Actualización en intervencionismo / Update in interventionism

El gran desarrollo de las técnicas de imagen en el estudio de las cardiopatías congénitas permite aumentar la calidad y resultado del intervencionismo en cardiología pediátrica, tanto en la indicación y contraindicación de los procedimientos como en su planificación y elección de los diferentes implantes. La ecocardiografía en •D muestra íntegramente la anatomía del septum interauricular (SIA) facilitando el procedimiento de cierre de los diferentes orificios. La angiografía rotacional en la misma sala de cateterismo muestra, en una sola inyección de contraste, toda la anatomía cardíaca y vascular en múltiples angulaciones, permitiendo diseñar la estrategia de intervencionismo a realizar y la curva ideal de los catéteres a emplear. Las medidas del defecto interatrial, espesor relativo de los bores existente, tamaños de la comunicación interventricular o diámetro del anillo aórtico, cada vez pertenecen más a la ecocardiografía que a la angiografía. La morfología del arco e istmo aórticos y el tamaño y función del ventrículo derecho (VD) son patrimonio de la resonancia magnética nuclear (RMN). No obstante, la evaluación hemodinámica del corazón malformado, la fluorografía de alta resolución para fracturas de stents o patillas de dispositivos y la integración de la angiografía rotacional en el plano principal de estudio convierten la sala de hemodinámica en un lugar de estudio fisiopatológico y tratamiento endovascular. Existen patologías que pueden ser ya consideradas como rescatadas dela cirugía convencional, como los ductus de cualquier tamaño, estenosis pulmonar, recoartaciones de aorta, fístulas coronarias, entre otras (AU)

The important developments in imaging techniques for the study of congenital heart diseases allows the interventionalist to an increase in quality, safety and outcome of the procedures, also helping to improve the accuracy in the indications, catheterization procedures. Rotational angiography shows the entire cardiac and vascular anatomy in multiple angles adding important anatomical information, in a single contrast injection and making it possible to design the interventional strategy to be performed and the ideal curve of the catheters to be used. Assessment of the size of the atrial or ventricular septal defects, relative thickness of the existing borders on the diameter of the aortic annulus, can be safely estimated now with ECHO techniques, during the procedure, instead of angiographic measures. The morphology of the aortic arch and the size and function of the right ventricle (RV) are now accurately assessed with the nuclear magnetic resonance (MRI). However, the hemodynamic evaluation of the malformed heart and a high resolution fluorography for stent or device strut fractures and the integration of the rotational angiography in the principal study plane, converts the catheterization laboratory in a sophisticated tool for the study of pathophysiology and treatment of simple and complex congenital heart disease. Several lesions can be considered at the present time as non surgical candidates, due to the result improvement of catheter based techniques. Among them, patent ductus arteriosus of any size, pulmonary valvar stenosis, a variety of native and post operative aortic coarctations, coronary fistulas, branch pulmonary arterial stenosis and multiple dehiscence’s and heart holes, can be sorted out in the catheter laboratory with very low morbidity and mortality (AU)

Idiopathic thoracic aortic aneurysm at pediatric age.

A 6-year-old-boy presented with epigastric pain and vomiting over 1 year. Chest X-ray and esophagogastric transit showed a mediastinal mass. A chest computerized tomography angiogram demonstrated a descending thoracic aortic aneurysm. Analytical determinations carried out were all negative. The aneurysm was surgically repaired using a Dacron patch. The anatomopathological study described atherosclerotic lesions with calcifications, compatible with an atherosclerotic aneurysm wall. Aneurysms are uncommon in the pediatric population. Usually, no pathogenesis can be determined, and thus, such cases are grouped as idiopathic. Direct repair with or without patch is a therapeutic alternative in pediatric aneurysms and can allow the growth of the aortic circumference.

