Transcatheter closure of a large aortopulmonary window with the novel device Multifunctional occluder (Konar) under TEE guidance (A case report).

Aortopulmonary window is a rare congenital heart disease. It results from incomplete separation of the aorta and pulmonary artery at the conotruncal septum. It accounts for 0.2%-0.6% of all congenital cardiac defects. Closure should be done in all cases. We present the case of a 12-month-old female child with a large aortopulmonary window, complicated by severe pulmonary hypertension. Cardiac catheterization was performed and showed pulmonary vascular resistance 3 Woods units. Ascending aortography showed a large aortopulmonary window measuring 5 mm. Balloon sizing of the defect showed stretched diameter of 8 mm. A multifunctional occluder device 12 × 10 mm (Konar, Lifetech, Shenzhen, China) was properly positioned across the defect under transesophageal echocardiography guidance. Pulmonary angiograms showed a well seated pulmonary disc with mild encroachment on pulmonary bifurcation. Follow up transthoracic echocardiography 24 hours after the procedure showed a well seated device with no residual flow, mean pulmonary artery pressure 25 mmHg, laminar flow into main pulmonary artery and pulmonary bifurcation. To the best of our knowledge this is the first successful closure to be reported for an aortopulmonary window with Konar multifunctional occluder. Having a double disc with a low profile and small sheath size may allow closure of larger defects in smaller children. .

Impact of atrial septal defect device size on biventricular global and regional function: a two-dimensional strain echocardiographic study.

OBJECTIVE: In this study, we assessed the acute changes in biventricular longitudinal strain after atrial septal defect transcatheter closure and its relation to the device size. METHODS: Hundred atrial septal defect patients and 40 age-matched controls were included. Echocardiography and strain study were performed at baseline and 24 hours and 1 month after the intervention. The study group was divided into two subgroups; group 1: smaller devices were used (mean device size = 1.61 ± 0.05 cm, n = 74) and group 2: larger devices were used (mean device size = 2.95 ± 0.07 cm, n = 26). RESULTS: At baseline, there was a significant difference between the study group and controls as regards right ventricular global longitudinal strain with significant hyperkinetic apex (p = 0.033, p = 0.020, respectively). There was a significant immediate reduction in right ventricular global longitudinal strain (from -24.43 ± 0.49% to -21.62 ± 0.47%, p < 0.001), which showed insignificant improvement after 1-month follow-up. While only left ventricular global longitudinal strain increased after 1 month. Within 24 hours of device closure, all the basal- and mid-lateral segments strains and apical right ventricular strains showed a significant reduction. There was a significant negative correlation between the indexed large device size and an immediate change in the right ventricular global longitudinal strain (r = -0.425, p = 0.034). CONCLUSION: Significant right ventricular global longitudinal strain reduction starts as early as 24 hours after transcatheter closure, irrespective of the device size used. The rapid impact of closure was mainly on the biventricular basal and lateral segments and right ventricular apical ones, especially with the large sized atrial septal defect.

Can Tei Index Predict High Syntax Score in Patients with Chronic Coronary Syndrome and Normal Left Ventricular Systolic Function?

OBJECTIVE: Some patients who had chronic coronary syndrome (CCS) and were recognized as low risk, however, developed cardiovascular events, whereas others who were categorized as high risk did not develop any cardiovascular events. Invasive coronary angiography is the gold standard tool for the assessment of coronary artery disease (CAD) severity. The SYNTAX score (SS) was recently recognized as an invasive angiographic-guided scoring system used in risk stratification of patients who have more than one-vessel CAD and undergoing revascularization with percutaneous cardiovascular intervention. It has a good predictive value of adverse cardiovascular events. Exploration for unique noninvasive modalities that may help in a better way for risk stratification of CCS patients by predicting the severity of CAD (as reflected by SS) would be of a paramount value. Tei index is a promising modality for that objective, which is a Doppler-derived time interval index that combines both systolic and diastolic cardiac performance. METHODS: We examined the relationship between the severity of CAD as assessed by the SS and Tei index in 100 patients with CCS and normal left ventricular systolic function. RESULTS: All the studied 100 patients had a normal ejection fraction with mean = 58.92 ± 7.88; the mean value of Tei index was 0.84 ± 0.26. There was a statistically significant positive association between Tei index and SS (P = 0.0001); moreover, there was a correlation between left anterior descending (LAD) affection and Tei index (P = 0.0001).The cutoff point of Tei index to detect SS above 22 was >0.93 (with specificity of 86.5% and sensitivity of 42.4%). CONCLUSION: Tei index significantly correlates with SS and LAD affection. Moreover, it is a cheap, radiation-free, noninvasive technique and may be used as a further risk stratification modality beyond others.

