Stenting of the Right Ventricular Outflow Tract Promotes Better Pulmonary Arterial Growth Compared With Modified Blalock-Taussig Shunt Palliation in Tetralogy of Fallot-Type Lesions.

OBJECTIVES: This study sought to compare pulmonary arterial (PA) growth during palliation after right ventricular outflow tract (RVOT) stenting versus modified Blalock-Taussig shunt (mBTS) in patients coming forward for complete repair of tetralogy of Fallot-type lesions. BACKGROUND: RVOT stenting is a recent alternative to mBTS in the initial palliation of selected patients with Fallot-type lesions. METHODS: This was a retrospective, single-center study of nonrandomized, consecutive palliated Fallot patients over a 10-year period. Differential left PA (LPA) and right PA (RPA) growth was assessed by serial echocardiograms in 67 patients after mBTS (n = 28) or RVOT stent (n = 39). Statistical data analysis was performed using mixed model analysis. RESULTS: RPA z-scores in the mBTS group improved from median -2.41 (interquartile range [IQR]: -2.97 to -1.32) to -1.13 (IQR: -1.68 to -0.59). LPA z-scores improved from -1.89 (IQR: -2.33 to -1.12) to -0.32 (IQR: -0.88 to -0.05). In the RVOT stenting group RPA z-scores improved from -2.28 (IQR: -3.28 to -1.82) to -0.72 (IQR: -1.27 to +0.48), and LPA z-scores from -2.08 (IQR: -2.90 to -0.61) to -0.05 (IQR: -0.88 to +0.48). Mixed model analysis showed significantly better RPA and LPA growth after RVOT stenting. The benefit of RVOT stenting versus mBTS was 0.599 z-scores for the LPA and 0.749 z-scores for the RPA. Rise in oxygen saturations was greater with RVOT stenting (p = 0.012). Median time to complete repair was shorter in the RVOT stent group (227 [142 to 328] days) compared with the mBTS group (439 [300 to 529] days; p < 0.0003). CONCLUSIONS: RVOT stenting promotes better pulmonary arterial growth and oxygen saturations compared with mBTS in the initial palliation of Fallot-type lesions.

Right ventricular outflow tract stent versus BT shunt palliation in Tetralogy of Fallot.

OBJECTIVE: This study sets out to compare morbidity, mortality and reintervention rates after stenting of the right ventricular outflow tract (RVOT) versus modified Blalock-Taussig shunt (mBTS) for palliation in patients with tetralogy of Fallot (ToF)-type lesions. METHODS: Retrospective case review study evaluating 101 patients (64 males) with ToF lesions who underwent palliation with either mBTS (n=41) or RVOT stent (n=60) to augment pulmonary blood flow over a 10-year period. Procedure-related morbidity, mortality and reintervention rates were assessed and compared. RESULTS: Admission rate to paediatric intensive care unit (PICU) was lower in the RVOT stent group (22% vs 100%; p<0.001). Thirty-day mortality in the RVOT stent group was (1/60 (1.7%)) compared with (2/41 (4.9%)) in the mBTS group (p=0.565). Mortality until surgical repair was comparable in both groups (5/60, 8.4%, including three non-cardiac death in the RVOT stent group vs 2/41, 4.9% (p=0.698)). Total hospital length of stay was shorter for the RVOT stent group (median 7 days vs 14 days; p<0.003). Time to surgical repair was shorter in the RVOT stent group (median 232 days, IQR 113-360) compared with the mBTS group (median 428 days, IQR 370-529; p<0.001) due to improved pulmonary arterial growth. CONCLUSION: RVOT stenting in Fallot-type lesions can be accomplished safely, with lower PICU admission rate, a shorter hospital length of stay and shorter duration of palliation until complete repair compared with mBTS palliation.

Stenting of the left pulmonary artery after palliation of hypoplastic left heart syndrome.