Cateterismo cardíaco transhepático en niños. Experiencia de un caso / Transhepatic cardiac catheterization in children. Report of one case

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[Balloon pulmonary valvuloplasty in the neonatal period. The clinical and echocardiographic effects]. / Valvuloplastia pulmonar con balón en el período neonatal. Efectos clínicos y ecocardiográficos.

AIM: To analyze the efficacy of balloon pulmonary valvuloplasty (BPV) as the elective treatment for neonatal critical pulmonary valvar stenosis (PVS). MATERIALS AND METHODS: The results of clinical and echocardiographic features before and after the BPV were reviewed in 29 neonates (18+/-12 days of life). Different hemodynamic and 2-D color Doppler echocardiographic were evaluated. The BPV result was classified as favourable if no other balloon or surgical therapy was required to normalise pulmonary flow and achieve a sustained right ventricle-pulmonary artery (RV-PA) Doppler gradient below 40 mmHg. It was considered unfavourable if the neonate died, needed surgery or redilation and/or the RV-PA Doppler gradient was > or =40 mm Hg. The study developed in three phases: pre BPV immediate post BPV until the hospital discharge (14+/-11 days), and in the mid-term follow-up of between 8 and 96 months (51+/-31 months). RESULTS: Mortality was not registered with BPV. The RV/left ventricular systolic pressure decreased from 1.4+/-0.3 to 0.8+/-0.3 (p<0.01) as a consequence of the dilation, and the the systemic oxygen saturation increased from 85 +/-12 to 92+/-6% (p<0.01). The RV-PA Doppler gradient diminished from 86+/-18 to 28+/-16 mm Hg immediately after BPV (p<0.01) and was registered at 13+/-6 mm Hg in the follow-up (n = 24). The RV-PA junction Z value grew from -1.25+/-0.9 before valvuloplasty to -0.51 +/-0.7 at the final echocardiogram (p<0.01). No changes in the tricuspid diameter were detected between both periods of time. Five neonates obtained unsatisfactory results: 4 in the immediate post BPV (systemic-pulmonary artery shunt 2, transannular patch 2), and 1 in the mid-term follow-up (valvectomy + transannular patch). The actuarial curve reflects that 82,7% of the patients were free form reinterventions at 8 years. CONCLUSIONS: BPV is safe and effective to relief PVS in the neonate. The balloon promotes advantageous changes in both, pulmonary annulus and the right ventricle. In addition, the RV-PA Doppler gradient observations in the follow-up, support the expectation that the BPV is a "curative" therapy.

[Percutaneous balloon pulmonary valvuloplasty: the medium-term results in a series of 100 consecutive pediatric patients]. / Valvuloplastia pulmonar percutánea con balón: resultados a medio plazo de una serie de 100 pacientes pediátricos consecutivos.

OBJECTIVE: To study medium-term follow-up in children with pulmonary stenosis (PS) with percutaneous balloon pulmonary valvuloplasty (PBVP). PATIENTS AND METHODS: Medium-term follow-up results of 106 consecutive PBVP procedures in 100 patients of the same health center are presented. The mean age of the patients was 61.3 +/- 5.1 months, 31 of them with severe PS. RESULTS: After PBVP, and once infundibular contraction ceased, the procedure was defined as successful in 85 children. PBVP was repeated in five patients, achieving satisfactory results in 3. Eight patients suffered from re-stenoses and surgery was performed in 7 of them. The other 12 patients in which PBVP failed underwent surgery. Follow-up of these 88 patients showed a cessation in clinical symptomatology at a mean of 10 +/- 0.7 months. Five-year actuarial probability of achieving a normal EKG axis was 61.7 +/- 9.1%. However, neither ECG nor chest radiology were useful in the diagnosis of high residual gradients. Pulmonary regurgitation was observed in 92% of the children, mild in all of them. The residual transpulmonary gradient obtained immediately after PBVP was the only variable that affected long-term results. CONCLUSIONS: Our results confirm the medium-term success of PBVP in the treatment of PS. The five year actuarial probability of restenosis is 12.4%. Mild pulmonary regurgitation is observed in more than 90% of patients.

