Unique challenges posed by a dysfunctional native right ventricular outflow tract for percutaneous pulmonary valve implantation using SAPIEN-S3 valve.

Dysfunctional right ventricular outflow tracts after a repair for tetralogy of Fallot using a transannular patch offer limited nonsurgical opportunities due to their large dimensions. A discrete subannular narrowing between a dilated right ventricle and the enlarged pulmonary trunk was a potential anatomical target for the creation of a landing zone using a prestent in a young male with severe pulmonary regurgitation and moderate stenosis. Asymmetric expansion of the prestent in the angulated outflow tract led to distal stent embolization that was stabilized by another telescoping stent before successful valve implantation. This manuscript details the unique challenges posed by a dilated regurgitant outflow tract for implanting a pulmonary valve.

Transcatheter closure of multiple secundum atrial septal defects using multiple occluder devices: A comparative experience between pediatric and adult patients.

Background: Device closure of multiple atrial septal defects (MASDs) is frequently done using a single centrally deployed septal or cribriform occluder, but multiple devices are needed for large defects separated more than 6 mm. There is a concern about complications while using multiple devices, especially in children. Methods: Patients who received multiple devices for closure of MASD were grouped according to their age and analyzed for procedural techniques, immediate and late complications. MASDs closed by a single device were not included. Balloon sizing was done when echocardiographic images were suboptimal before simultaneous device deployment through two venous accesses or sequential deployment through one access. Duration and number of antiplatelet drugs and residual flows were analyzed on follow-up. Results: Twenty-five patients received multiple devices. Balloon interrogation was performed in 16/18 adults but only in 2/7 children. Device size was 2-5 mm larger than echocardiographic defect size or equal to balloon waist. There were no procedural failures; 7/25 showed small postprocedural residual flows. Complications including embolization in one, arrhythmia in one, and cobra deformity in two were managed successfully. On a median follow-up of 5.5 years (1-12 years), residual flows disappeared in 4/7 and there were no major late complications. Conclusions: Use of multiple devices for closing MASD is feasible with good technical success. Echocardiography and balloon interrogation are the keys for success. Simultaneous deployment is often needed and sequential delivery is feasible rarely if the defects are far apart. Minor residual leaks are common but improve on follow-up. There are no significant new complications on long-term follow-up.

Prospective concurrent head-to head comparison of three different types of nitinol occluder device for transcatheter closure of secundum atrial septal defects.

AIMS: Previous comparisons between AMPLATZER septal occluders and other designs were retrospective, non-randomised, non-concurrent and involved fewer patients. A prospective concurrent head-to-head comparison of AMPLATZER (ASO), Cera (CSO) and Figulla (FSO) septal occluders was planned to study the patient outcomes. METHODS AND RESULTS: The three occluders were serially allocated in a cycle of three to consecutively included patients. Demographic, procedural details and complications were analysed. After calculating a sample size of 122 patients in each group, additional patients were recruited to ensure at least 80% follow-up. Four hundred and fifty (450) consecutive patients equally divided among the three designs were comparable in all parameters. There were no major complications and procedural success was 99.6%. The defects and device sizes were similar in all groups; the delivery system was significantly smaller with the ASO. The FSO needed special deployment techniques less often and formed a cobra deformity more often, though this was not statistically significant. Patient outcome was similar among the groups at a follow-up of 12-47 months. CONCLUSIONS: The new occluders are comparable to the ASO with good outcomes and low complication rates in the current era. The new modified structural designs do not show any advantages in terms of procedural complications on early and midterm follow-up, but long-term studies are warranted.

Stent angioplasty of narrowed right ventricular outflow conduits and pulmonary arteries consistently reduces right ventricular systolic pressures and delays subsequent surgeries.

OBJECTIVES: Narrowed right ventricular (RV) outflow conduits and pulmonary arteries (PA) increase RV pressures and warrant interventions. Stent angioplasty is an alternative to more morbid redo-surgery in developing countries. We evaluate the efficacy and safety of stenting and assess need for redo-surgical reinterventions on midterm follow-up after stent angioplasty. METHODS: Patients who underwent conduit, main PA and bilateral branch PA stenting for elevated RV pressures were analyzed retrospectively. Success was defined as 20% reduction in RV pressures or RV-aortic pressure ratio; 50% reduction in gradients or 50% increase of luminal diameter. Procedural results, complications and need for redo surgeries on follow-up were assessed. RESULTS: Among 60 patients aged 1-46years, 57 were post-operative patients, who needed stenting at a median period of 48 months after surgery. Stenting succeeded in 98% and reduced RV pressures from 105.42±28.39mmHg to 54.46±16.89mmHg. Direct major procedural complications in five (8%) patients included procedural failure in one, stent migration in three and lung hemorrhage in one. None of the stented conduits needed a surgical change on a follow-up ranging 3-120 months. Following bilateral PA stenting in twenty-four patients, only two needed a repeat open-heart surgery during follow-up ranging 3-108 months. Catheter reinterventions on follow-up included elective percutaneous pulmonary valve implantation in nine patients and stent redilation in seven patients. CONCLUSIONS: Stent angioplasty was safe and effective. Surgery was postponed in all stenosed conduits. Elective redilation of stents after bilateral PA stenting may be needed for somatic growth; but open-heart repeat surgeries can be avoided in a majority.

Challenges for bilateral pulmonary artery stenting due to occluded femoral veins.

When the inferior caval vein is occluded or abnormal, jugular and hepatic veins provide alternative routes for interventions. For pulmonary artery stenting, transhepatic access may give a relatively straighter route than that from the jugular veins. We describe the challenges and strategies during transhepatic bilateral pulmonary artery stenting after arterial switch operation complicated by occluded inferior caval vein and congested hepatic veins.