-enhanced MRI was performed, and deep intertrabecular recesses presented in the apical and lateral wall of the left ventricle. The near-transmural delayed enhancement occurred in the interventricular septum, and diffuse enhancement presented in the free wall and the trabecular meshwork region of the left ventricle. In addition, CE-MRI detected the left ventricular thrombus and pericardial and pleural effusions. One week later, informed consent was obtained, and heart transplantation was carried out. The pathological findings of the explanted heart were compared with the previous in vivo CE-MRI (Fig. 1 ). In the compacted myocardium with delayed enhancement, extensive fibrosis was identified and predominantly localized in the mid-myocardial wall. The collagen volume fraction was 27.9% in the histological section, which came from the region of near-transmural delayed enhancement in the interventricular septum. In the noncompacted myocardium with delayed enhancement (the trabecular meshwork region of left ventricle), however, 2 types of pathological findings presented: mucoid degeneration in the endocardium and fibrosis within the trabeculations. The collagen volume fraction of trabeculations was 37.4% in the left ventricular apex and 32.8% in the lateral wall of the left ventricle. In the myocardial regions without delayed enhancement, there was no significant increase in the amount of fibrosis. The epicardial coronary arteries were normal in the patient.

The results of this study demonstrated that fibrosis was identified histologically in both compacted and noncompacted myocardium. In the compacted myocardium, the regions of delayed enhancement corresponded well with the focally increased fibrosis. Furthermore, CE-MRI may overestimate the degree of fibrosis replacement, as we found in the interventricular septum. In the noncompacted myocardium, delayed enhancement was associated with fibrosis within the trabeculations as well as mucoid degeneration in the endocardium.
Previous studies have showed that myocardial delayed enhancement presented in patients with LVNC, and it has been proposed that the regions of delayed enhancement probably reflected the regions of increased myocardial fibrosis (1,2). Pathological analysis also demonstrated that fibrosis occurred in the left ventricular myocardium of LVNC patients (4,5). However, further research was lacking to assess the histopathological correlation of myocardial delayed enhancement in LVNC. In the present study, our findings show that the fibrosis is the histological basis in the delayed enhancement of compacted myocardium; however, it is still unknown which mechanism plays the leading role in the delayed enhancement of noncompacted myocardium.

Adult CHD: Risk factors for death in pediatric hospitals

Risk Factors for Death After Adult Congenital Heart Surgery in Pediatric Hospitals

1. Yuli Y. Kim, MD,
2. Kimberlee Gauvreau, ScD,
3. Emile A. Bacha, MD,
4. Michael J. Landzberg, MD and
5. Oscar J. Benavidez, MD, MPP

CIRCOUTCOMES.110.958256Published online before print June 21, 2011

1. From the Divisions of Cardiology (Y.Y.K.), Hospital of the University of Pennsylvania and Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA; the Department of Cardiology (K.G., M.J.L., O.J.B.), Children's Hospital Boston, Harvard Medical School, Boston, MA; Boston Adult Congenital Heart (BACH) Program (M.J.L.), the Department of Cardiology, Children's Hospital Boston, Boston, MA; the Division of Cardiology (M.J.L.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; and the Department of Surgery (E.A.B.), Morgan Stanley Children's Hospital of New York, Columbia University College of Physicians and Surgeons, New York, NY.

1. Correspondence to Oscar J. Benavidez, MD, Department of Cardiology, Children's Hospital Boston, 300 Longwood Ave, Boston, MA 02115. E-mailOscar.Benavidez@cardio.chboston.org

Abstract

Background Despite the central role that pediatric hospitals play in the surgical treatment of congenital heart disease, little is known about outcomes of adult congenital cardiac surgical care in pediatric hospitals. Risk factors for inpatient death, including adult congenital heart (ACH) surgery volume, are poorly described.