Stent implantation for post-Mustard systemic venous obstruction.

In this paper, we report on the use of stents in the treatment of late-onset post-Mustard systemic venous obstruction in three patients with clinical signs of obstructive caval syndrome. After unsuccessful balloon dilation, Palmaz-Schatz stents were implanted at the veno-atrial junction. Further dilation has been achieved using high-pressure balloons. Vessel diameter increased from 4.4+/-1.8 to 13+/-1.7 mm (P < 0.05) and the trans-stenotic pressure gradient dropped from 8+/-6 to 0 mmHg (P < 0.01), with clinical improvement. After 26+/-4 months of non-invasive follow-up, no signs of recurrent stenosis were observed. Stent implantation is effective in the treatment of systemic venous obstruction after Mustard operation.

Patent ductus arteriosus occlusion using detachable coils.

Occlusion of patent ductus arteriosus was performed using detachable coils in 193 cases, with 181 successful implants and a low embolization rate. This technique is safe and effective for occlusion of ductuses of various sizes, and is low cost.

[Extracorporeal membrane oxygenation in myocardial failure after pediatric heart surgery]. / Oxigenación con membrana extracorpórea en el fallo miocárdico después de cirugía cardíaca pediátrica.

In spite of progressive improvement not only in myocardial protection but also in anesthetic and surgical techniques, the repair of complex congenital heart defects can still lead to cardiopulmonary compromise refractory to conventional treatment. We describe two patients in whom successful surgical repair of congenital heart defects was followed by severe heart failure refractory to medical treatment. Both patients were managed by extracorporeal membrane oxygenation (ECMO). We discuss the indications, contraindications and use of ECMO in the postoperative intensive care unit.

[The role of the stent in non-coronary cardiopathies]. / Papel del stent en las cardiopatías no coronarias.

INTRODUCTION: The stent has demonstrated to be a useful device in the prevention of postangioplasty coronary restenosis and it is expected to have a favourable effect as an alternative or complementary treatment of stenotic lesions in arteries or veins associated with congenital defects. The aim of this study is to analyze our experience in this setting. MATERIAL AND METHODS: From February 1992 to March 1996, 28 stenting procedures were performed in 26 patients (mean age: 8.6 +/- 0.7 years; mean weight: 26.2 +/- 3 kg). In 12 patients, stenting was single, and a iliac Palmaz stents were always used. Stenting location was: pulmonary artery branches in 17 patients, right ventricular outflow in 2 patients, in the junction of right atrium with pulmonary artery in 2 patients, systemic veins in 2 patients and in post Mustard intratrial channel stenosis in 2 patients. 25 patients had previously undergone at least one surgical procedure. RESULTS: The stenotic diameter of the treated lesions increased significantly after the procedure (4.4 +/- 0.3 mm before stenting vs 11.6 +/- 0.3 mm after stenting, p < 0.0001) and the transtenotic gradient decreased from 38.1 +/- 5 to 12 +/- 3.8 mmHg. Those changes were associated with a diminution of right ventricular pressure (81.6 +/- 3 vs 56.7 +/- 6 mmHg, p < 0.0001) in patients with pulmonary branch stenosis without septal defects. There was no mortality among the percutaneously treated patients and only one patient needed surgery. Nevertheless, one patient died after bilateral intraoperative stenting. CONCLUSION: The treatment of proximal or distal stenotic lesions in the pulmonary tree, systemic veins, and obstructed intraatrial channels with stents, can replace or complement conventional balloon angioplasty. It also offers a useful and effective alternative to surgery, when it is impossible or carries a risk.

[Aortico-left ventricular tunnel associated with pulmonary valve stenosis]. / Túnel aorta-ventrículo izquierdo asociado con estenosis valvular pulmonar.