BACKGROUND: Left pulmonary artery stenosis and hypoplasia is a well-recognized complication following surgical palliation of hypoplastic left heart syndrome. These lesions produce increased after load in a circulation in series so need to be effectively treated. METHODS: Between 2000 and 2011, 86 patients after surgical palliation for hypoplastic left heart syndrome had left pulmonary artery stents implanted. Median age at implantation was 4.7(1.3-15.2) years and median weight was 16.4(9.3-55.2) kg. Uncovered peripheral vascular stents were implanted (median diameter 10(8-15) mm). This is a retrospective review of the incidence of in-stent restenosis over the medium to long term. RESULTS: During primary stenting procedures, there were 2/88(2.3%) major complications of stent migration with no stroke or mortality. Follow-up was for a median period of 4.1(0.5-13.4) years. Follow-up catheter procedures were performed after a median time of 2.3(0.02-9.6) years in 59 patients (68.6%). 55/59(93.2%) had at most mild restenosis (≤10% loss of stent lumen) and 47/59(79.6%) had no evidence of any restenosis at all caused by neointimal in-growth. Freedom from reintervention was 77% at 5 years including stent dilation to compensate for somatic growth. Freedom from reintervention for restenosis was 93% at 5 years. Restenosis was successfully treated with standard balloon angioplasty or restenting. There was only 1/94 (1.1%) major complication in the follow-up catheterizations of stent embolization with successful transcatheter retrieval. CONCLUSIONS: Stenting of the left pulmonary artery after Norwood/Fontan palliation is safe and effective. Stents can be redilated to match somatic growth. The incidence of neointimal proliferation is extremely low and can be addressed by balloon dilation or stent implantation. © 2016 Wiley Periodicals, Inc.

Initial experience with the cook formula balloon expandable stent in congenital heart disease.

INTRODUCTION: Balloon expandable stents are an integral part in the catheter treatment of congenital heart disease. In the growing child, stents require dilatation to greater diameters over time. The Cook Formula stent is a recent 316 stainless steel open-cell design licensed for peripheral vascular work. METHODS: Following extensive ex vivo studies, 112 stents were implanted in 97 children [median age 3.9 (0.01-17.6) years; median weight 13.7 (2.4-62.8) kg] over a 27-month (Oct 2011-Dec 2013) period. RESULTS: Bench testing revealed that there was no stent shortening for dilatation to nominal diameter and beyond. The 5 mm stents could be dilated up to 10 mm, and the 10 mm stents to 20 mm. Stents were implanted through 4-7F sheaths or guide catheters over appropriate wires. Stent tracking and delivery was excellent. Twenty-three stents were implanted in the right ventricular outflow tract in Fallot-type lesions, 53 for branch pulmonary artery stenosis (22 post cavopulmonary shunt/Fontan), 14 conduit stenosis, 13 Fontan fenestrations, 3 PDA in hybrid stage I Norwood, 5 in coarctation, and 1 for SVC obstruction. Sixty-one stents (54%) were overdilated. There were no stent fractures. Radial strength was very good, whereas stent conformability was limited. CONCLUSIONS: The Cook Formula stent is a premounted balloon-expandable stent that can be significantly overdilated with virtually no shortening allowing for precise placement and minimal protrusion into adjacent vessels. The Formula stent is a very versatile addition to the range of stents for use in the catheter treatment of complex congenital heart disease in children. © 2014 Wiley Periodicals, Inc.

Effect of nepafenac eye drops on intraocular pressure: a randomized prospective study.

