Congenital Heart Interventions

Combined Echo and Fluoroscopy-Guided Pulmonary Valvuloplasty in Neonates and Infants: Efficacy and Safety. Brown NK, Husain N, Arzu J, Ramlogan SR, Nugent AW, Tannous P.Pediatr Cardiol. 2022 Mar;43(3):665-673. doi: 10.1007/s00246-021-02771-2. Epub 2021 Nov 28. PMID: 34839381    Take Home Points: Combining transthoracic echocardiography and fluoroscopy to guide balloon pulmonary valvuloplasty (BPV) is equally effective and safe as standard BPV in treating neonates and infants with isolated pulmonary valve stenosis. Echo-guided BPV results in significantly reduced exposure to radiation and contrast by essentially eliminating the need for cine angiography to measure the pulmonary valve annulus. The subcostal right anterior oblique view by echocardiography was most helpful for guiding the intervention. Commentary from Dr. Milan Prsa (Switzerland, Europe), section editor of Congenital Heart Disease Interventions Journal Watch: Balloon pulmonary valvuloplasty (BPV) is the therapy of choice for isolated valvar pulmonary stenosis (PS). In an effort to reduce the secondary risks of radiation and contrast use, the authors of this study developed an institutional protocol using echocardiography guidance as an alternative to fluoroscopy and/or angiography for parts of the procedure. They report their initial experience and compare the results to standard BPV. Between September 2019 and December 2020, 10 infants with isolated valvar PS (including two with critical PS) underwent echo-guided BPV. They were compared to 19 infants (including six with critical PS) who underwent standard BPV between December 2017 and October 2019. There was no difference in demographic or pre-procedural data between the two groups. All procedures were performed successfully (i.e. residual peak-to-peak gradient <35 mmHg) with no difference in residual cath gradient and no adverse events. There were no differences in the number of balloons used, final balloon-to-annulus ratio, and fluoroscopy time or total sheath time. Naturally, there was an 80% reduction in total dose area product (33.8 versus 167.4 cGY∙cm2, p<0.001) and an 84% reduction in contrast load (0.8 versus 5.0 ml/kg, p=0.003) in the echo-guided BPV group compared to the standard BPV group, principally owing to measuring the pulmonary valve by echo instead of angiography (Table 1).     Table 1. Comparison of results between standard and echo-guided BPV   Although this was a single-center retrospective case-control study, it shows that echo-guided BPV in neonates and infants can yield the same results as standard BPV while using much less radiation and contrast. In addition, the authors demonstrate a shallow learning curve, having performed five of their last six cases wholly without contrast. Their efforts underline the value of adopting a multi-disciplinary team approach in applying the ALARA (As Low as Reasonably Achievable) principle in pediatric cardiac catheterization, and should be emulated as much as possible.   

Factors Influencing Reintervention Following Ductal Artery Stent Implantation for Ductal-Dependent Pulmonary Blood Flow: Results From the Congenital Cardiac Research Collaborative. Shahanavaz S, Qureshi AM, Petit CJ, Goldstein BH, Glatz AC, Bauser-Heaton HD, McCracken CE, Kelleman MS, Law MA, Nicholson GT, Zampi JD, Pettus J, Meadows J.Circ Cardiovasc Interv. 2021 Dec;14(12):e010086. doi: 10.1161/CIRCINTERVENTIONS.120.010086. Epub 2021 Nov 18.PMID: 34789017   Take Home Points: This study included 53 re-interventions in 41/105 (39%) patients <1 year of age who had PDA stent implantation for ductal-dependent pulmonary blood flow. Balloon pulmonary valvuloplasty was associated with decreased likelihood of re-intervention, while greater PDA tortuosity, use of drug-eluting stents, and anticipated single-ventricle physiology were associated with higher hazard of re-intervention. Commentary from Dr. Arash Salavitabar (Columbus, OH, USA), section editor of Congenital Heart Disease Interventions Journal Watch: The authors of this study sought to further understand and describe the rates and types of re-intervention following PDA stent implantation, as well as to identify risk factors associated with re-intervention. This was a retrospective, multi-center cohort study through the Congenital Cardiac Research Collaborative (CCRC) which included all infants <1 year of age with ductal-dependent pulmonary blood flow (DDPBF) and confluent pulmonary arteries palliated at <1 year of age with a PDA stent from 1/1/2008 through 11/1/2015. The primary outcome was re-intervention, whether catheter-based on the PDA or surgically to augment pulmonary blood flow.   This study included 105 patients of median age 9 days (5-15) at 1st intervention and weight of 3.2 kg (2.7-3.7). Prematurity was present in 26 (25%) patients. PDA tortuosity classification was 58 (55.2%) Type I and 47 (44.8%) Type II/III. Antegrade PBF was noted in 62% of the cohort and balloon pulmonary valvuloplasty (BPV) was performed either prior to or as a concomitant procedure with PDA stent implantation. Fifty-three re-interventions (7 surgical, 46 transcatheter) were performed in 41 (39%) patients, all but one occurring within 6 months of the initial procedure. Transcatheter interventions included 35 stent balloon angioplasties and 11 additional stent implantations.     The re-intervention and non-re-intervention groups were compared, showing no difference in baseline characteristics, however the following variables had associations with re-intervention: BPV was associated with decreased likelihood of re-intervention (HR 0.24 [0.10–0.60]; P=0.002); anticipated single-ventricle physiology had an increased hazard of re-intervention (HR, 3.27 [1.74–6.16]; P<0.001); PDA tortuosity classification of Type II/III had a higher risk of re-intervention (HR, 2.12 [1.15–3.91]; P=0.016); use of drug-eluting stents (DES) was associated with higher hazard of re-intervention (HR, 2.29 [1.04–5.02]; P=0.039). It was noted that DES were more likely be implanted in patients who had expected single-ventricle status and with single-source PBF. Interestingly, the number of patients whose ductal length was entirely covered did not differ between the re-intervention and non-re-intervention groups, nor did the PDA length or number of stents implanted. Patients undergoing unplanned re-intervention were noted to be significantly smaller at the time of the initial PDA stent implantation (P=0.045) and were more likely to have had partial or complete jailing of the pulmonary arteries at the initial implant (P<0.001). There was no significant difference in the duration of the interstage interval between the patients who underwent re-intervention related to the PDA stent to those without (P=0.522). No differences were seen in hazard of re-intervention based on antiplatelet/anticoagulant strategy.   The authors address an important question in this paper, and one that is constantly evolving with new techniques and stent types. Re-intervention is relatively safe and found to be nonurgent in this study. Further understanding of confounding variables in the understanding of the “natural history” of ductal stents will be important and ongoing.