Novel transcatheter intervention for iatrogenic cyanosis due to surgical rerouting of inferior vena cava to the left atrium.

Improper identification of the atrial septal defect margins during surgery and inadvertent suturing of the surgical patch to the Eustachian valve of the inferior vena cava (IVC) results in the diversion of inferior venacaval blood to the left atrium causing cyanosis. This complication has been dealt so far with surgery. We report the planning and implementation of a novel transcatheter rediversion of the IVC to the right atrium using a covered stent.

Risk factors associated with device embolisation or malposition during transcatheter closure of patent ductus arteriosus.

BACKGROUND: Device embolisation is a serious adverse event during transcatheter duct closure. This study analyses risk factors for embolisation. METHODS: Demographic parameters, echocardiographic anatomy, haemodynamics, and procedural characteristics of consecutive duct closures in a tertiary centre over 8 years were analysed. Procedures complicated by embolisation were compared to uncomplicated procedures. RESULTS: Fifteen embolisations occurred during 376 procedures. All except one embolisation were in infants. The pulmonary artery: aortic pressure ratio was 0.78 ± 0.22. Embolisation was seen significantly more commonly in Type C tubular ducts. Vascular plugs were more significantly associated with embolisations. Logistic regression analysis showed device embolisation was significantly higher in age group of < 6 months compared to 6-12 months (p = 0.02), higher in those with tubular ducts versus conical ducts (p = 0.003), use of vascular plugs compared to conventional duct occluders (p = 0.05), and in duct closure with undersized devices (p = 0.001). There was no in-hospital mortality. Three patients needed surgical retrieval while others were successfully managed in catheterisation laboratory. CONCLUSIONS: Device embolisation complicates 4% of transcatheter duct closures, with need for surgery in one-fifth of them. Larger ducts with high pulmonary artery pressures in younger and smaller infants are more often associated with device embolisation. Tubular ducts are more prone for embolisation compared to usual conical ducts. Softer vascular plugs are often associated with embolisations. Intentional device undersizing to avoid vascular obstruction in small patients is a frequent risk factor for embolisation. Precise echocardiographic measurements, correct occluder choice, proper technique and additional care in patients with high pulmonary artery pressures are mandatory to minimise embolisations.

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.

Single center experience of transcatheter closure of mitral and aortic Paravalvular leaks using the new rechristened rectangular Amplatzer PVL plug.

Amplatzer Paravalvular leak (PVL) plug is rectangular in shape, that might suit closure of crescentic PVL. Among 79 transcatheter PVL closures from a single center, a subgroup of 16 patients who received Amplatzer PVL plugs were analyzed. All procedures were successful, as the plug auto-oriented to the leak, without mechanical leaflet interference, though needing additional 31 devices. Two patients needed an elective re-intervention. NYHA class improved from III-IV before procedure to less than II after procedure. Complications were not directly related to the Amplatzer PVL plug. The rectangular shape for crescentic leaks, auto-orientation and non-interference with mechanical leaflets were good attributes.

First report of a percutaneous valve-in-Valve implantation of tricuspid valve in a systemic right ventricle.

Severe tricuspid regurgitation in corrected transposition of great arteries is treated with early bioprosthetic replacement to prevent right ventricular failure. When bioprosthesis degenerates, surgery on cardioplegic arrest further complicates right ventricular function. We report the first transcatheter valve-in-valve implantation of tricuspid valve in a systemic right ventricle in corrected transposition describing the modifications due to anatomical differences in these patients.

Endovascular Treatment of Acquired Atheromatous Postsubclavian Aortic Coarctation.

Coral reef aorta is a rare calcifying obstructive disease that involves the thoracoabdominal aorta. Similar presentations in the postsubclavian aorta may result in acquired atheromatous aortic coarctation leading to systemic hypertension and heart failure. The associated calcification makes surgical anatomic or extraanatomic bypass and thromboendarterectomy challenging. Extensive circumferential calcification often precludes endovascular intervention. We present the case of a 25-year-old man with an acquired atheromatous coarctation of the postsubclavian aorta who underwent successful endovascular treatment with use of a balloon-expandable covered stent.

