Implantation of stents for postsurgical recoarctation of the aorta in adolescents and adults.

BACKGROUND: Results of stent implantation (SI) of postsurgical recoarctation of the aorta (ReCoA) are not frequently published. AIM: This study sought to retrospectively evaluate results of SI in ReCoA in older children and adults. METHODS: Twenty-eight SIs were performed on 26 ReCoA patients with a median age of 23 (10-65) years. Dependent upon availability, the following stents were applied: Palmaz, Cheatham Platinum (CP), Andrastents XL/XXL (AS), Covered CP (CVCP) stents, and self-expanding stents (Smart). Generally, high-pressure balloons were applied to dilate stents. RESULTS: The procedure was effective in 20/26 patients (77.7%). The mean peak systolic gradient reduced from 40.5 ± 18.7 mm Hg to 13.1 ± 12.1 mm Hg (p < 0.05), and the diameter of the stenosed segment increased from 7.5 ± 3.02 mm to 13.1 ± 3.32 mm (p < 0.05). In six cases (including a patient treated with a Smart stent) transaortic pressure gradient after SI remained > 20 mm Hg (stiff postsurgical lesion). For one patient (40-year-old male), an acute dissection of the aorta occurred during balloon predilatation. Immediate CVCP implantation resolved this problem. Two more CVCPs were used - one to close a small aortic aneurysm that appeared five years after a Palmaz SI and another to stabilise a broken CP bare metal stent. There were no deaths or aortic dissections during follow-up, and most patients were able to reduce or suspend their medication for systemic hypertension. CONCLUSIONS: Endovascular stenting of ReCoA in adults and adolescents appears to be an acceptable method of treatment in experienced hands. However, for some patients the presence of a stiff lesion can provoke suboptimal results. Considering the serious complications that can occur after SI, all patients should have regular follow-up (including an imaging study). Covered stents should always be available in the cathlab as a rescue device when implanting stents in coarctation of the aorta patients.

Native aortic coarctation stenting in patients ≥ 46 years old.

INTRODUCTION: Stent implantation is an effective therapy for aortic coarctation (CoA) in adolescents and adults. AIM: To present a unique group of patients with native coarctation of the aorta older than or equal to 46 years treated with bare metal or covered stents. MATERIAL AND METHODS: Since 2002 we have performed stent implantations by applying bare metal stents or covered stents using femoral access in 24 patients aged 46 and older. RESULTS: We used the Mullins technique in all cases, implanting different stents: Palmaz, Cheatham-Platinum (CP), covered CP or Andrastents XL/XXL. Twenty-one procedures were elective and 3 were urgent. Eighteen bare metal stents (2 stents in one patient) and 7 covered stents were used. All procedures were effective (CoA gradient reduced < 20 mm Hg), despite 2 migrations of bare metal stents. Mean gradient was reduced from 50.6 ±15.3 to 6.8 ±6.5 mm Hg (p < 0.001) and mean lumen diameter of stenosed aorta increased from 5.5 ±2.5 to 14.9 ±5.2 mm (p < 0.001). One special case is discussed - a 49-year-old man with end staged heart failure and severe CoA, who underwent a rescue procedure with a bare metal stent. One serious complication - stroke of the central nervous system - was observed in a 53-year-old woman during covered stent implantation (symptoms resolved during rehabilitation process). CONCLUSIONS: Stent implantation of native coarctation of the aorta is also a safe procedure in the eldest patients and is associated with persistent relief of aortic obstruction.

Are the AMPLATZER Duct Occluder II Additional Sizes devices dedicated only for smaller children?

