Trans-catheter closure of a rare cause of pre-tricuspid left-to-right shunt: A "double" levoatriocardinal vein without left heart obstructive lesions.

The levoatriocardinal vein is a rare vascular anomalous connection between the left atrium and the superior vena cava (or left innominate vein). This defect is usually associated with left heart obstructive lesions, while it is rarely found in an isolated form. In the former case, the anomalous connection causes a pre-tricuspid left-to-right shunt with right-heart volume overload. We describe the first case of "double" homolateral levoatriocardinal vein in a child with signs and symptoms of right-heart failure and pulmonary blood-flow overload. A trans-catheter closure of both vascular connections was performed with two Amplatzer Vascular Plug type II (Abbott, Plymouth, MN, USA). The percutaneous approach proved to be safe and effective, with early improvement in the signs and symptoms of heart failure. .

Hybrid transcatheter--surgical approach in complex pulmonary artery stenosis due to arterial tortuosity syndrome.

Arterial tortuosity syndrome is a connective tissue disorder characterized by elongation and tortuosity of large elastic arteries, potentially resulting in multiple vascular stenoses. This paper reports a novel hybrid strategy to treat 'complex' bilateral peripheral pulmonary artery stenoses consisting of transcatheter stent implantation via midline sternotomy and reductive angioplasty of the proximal pulmonary arteries.

Bilateral arterial duct 'stenting' in a low-weight neonate with complex congenital heart defect.

Bilateral arterial ducts feeding discontinuous pulmonary arteries are a very rare anatomic arrangement in complex heart malformations with pulmonary atresia. In this setting, neonatal ductal closure may result in abrupt pulmonary hypoperfusion and life-threatening systemic hypoxia. In high-risk patients, percutaneous arterial duct stenting might be an engaging and cost-effective alternative to surgery. This paper reports on a critical low-weight neonate with complex heart disease and discontinuous pulmonary arteries dependent on bilateral arterial ducts who underwent successful transcatheter ductal stenting as an alternative to a high-risk surgical palliation.

Short-term electrogeometric atrial remodelling after percutaneous atrial septal defect closure.

BACKGROUND: Atrial arrhythmias are well known long-term complications of atrial septal defect (ASD), presumably due to chronic atrial enlargement and stretch. Surgical repair often fails to revert the arrhythmic risk despite atrial volumetric unloading, maybe as a consequence of atriotomic scar. Avoiding atrial incision, percutaneous ASD closure should result in atrial unloading and arrhythmic risk decrease. This study evaluated the atrial short-term electrogeometric effects of percutaneous ASD closure. METHODS: Fifteen asymptomatic patients (age 23 +/- 5 years) submitted to percutaneous closure of large ASD (QP/QS 2.4 +/- 0.3) using the Amplatzer Septal Occluder device (24 +/- 2 mm) underwent atrial echocardiographic (indexed right atrial size and left atrial size as well as right atrial/left atrial volume ratio) and electrocardiographic (P-wave duration and dispersion, PR conduction time and dispersion) evaluation at 1 and 6 months after ASD closure. RESULTS: After 6 months, the indexed right atrial volume and the right atrial/left atrial volume ratio had significantly decreased (from 39 +/- 5 to 20 +/- 2 ml/m2, P < 0.001 and from 2.0 +/- 0.2 to 1.0 +/- 0.1, P < 0.0001, respectively) as did the P-wave dispersion (from 32 +/- 2 to 28 +/- 1 ms, P = 0.03) despite a significant increase of both P-wave maximal (from 75 +/- 3 to 81 +/- 3 ms, P < 0.01) and minimal (from 42 +/- 3 to 53 +/- 3 ms, P < 0.005) duration. CONCLUSION: Percutaneous ASD closure causes a short-term positive atrial electrogeometric remodelling. The electrocardiographic predictors of atrial arrhythmias, however, tend to worsen early after device implantation despite a marked volumetric unloading, possibly due to a 'foreign body' effect of the occluding device. This might warrant a closer follow-up during the first few weeks after device implantation.

Hybrid approach in a case of arterial tortuosity syndrome.