Early multicenter experience of a new balloon expandable MyVal transcatheter heart valve in dysfunctional stenosed right ventricular outflow tract conduits.

BACKGROUND: Transcatheter pulmonary valve implantation (TPVI) is a surgical alternative for correcting dysfunctional right ventricular outflow tract conduits in previously operated patients. MyVal transcatheter heart valve (THV) (Meril Life Sciences, India), a new transcatheter valve designed for aortic position has not been used for TPVI. METHODS: Patients with stenosed dysfunctional conduits from the right ventricle to pulmonary artery (RV-PA) were prestented after initial computed tomography and balloon interrogation before the implantation of MyVal. Size of MyVal was chosen based on the final diameter of the prestent. Procedural details and post-TPVI follow-up were analyzed. RESULTS: Seven patients aged 17-60 years (median 26 years) had stenosed RV-PA conduits implanted 5-17 years (median 9 years) ago for tetralogy of Fallot in three, following Ross procedure in two, repair of pulmonary stenosis, and following PA debanding in one patient each. Prestenting improved the conduit diameter from 9.3 ± 2.8 mm to 20.8 ± 1.1 mm and relieved the gradient from 87.3 ± 31.7 mmHg (50-137 mmHg) to 12.7 ± 6.4 mmHg (5-20 mmHg). A 23 mm MyVal was implanted in all the seven patients successfully; one patient needed an additional 24.5 mm MyVal valve in valve implantation for residual regurgitation. The mean fluoroscopic time and dose area product were 38.7 ± 25.3 min and 66.917 ± 39.211Gray. cm2, respectively. At a median follow-up duration of 16 months (10-22 months), all patients were asymptomatic receiving dual antiplatelet therapy with no PR and the gradient was 12.5 ± 5.8 mmHg on echocardiography. Although one patient needed an additional valve-in-valve implantation, there were no valve-related adverse events. CONCLUSIONS: Early experience of TPVI with MyVal THV in prestented conduits is encouraging with procedural success in all patients and acceptable mid-term outcomes.

Tetra ostial coronary arterial anatomy-A rare pattern in transposition.

BACKGROUND: Meticulous transfer of coronary arteries is of crucial importance in transposition and determines the success of the switch procedure. This report describes a coronary arterial anatomy consisting of four separate ostia from the two facing sinuses in a 6-month-old infant presenting with transposition and ventricular septal defect. CONCLUSION: Being a rare coronary arterial pattern not described in previous coding systems, the surgeon would do well to be aware of this possibility while performing the switch procedure.

Unconventional combination of left atrial appendage device occlusion in patients with atrial fibrillation who needed concomitant catheter interventions for underlying structural heart disease.

OBJECTIVES: Left atrial appendage occlusion (LAAO) in non-valvar atrial fibrillation (AF) reduces cardioembolic strokes. Despite increased risk, trials exclude valvar AF in structural heart diseases where clots extend beyond appendage. METHODS: Patients with AF and relative risks for oral anticoagulation (OAC) needing structural interventions underwent concomitant LAAO. After six months of OAC, aspirin was continued. Transesophageal echocardiogram was done three monthly till one year and yearly thereafter. The patient demographics, procedural details, post-procedural follow-up were analyzed. RESULTS: Nine patients aged 51.5 ± 6.3 years with AF underwent LAAO concomitantly with balloon mitral valvotomy in four patients, atrial septal defect device closure in four and periprosthetic mitral leak closure in one patient. Six patients had heart failure, four had prior embolic events, and two had documented LAA thrombus. The mean CHADS2VASc score was 2.44 ± 0.8 and mean HASBLED score was 3.0 ± 0.8. Devices included Amplatzer Cardiac Plug™ in six patients, LAmbre™ Lifetech device in two and Watchman™ device in one. All procedures were successful without acute complications. A patient developed pericardial effusion at six months requiring pericardiocentesis. Early device-associated thrombus in one patient resolved after OAC for six months. No embolic events occurred on follow-up. CONCLUSION: On a detailed literature search, this largest LAAO experience in structural heart diseases indicates its utility. OAC for six months followed by aspirin seems to prevent thrombus formation in these patients. The only incidence of early thrombus formation indicates immunity from clot formation after device endothelialisation. Larger multicenter trials combining LAAO with structural interventions in valvular AF are warranted in developing nations.