AIMS: The aim of this study was to present our experience with the AMPLATZER Duct Occluder II Additional Sizes (ADOIIAS) for the closure of different types of patent ductus arteriosus (PDA) in patients of various age groups. METHODS AND RESULTS: A group of 103 patients, in whom the PDA (diameter below 3.5 mm) was closed using the ADOIIAS, was analysed. The median age of treated patients was 3.0 years (from 0.1 to 24 years), and 55 patients (53.4%) were older than three years. Ductal anatomy defined by angiography showed type A in 42 patients (40.8%), type C in six patients (5.8%), type D in 21 patients (20.5%), and type E in 34 patients (33.0%). In two cases, embolisation of the device occurred shortly after implantation. Both occluders were retrieved percutaneously. One death occurred in a neonate four days after ADOIIAS implantation (not related to the procedure: multi-organ failure). Total occlusion of PDA was confirmed in all patients the day after the procedure. No protrusion of the device into the aorta or pulmonary artery was observed in any patient during follow-up. CONCLUSIONS: The use of the ADOIIAS is a good therapeutic option for the treatment of selected PDA. The implant may be successfully substituted for coil implantation in all age groups.

Application of new balloon catheters in the treatment of congenital heart defects.

INTRODUCTION: Balloon angioplasty (BAP) and aortic or pulmonary balloon valvuloplasty (BAV, BPV) are well-established treatment options in congenital heart defects. Recently, significant technological progress has been made and new catheters have been implemented in clinical practice. AIM: To analyze the results of BAP, BAV and BPV with the new balloon catheter Valver and its second generation Valver II, which the company Balton (Poland) launched and developed. These catheters have not been clinically evaluated yet. MATERIAL AND METHODS: We performed 64 interventions with Valver I and Valver II. With Valver I the following procedures were performed: 17 BPV (including 9 in tetralogy of Fallot - TOF), 10 BAV and 27 BAP in coarctations of the aorta (CoA) - including 9 native and 18 after surgery. With Valver II ten interventions were done - 3 BPV, 2 pulmonary supravalvular BAP (after switch operations), 2 BAP of recoarctations and 3 other BAP. Age of the patients ranged from a few days to 40 years. RESULTS: All procedures were completed successfully, without rupture of any balloon catheters. The pressure gradient drop was statistically significant in all groups: BPV in isolated pulmonary valvular stenosis 28.1 mm Hg (mean), BPV in TOF 18.7 mm Hg, BAV 32.8 mm Hg, BAP in native CoA 15.4 mm Hg and in recoarctations 18.6 mm Hg. In 3 cases during rapid deflation of Valver I, wrinkles of the balloons made it impossible to insert the whole balloon into the vascular sheath (all were removed surgically from the groin). No such complication occured with Valver II. CONCLUSIONS: Valver balloon catheters are an effective treatment modality in different valvular and vascular stenoses.

Use of the AndraStent XL and XXL for the treatment of coarctation of the aorta in children and adults: immediate and midterm results.

AIMS: The aim of this study is to present our experience with a new type of extra-large stent, namely the AndraStent XL/XXL. METHODS AND RESULTS: AndraStents were implanted in 46 patients, 38 with native coarctation of the aorta (CoA) and eight with recurrent coarctation of the aorta following previous surgery (ReCoA). All patients had arterial hypertension in the upper limbs, absent or weak femoral pulses, and continuous flow in the abdominal aorta on Doppler examination. The median age of patients was 25 years (range from nine to 65). The stents (cobalt-chromium with semi-open cell design) were manually mounted on balloon catheters and delivered through 10 to 14 Fr Mullins sheaths using a conventional femoral approach. All procedures were successful (no stent migration, proper expansion, no aorta dissection/rupture, major bleeding or major vessel injury). The systolic gradient across the aorta decreased from 40.6 mmHg before the procedure to 11.6 mmHg after the procedure (p<0.001). The mean fluoroscopy time was 5.7 minutes. Imaging examinations were scheduled and performed between six and 12 months after the initial procedure in 40 patients (angiography or angio CT or both). Procedural outcome remained favourable during a mean 2.4 years of follow-up. Neither stent fracture nor dislocation was observed in any patient at follow-up. In two patients, small aneurysm formation was observed six and eight months after the procedure -they were treated successfully with subsequent covered stent implantation. Re-dilatation of the implanted stent was performed between four and 26 months in 14 patients. CONCLUSIONS: Implantation of new large cobalt-chromium stents is a good therapeutic option for the treatment of native and recurrent CoA.