The changes in biventricular remodelling and function after atrial septal defect device closure and its relation to age of closure.

BACKGROUND: The trans-catheter closure of atrial septal defect (ASD) usually has a rapid impact on biventricular remodelling and functions. Whether the transcatheter closure of ASD at early childhood or at adulthood age would affect the improvement in biventricular dimensions and functions remains an area of active research. RESULTS: This prospective observational study enrolled 70 subjects (50 ASD cases and 20 control subjects). Tissue Doppler imaging (TDI) and strain (S) were performed for the control group and ASD patients at baseline and at 24 h and 1 month after ASD device closure. The total ASD group was subdivided into two subgroups: group-1-children and adolescent with ASD, who underwent transcatheter closure at age ≤ 19 years; group-2-adult who underwent ASD device closure at age > 19 years old. The right and left ventricular global longitudinal systolic strain (RV/LV-GLS) and RV free wall longitudinal strain (RV free wall LS) showed a significant decline after 24 h of device closure (RVGLS-P = 0.001, LVGLS-P = 0.048, RV free wall LS-P < 0.001). However, after a 1-month follow-up, the LVGLS increased in comparison with 24 h changes after device closure (P = 0.038). The baseline mean value of RV free wall LS of G2 was significantly lower than G1 value (P < 0.001). There was no statistically significant difference between the 2 age subgroups regarding biventricular GLS and RV free wall LS changes after device closure. The changes in LV diastolic function immediately and after 1 month of device closure showed a statistically significant change in e' and its delta change value in group-2 in comparison with its baseline values and to group-1 delta changes (P = 0.002, P = 0.011, P = 0.019, respectively). CONCLUSION: The ASD transcatheter closure reduced biventricular global and RV free wall longitudinal systolic strain within 1 day of intervention and was associated with a short-term improvement in the LV-GLSS after a 1-month duration. The progressive increase in LV preload results in its strain growth and reduction in diastolic function after transcatheter ASD closure. The older age at the time of ASD device closure was associated with a significant decrease in the RV free wall LS and septal e' velocity towards abnormality.

Feasibility and accuracy of real-time three-dimensional echocardiography in evaluating the aortic valve in children.

BACKGROUND: Aortic valve assessment by 2D transthoracic echocardiography is a relatively complex task owing to the unique anatomical features of the left ventricular outflow tract and its dynamic nature. We aimed to evaluate the accuracy of 3D transthoracic echocardiography [3D TTE] in assessing the aortic valve in children. RESULTS: The first group included 11 males and six females, with a mean age of 5.76 ± 6.39 years. All of these patients had aortic valve disease with a bicuspid variant. The second group included seven males and seven females, with a mean age of 4.4 ± 4.05 years. All of these patients had normal aortic valve morphology and had another congenital cardiac anomaly. The aortic valve annulus was assessed using the three modalities; 2D, 3D echocardiography in the vertical and horizontal diameters, and angiography. The aortic valve area was measured by 2D and 3D echocardiography using multiplane reformatted mode. The results of the analysis were then compared. They revealed that 3D echocardiographic measurement of the aortic annulus (horizontal diameter) correlated better with angiography than 2D and 3D (vertical diameter) echocardiographic measurements. There was a significant difference between the aortic valve area measured by 2D echocardiography and that measured by 3D echocardiography among the two groups, 2D echocardiography seems to underestimate the true aortic valve area. CONCLUSION: The study concluded that 3D TTE with multiplane reformatted mode allows a more accurate assessment of the aortic valve when compared to 2D echocardiography and this correlates better with the angiographic findings.

Noninvasive Predictors of Functional Capacity in Patients with Pulmonary Hypertension due to Congenital Heart Disease: A Pilot Echocardiography Single-Center Study.