Simple Diagnostic Tools May Guide Transcatheter Closure of Superior Sinus Venosus Defects Without Advanced Imaging Techniques.

BACKGROUND: There is a recent interest in nonsurgical correction of superior sinus venosus defects. Patient selection is currently based on advanced imaging and printing technologies. Simple clinical tools to select patients will expand its applicability in developing countries. METHODS: Defects caudally extending toward the oval fossa and right upper pulmonary veins draining beyond the cavoatrial junction on transesophageal echocardiography were excluded. Balloon interrogation of cavoatrial junction confirmed complete occlusion of the defect with unobstructed pulmonary venous drainage to left atrium. Single long covered stents or overlapping covered stents were used to exclude sinus venosus defects. Closure of left-to-right interatrial shunt without causing pulmonary vein occlusion was confirmed on follow-up imaging. RESULTS: Forty-four patients selected after transesophageal echocardiography underwent balloon interrogation with monitoring of right upper pulmonary vein. Eighteen out of 44 patients were ineligible. Twenty-four eligible patients with closure of left-to-right interatrial shunt without pulmonary vein occlusion underwent covered stent exclusion using single long stents in 15 and overlapping stents in the rest, while 2 patients are awaiting the procedure. Four patients aged 6 to 16 years received stents that were 18 mm or larger. Three patients had stent embolization that required surgical correction in 2 but in the last patient was managed nonsurgically with an overlapping covered stent with good final outcomes. Procedure was successful in 22 patients. At a median follow-up of 20 months (range, 3-54 months), there were no adverse events. Follow-up imaging showed trivial left-to-right shunt in 4 and unobstructed pulmonary veins in all patients. CONCLUSIONS: Transesophageal echocardiography and balloon interrogation identified 60% of the patients with sinus venosus defects to be eligible for catheter closure. Overlapping stents are an alternative to custom-made long stents. Transesophageal echocardiography confirms procedural success on follow-up. Advanced imaging and printing technologies are not essential for successful outcomes and thus simple tests increase the feasibility in developing countries.

Percutaneous coronary intervention for coronary allograft vasculopathy with drug-eluting stent in Indian subcontinent: Issues in diagnosis and management.

Coronary allograft vasculopathy fails to give a warning anginal pain due to denervation and often presents with acute coronary syndrome, ventricular dysfunction, or sudden cardiac death. Early diagnosis in a pediatric patient is difficult as it involves invasive coronary angiography or advanced imaging such as intravascular ultrasound or optical coherence tomography. A 12-year-old boy developed acute coronary syndrome, elevated troponins, and right bundle branch block, 5 years after cardiac transplantation and was treated with culprit-vessel angioplasty with a drug-eluting stent. Advanced imaging showed the involvement of nonculprit vessels too. In a detailed literature search, we failed to identify a similar clinical presentation and management in the subcontinent, hence our interest in publishing this report for educational value. Issues in diagnosis, management, prognosis, and prevention are discussed.

Serum Sirolimus Levels After Implantation of Third Generation Drug Eluting Cobalt Chromium Coronary Stent in Ductus Arteriosus in Neonates with Duct-Dependent Pulmonary Circulation.