Potts' shunt in a child with idiopathic pulmonary arterial hypertension - one-and-a-half year observation.

This paper presents the case of a young girl with idiopathic pulmonary hypertension, who developed signs of severe heart failure within a short period of time. Pharmacotherapy with sildenafil and bosentan (among other drugs) was ineffective. Heart catheterization revealed suprasystemic pressure in the pulmonary artery. At the age of 7.5 years, the patient underwent a surgical Potts shunt (namely, a direct side-by-side anastomosis from the left pulmonary artery to the descending aorta). The procedure resulted in a significant improvement of the clinical, echocardiographic, and biochemical parameters, which persists after one and a half years of follow-up. After the surgery, pharmacotherapy with bosentan was gradually discontinued.

Atopic allergy and chronic inflammation of the oral mucosa in a 3-year-old boy after heart transplantation - diagnostic and therapeutic difficulties.

In recent years, we have been observing an increased proportion of atopic diseases in children after solid organ transplantation. The pathogenesis of post-transplantation allergy is not completely understood and probably involves several factors, including immunosuppressive therapy. In this paper we present a case of 3-year old boy, after orthotopic heart transplantation at 6 months of age, with symptoms of food allergy associated with atopic dermatitis and changes in the orofacial area. The mentioned symptoms and elevated levels of total and specific IgE occurred with a year of transplant. Because of failure to achieve remission after typical allergy therapy we suspected that the reason of allergy in this case can be immunosuppressive therapy.

Spontaneous closure of a large atrial septal defect in an infant.

We describe a patient who, at the age of 6 months (body weight 6.1 kg), was diagnosed with a large atrial septal defect (with diameter 10-11 mm) that had spontaneously closed in a 1-year period. The timing of transcatheter intervention in children should be considered individually, paying close attention to subsequent echocardiographic data.

Preliminary experience in the use of CERA occluders for closure of different intracardiac and extracardiac shunts.

BACKGROUND: Transcatheter closure has become the method of choice for treatment of many heart defects. Recently, Lifetech Scientific introduced the Cera occluder (CO), a self-expandable nitinol wire-mesh device covered with ceramic coating. We present our preliminary experience in transcatheter closure of atrial septal defect (ASD), patent foramen ovale (PFO), patent ductus arteriosus (PDA), and post-infarction ventricular septal defect (PIVSD) with the CO. METHODS: The study population consisted of 25 patients (17 female) ages 1.1-82 years (median age, 34.0 years) with either ASD (n = 7), PFO (n = 11), PDA (n = 6), or PIVSD (n = 1). All patients were treated percutaneously with appropriate CO devices, without any preliminary patient selection. The implantation technique applied in these procedures was the same as previously described for Amplatzer occluders. RESULTS: All procedures were performed successfully. Complete shunt closure was achieved in all but 1 patient with PIVSD. No complications were observed during procedures or during follow-up of 0.5-4 months. CONCLUSIONS: Our preliminary experience in the clinical application of COs for transcatheter closure of ASD, PFO, PDA, and PIVSD has confirmed their utility, feasibility, and safety, at least in the short-term follow-up.

Radiofrequency catheter ablation in children and adolescents with preexcitation syndrome.