Arterial tortuosity syndrome is a rare connective tissue disorder characterised by elongation, tortuosity, stenosis and aneurysms of the large and middle-sized arteries. The symptomatology is correlated to the artery affected by the pathology with correlated stenosis. We describe our hybrid surgical procedure in the treatment of a case of kinking of the pulmonary branches with significant gradient and hypertension. Aortic arch and supraaortic vessels presented various deviousness without hemodynamic alterations.

Transcatheter ductal stenting in critical neonatal Ebstein's anomaly.

BACKGROUND: Symptomatic neonatal Ebstein's anomaly shows a very poor outcome, most frequently due to duct-dependent pulmonary circulation caused by functional pulmonary valve atresia. In this setting, percutaneous ductal stenting using high-flexibility coronary stents might be a highly cost-effective alternative to systemic-to-pulmonary shunt. METHODS: Three newborns (age 4.7 +/- 2.9 days; weight 3.0 +/- 0.3 kg) with critical, duct-dependent tricuspid valve Ebstein's anomaly and functional pulmonary atresia unresponsive to prostaglandin infusion and multidrug vasodilator therapy, underwent duct stabilization with high-flexibility, open-cell stents as an alternative to surgical palliation. Their echocardiographic picture predicted a very high mortality rate. In two cases, the ductus arteriosus was recanalized using a combined pharmacological (local prostaglandin infusion) and mechanical (hydrophilic coronary guide-wire manipulation) approach. RESULTS: Stent implantation increased duct diameter from 0.5 +/- 0.7 to 3.2 +/- 0.2 mm (P < 0.0001), resulting in a significant rise in oxygen saturation from 67 +/- 9 to 92 +/- 4% (P < 0.00001). After the procedure, the patients were quickly weaned from mechanical ventilation and discharged after 16 +/- 7 days. Uneventful spontaneous ductal closure ensued in two patients in a few months, and percutaneous oxygen saturation was 87 +/- 3% at the last follow-up session (12 +/- 10 months). CONCLUSIONS: In critical newborns with severe, duct-dependent Ebstein's anomaly unresponsive to medical therapy, ductal stenting could be a reliable, safe and cost-effective alternative to either long-term prostaglandin treatment or surgical palliation, in view of lower-risk corrective surgery at older age. This option may also be attempted successfully within a few days of spontaneous ductal closure using a combined pharmacological and mechanical approach.

Symptomatic aorto-pulmonary collaterals early after arterial switch operation.

Enlarged bronchial arteries and/or systemic-to-pulmonary collaterals have been frequently demonstrated in association with transposition of the great arteries. They are usually clinically silent, although they might be large enough to cause accelerated pulmonary vascular obstructive disease or symptomatic cardiac volume overload after surgical repair. We report on a low-weight neonate with transposition of the great arteries and intact ventricular septum who showed a stormy postoperative course because of multiple aorto-pulmonary collaterals early after a successful arterial switch operation. Percutaneous coil embolization of these anomalous vessels resulted in sudden weaning from mechanical ventilation and hospital discharge in a few weeks.

The impact of interventional cardiology for the management of adults with congenital heart defects.

The objective of this study is to assess the impact of interventional cardiology procedures for the management of ACHD. The interventional approach to the management of CHD in the adult population is becoming increasingly recognized as the preferred treatment option for a wide number of congenital cardiac conditions. The files of all consecutive patients over 18 years of age who were hospitalized in our department from January 2000 to December 2004 were reviewed. Over the study period, 1,115 ACHD (583 women; mean age 41 +/- 13.8, years, range 18-72 years) were hospitalized in our department; 752 patients underwent cardiac catheterization and 82.4% of them had an interventional procedure carried out. ASD (329/620) and PFO (159/620) closure account for 78% of all the procedures carried out, with a 2.7% of major complications incidence (all of them closing ASDs). Other procedures such as stenting aortic coarctation (40/620), ventricular septal defect closure (33/620), patent ductus arteriosus embolization (30/620), pulmonary valvuloplasty (12/620), stenting pulmonary artery branches (8/620), etc (5/620) were carried out. The most important complication was one death, which occurred in the case of a 22-year-old woman after stent implantation for a recurrent aortic coarctation. A trivial residual shunt was detected in only 5% of the patients who had a 6-month follow-up after VSD closure; no residual shunt was found after PDA embolization during the 12-month follow-up. In conclusion, we believe that the interventional approach is a safe and successful treatment option for a wide number of congenital cardiac conditions. The increasing use of catheter interventions for these patients will be responsible for an increase of complex cases in surgery.

