Transhepatic catheterization using ultrasound-guided access.

The efficacy and safety of ultrasound guidance to obtain transhepatic access for cardiac catheterization were investigated in this study. The transhepatic route for access to perform cardiac catheterization has become an acceptable alternative when conventional routes of access have failed. However, the use of ultrasound to guide transhepatic access has not been reported in the literature. We performed a retrospective chart review. Patient characteristics, indications for catheterization, procedures performed, and complications were recorded. All patients who underwent transhepatic cardiac catheterization at Duke University Medical Center were included in this study. Eight patients underwent 12 catheterizations. The median age was 5.3 years (range, 9 months to 13 years) and median weight 18.7 kg (range, 7.1-44.8 kg). Seven catheterizations were diagnostic and 5 were interventional. There were no complications. Transhepatic access with ultrasound guidance is a safe and effective option for obtaining venous access for cardiac catheterization.

An infant with subvalvar and valvar aortic stenosis, subvalvar and valvar pulmonary stenosis, severe biventricular hypertrophy and pulmonary hemorrhage.

An infant with subvalvar and valvar pulmonary stenosis, subvalvar, and valvar aortic stenosis and hypertrophic cardiomyopathy, who presented with pulmonary hemorrhage, is reported. He had right ventricular hypertrophy, thickened pulmonary valve leaflets, severe asymmetric left ventricular hypertrophy with outflow tract obstruction, and a thickened and dysplastic aortic valve.

Intraoperative stents to rehabilitate severely stenotic pulmonary vessels.

BACKGROUND: Patch enlargement of severe branch pulmonary artery stenosis (PAS) or pulmonary vein ostial stenosis (PVS) can be technically challenging. Recurrences are common and exposure may require long periods of cardiopulmonary bypass (CPB). METHODS: Since 1993, we performed 31 procedures on 27 patients with endovascular stents placed intraoperatively under direct surgical vision: 22 patients with tight PAS and 5 patients with PVS. Selection for intraoperative (vs catheterization laboratory) stent placement was prompted by: (1) the need for a concomitant cardiac surgical procedure (16 cases); (2) limited vascular access for catheterization laboratory stent placement (11 cases); or (3) "rescue" of patients with complications after attempted placement of stents (4 cases). RESULTS: In this group of very complex and challenging patients there were 5 hospital deaths (hospital survival, 81%). Follow-up of survivors has ranged from 1 month to 7 years (mean 2.8 +/- 1.7 years). There have been 3 late deaths (late "series" survival, 70%). No complication or death was related to stent placement. Surviving patients have had significant clinical improvement. Mean pulmonary gradient (postoperative vs preoperative echo) has fallen in all survivors and has decreased from a mean of 66 mm Hg preoperatively to 28 mm Hg postoperatively (p = 0.01). All pulmonary arteries are appreciably enlarged and will be easier to deal with at a later date if necessary. One patient (DORV, HLHS ) with pulmonary vein stents has gone on to a successful Glenn procedure. The other two surviving patients with PV stents have occlusion of their proximal PVs on follow-up catheterization; thus only 1 of 5 patients with stents for PVS has had a successful outcome. Four patients have had repeat surgery. Stents have produced no impediment to subsequent surgical procedures, and the pulmonary arteries were easy to work with. CONCLUSIONS: Intraoperative stenting provides an attractive option for "rehabilitation" of pulmonary vessels. Direct vision insertion on CPB is extremely quick and immediately effective, limiting the CPB exposure required to treat this problem. Once stented, vessels remain open and are amenable to future surgical intervention as necessary. Outcome is better for patients with PAS versus those with PVS.

Microvena atrial septal defect occlusion device--update 2000.

This article (1) summarizes the Duke University results with the Das-Angel Wings atrial septal defect occlusion device, (2) outlines the rationale for design changes in the device, and (3) describes the new Microvena atrial septal defect occlusion device characteristics, and plans for the future. At Duke University, investigators using the first-generation device attempted closures in 35 patients with atrial level communications. Ages ranged from 5 to 83 years with a median of 28 years, and weights ranged from 16 to 100 kg. Thirty-two of the 35 defects had successful device placement. On follow-up, the defects of 27 of 32 patients with an implanted device were completely closed, and 5 patients had < 2-mm residual leaks. Three patients had malposition of the device, two of whom were treated surgically and one of whom was treated with percutaneous device retrieval. Complications included one small mitral valve perforation with no clinical sequelae. There have been no strokes, delayed embolizations, nor procedure or device related deaths. There have been no new or late problems in the cohort in a follow-up extending to 63 months. Opportunities for improvement of the device were noted during the clinical study. The manufacturer, Microvena Corporation, voluntarily withdrew the occluder for a redesign initiative. The objectives of redesign were ready deployment, reduction of device manipulation, rounding of the device, and retrievability. The Guardian Angel device has been the product of the redesign effort. It is a percutaneously inserted atrial septal defect occlusion device that uses the same materials as the initial device, but which has advantages of retrievability, repositionability, and no need for device manipulation. Initial studies have been performed in experimental animals, and clinical trials are planned for the near future.