BACKGROUND: Atrioventricular reentrant tachycardia (AVRT) is the most common tachycardia, accounting for 70% of regular narrow-QRS arrhythmias in children. Because of the potential disadvantages of a life-long drug therapy and relatively favourable results from radiofrequency catheter ablation (RFCA) therapy in adults, the indications for ablation therapy in children with preexcitation syndrome (PS) need to be considered. AIM: To assess efficacy and safety of RFCA in children and adolescents with PS. METHODS: The study population consisted of 302 consecutive, symptomatic, drug-refractory patients with PS undergoing RFCA. Two age groups were selected: 52 patients younger than 19 years (24 females, age 15.38+/-2.53 years); and 250 adults (115 females, age 38.67+/-13.1 years). In all study patients electrophysiological study and radiofrequency catheter ablation were performed. Comparative analysis between groups was performed with respect to procedure duration, fluoroscopy exposure time, location of accessory pathways (AP), success rate, recurrences and complications. RESULTS: No significant differences between the groups were noted with respect to procedure duration and exposure time. Success and recurrence rates did not differ between the two-age groups. The mean procedure time for children was 124.12+/-43.48 min (range 45-285) and for adults - 126.3+/-61.49 min (range 25-330) (NS). The mean fluoroscopy time for children was 27.95+/-16.86 min (range 4-75) and for adults - 31.27+/-25.51 min (range 1-131) (NS). The initial RF ablation procedure was successful in 48 (92.31%) children and in 233 (93.2%) adults (NS). Recurrence rate was 12.5% (6 patients) in children vs. 8.58% (20 patients) in adults (NS). In one child (1.92%) and in two adult patients (0.8%) serious complication occurred (NS). Electrophysiological study revealed significantly more frequent presence of the right free wall and right antero-septal AP in children than in adults (21.15 vs. 7.6%, and 17.31 vs. 5.2%, respectively, p <0.01). In adults more frequent left antero-lateral AP was detected: 32.4 vs. 7.69%, p <0.01. CONCLUSIONS: Radiofrequency catheter ablation is a safe and efficient procedure in paediatric patients with preexcitation syndrome. Effectiveness, safety, recurrence rate and RFCA procedural aspects, including total procedure time and fluoroscopy time, are comparable in paediatric patients with PS and in adults.

A comparison of the clinical course of preexcitation syndrome in children and adolescents and in adults.

BACKGROUND: Atrioventricular reentrant tachycardia (AVRT) in patients with preexcitation syndrome (PS) is the main cause of paroxysmal regular arrhythmias in children and adolescents. While the previously published data most commonly concern clinical consequences of PS in adults, few researchers have evaluated the problem in children and adolescents. The aim of the study was to compare the clinical course of PS between the population of children and adolescents below 19 years of age and the population of adult patients. METHOD: The study population consisted of 302 consecutive PS patients managed between January 2001 and June 2005 with radiofrequency catheter ablation (RFCA). The study population was divided into two groups: Group 1 consisting of 52 patients aged 15.38 years on average (7-18 +/- +/- 2.53) and Group 2 consisting of 250 adult patients aged 38.67 years on average (19-72 +/- 13.1). RESULTS: Patients from Groups 1 and 2 experienced their first episode of AVRT at the mean age of 13.3 years and 29.1 years, respectively (p < 0.05). The mean annual numbers of AVRT episodes in Groups 1 and 2 were 12.97 (range, 2-96; median, 8) and 8.86 (range, 2-25; median, 6), respectively (p = non-significant). Two patients from Group 1 (3.85%) and 42 patients from Group 2 (16.8%) experienced episodes of atrial fibrillation (AF) (p < 0.05). Location of the accessory pathways (AP): In Group 1, the right free wall and anteroseptal AP locations were significantly more common [11 (21.15%) and 9 (17.31%) patients, respectively, vs.q 19 (7.6%) and 13 (5.2%) patients in Group 2; p < 0.01]. In Group 2, the left anterolateral AP location was more common [81 (32.4%) vs. 4 (7.69%) in Group 1; p < 0.01]. CONCLUSIONS: In children and adolescents with PS, a significantly lower incidence of AF was found. In Group 1, RFCA was performed significantly more frequently due to the development of AVRT caused by right free wall and right anteroseptal AP, while in the group of adults, the left anterolateral AP location was found more commonly. (Cardiol J 2007; 14: 384-390).

Radio-frequency ablation of arrhythmias following congenital heart surgery.