BACKGROUND: Pulmonary hypertension (PH) with congenital heart disease (CHD) affects the functional capacity (FC), quality of life, and survival. However, the importance of different echocardiographic parameters and their correlation with FC is unclear. METHODS AND RESULTS: A custom-made sheet for 34 consecutive patients with PH due to CHD was made to include patient's demographic data, underlying cardiac disorder, and FC by 6-min walk test (6MWT). The patients were subdivided into Group 1 with 6MWT < 330 m and Group 2 with 6MWT > 330 m. A cutoff value of 330 m was selected because it reflected the survival and outcome of patients in many studies before. Left ventricle global radial strain, baseline saturation, and saturation after 6MWT showed a significant strong positive correlation with 6MWT (r = 0.755, 0.714, and 0.721, P = 0.001, 0.000, and 0.000, respectively). Multiple regression analysis using a multivariate model showed that the mean pulmonary artery pressure (MPAP) and baseline saturation are the most independent predictors of the FC (P = 0.028 and 0.049, respectively), with a cutoff point for MPAP > 30 mmHg (area under the curve [AUC]: 0.85) with a sensitivity and specificity of 69.23% and 95.24%, respectively, and cutoff point for saturation < 94% (AUC: 0.852) with a sensitivity and specificity of 92.31% and 76.19%, respectively. CONCLUSION: The MPAP and the baseline oxygen saturation were the most independent predictors of impaired FC. They can be used for risk stratification and as surrogate predictors of outcome in this group of patients.

A novel three-dimensional echocardiographic method for device size selection in patients undergoing ASD trans-catheter closure.

BACKGROUND: Proper device size selection is a crucial step for successful ASD device closure. The current gold standard for device size selection is balloon sizing. Balloon sizing can be tedious, time consuming and increase fluoroscopy and procedure times as well as risk of complications. We aimed to establish a simple and accurate method for device size selection using three-dimensional echocardiographic interrogation of the ASD.This is a prospective observational study conducted over a period of 12 months. All patients underwent 2D TTE, three-dimensional echocardiographic assessment of the IAS and transesophageal echocardiogram. Comparison between echocardiographic variables was done using independent sample t test. Linear correlation was established between three dimensional echocardiographic variables and respective variables of device size and 2D TTE and TEE measurements. RESULTS: The study included 50 patients who underwent successful ASD device closure with properly sized device. There was no significant difference between 3D ASD maximum diameter and all diameters measured by TTE and TEE. There was a strong positive correlation between device size used for closure and both 3D measured ASD area (r = 0.907, P<0.0001) and 3D measured ASD circumference (r = 0.917, P<0.0001). Two regression equations were generated to determine proper device size where Device size = 10.8 + [3.95 x 3D ASD area] and Device size = [3.85 x 3D ASD circumference] -1.02 CONCLUSION: Three-dimensional echocardiogram can provide a simple and accurate method for device size selection in patients undergoing ASD device closure using either 3D derived ASD area or ASD circumference.

Immediate and short term effects of percutaneous atrial septal defect device closure on cardiac electrical remodeling in children.

BACKGROUND: The beneficial effects of atrial septal defect (ASD) device closure on electrical cardiac remodeling are well established. The timing at which these effects starts to take place has yet to be determined. OBJECTIVES: To determine the immediate and short term effects of ASD device closure on cardiac electric remodeling in children. METHODS: 30 pediatric patients were subjected to 12 lead Electrocardiogram immediately before ASD device closure, 24 h post procedure, 1 and 6 months after. The maximum and minimum P wave and QT durations in any of the 12 leads were recorded and P wave and QT dispersions were calculated and compared using paired T test. RESULTS: The immediate 24 h follow up electrocardiogram showed significant decrease in P maximum (140.2 ±â€¯6 versus 130.67 ±â€¯5.4 ms), P dispersion (49.73 ±â€¯9.01 versus 41.43 ±â€¯7.65 ms), PR interval (188.7 ±â€¯6.06 ms versus 182.73 ±â€¯5.8 ms), QRS duration (134.4 ±â€¯4.97 ms versus 127.87 ±â€¯4.44), QT maximum (619.07 ±â€¯15.73 ms versus 613.43 ±â€¯11.87), and QT dispersion (67.6 ±â€¯5.31 versus 62.6 ±â€¯4.68 ms) (P = 0.001). After 1 month all the parameters measured showed further significant decrease with P dispersion reaching 32.13 ±â€¯6 (P = 0.001) and QT dispersion reaching 55.0 ±â€¯4.76 (P = 0.001). These effects were maintained 6 months post device closure. CONCLUSION: Percutaneous ASD device closure can reverse electrical changes in atrial and ventricular myocardium as early as the first 24 h post device closure.