Ductal stenting (DS) palliates duct-dependent lesions using coronary stents. Sirolimus-eluting stents have replaced bare-metal stents in coronary interventions. Concerns exist about sirolimus levels in neonates. Therapeutic immunosuppressive sirolimus level is 5-15 ng/ml. After neonatal DS, drug levels were assessed at 24 h, 7 days and monthly thereafter till they were undetectable. Clinical course, ductal patency till their final corrective surgery was analyzed. The exact quantity of sirolimus in each stent was known. Twelve neonates with median age of 5.5 days received sirolimus-eluting stents, one stent in nine and two in the rest. The lesions were pulmonary atresia intact ventricular septum(PAIVS) in four, univentricular lesions with pulmonary atresia in four, biventricular lesions with pulmonary atresia in three and right ventricular rhabdomyoma in one neonate. If single stents up to 22 mm length, 24-h drug levels were less than 5 ng/ml. Even though 24-h levels were above 5 ng/ml in patients with single longer stent or two stents, it reduced to very low levels by seventh day. Two hospital deaths included rhabdomyoma with complete heart block and post-valvotomy cardiac failure for PAIVS. Stent patency after valvotomy for PAIVS exceeded three years. Patency was retained for 8-27 months till their elective corrective surgery in others. Sirolimus levels were acceptable at 24 h in all neonates receiving single stent under 22 mm length. In patients needing two stents, drug levels were in immunosuppressive range at 24 h but reduced rapidly within 7 days. The palliation provided by sirolimus-eluting DS was sufficiently long to provide clinical benefit.

Corkscrew aortic arch in PHACES syndrome: Multimodal imaging of an unusual morphology of tortuous aortic arch in a rare but well-defined syndrome.

PHACES syndrome, a diffuse aortocraniocerebral vasculopathy, is a neural tube migration disorder, characterized by aortic coarctation and aberrant arch branches. Clinical diagnosis, echocardiography, and surgical management of coarctation in this syndrome are challenging due to peculiar morphological differences. Corkscrew aortic arch, an extreme tortuosity of the aortic arch described in arterial tortuosity syndrome, is not reported in PHACES syndrome so far. Multimodal imaging of this unusual corkscrew aortic arch in two patients with PHACES syndrome is presented.

Utility of three-dimensional echocardiography and magnetic resonance imaging in the diagnosis of double-orifice tricuspid valve.

Duplication of atrioventricular valves involves the mitral valve more often than the tricuspid valve and is often associated with other cardiac defects. Double-orifice tricuspid valve (DOTV) is often identified in surgery or autopsy and missed on echocardiography, as the two orifices are orthogonal to the imaging plane. If suspected on echocardiography, it masquerades as mild tricuspid hypoplasia. Three-dimensional echocardiography and magnetic resonance imaging of a DOTV are presented.

Clues to echocardiographic diagnosis of isolation of right subclavian artery in a patient with DiGeorge syndrome and its transcatheter management with its associated anomalies.

Isolated subclavian artery is a rare anomaly. A second steal due to a patent arterial duct further reduces arm perfusion. Surgical anastomosis of the isolated vessel to aorta normalises arm perfusion. Simple echocardiographic clues aid in the diagnosis. An associated moderate sized ventricular septal defect was non-surgically closed along with catheter closure of the duct resulting in improved arm perfusion.

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.

Successful retrieval of a migrated neonatal ductal stent and strategies to reposition the expanded stent in the duct.

A neonatal ductal stent deployed in a straight short conical duct on second postnatal day migrated owing to inadequate ductal constriction. It was successfully retrieved using a larger balloon and redeployed in the duct again. Intravenous indomethacin prevented further stent migration. This is the first report of successful transcatheter retrieval and repositioning of a migrated expanded neonatal ductal stent.

Coronary sinus atrial septal defect without persistent left superior vena cava: Three-dimensional imaging of a rare defect.

Coronary sinus defects refer to interatrial communications that lie out of the confines of the atrial septum and leads from left to right shunt through the ostium of the coronary sinus. When associated with persistent left superior vena cava (PLSVC), mild systemic desaturation may occur depending on the extent of unroofing of the coronary sinus. Isolated defects without PLSVC are rare. Three-dimensional echocardiographic and surgical images are presented.

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.