Aortico-left ventricular tunnel is an unusual cardiac anomaly. The main clinical feature is early, severe aortic regurgitation, and surgical management is mandatory. Exceptionally this defect is associated with pulmonary valve stenosis. A case of a newborn with aortico-left ventricular tunnel plus pulmonary valve stenosis is reported. Initially she underwent percutaneous pulmonary valvuloplasty during diagnostic cardiac catheterization and with surgical closure of the tunnel later.

[Therapeutic catheterization: the percutaneous closure of a persistent ductus arteriosus and of interatrial communication]. / Cateteristmo terapéutico: cierre percutáneo del ductus arteriosus persistente y comunicación interauricular.

Between february and december 1990, we attempted percutaneous closure of patent ductus arteriosus (PDA) in 26 patients and in one ostium secundum atrial septal defect (ASD). One of the PDA was right sided with right aortic arch and two were post surgical leaks. We used the "USCI-Rashkind PDA double disc occluder" and the newly designed "Lock Clamshell" occluder for the ASD. Twenty seven patients (20 females and 7 males), aged 1.3 to 16 years (M = 5.6) and weighing 9.5 to 56 kg (M = 21.3), were studied. Diagnosis was made clinically with the aid of Doppler colour flow echocardiography, with follow-up studies at 24 hours, 6 months and 1 year after the procedure. Diameter of the ductus varied from 1.6 to 8.2 mm (M = 2.6). Successful implant of the device was achieved in 25 cases (95%), of which 18 (72%) were totally occluded at 24 hours and 21 (84%) after 6 months, remaining small residual leaks in four (16%). In only one patient total occlusion was demonstrated 1 year after device implantation. We achieved 22 (88%) total occlusions. One case was not possible to occlude, due to its large size. Angiocardiography demonstrated adequate anatomy in 18, and difficult in 8 patients. Twelve and 17 mm devices were used in 16 and 9 patients, respectively. Successful second implant with subsequent total occlusion was achieved in one patient with a previous moderate residual leak. The ASD was central and single, with a diameter of 20 mm. Immediate total occlusion was achieved. We conclude that percutaneous PDA closure is a safe and effective procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

[The angiographic diagnosis of the connection of the persistent left vena cava superior to the left atrium by the absence of the roof of the coronary sinus in a child with a Holmes' heart]. / Diagnóstico angiográfico de la conexión de la vena cava superior izquierda persistente a la aurícula izquierda por ausencia de techo del seno coronario en un niño con corazón de Holmes.

We describe a patient with angiographic findings of a left superior persistent vena cava draining in the left atrium with absence of the coronary sinus' roof and coexisting with Holmes' heart. The diagnosis can be made by selective angiography in the left atrium, pulmonary vein or at the left superior vena cava. We want to emphasize the importance of knowing this sort of anomaly before surgical treatment.

[Non-surgical closure of patent ductus arteriosus in children with the Rashkind double disk occluder]. / Chiusura non chirurgica del dotto arterioso pervio in età pediatrica con dispositivo di Rashkind a doppio ombrello.

Since the first clinical application of transcatheter closure technique for patent ductus arteriosus in children and infants in 1977 by Rashkind and Coll., this technique is routinely performed only in a few major Pediatric Cardiology Centers. We report our successful series which is the first of its kind both in Italy and in Southern Europe. The series included 11 children aged 1.6 to 10 years (mean age 4.5 years) all affected with patent ductus arteriosus (PDA). Subaortic stenosis (1) and ventricular septal defect with pulmonary stenosis (1) were associated anomalies. In all of the cases, after the standard percutaneous cardiac catheterization, the Mullins method was attempted to advance and deliver the Rashkind PDA double-disk occluder. Successful closure was accomplished in 10 while almost complete closure was achieved in the 11th. Normal Doppler flow pattern after the procedure confirmed the successful results. No complications occurred. Although our experience is limited, non-surgical PDA closure provided an excellent alternative to surgical procedure.