Determinants of platelet count in pediatric patients with congenital cyanotic heart disease: Role of immature platelet fraction.

OBJECTIVES: Congenital heart defects are common noninfectious causes of mortality in children. Bleeding and thrombosis are both limiting factors in the management of such patients. We assessed the frequency of thrombocytopenia in pediatric patients with congenital cyanotic heart disease (CCHD) and evaluated determinants of platelet count including immature platelet fraction (IPF) and their role in the pathogenesis of thrombocytopenia. METHODS: Forty-six children and adolescents with CCHD during pre-catheter visits were studied; median age was 20.5 months. Complete blood count including IPF as a marker of platelet production and reticulated hemoglobin content (RET-He) as a marker of red cell production and iron status were done on Sysmex XE 2100 (Sysmex, Japan). C-reactive protein, prothrombin time (PT), Activated partial thromboplastin time (APTT) were also assessed. RESULTS: Thrombocytopenia was found in 6 patients (13%). PT was prolonged (P = .016) and IPF was significantly higher in patients with thrombocytopenia compared with patients with normal platelet count (14.15 ± 5.2% vs 6.68 ± 3.39%; P = .003). Platelet count was negatively correlated with IPF while significant positive correlations were found between IPF and hemoglobin, red blood cells (RBCs) count, hematocrit (Hct), PT, reticulocytes count, and immature reticulocyte fraction. CONCLUSIONS: We suggest that elevated IPF in CCHD patients with thrombocytopenia may denote peripheral platelets destruction as an underlying mechanism. Hemoglobin level, RBCs count, Hct, and RET-He were not significant determinants for platelet count in CCHD.

Echocardiographic predictors of coil vs device closure in patients undergoing percutaneous patent ductus arteriosus closure.

AIM: To determine anatomic and hemodynamic echocardiographic predictors for patent ductus arteriosus (PDA) device vs coil closure. METHODS: Seventy-six patients who were referred for elective transcatheter PDA closure were enrolled in the study. All patients underwent full echocardiogram including measurement of the PDA pulmonary end diameter, color flow width and extent, peak and end-diastolic Doppler gradients across the duct, diastolic flow reversal, left atrial dimensions and volume, left ventricular sphericity index, and volumes. RESULTS: The study group was subdivided into 2 subgroups based on the mode of PDA closure whether by coil (n = 42) or device (n = 34). Using univariate analysis there was a highly significant difference between the 2 groups as regard the pulmonary end diameter measured in both the suprasternal and parasternal short-axis views as well as the color flow width and color flow extent (P < .0001). The device closure group had statistically significant higher end-systolic and end-diastolic volumes indexed, left atrial volume, and diastolic flow reversal. Receiver operating characteristic curve analysis showed a pulmonary end diameter cutoff point from the suprasternal view > 2.5 mm and from parasternal short-axis view > 2.61 mm to have the highest balanced sensitivity and specificity to predict the likelihood for device closure (AUC 0.971 and 0.979 respectively). The pulmonary end diameter measured from the suprasternal view was the most independent predictor of device closure. CONCLUSION: The selection between PDA coil or device closure can be done on the basis of multiple anatomic and hemodynamic echocardiographic variables.

Independent predictors of developing pulmonary hypertension in heart failure with reduced versus preserved ejection fraction.

OBJECTIVES: To investigate the different clinical and echocardiographic predictors of evolving PH in patients with heart failure with and without reduced ejection fraction. METHODS AND RESULTS: The study included 153 heart failure patients with reduced ejection fraction (HFrEF) (n = 89) and preserved ejection fraction (HFpEF) (n = 64) both of which were subdivided into 2 subgroups according to the presence of PH. All patients were subjected to detailed clinical assessment and full transthoracic echocardiogram. There were significant differences between the 2 HFrEF subgroups regarding systolic BP, presence of diabetes, dyslipidemia, diuretics usage, all LV parameters, LAD, LAV and LAV indexed to BSA, E/A ratio, DT and severity of TR. Using multivariate analysis, the presence of diabetes (P = 0.04), diuretics usage (P = 0.04), LAV (P = 0.007) and TR grade (P < 0.001) were significant independent predictors for the development of PH among HFrEF patients. There were significant differences between the 2 HFpEF subgroups regarding presence of hypertension, diuretics usage, LAD, LAA, TR severity. Using multivariate analysis, only diuretics usage (P = 0.02) and TR grade (P < 0.0001) were significant independent predictors for the development of PH among HFpEF patients. CONCLUSION: Neither the decrease in EF among HFrEF patients nor the DD grade in HFpEF patients act as independent predictor for evolving PH. Common independent predictors for evolving PH in both HFrEF and HFpEF patients are TR grade and use of diuretics. Other independent predictors in HFrEF and not HFpEF patients are the presence of diabetes and increased LAV.