Stress stent fracture: is stent angioplasty really a safe therapeutic option in native aortic coarctation?

An 11-year-old boy was successfully treated by stent implantation for native aortic coarctation. At the 1-year control a severe re-coarctation was found at Doppler analysis and subsequent angiography revealed a transverse stent fracture. A stent-in-stent implantation was performed. Several hypotheses could explain this complication. Interventional cardiologists may pay more attention in following up these patients!

Time-course of cardiac remodeling following transcatheter closure of atrial septal defect.

BACKGROUND: Right chamber dilatation and right-to-left volumetric unbalance are well-known cardiac consequences of atrial septal defect (ASD) shunt, accounting for most of its long-term complications. Thus, cardiac volumetric unloading is a major aim of ASD closure. Different from surgery, transcatheter option might be considered as an "unbiased" tool to evaluate the cardiac geometric remodeling following ASD closure. METHODS: Extent and time-course of cardiac geometric changes were assessed by echocardiography 24 h, 1 and 6 months after percutaneous closure of large ASD (mean diameter 17+/-6 mm, QP/QS 2.2+/-0.9) in 42 asymptomatic patients (age 22+/-18 years). RESULTS: Transcatheter closure was accomplished using the Amplatzer Septal Occluder device (mean 23+/-7 mm, median 24 mm), achieving a complete occlusion in all patients at the 6-month follow-up control. After ASD closure, right atrial (RA) volume reduced from 45+/-24 to 28+/-12 ml (-37.8%, p<0.001), while left atrial (LA) volume did not significantly change. Inlet and infundibulum right ventricular (RV) end-diastolic diameters reduced by 23+/-2% and 23+/-3%, respectively (p<0.001 for both measurements), although with a different time-course of changes. Finally, transverse left ventricular (LV) end-diastolic diameter increased from 39+/-7 to 44+/-5 mm (+11.4%, p<0.01). These geometric changes resulted in an RV/LV diameter ratio decrease by 34+/-3% (p<0.001). Nearly 90% of cardiac remodeling ensued within 1 month from shunt disappearance (50% within 24 h). CONCLUSIONS: Percutaneous ASD closure results in early and striking cardiac geometric changes that almost completely revert the right-to-left volumetric unbalance. Most of this geometric remodeling ensues within a few weeks from ASD closure.

Results and mid-long-term follow-up of stent implantation for native and recurrent coarctation of the aorta.

AIMS: Since the late 1980s, endovascular stents have been used in the treatment of several vascular lesions. In the last decades, stent implantation has been proposed as a reliable option for the treatment of coarctation of the aorta. In this setting, it seems to have some advantages, rendering it superior to angioplasty alone. METHODS AND RESULTS: Between December 1997 and December 2004, 71 consecutive patients (44 males and 27 females) underwent cardiac catheterization for native or recurrent coarctation of the aorta. Seventy-four stents were implanted. All discharged patients were enrolled in a follow-up programme. Every patient underwent clinical evaluation, echo-colour Doppler studies, and exercise ECG at 1 and 6 months after the stent implantation. Peak systolic gradient dropped from 39.3 +/- 15.3 to 3.6 +/- 5.5 mmHg (P = 0.0041). The diameter of the coarcted segment increased from 8.3 +/- 2.9 to 16.4 +/- 3.8 mm (P = 0.037). In our series, one death occurred in a 22-year-old girl with a recurrent coarctation of the aorta, just after stent implantation. The rate of minor complications was <2%. Re-dilatation of a previously implanted stent was performed in three patients. CONCLUSION: In our experience (the largest reported to the best of our knowledge), stenting of a coarctation/re-coarctation of the aorta represents a safe alternative treatment without a significant mid-long-term complication.

Atrial function after surgical and percutaneous closure of atrial septal defect: a strain rate imaging study.