Congenital agenesis of the right pulmonary artery.

A 44-year-old woman with recurrent pulmonary infections developed severe hemoptysis. Chest radiography revealed a hypoplastic right lung. Absence of the right pulmonary artery, a very rare congenital anomaly, was demonstrated by computed tomography and cardiac catheterization. Severe pulmonary hypertension in the contralateral lung precluded right pneumonectomy but percutaneous embolization of a large systemic arterial collateral to the right lung provided palliative relief of hemoptysis.

Percutaneous stenting of right pulmonary artery stenosis in fibrosing mediastinitis.

Pulmonary artery stenosis is an uncommon complication of fibrosing mediastinitis. Previous medical and surgical therapies have provided limited clinical efficacy without objective evidence of clinical improvement. With the advantages of limited invasiveness and absent need for prolonged drug therapy, percutaneous stent deployment to relieve pulmonary artery obstruction represents a novel treatment for this rare disorder.

Bedside transseptal balloon dilation atrial septostomy for decompression of the left heart during extracorporeal membrane oxygenation.

A 10-year-old male presented with severe heart failure secondary to myocarditis. Venoarterial extracorporeal membrane oxygenation was instituted. He developed severe left heart distention with acute pulmonary hemorrhage. Balloon dilation of the atrial septum to decompress the left atrium was performed at the bedside with transesophageal echocardiographic guidance.

Congestive heart failure in children.

Although revitalizing dead or severely injured myocardial cells is still beyond the reach of modern treatment, the ability to change the loading conditions and the contractile state of the heart has enabled practitioners to reverse deleterious compensatory mechanisms in patients with CHF. Several new and improved medicines have made this strategy possible. Early and determined surgical treatment of patients with CHF has enabled cure of some previously debilitating or fatal defects. The combined use of surgery and interventional catheterization has allowed many patients to profit from the benefits not available from either modality alone. In the future, cellular, subcellular, and gene therapy may make the treatment of patients with CHF simple and even prevent CHD.

Transcatheter occlusion of the patent ductus arteriosus: use of the retrievable coil device.

The Cook Retrievable Embolization Coil has been designed to improve delivery and positioning during coil embolization of the patent ductus arteriosus (PDA). We report our experience with the use of this new technique. Twenty-eight patients underwent coil embolization of a PDA using the retrievable system. The median patient age was 4.5 years (range, 2 months to 33 years), median weight 17.2 kg (range, 3.1-100 kg). The mean minimum diameter was 1.1 mm (range, 0.3-3.8 mm). One or two Cook Retrievable Embolization Coils were implanted in each PDA. Successful delivery was achieved in 27 cases. There was no shunt by angiography in 19 of the patients (70%). Color echocardiography documented no shunt in 13 of 17 patients (77%). The retrievable coil system represents a successful method of PDA occlusion with good control of coil positioning and delivery.

Hypoxemia after prior cardiac surgery due to interatrial shunting and its treatment with a novel transcatheter occlusion device.

We describe two unusual cases of hypoxemia after cardiac surgery due to intracardiac right-to-left shunting through a patent foramen ovale or atrial septal defect. The interatrial defects were successfully occluded by placement of a novel, transcather device, the Angelwings Atrial Septal Defect Occluder Device, with resolution of hypoxemia.

Partially anomalous pulmonary venous connection: demonstration of dual drainage allowing nonsurgical correction.

We describe a novel percutaneous approach for correction of partially anomalous pulmonary venous connection. We describe two cases of dual pulmonary venous drainage where embolization of the anomalous pulmonary venous connection was successful.

Percutaneous stenting of superior vena cava syndrome: a case report and review of the literature.

Superior vena cava syndrome (SVCS) is a distressing manifestation of benign or malignant disease obstructing return of blood flow through the superior vena cava (SVC). Treatment, often centering around management of the underlying illness, may be slow in relieving symptoms, relying on the recruitment of collateral veins to reestablish blood flow. Percutaneous delivery of metallic stents into the vena cava has been used with success to relieve obstruction to blood flow quickly and completely. We present the case of a patient with complete occlusion of the SVC who underwent successful vena caval revascularization with placement of balloon expandable metallic stents. We also review published reports on the use of stents for SVCS. Results from several series demonstrate that stents can be used with excellent results. Response rates in these series reviewed range from 68% to 100%. Recurrence of symptoms occurred in 4% to 45% of patients but could often be treated with anticoagulation, angioplasty of the stented area, or repeat stenting. Stenting has been used successfully in patients with malignant diseases and in the less common cases of SVCS from a benign etiology. Complications are uncommon and usually of minor consequence. Anticoagulation, thrombolytics, and thrombectomy or atherectomy catheters have also been used during or following stent implantation although their use remains primarily empiric. Percutaneous treatment of SVC obstruction offers patients hope for prompt and dramatic relief from the symptoms of SVCS.