The additional utility of two-dimensional strain in detection of coronary artery disease presence and localization in patients undergoing dobutamine stress echocardiogram.

BACKGROUND: Dobutamine stress echocardiogram (DSE) is a feasible and safe exercise-independent stress modality for diagnoses of coronary artery disease (CAD), but it is subjective, and operator dependant. Two-dimensional strain at peak stress could overcome these limitations and thus increase the accuracy of DSE. METHODS AND RESULTS: This was a prospective observational study in which 80 patients underwent DSE, two-dimensional strain at peak stress, and coronary angiography. Global longitudinal strains (GLS) cutoff point of -16.75 had 77.42% sensitivity and 83.33% specificity to detect significant CAD. Global circumferential strain (GCS) cutoff point of -20.75 had 93.55% sensitivity and 66.67% specificity to detect significant CAD (P=.003, areas under the curve [AUC]=0.73). The average territorial strain cutoff point for significant left anterior descending (LAD) lesion was -15.4 with 77.78% sensitivity and 82.86% specificity (P=.0001, AUC=0.78) and for non-LAD lesion was -16.9 with 82.93% sensitivity and 53.85% specificity (P=.0009, AUC=0.69). Two-dimensional strain at peak stress showed better agreement than DSE as regard number of vessels affected (K=0.579 vs 0.107), LAD lesion detection (K=0.783 vs 0.438), and non-LAD lesion detection (K=0.699 vs 0.233). Global longitudinal strain (GLS) at peak stress reduced DSE false positivity by 83%; the number of false-positive patients was reduced from 18 patients to only three patients. CONCLUSION: Two-dimensional strain at peak stress had an incremental value over DSE visual assessment/ wall-motion score index (WMSI) in reducing false-positive results of DSE. Two-dimensional strain at peak stress had greater accuracy than DSE alone not only in detection of significant CAD but also in detection of number of vessels with significant lesion as well as CAD localization.

Serum apelin as a novel non-invasive marker for subclinical cardiopulmonary complications in children and adolescents with sickle cell disease.

BACKGROUND: Cardiovascular involvement represents a leading cause of mortality and morbidity in sickle cell disease (SCD). Apelin is a peptide involved in the regulation of cardiovascular function. AIM: To determine serum apelin among 40 children and adolescents with SCD compared with 40 healthy controls and assess its relation to markers of hemolysis, iron overload as well as cardiopulmonary complications. METHODS: SCD patients, in steady state and asymptomatic for heart disease, were studied stressing on hydroxyurea/chelation therapy, hematological profile, serum ferritin and apelin levels. Full echocardiographic study including assessment of biventricular systolic function and pulmonary artery pressure was done. RESULTS: Apelin levels were significantly lower in SCD patients compared with controls (P<0.001). Cardiopulmonary complications were encountered in 30% of patients. Apelin was significantly decreased among patients with cardiopulmonary disease (P=0.006) whether those at risk of pulmonary hypertension (P=0.018) or patients with heart disease (P=0.043). Hydroxyurea-treated patients had higher apelin levels than untreated ones (P=0.001). Apelin was negatively correlated to lactate dehydrogenase, indirect bilirubin, serum ferritin, end systolic diameter, tricuspid regurgitant jet velocity, right ventricle systolic pressure, pulmonary vascular resistance and tissue Doppler imaging S wave. Apelin cutoff value of 1650ng/L could significantly detect the presence of cardiopulmonary complications in SCD with 90.9% sensitivity and 72.4% specificity. CONCLUSION: Apelin is a promising marker for screening of SCD patients at risk of cardiopulmonary disease because it is altered during the early subclinical stage of cardiac affection. A combination of apelin and echocardiography provides a reliable method to assess cardiopulmonary affection in young SCD patients.

Mitral Annular Plane Systolic Excursion-Derived Ejection Fraction: A Simple and Valid Tool in Adult Males With Left Ventricular Systolic Dysfunction.