The effect of operation and the effect of the imposition of an occluding device on atrial function for patients with an atrial septal defect (ASD) has never been studied. Thus, the aim of this study was to evaluate for the first time both left atrial (LA) and right atrial (RA) function of children after transcatheter ASD closure with that of sex- and age-matched patients with surgically treated ASD, and sex- and age-matched control subjects using strain (epsilon) and epsilon rate imaging (SR). In all, 45 participants formed our studied sample: 15 patients after successful ASD device closure (ASD-D [atrial septal defect device closure] group, mean age: 9 +/- 3 years) and 15 age- and sex-matched patients after successful ASD surgical closure (ASD-S [atrial septal defect surgical closure] group, mean age: 9 +/- 3 years). All patients underwent ASD correction at least 6 months before the study. As a control group we selected 15 age- and sex-matched control subjects. In the ASD-S group the peak systolic epsilon and SR values were significantly reduced in both RA and LA when compared with control and ASD-D groups (P < .01). In the ASD-D group there was no significant difference in both LA and RA deformation properties when compared with control subjects. SR imaging indexes could provide new, noninvasive, clinically relevant insight on regional changes in atrial function for patients with ASD. ASD percutaneous closure is useful not only because it is less expensive and invasive than open-heart operation but also for its conservation of both LA and RA regional myocardial properties.

Comparison of strain rate imaging for quantitative evaluation of regional left and right ventricular function after surgical versus percutaneous closure of atrial septal defect.

For the first time, peak systolic strain and strain rate (SR) were used to assess right ventricular (RV) and left ventricular (LV) regional function in children after transcatheter and surgical atrial septal defect (ASD) closure. Fifteen patients with successful ASD device closure (the ASD-D group, mean age 9 +/- 3 years), 15 age- and gender-matched patients with successful ASD surgical closure (the ASD-S group, mean age 9 +/- 3 years), and 15 age- and gender-matched controls were enrolled. Regional RV and LV longitudinal function was significantly reduced in the ASD-S group compared with controls in all the studied segments. The ASD-D group presented significantly (p <0.001) reduced strain and SR values only on the basal and mid segments of the septal wall compared with controls. In the ASD-D group, only the RV basal segment showed significantly (p <0.001) reduced strain and SR values compared with controls but significantly greater values than those measured in the ASD-S group. SR imaging indexes could provide new, noninvasive, clinically relevant insight into regional changes in RV function and support the transcatheter approach to ASD for its less negative impact on RV and LV function.

Percutaneous treatment of moderate-to-large patent ductus arteriosus with different devices: early and mid-term results.

BACKGROUND: Transcatheter closure is now accepted as the first-choice therapeutic option in patients with patent ductus arteriosus (PDA). However, this procedure is still challenging in large PDA and/or younger patients. This study evaluated feasibility and results of this approach in large, symptomatic PDA using different devices. METHODS: Between April 2000 and July 2004, 57 patients underwent attempt of transcatheter closure of a large PDA at our Institution. Nineteen patients (33.3 %) were on pharmacologic therapy for congestive heart failure. PDA diameter was 3.2+/-1.2 mm (range 1.8-9 mm), resulting in a pulmonary to systemic flow ratio of 2.1+/-1.8 (range 1.4-5). RESULTS: The procedure was successfully performed in 54 patients (94.7%), using the Amplatzer duct occluder (ADO) device (34 patients) or a multiple detachable coil approach (20 patients). Complete PDA occlusion was recorded in 77.8% of patients at 24 hours, 92.6% at 1 month, and 94.4% at last follow-up control (23+/-12 months). PDA morphology and pulmonary to systemic flow ratio did not influence the success rate of the procedure or the residual shunt. A trend toward a higher occlusion rate at any follow-up point was recorded in the ADO group (79.5 vs 75.0% at 24 hours, 97.1 vs 85.0% at 1 month, and 97.1 vs 90% at last follow-up control, p = NS for all comparisons). CONCLUSIONS: Percutaneous closure might be considered effective and safe also in large, clinically significant PDA, by tailoring the device choice to the patient size and ductal morphology. In this setting, the multiple coil option revealed as effective as the ADO device over a mid-term follow-up.