Congenital Heart Interventions

Transcatheter closure of ventricular septal defects: preliminary results in children weighing 10 kg or less Kamran Mirza M, Shaad Abqari, Azam Haseen and Mayank Yadav   Take Home Points Patients ≤10kg with least a 3mm tissue rim separating the VSD from the AV or TV, and no/minimal baseline aortic regurgitation were considered for device closure with a 90% success rate ADO I devices were used for defects with a septal aneurysm, ADO II for smaller defects, and muscular VSD device for larger defects via retrograde and antegrade approaches Commentary from Dr. Arash Salavitabar (Ann Arbor, MI, USA), section editor of Congenital Heart Disease Interventions Journal Watch:   The authors report on the results of a retrospective single-center study on the feasibility and short-term outcomes of percutaneous ventricular septal defect (VSD) closure in patients weighing ≤10kg. Patients were included is they had a hemodynamically significant VSD by both clinical and echocardiographic and catheterization criteria. Patients ≤10kg were considered amenable for device closure if there was at least a 3mm tissue rim separating the defect from the AV or TV, and there was no or minimal baseline aortic regurgitation.   This procedure was performed in 50 patients, 47 of which were performed under conscious sedation and all of which were approached via the right internal jugular vein and right femoral vein and artery. Mean patient weight was 7.46 ± 1.89 kg (2.3–10 kg) and mean age was 19.4 ± 11.88 months (4–48 months). VSD types consisted of 35 (70%) perimembranous, 7 (14%) upper muscular, 3 (6%) mid-muscular, 2 (4%) lower muscular, 3 (6%) outlet muscular. Pulmonary hypertension was present in 29 (58%) patients, which was defined based on mPAP >25mmHg (as opposed to being defined by pulmonary vascular resistance). Retrograde device closure was performed in 27 (54%) and antegrade device closure was performed in 15 (38%) via RFV and 3 (6.6%) with mid-muscular and lower muscular defects via RIJ access. Device choice was based on VSD characteristics, with a size 1-2mm larger than the largest defect diameter on the RV side. ADO I devices (15 cases, 30%) were used for defects with a septal aneurysm, ADO II (27 cases, 52%) for smaller defects, and muscular VSD device for larger defects.   Device closure was successful in 45 patients (90%), 5 (12%) of which had minimal intra-device residual flow at discharge which had resolved by 1-month follow-up. There were no incidences of aortic or tricuspid regurgitation. There was 1 (2%) immediate device embolization. Unsuccessful attempts included device embolization of undersized ADOII, severe bradycardia during delivery sheath advancement via an AV loop, aortic regurgitation caused by ADOII disc, and poor device position, each of which resulted in conversion to surgical closure.   Of the devices used in this study, the authors concluded that the most suitable device for closure of VSDs which are not very large (>5mm) and perimembranous in location is ADOII because of its feasibility to deliver it via a retrograde approach without forming an AV loop, as well as its softer profile to limit the chance of injury to adjacent structures.   

Real-Time Ultrasound Guidance for Umbilical Venous Cannulation in Neonates With Congenital Heart Disease Benjamin W Kozyak, María V Fraga, Courtney E Juliano, Shazia Bhombal, David A Munson, Erik Brandsma, Jason Z Stoller, Ankit Jain, Russell Kesman, Malorie Meshkati, Caroline Y Noh, Aaron G Dewitt, Andrew T Costarino, David A Hehir, Alan M Groves. Pediatr Crit Care Med. 2022;23(5):e257-e266. doi: 10.1097/PCC.0000000000002919. Epub 2022 Mar 7. PMID: 35250003   Take Home Points: Ultrasound guidance, coupled with liver pressure, can markedly improve successful placement of umbilical venous catheters in neonates with congenital heart disease (CHD). Routine use and training of this point-of-care ultrasound technique may reduce x-ray imaging and spare central veins, which are essential in patients with complex CHD. Commentary from Dr. Milan Prsa (Switzerland, Europe), section editor of Congenital Heart Disease Interventions Journal Watch:   Umbilical venous access is routinely obtained in neonatal ICUs and is indispensable for optimal care of patients with complex congenital heart disease (CHD). However, successful placement of an umbilical venous catheter (UVC) at the inferior cavoatrial junction has been reported at only 50-75%. The authors describe and report on the success of their technique to rescue malpositioned UVCs.   Over a period of 26 months, 32 neonates with CHD underwent ultrasound-assisted UVC placement by experienced neonatologists across three centers, all after previous failed attempts at traditional, blind insertion. The technique used starts with imaging the trajectory the UVC will follow from the umbilical vein (UV) to the portal sinus, and then through a patent ductus venosus (DV) to the inferior cavoatrial junction. Patency of the DV is evaluated with color Doppler or injection of agitated saline. The catheter is then advanced under direct visualization to the portal sinus, where probe pressure on the liver distorts the portal sinus to enhance its alignment with the DV, allowing a straighter trajectory from the UV and preventing malposition of the catheter in the portal veins (Figure 1). With this technique, malpositioned UVCs were rescued in 23 of 32 patients (72%), including 18 of 24 patients (75%) on prostaglandin. None of the patients required other central venous access, and there were no catheter-associated complications or cases of portal vein thrombosis.     Figure 1. Effect of liver pressure on producing a straighter trajectory from the UV to the DV (*), avoiding malposition in the portal veins (# and arrows).   This multicenter case series demonstrates that use of point-of care ultrasound (POCUS) to rescue malpositioned UVCs has a high success rate in neonates with complex CHD. However, this was possible in large academic centers with providers who had significant prior experience with POCUS. Nevertheless, the potential benefits of preserving precious central veins and reducing radiation exposure in patients with complex CHD should serve to encourage providers in centers with POCUS capabilities to undergo formal training and implement this technique.