PURPOSE: To report the effect of nepafenac (0.1%) eye drops on intraocular pressure in eyes with cataract. DESIGN: Prospective randomized clinical trial. METHODS: Three hundred and twenty-seven patients with bilateral cataracts in an institutional setting were included. All patients had a baseline intraocular pressure (IOP) ≤ 21 mm Hg without a history of intraocular surgery in the past 3 months. One eye of each individual was randomized to the treatment group, with the other eye acting as a control. Nepafenac (0.1%) eye drops were instilled 3 times a day in the eye that received treatment. Intraocular pressure (IOP) with Goldmann applanation tonometer (GAT) was measured at baseline and at 4 and 8 weeks. Proportion of eyes with an IOP elevation of >4 mm Hg was the main outcome measure. RESULTS: The mean age of the participants was 45.7 ± 4.4 years. Participants included 192 female and 135 male patients. The mean IOP at baseline in the treated and control eyes was, respectively, 13.8 ± 2.5 mm Hg and 13.4 ± 3.0 mm Hg, which reduced to 12.0 ± 2.0 mm Hg and 12.1 ± 1.5 mm Hg, respectively, at the end of 8 weeks. This reduction in IOP in both groups was significant (P < .01). The difference between the IOP in the treated and control eyes at 8 weeks was not statistically significant (P = .34). One eye in the treated group and 2 eyes in the control group had an IOP elevation of >4 mm Hg. CONCLUSION: Nepafenac eye drops do not increase the IOP. They can possibly be used as an alternative to steroid medications where steroid responsiveness is a concern.

Stenting of the right ventricular outflow tract.

OBJECTIVE: To assess the indication, technical aspects, and outcome of stenting of the right ventricular outflow tract (RVOT) in the management of symptomatic patients with severely limited pulmonary blood flow. METHODS: Retrospective case note and procedure review of patients undergoing stenting of the RVOT over an 8 year period. PATIENTS: Between 2005 and 2012, 52 selected patients underwent percutaneous stent implantation into a very narrow RVOT to improve pulmonary blood flow. Median age at stent implantation was 63 (range 4-406) days and median weight was 3.8 (1.7-12.2) kg. RESULTS: 52 patients underwent stent implantation. Median procedure time was 57 (24-260) min and fluoroscopy time 16 (5.5-73) min. There was one procedural death (1.9%) and one emergency surgery (1.9%). Saturations increased from 71% (52-83%) to 92% (81-100%) (p<0.001). Two patients required early shunts due to inadequate palliation and two died from non-cardiac causes. Sixteen further catheter interventions were undertaken (balloon in 7, further stent in 9). Twenty-nine patients underwent delayed surgery (complete repair in 26, palliative in 3) at a median of 172 (52-758) days post-stenting. Left pulmonary artery Z score increased from a pre-interventional value of -1.75 (-4.96 to 0.67) to a pre-surgical value of -0.55 (-4.12 to 1.97), (p<0.01). Median right pulmonary artery Z score increased from -2.63 (-7.70 to 0.89) to -0.75 (-6.69 to 1.18) (p<0.01) . Seventeen patients remain well palliated after a median of 122 (40-286) days. CONCLUSIONS: Stenting of the RVOT is an effective treatment option in the initial management of selected patients with very reduced pulmonary blood flow.

Surgery following primary right ventricular outflow tract stenting for Fallot's tetralogy and variants: rehabilitation of small pulmonary arteries.

OBJECTIVES: Primary surgical repair of Tetralogy of Fallot (ToF) in small infants with small pulmonary arteries (PAs) or complex anatomies can be hazardous. We assessed the effect of right ventricular outflow tract (RVOT) stenting on subsequent surgical intervention with attention to growth of the PAs. METHODS: Primary RVOT stenting was performed in 32 symptomatic patients with ToF physiology. Twenty patients had surgical intervention, with 15 undergoing complete repair to date. Median age at stenting was 61 (range 8-406) days, and median weight, 3.9 (range 1.8-12.2) kg. RESULTS: Stenting improved saturations from 72 ± 8 to 92 ± 2% (P < 0.001). Four patients required early surgical palliation for persistent desaturation (within 4 weeks). Twenty patients went on to have surgical intervention at a median time of 220 days after stenting. There was no operative mortality after complete repair. Removing the stent lengthened the procedure time and 86% required transannular patch (TAP; bypass time 109 ± 42 min, cross clamp 68 ± 29 min). Median intensive therapy unit stay was 2 days. There was 1 late death at 3 months due to chronic lung disease. The median left PA Z-score increased from a preinterventional value of -1.27 (-0.19 to -2.87) to a presurgical value of +0.11 (-4.12 to +1.97). The median right PA Z-score increased from -2.02 (-1.77 to -4.68) to -0.65 (-0.29 to -2.04) over the preinterventional and presurgical time intervals. Growth was greatest in the right PA. CONCLUSIONS: Primary RVOT stenting facilitates staged palliation for ToF in small infants and complex anatomies. Improved PA blood flow generated by the stent leads to growth of the branch PAs and may improve the substrate for subsequent surgical repair. Surgery is safe; however, the majority will require a TAP.

