Congenital Heart Interventions

Transcarotid Approach to Ventricular Septal Defect Closure in Small Infants. Breatnach CR, Kenny D, Linnane N, Al Nasef M, Ng LY, McGuinness J, McCrossan B, Nölke L, Oslizlok P, Redmond M, Walsh K.Pediatr Cardiol. 2021 Oct;42(7):1539-1545. doi: 10.1007/s00246-021-02638-6. Epub 2021 Jun 3.PMID: 34081172   Take Home Points: Using a team approach, perimembranous ventricular septal defects can be closed via a minimally invasive, “pseudo-percutaneous” approach with good safety and efficacy. Commentary from Dr. Konstantin Averin (Edmonton), catheterization section editor of Pediatric Cardiology Journal Watch: Percutaneous closure of perimembranous ventricular septal defects (pmVSD) is experiencing a resurgence as cumulative experience with newer devices demonstrates a favorable safety profile. The approach is generally limited to larger children due to the need for relatively large delivery systems. The authors undertook to describe their novel approach to closing pmVSDs in small children via a surgical right carotid cut-down.   Patients ≥5kg were included if they had evidence of a hemodynamically significant pmVSD without coronary cusp prolapse or aortic insufficiency. Procedures were done in a hybrid cardiac catheterization laboratory with both surgical and interventional teams. A 7 French sheath was placed in the right carotid artery via surgical cut down and the defects were primarily assessed via trans-esophageal echocardiography. The remainder of the procedural steps are summarized in the text but are generally similar to other descriptions of retrograde pmVSD closure. The Figure below demonstrates fluoroscopy of the steps in closure.   Between December 2016 and April 2020, 18 infants (median [IQR] age 7 [5-9] months and weight 7.1 [6.5-7.8] kg) underwent attempted pmVSD closure via this approach. Outcomes are summarized in the table below. Most patients (15/18) had their defects closed successfully with the remaining 3 requiring conversion to open repair (1 – device embolization, 1 – tricuspid valve injury, 1 – device instability). Most patients were discharge after overnight observation on the ward. All 12 patients who had follow up assessment of carotid artery demonstrated no abnormalities.   While not revolutionary, this very interesting report brings together 3 current trends in pediatric cardiac catheterization – the increasing interest in percutaneous closure of pmVSD, use of the carotid artery for interventions in young children, and a collaborative approach to dealing with issues in congenital heart disease. The authors are to be commended for their innovative thinking and good outcomes.       

Title: Echocardiographic Left Ventricular Z-score Utility in Predicting Pulmonary-Systemic Flow Ratio in Children with Ventricular Septal Defect or Patent Ductus Arteriosus Authors: Sumitomo NF, Kodo K, Maeda J, Miura M, Yamagishi H Circulation Journal 2022;86: 128-135, doi 10.1253/circj.CH-21-0559   Take Home Points: Left ventricular end diastolic dimension Z scores (cut point +1.76) have a good correlation (88% specificity overall and 96% specificity in children > 2 yo) with catheterization measured Qp:Qs (cQp:Qs) of 1.5 or more from a VSD or PDA. Left ventricular end systolic dimension Z scores also had a good correlation (72% specificity overall and 84% specificity in children > 2 yo) with cQp:Qs > 1.5 from a VSD or PDA. There was a reasonable correlation between echo derived and catheterization measured Qp:Qs with a r = 0.724 This cannot be applied to patients with genetic abnormalities, to those with moderate or greater TR or MR or concomitant ASDs > 5 mm or defects other than VSD or PDA as this was not studied in this population Commentary from Dr. Thomas Zellers (Dallas, USA), section editor of ACHD Journal Watch: This is a good study that evaluates the correlation between cardiac catheterization measured pulmonary to systemic flow ratios, cQp:Qs, with echo predicted eQp:Qs and then with Z-scores for echo measured LV end-diastolic and LV end systolic dimensions.   The study applies only to patients with VSDs or PDAs. There were a lot of exclusions including patients with more than mild tricuspid, mitral, aortic or pulmonary valve regurgitation, atrial septal defects > 5 mm, any patient with genetic abnormalities, low birth weight (< 2500 gms) or premature infants, patients with poor growth (SD <-2), age < 1 month, PAH with mean PA pressure of 40 mmHg or more, RV systolic pressure > 70% of systemic pressure, and LVEF < 55%.   The authors started with 175 patients evaluated between 2015 and 2019 at two centers in Tokyo and ended with 70 patients in the study because of all of the exclusions. All patients had a cardiac catheterization with Qp:Qs measurements using the Fick method and all had a transthoracic echo with imaging and Doppler within one week of the cardiac catheterization. The LVEDd and LVESd dimension were measured using a standardized M-mode format for each patient. One echocardiographer, blinded to cardiac catheterization data, reassessed all echo measurements and, to determine intra- and inter-observer variations, a sample of patient measurements were evaluated by 4 blinded physicians. The Z-scores were derived from Patterson’s methods. Patients were also divided into younger than and older than 2 years of age and comparisons made between the two age groups.   The authors found a strong and significant correlation between the cQp:Qs and LVEDd. Using regression analysis, the LVEDd Z-score of 1.76 served as a cut point for a cQp:Qs of 1.5:1 or greater with a specificity of 88% for the cohort and 96% in the children more than 2 years of age. In addition, the authors found a statistically significant correlation with the LVESd and cQp:Qs with a Z-score of 1.1 as a cut point for a cQp:Qs of 1.5 or greater. The sensitivity was 89% with a specificity of 72%.   While the correlation between cQp:Qs and eQp:Qs was good with an r = 0.724, the eQp:Qs is overestimated compared to cQp:Qs between 1 and 1.5:1 and is underestimated as the cQp:Qs values exceeded 2:1.   Limitations: This was a retrospective study from two centers with a modest sized group of patients (n=70) due to exclusions in a limited data set (VSD or PDA). The measured dimensions were taken from M-mode only but the inter and intra observer variability was low.