Congenital Heart Interventions

Adverse Events Associated with Cardiac Catheterization in Children Supported with Ventricular Assist Devices. Power A, Navaratnam M, Murray JM, Peng LF, Rosenthal DN, Dykes JC, Yarlagadda VV, Maeda K, Almond CS, Chen S.ASAIO J. 2022 Sep 1;68(9):1174-1181. doi: 10.1097/MAT.0000000000001627. Epub 2021 Dec 28.PMID: 34967779 Take Home Points: Ventricular assist devices are increasingly being used as a bridge to heart transplant. Cardiac catheterization can be useful to help evaluate and optimize the support and intervene as needed. Need for ICU support, BiVAD support, and clinical deterioration prior to the catheterization are risk factors for adverse events related to the catheterization. Commentary from Dr. Ryan Romans (Kansas City, MO), section editor of Congenital Heart Disease Interventions Journal Watch: Ventricular assist device (VAD) use has increased as a viable means of mechanical circulatory support for children over the last 2 decades (now more than 50% of pediatric dilated cardiomyopathy patients on VADs at time of transplant), with improving technology and experience with management leading to improved outcomes. Cardiac catheterization can provide essential diagnostic information in patients supported with VADs (filling pressures, fluid status, pulmonary vascular resistance, etiology of hypoxia) and is also at times necessary for interventional procedures. Additionally, ramp studies (serial hemodynamic measurements while adjusting VAD settings) can be performed during a catheterization to help optimize VAD settings. This study is the first to evaluate the safety of cardiac catheterization in pediatric patients on VAD support. A retrospective review was performed of all patients on VAD support who underwent cardiac catheterization at Lucile Packard Children’s hospital from 1/2014-9/2019. The indication for catheterization was categorized as hemodynamic assessment in stable clinical condition, hemodynamic assessment due to worsening clinical status, and planned intervention. Major adverse events (AE) were defined as arrhythmia leading to hemodynamic compromise/requiring treatment, respiratory failure >24 hours after cath, acute kidney injury, major bleeding, stroke within 7 days, pericardial effusion within 7 days, device malfunction/pump thrombus, bacteremia within 7 days, death within 7 days, need for CPR/ECMO, or other. AEs were reviewed by two blinded authors who determined if they were related to the catheterization or not based on clinical notes (i.e., if dialysis was already planned at the time of the catheterization AKI was not a complication of the catheterization). A total of 71 patients were supported with VADs; of these 39 patients underwent a total of 60 cardiac catheterizations. Many of these patients (54%) had dilated cardiomyopathy with single ventricle congenital heart disease (1V-CHD) the next most common (31%). 60% of the patients were in the ICU at the time of the procedure. 63% of the catheterizations were performed for hemodynamic assessment in patients in stable clinical condition (most to assess candidacy for heart transplant) with the remaining done in patients with deterioration clinical condition. Ramp assessments were included in 37% of catheterizations. Interventions were performed in 25% of catheterizations (planned in 11, unplanned in 4). During the catheterization, 19 (32%) cases required a fluid bolus (n=9) and/or vasoactive boluses (n=8)/escalation in vasoactive infusions (n=5). 12/60 (20%) cases had at least one adverse event noted (total AEs 16) with 9 of these in 8 different patients determine to be possibly related to the catheterization. The adverse events were respiratory failure (n=6), major bleeding (n=2) and arrhythmia (n=1). All patients who had an AE were in the ICU prior to their catheterization. Additionally, AEs were more likely in patients on BiVAD support and in those undergoing catheterization for worsening clinical condition. This single center study shows that cardiac catheterizations in pediatric patients supported with VADs are reasonably safe (cases had a 13% AE rate). Not surprisingly, AEs were more common in those hospitalized in the ICU, on BiVAD support, and who have had clinical deterioration prior to the catheterization. The most common complication was need for increased respiratory support in patients who were already  on high flow or positive pressure respiratory support. Importantly, there were no cardiac arrests/need for ECMO support.

Balloon Interrogation of Intervening Tissue: A Novel Method to Decide Strategy for Closing Multiple Atrial Septal Defects. Dalvi B, Bhalgat P. Circ Cardiovasc Interv. 2022 Sep;15(9):e012048. doi:10.1161/CIRCINTERVENTIONS.122.012048. Epub 2022 Sep 20.PMID: 36126135 Free article. Take Home Points:  Balloon interrogation of patients with two secundum atrial septal defects beyond the typical “stop-flow” and “balloon stretch” techniques allow for determination of candidacy for a single-device approach to percutaneous device closure. If balloon interrogation of one of two ASDs does not result in intervening tissue impingement and cessation of flow through the 2nd defect, it is important to separately interrogate the 2nd defect to determine if that is a single-device candidate. Commentary from Dr. Arash Salavitabar (Columbus, OH, USA), section editor of Congenital Heart Disease Interventions Journal Watch:  The authors report on an approach to a challenging dilemma of performing device closure of two separate ostium secundum atrial septal defects (ASDs). The clinical decision of whether to use a single device to cover both defects and/or use multiple devices can be a difficult judgement call.  This was a prospective study of 20 patients (age range 3-67 years, weight range 11-71 kg) with 2 secundum ASDs who underwent device closure. In these patients, an Amplatzer sizing balloon was inflated across one of the defects until flow through that defect stopped completely. This was then further inflated to determine whether the intervening tissue between the ASDs demonstrated enough mobility to also stop flow through the 2nd defect. A “successful balloon interrogation” was if this technique stopped flow through both defects and the diameter at which flow stopped through both defects was referred to as the “balloon interrogated diameter” (Figure 4). If flow did not cease in the 2nd defect, that additional defect was crossed separately from the contralateral femoral vein and balloon interrogation was performed using the same technique to determine if a single device could be utilized within that defect (Figure 5). An “unsuccessful” balloon interrogation resulted in a 2-device strategy. When a single device was used, 1-2mm were added to the balloon-interrogated diameter, whereas in the 2-device approach, 1-2mm were added to each balloon-stretched diameter. When deploying 2 devices, the smaller device was delivered first, followed by the larger device. A single device was implanted successfully and without residual shunt in 15/20 patients. Four of the 15 patients had an initially unsuccessful balloon interrogation but was subsequently successful when performed in the 2nd defect. The remaining 5 patients received 2 devices. Although statistical analysis was not reported, the authors found that successful single-device approach was more likely if the smaller defect was <10 mm in diameter, that the width of tissue separating defects was shorter in patients who received a single device, as compared with 2 devices (5.2±2.4 mm for 1 versus 8±1.1 mm for 2). Successful single-device strategy also tended to be in younger patients. Importantly, the single-device strategy required use of a significantly larger (35±14%) device and the Amplatzer Septal Occluder was used in all of these single-device cases. This study provides a logical, stepwise approach to interrogation and decision-making in percutaneous treatment of two secundum atrial septal defects. The authors provide a small cohort with success using this strategy of triaging patients who are candidates for a single-device approach. Given that a larger device is needed to perform this single-device strategy, it will be important to have subsequent follow-up data regarding device-related complications, such as erosion.