OBJECTIVES: Validation of a mitral annular plane systolic excursion (MAPSE)-derived formula to calculate the ejection fraction where EF = 4.8 × MAPSE (mm) + 5.8 in adult males with left ventricular (LV) dysfunction. BACKGROUND: Echocardiographic assessment of LV function generally requires expert echocardiographer and is somewhat subjective and prone to reader discordance. MAPSE has been suggested as a surrogate measurement for LV function. METHODS: Prospective analysis of 170 male patients with systolic dysfunction by two-dimensional transthoracic echocardiography was carried out. MAPSE and ejection fraction measured by qualitative visual inspection, M-mode, and biplane modified Simpson's rule were measured. MAPSE-derived EF was compared against other conventional methods to measure EF using Bland-Altman analysis and independent t-test. RESULTS: There was a significant positive correlation between average MAPSE and EF measured by M-mode (r = 0.554, P < 0.001), Simpson's rule (r = 0.585, P < 0.001), and visual inspection (r = 0.611, P < 0.001). An average MAPSE cutoff value <= 5 provided the best balanced sensitivity (67.1%) and specificity (76.5%) to predict EF < 30%. The mean difference between MAPSE-derived EF and EF measured by visual inspection and by Simpson's method was 3.86 ± 5.24% and 3.57 ± 5.97%, respectively. The least mean difference of 0.5 ± 5.69% was present between MAPSE-derived EF and M-mode-measured EF (P value 0.2). CONCLUSION: MAPSE-derived EF using the equation EF = 4.8 × MAPSE (mm) + 5.8 is a valid technique in adult males with severely impaired LV EF.

Immediate and short-term effect of balloon mitral valvuloplasty on global and regional biventricular function: a two-dimensional strain echocardiographic study.

AIM: To assess the effect of balloon mitral valvuloplasty (BMV) on global and regional ventricular functions using 2D strain. METHODS AND RESULTS: Thirty-two patients with mitral stenosis (MS) and 30 healthy subjects underwent full echocardiographic examinations, including left ventricle (LV) and right ventricle (RV) regional and global longitudinal strain (GLS) measurements. In MS patients, measurements were repeated within 24 h and 3 months after BMV. Patients with MS had lower LV and RV GLS compared with control group (-16.5 ± 2.7% vs. -21.0 ± 1.5) and (-18.3 ± 4.7 vs. -19.8 ± 1.3), respectively. Significant decrease was noted in the basal and septal segments compared with the apical LV segments and RV free wall. BMV resulted in significant improvement in LV and RV GLS within 24 h post-BMV compared with baseline values (P = 0.0001 and 0.0002, respectively), an improvement which was maintained after 3 months. There was significant positive correlation between both LV and RV GLS at baseline and mitral valve mean pressure gradient and RV systolic pressure and significant inverse correlation between LV GLS and MVA. CONCLUSION: MS patients have subclinical LV and RV systolic dysfunction by GLS despite normal ejection fraction and fractional area change. BMV results in marked improvement in LV and RV GLS immediately post-BMV with trend towards normalization at follow-up after 3 months. A mixed aetiology theory involving a myocardial as well as a haemodynamic factor is believed to be the cause for this subclinical biventricular dysfunction and its improvement at short-term follow-up post-BMV.

Left atrial wall dissection: a rare sequela of native-valve endocarditis.

Left atrial wall dissection is a rare condition; most cases are iatrogenic after mitral valve surgery. A few have been reported as sequelae of blunt chest trauma, acute myocardial infarction, and invasive cardiac procedures. On occasion, infective endocarditis causes left atrial wall dissection. We report a highly unusual case in which a 41-year-old man presented with native mitral valve infective endocarditis that had caused left atrial free-wall dissection. Although our patient died within an hour of presentation, we obtained what we consider to be a definitive diagnosis of a rare sequela, documented by transthoracic and transesophageal echocardiography.

Factors affecting vascular access complications in children undergoing congenital cardiac catheterization.