Catheter rehabilitation of occluded aberrant pulmonary artery.

A 10-year old girl underwent a CT angiogram to investigate right lung hypoplasia. This showed a normal bronchial tree, lung parenchyma and pulmonary venous drainage, but an absent right pulmonary artery. Cardiac catheterization with pulmonary vein wedge injections identified a disconnected hypoplastic right pulmonary artery system supplied by an occluded right-sided ductus arteriosus. Transcatheter recanalization of the ductus re-established right pulmonary artery flow and growth. Ultimately, this allowed for complete surgical repair and restoration of normal perfusion of the right lung, leading to complete functional rehabilitation.

Localized Serous Retinal Detachment of Macula as a Marker of Malignant Hypertension.

The association between serous retinal detachment of macula (SRD) in hypertensive retinopathy (HTR) and malignant hypertension has been reported. This cross-sectional study included 14 consecutive patients on treatment for hypertension, who were referred for ophthalmic evaluation and were found to have macular SRD, documented by optical coherence tomography. All underwent systemic evaluation for hypertensive status and to rule out other associated/similar diseases such as diabetes, coagulopathies, lupus etc. The mean age of the patients was 44.35 +/- 15.5 years; the mean best-corrected visual acuity was 6/12. All had grade 3-4 HTR; 10 patients had bilaterally symmetrical retinopathy (grade 3 or 4); 4 had asymmetric fundus changes. Systemically, every patient was found to have malignant hypertension. The mean systolic and diastolic pressures were 208.57 +/- 32.78 and 117.86 +/- 14.2 mm Hg, respectively. SRD predicted malignant hypertension more consistently than papilledema (P = .0132). The presence of macular SRD in a hypertensive patient may serve as an indicator of malignant hypertension.

Purtscher-like retinopathy with serous retinal detachment in preeclampsia of pregnancy: complications and management.

PURPOSE: We report the management of a young woman with preeclampsia of pregnancy who developed bilateral Purtscher-like retinopathy and serous retinal detachment subsequently complicated by macular hole and tractional retinal detachment. METHODS: The best-corrected visual acuity was 20/1000 bilaterally. Fundus examination showed a picture of Purtscher-like retinopathy bilaterally and a macular hole in the right eye. Fluorescein angiography showed areas of capillary dropout and Elschnig spots bilaterally. Optical coherence tomography confirmed the macular hole in the right eye and a shallow serous retinal detachment bilaterally. Systemic and laboratory workup was unremarkable. Triamcinolone acetonide (4 mg/0.1 mL) was injected intravitreally in the left eye; vitrectomy was advised for the right eye. However, when the patient returned after 4 months, the right eye had developed a macular tractional retinal detachment. Vitrectomy, membrane peeling, and gas tamponade were performed. RESULTS: When the patient returned 4 months after the intravitreal injection in the left eye, best-corrected visual acuity had improved to 20/40 with complete resolution of serous retinal detachment in that eye. Best-corrected visual acuity in the right eye remained at 20/1000 but with anatomic deterioration. One month after vitrectomy for the macular hole and tractional retinal detachment in the right eye, best-corrected visual acuity improved to 20/240 with normalizing foveal contours. Status quo was observed in both eyes for the next 8 months. Final best-corrected visual acuity was 20/200 in the right eye and 20/40 in the left eye. CONCLUSION: An unusual combination of Purtscher-like retinopathy with serous retinal detachment in preeclampsia of pregnancy and its complication-macular hole with tractional retinal detachment-were managed by surgery and pharmacotherapy.