Methods and Results We obtained inpatient data from 42 free-standing pediatric hospitals using the Pediatric Health Information System data base 2000 to 2008 and selected ACH surgery admissions (ages 18 to 49 years). We examined admission characteristics and hospital surgery volume. Of 97 563 total (pediatric and adult) congenital heart surgery admissions, 3061 (3.1%) were ACH surgery admissions. Median adult age was 22 years and 39% were between ages 25 to 49 years. Most frequent surgical procedures were pulmonary valve replacement, secundum atrial septal defect repair, and aortic valve replacement. Adult mortality rate was 2.2% at discharge. Multivariable analyses identified the following risk factors for death: age 25 to 34 years (adjusted odds ratio [AOR], 2.1; P=0.009), age 35 to 49 years (AOR, 3.2; P=0.001), male sex (AOR, 1.8; P=0.04), government-sponsored insurance (AOR, 1.8; P=0.03), and higher surgical risk categories 4+ (AOR, 21.5; P=0.001). After adjusting for case mix, pediatric hospitals with high ACH surgery volume had reduced odds for death (AOR, 0.4; P=0.003). There was no relationship between total congenital heart surgery volume and ACH inpatient mortality.

Conclusions Older adults, male sex, government-sponsored insurance, and greater surgical case complexity have the highest likelihood of in-hospital death when adult congenital surgery is performed in free-standing pediatric hospitals. After risk-adjustment, pediatric hospitals with high ACH surgery volume have the lowest inpatient mortality.

Cath: Hybrid Procedure - Aortic stent placement for recoarctation after Norwood Procedure

1. Hybrid aortic reconstruction for treatment of recurrent aortic obstruction after stage 1 single ventricle palliation. Medium-term outcomes and results of redilataion.

1. Shelby Kutty MD¹,
2. Redmond P. Burke MD²,
3. Robert L. Hannan MD²,
4. Evan M. Zahn MD, FSCAI^2,*

Catheterization and Cardiovascular Interventions

Volume 78, Issue 1, pages 93–100, 1 July 2011

Catheterization and Cardiovascular Interventions

Volume 78, Issue 1, pages 93–100, 1 July 2011

Abstract

Objective:

We describe a hybrid approach to the treatment of aortic obstruction after stage 1 palliation (S1P) of hypoplastic left heart syndrome.

Background:

Recurrent aortic obstruction is a common problem after S1P of hypoplastic left heart syndrome. Even mild aortic obstruction is poorly tolerated so early and definitive therapy is desirable. Although stent implantation is an effective treatment for aortic obstruction in older children and adults, technical issues due to small vessels and concerns regarding future potential for expansion have generally precluded the use of stents in this setting.

Methods:

Six patients underwent hybrid aortic reconstruction (HAR) in the operating room or catheterization laboratory, with the interventional cardiologist and cardiac surgeon working in cooperation.

Results:

Patients had a mean weight of 5.8 kg (2.9–7.7) and a mean age of 5.6 months (0.5–12.9) at the time of HAR. Five patients had undergone prior balloon angioplasty at a mean age of 2.8 months (2.1–3.5), and five had moderately depressed single ventricular function prior to HAR. The balloons used had a diameter of 7–10 mm and introducer sheath size ranged from 6 to 10 F. There were no immediate or late procedure related complications. Stent redilation was performed in 5 patients for relief of recurrent obstruction or to keep pace with somatic growth. At a median follow up of 4.8 years (0.2–7.9), there were 3 patients progressing well after Fontan palliation and 3 deaths.

Conclusions:

HAR allows for placement of stents that can ultimately reach adult size in small infants who have recurrent aortic obstruction after balloon angioplasty following S1P. Advantages include freedom from delivery sheath constraints when determining stent type/size, facilitation of precise stent position, and avoidance of vascular damage or hemodynamic compromise during the procedure. Longer follow-up and larger experience are required to determine if this therapy will provide a long-term solution to this difficult problem. © 2011 Wiley-Liss, Inc