Congenital Heart Interventions

Utility of the long DrySeal sheath in facilitating transcatheter pulmonary valve implantation with the Edwards Sapien 3 valve

Utility of the long DrySeal sheath in facilitating transcatheter pulmonary valve implantation with the Edwards Sapien 3 valve Fukuda T, Tan W, Sadeghi S, Lin J, Salem M, Levi D, Aboulhosn J. Catheter Cardiovasc Interv. 2020 Feb 19. doi: 10.1002/ccd.28776. [Epub ahead of print] PMID: 32073725 Similar articles Select item 32073720   Take Home Points: The traditional delivery approach for implantation of the Edwards Sapien 3 valve in the pulmonary position comes with risks of tricuspid valve injury and need for additional steps for advancement of the valve into proper position. The modified technique of using a Gore DrySeal long sheath for valve delivery, instead of the recommended Edwards expandable sheath (e-sheath), can decrease delivery time, increase procedural safety, and improve ease of retrieval of ruptured balloons.   Commentary from Dr. Arash Salavitabar (Ann Arbor MI), catheterization section editor of Pediatric Cardiology Journal Watch: Percutaneous transcatheter pulmonary valve implantation (TPVI) with the Edwards Sapien 3 (S3) valve is a well-described procedure that clearly fills a void in TPVI choices for patients with congenital heart disease. Tricuspid valve (TV) injury is a known complication TPVI with the Edwards S3 valve when using the recommended Edwards expandable sheath (e-sheath). This risk is thought to be increased due to the need to advance an uncovered, balloon-mounted stented valve across the tricuspid valve and into the right ventricular outflow tract (RVOT) with this system. The authors report on single-center outcomes of an off-label modified delivery technique, which involves the use of a Gore DrySeal long sheath, in place of the standard e-sheath, for delivery of the S3 valve.   Of the 94 patients who underwent percutaneous implantation of the S3 valve in the pulmonic position during an approximately 4-year period, the DrySeal sheath was utilized in 29 patients (30.8%). The most common (38.3%) landing zone was a patched, or “native”, RVOT. Pre-stents were utilized in 1/3 of patients, most often in the setting of a RV-to-PA conduit.   The authors found that valve delivery time (time from insertion of S3 valve into sheath to valve deployment) was shorter in the DrySeal group when compared to the e-sheath group (median 4 min 33 sec vs. 9 min 6 sec, p=0.002). The delivery time was reported to be longest with the first 2 patients of center’s experience with utilizing the DrySeal sheath for this indication, and this was thought to be secondary to not obtaining sheath position distal enough into the MPA or proximal branch pulmonary artery prior to valve insertion. Those cases were complicated by the sheath dropping into the RV cavity, resulting in ventricular arrhythmias and valve delivery similar to the steps taken when using the e-sheath. Delivery times were improved once the technical adjustment was made to obtain more distal sheath position. Median fluoroscopy time was shorter for the DrySeal group as well (median 33 min 24 sec vs. 44 min 1 sec, p=0.04).   There was a significantly higher rate of complications in the e-sheath group (13.9% vs. 0%, p=0.04). Notably, the 2 types of complications that are thought to be protected against by utilizing the DrySeal sheath comprised 5 of 9 acute procedural complications in the e-sheath group: tricuspid valve injury (4) and femoral venous dissection (1). Importantly 3 of the 4 TV injuries ultimately required surgical intervention. Additionally, 2 cases were reported in which retrieval of a ruptured delivery balloon was difficult with the e-sheath and resulted in embolization of the tip of the e-sheath in one and TV injury in the other.   Although this is an initial single-center experience with this modified delivery technique for TPVI with the Edwards Sapien 3 valve, the authors present promising results of decreased procedural time and safety with this approach.        

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Implantable pulmonary artery pressure monitoring device in patients with palliated congenital heart disease: Technical considerations and procedural outcomesko

Implantable pulmonary artery pressure monitoring device in patients with palliated congenital heart disease: Technical considerations and procedural outcomes Salavitabar A, Bradley EA, Chisolm JL, Hickey J, Boe BA, Armstrong AK, Daniels CJ, Berman DP. Catheter Cardiovasc Interv. 2020 Feb;95(2):270-279. doi: 10.1002/ccd.28528. Epub 2019 Oct 14. PMID: 31609082   Take Home Points: Patient with complex congenital heart disease increasingly survive into adulthood and experience significant morbidity related to heart failure. Use of implantable hemodynamic monitor (CardioMEMS™) in this patient population is feasible and safe and allows for continuous tracking of pulmonary artery pressures. More work needs to be done to assess the long-term safety and clinical utility of such devices.     Commentary from Dr. Konstantin Averin (Edmonton), catheterization section editor of Pediatric Cardiology Journal Watch: Heart failure (HF) causes significant morbidity in adults with congenital heart disease (CHD). In non-CHD populations the use of implantable hemodynamic monitors (IHM) has been shown to decrease HF-related hospitalizations. To date, the use of these devices in CHD patients has been very limited. The authors sought to describe a single center experience utilizing IHM’s in adult patients with complex CHD – focusing on technical aspects and procedural outcomes.   The authors utilized the CardioMEMS™ device (Abbott Medical, Chicago, IL; picture below), a radiopaque sensor which is delivered via a 12 French sheath over a 0.018”wire and is anchored in a branch pulmonary artery (target diameter 7-15 mm) by a nitinol loop at each end. Fourteen patients (35.5 ± 9.2 years; 72 ± 12 kg) met inclusion criteria (adult with complex CHD; NYHA FC III HF; and at least one decompensated HF admission referred for hemodynamic catheterization) and underwent successful implant of the CardioMEMS™ device. All patients had either Fontan (n = 8) or d-TGA s/p atrial switch (6) anatomy. The devices were implanted via a femoral vein in most (13/14) and a long sheath was utilized in slightly more than half (8/14). A long sheath was particularly useful when advancing the device in patients who had undergone a Mustard operation (5/8). The device was implanted in the LPA in most patients (12/14) due to easier calibration and subsequent data transmission in this location.   Calibration and subsequent data transmissions were accomplished in all patients. One patient required recalibration (with hemodynamic catheterization) due to significant changes in IHM transmissions. There was one major complication – device migration from the LPA to the RPA – with no clinical sequelae.   The use of IHM’s in patients with CHD is almost non-existent, even though invasive hemodynamics in this patient population are often felt to not be truly representative of patients in their daily lives. The authors have nicely demonstrated that despite the complex anatomies of adults with CHD, IHM implantation is feasible and safe in this patient population. Further studies are clearly needed to demonstrate long-term safety of these devices as they will likely remain in place forever and whether they will improve clinical outcomes.      

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Septal Flash-like Motion of the Earlier Activated Ventricular Wall Represents the Pathophysiology of Mechanical Dyssynchrony in Single-Ventricle Anatomy

Septal Flash-like Motion of the Earlier Activated Ventricular Wall Represents the Pathophysiology of Mechanical Dyssynchrony in Single-Ventricle Anatomy Hayama Y, Miyazaki A, Ohuchi H, Miike H, Negishi J, Sakaguchi H, Kurosaki K, Shimizu S, Kawada T, Sugimachi M. J Am...

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Early experience with the HeartMate 3 continuous-flow ventricular assist device in pediatric patients and patients with congenital heart disease: A multicenter registry analysis

Early experience with the HeartMate 3 continuous-flow ventricular assist device in pediatric patients and patients with congenital heart disease: A multicenter registry analysis O'Connor MJ, Lorts A, Davies RR, Fynn-Thompson F, Joong A, Maeda K, Mascio CE, McConnell...

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