BACKGROUND: Complications at the vascular access sites are among the most common adverse events in congenital cardiac catheterization. The use of small-gauge catheters may reduce these events; however, other factors can contribute to the development of vascular complications. OBJECTIVES: To determine factors associated with the development of vascular access complications in children undergoing congenital cardiac catheterization. METHODS: We performed a prospective study of 403 patients who underwent diagnostic (62.5%) or interventional (37.5%) cardiac catheterization over a period of 6 months, and analysed the vascular complications during and immediately after the procedure. RESULTS: The most common access-related adverse event was transient loss of pulsation (17.6%). Other less common access-related adverse events included subcutaneous haematoma (2%), bleeding (3%), vessel tear (0.2%), and vein thrombosis (0.2%). Patients who had no access-related adverse events had significantly higher age and body weight compared with those who had one or more access problems. Among 81 patients who had vascular access established in unplanned access sites, 30 patients (37%) had lost pulsations. Among the 322 patients who had vascular access established in planned access sites, however, only 41 patients had lost pulsation (13%). In addition, patients who had lost pulsations had significantly longer puncture time compared to those who had normal pulsations (p value 0.01). CONCLUSION: Factors other than sheath size can contribute to access-related adverse events in children undergoing cardiac catheterization. Obtaining vascular access in unplanned access sites and longer puncture times increases the incidence of lost pulsations after catheterization. Younger age and smaller body weight are also associated with significant increase in access-related adverse events.

Radiation exposure in children during the current era of pediatric cardiac intervention.

Cardiac catheterizations are among the X-ray procedures with the highest patient radiation dose and therefore are of great concern in pediatric settings. This study aimed to evaluate factors that influence variability of X-ray exposure in children with congenital heart diseases during cardiac catheterization. The study included 107 children who underwent either diagnostic (n = 46) or interventional (n = 61) procedures. A custom-made sheet for patient and procedural characteristics was designed. Data were collected, and different correlations were applied to determine factors that influence variability of X-ray exposure. The fluoroscopy time (FT) differed significantly between the diagnostic (8.9 ± 6.3 min) and intervention (12.8 ± 9.98 min) groups (P = 0.032). The mean dose-area product (DAP) differed significantly between the two groups (3.775 ± 2.5 Gy/cm(2) vs. 13.239 ± 15.4 Gy/cm(2); P = 0.003). The highest DAP was during left anterior oblique (LAO) cranial 30° angulation (2.8 Gy/cm(2)/4 s cine). The mean cumulative dose (CD) was 0.053 Gy in diagnostic cases and 0.48 Gy in intervention cases. The effective dose was 5.97 ± 7.05 mSv for therapeutic procedures compared with 3.42 ± 3.64 mSv for diagnostic procedures. The FT correlated significantly with both the DAP (r = 0.718; P < 0.001) and the CD (r = 0.701; P < 0.001). Other correlations were reported. An increasing number of therapeutic catheterization procedures are being performed for children. The justification for these procedures is evident because they avoid complicated surgery. However, the complexity of these procedures results in higher radiation exposures.

Visualization of patent ductus arteriosus using real-time three-dimensional echocardiogram: Comparative study with 2D echocardiogram and angiography.

PURPOSE: To determine the feasibility and accuracy of real time 3D echocardiography (RT3DE) in determining the dimensions and anatomical type of the patent ductus arteriosus (PDA). METHODS: The study included 42 pediatric patients with a mean age of 3.6 years (ranging from 2 months to 14 years) who were referred for elective percutaneous PDA closure. All patients underwent full 2D echocardiogram as well as RT3DE with off line analysis using Q lab software within 6 h from their angiograms. The PDA was studied as regard the anatomical type, length of the duct as well as the ampulla and the pulmonary end of the PDA. Data obtained by RT3DE was compared against 2D echocardiogram and the gold standard angiography. RESULTS: Offline analysis of the PDA was feasible in 97.6% of the cases while determination of the anatomical type using gated color flow 3D acquisitions was achieved in 78.5% of the cases. The pulmonary end of the duct was rather elliptical using 3D echocardiogram. There was significant difference between the pulmonary end measured by 3D echocardiogram and angiography (P < 0.001). There was no significant difference between either the length or the ampulla of the PDA measured by 3D echocardiogram and that measured by angiography (P value = 0.325 and 0.611, respectively). There was a good agreement between both 2D or 3D echocardiogram and angiography in determining the anatomical type of the PDA (K = 0.744 and 0.773, respectively). However 3D echocardiogram could more accurately determine type A and type E ductus compared to 2D echocardiogram. CONCLUSION: 3D echocardiogram was more accurate than 2D echocardiogram in determining the length and the ampulla of the PDA. The morphologic assessment of the PDA using gated 3D color flow was achieved in 78.5% of the patients. Nevertheless the use of 3D echocardiogram in assessment of small vascular structures like PDA in children with rapid heart rates is still of limited clinical value.