BACKGROUND: Cardiac arrhythmias as a late complication following congenital heart surgery are encountered more and more frequently in clinical practice. The use of new electrophysiological methods of visualisation and mapping improves the efficacy of radio-frequency (RF) ablation of these arrhythmias. AIM: To assess patterns of atrial arrhythmias following congenital heart surgery and to examine the efficacy of RF ablation using the electro-anatomical CARTO system. METHODS: Electrophysiological diagnostic study and RF ablation were performed in 24 consecutive patients (mean age 36+/-18 years) who had atrial arrhythmias following congenital heart surgery. The mechanism of arrhythmia (ectopic or reentrant) and strategy of RF ablation procedure were based on the results of the right atrial map performed during index arrhythmia. RESULTS: The patients were divided into five groups according to the type of congenital heart surgery. The ASD group consisted of 17 patients who had undergone in the past surgery due to atrial septal defect, four patients had a history of surgery due to ventricular septal defect (VSD group), and one patient each had undergone surgery due to corrected transposition of the great arteries (ccTGA), tetralogy of Fallot (TF) or dual-outflow right ventricle (DORV). During diagnostic electrophysiological study typical atrial flutter (AFL) was diagnosed in nine patients from the ASD group, atypical AFL in three ASD patients, and ectopic atrial tachycardia (EAT) in six ASD patients. In one patient EAT was induced after ablation of typical AFL. Of the VSD patients, three had atypical AFL, and one had typical AFL. The patient following surgery for ccTGA had atypical AFL and EAT, whereas in the two remaining patients (DORV and TF) atypical AFL was demonstrated. The efficacy of the first session of RF ablation was 83% and no complications were observed. The efficacy of RF ablation of typical AFL was 90%, atypical AFL 78%, and EAT 86% (NS). During the long-term follow-up (24+/-17 months) arrhythmia recurrences were noted in 2 (10%) out of 20 patients who were effectively treated during the first RF ablation session. CONCLUSIONS: Reentry is the most common electrophysiological mechanism of incisional tachycardias, followed by ectopic atrial tachycardia. RF ablation using the electro-anatomical CARTO system is effective and safe in this group of patients.

Iatrogenic cardiac arrhythmias following transcatheter or surgical closure of atrial septal defect in children.

BACKGROUND: Invasive procedures involving the atria may promote the development of iatrogenic cardiac arrhythmias. AIM: To analyse the prevalence of cardiac arrhythmias following transcatheter or cardiosurgical closure of the secundum type atrial septal defect (ASD). METHODS: The study group consisted of 91 patients, aged 2-18 years with haemodynamically significant ASD who underwent surgical (n=44) or transcatheter (Amplatzer occluder) (n=47) closure of ASD. Standard ECG and Holter ECG recordings, obtained before and after the procedure, were analysed. The follow-up duration ranged from 2.5 to 5.5 years. Cardiac arrhythmias were divided into benign or significant (requiring pharmacological therapy), early or late, and transient or permanent. RESULTS: Cardiac arrhythmias were detected in 16 (36%) patients who underwent surgery compared with 1 (2.1%) patient who underwent transcatheter ASD closure (p<0.05). In surgically treated patients, arrhythmias were benign in 9 patients, significant in 7 children, early in 15 subjects, late in one patient, transient in 13 children and permanent in 3 subjects. One patient, who underwent transcatheter ASD closure, developed paroxysmal supraventricular tachycardia one day after the procedure, successfully terminated with verapamil. CONCLUSIONS: Transcatheter closure of ASD is associated with a lower risk of procedure-related arrhythmias than surgical treatment. However, longer follow-up in patients treated with transcatheter procedure is needed in order to draw definite conclusions.

Comparison of heart rate variability between surgical and interventional closure of atrial septal defect in children.

This study was designed to compare reduced heart rate variability (HRV) in children with atrial septal defect (ASD) after surgical ASD closure with interventional (Amplatzer device) closure. Reduced HRV was observed in all children with ASD before treatment. HRV was further impaired 1 month after surgical ASD closure but not after catheter device closure. Three months after treatment, HRV indexes tended to normalize in both groups.