Congenital Heart Interventions

Incidence, risk factors, and management following cardiac catheterization via carotid and axillary artery approaches: A single-center experience on pseudoaneurysms in young infants. Takajo D, Newkirk B, Shahanavaz S. Catheter Cardiovasc Interv. 2024 Mar;103(4):580-586. doi: 10.1002/ccd.30966. Epub 2024 Feb 14.PMID: 38353500 Take-Home Points: Screening for pseudoaneurysms after procedures using carotid or axillary artery access aids in early detection and treatment. Longer sheath dwell times (in-to-out time) and higher activated clotting times (ACT) might be associated with pseudoaneurysm development. Commentary from Dr. Subhrajit Lahiri, section editor of Congenital Heart Disease Interventions Journal Watch: The authors accurately note that pseudoaneurysms following arterial access have been studied in adults. In these studies, interventional procedures, electrophysiology procedures, large sheath sizes, and left groin access were identified as risk factors. While Bauser-Heaton et al. reported pseudoaneurysms after carotid or axillary access in children, their lack of post-procedural complication screening limited the true incidence. This paper describes the authors' institutional practice of performing ultrasound screening 24 hours after every axillary or carotid access. They analyzed 29 young infants who underwent cardiac catheterization between 2013 and 2022. The median patient age was 6 days, with most having single ventricles. Procedures included PDA stenting, aortic valvuloplasty, and thrombectomy. Both carotid and axillary access were used, with ultrasound guidance for access establishment. Hemostasis was achieved using compression, and heparin was administered to maintain target ACT levels. The median procedure duration was 82 minutes, and the median compression time was 20 minutes. ACT values were recorded for most patients, with a median closing ACT of 208 seconds. All 29 patients underwent Doppler ultrasound within this timeframe. Four patients with carotid access and one with axillary access were diagnosed with access-related pseudoaneurysms. Bedside ultrasound compression in the ICU resolved the pseudoaneurysm in 3 patients. One patient underwent trans-arterial flow-diverting stent placement at 6 weeks, and another required embolization of the left common carotid artery. Comparing groups with and without pseudoaneurysms revealed significantly longer sheath dwell times (135 minutes vs. 75 minutes) and higher ACT (268 seconds vs. 200 seconds) in the pseudoaneurysm group. The authors acknowledge the lack of treatment guidelines for carotid or axillary pseudoaneurysms in children, with treatment depending on factors like size, location, and physician preference. However, they emphasize the importance of early detection. Limitations: Small sample size limits the statistical power of the conclusions. Lack of data on: Number of puncture attempts Bleeding after access Standardization in early cases Variability in post-procedural holding pressure Conclusion: This valuable study highlights a rare but important complication of carotid and axillary artery access, a common practice in cardiac catheterization labs. It encourages multicenter studies to establish guidelines for managing such complications.

Cardiac Catheterization Interventions in the Right Ventricular Outflow Tract and Branch Pulmonary Arteries Following the Arterial Switch Operation. Gritti MN, Farid P, Hassan A, Marshall AC. Pediatr Cardiol. 2024 Feb 10. doi: 10.1007/s00246-024-03408-w. Online ahead of print. PMID: 38341390 Take Home Points: Residual MPA/branch PA stenosis following the arterial switch operation can result in significant right ventricular hypertension. Branch PA angioplasty and branch PA stenting can improve RV hypertension, decrease gradients across the branch PAs, and improve the caliber of the vessel without major adverse events. More concrete indications for intervention and long term follow up, especially of stented branch PAs following ASO is needed to help guide optimal therapy. Commentary from Dr. Ryan Romans (Kansas City, MO), section editor of Congenital Heart Disease Interventions Journal Watch: Dextro-transposition of the great arteries (d-TGA) is repaired in the neonatal period via the arterial switch operation (ASO) +/- closure of a ventricular septal defect if present. Pulmonary artery translocation with the LeCompte maneuver can results in the branch pulmonary arteries (PAs) both sitting on top of the ascending aorta. Branch PA stenosis is relatively common following this (up to 28% in previous studies) secondary to multiple factors. Additionally, pulmonary artery stenosis at the anastomotic site can also occur, though seem to be decreasing in frequency with improvement in surgical techniques. This, along with branch PA stenosis, can lead to RV hypertension. This study sought to describe the outcomes of transcatheter interventions in this patient population. A retrospective review of all patients who underwent both an ASO and cardiac catheterization (excluding balloon atrial septostomy) was performed at a single center from 1/2004-12/2020. Patients were excluded if they did not have a right heart catheterization (RHC) performed. A total of 544 patients had an ASO during this time. 110 patients had a cardiac catheterization performed, with 58 patients meeting inclusion criteria. 9 patients underwent a diagnostic RHC only. 49 patients underwent 76 right sided interventional cardiac catheterizations at a median age of 3 ± 3.9 years. Many patients had a cardiac catheterization performed for RV hypertension (42%), branch PA pressure gradient (29%), and significant branch PA size discrepancy (19%). The RV to systemic pressure ratio was higher in the interventional group vs the diagnostic group (0.68±0.21 vs 0.52±0.16, p<0.02). In the intervention group, 33% of patients had a significant RPA gradient and 33% LPA. 17% had a significant size discrepancy. In the 76 interventional catheterizations, balloon angioplasty of the RPA was performed 27, LPA in 42, and MPA in 10. Reduction in the RV hypertension was accomplished with angioplasty of the RPA (0.69±0.17 to 0.54±0.15, p<0.001) and LPA (0.66±0.17 to 0.54±0.17, p<0.001). The RPA gradient was reduced from a mean of 21.4 mmHg to 10.5 mmHg and LPA gradient from 22.8 mmHg to 13.3 mmHg. The size of both branch PAs increased following angioplasty as well (RPA 4.6 to 5.2 mm, LPA 4.4 to 6.8 mm). 15 patients had a stent placed in their RPA and 16 in their LPA with significant reduction in the RV pressure and gradients with near doubling in vessel caliber. 5 patients had stents placed in both branch PAs. There were no complications in the diagnostic RHC cohort and 9 (12%) in the interventional cohort. None of these complications were considered high severity. This study showed that branch PA interventions in young children following ASO can result in a significant decrease in RV hypertension with an acceptable risk profile. Unfortunately, this study was not able to clearly delineate indications for intervention as determined by noninvasive imaging. I expect there is still significant practice variation across centers given this. Long term follow-up of this population is needed, especially following branch PA stenting, given the known risk of late aortopulmonary fistula formation. Additionally, it is unclear what degree of RV hypertension and/or branch PA flow discrepancies are clinically significant in patients post ASO.

Comparison of ductus stent versus surgical systemic-to-pulmonary shunt as initial palliation in patients with univentricular heart. Grozdanov D, Osawa T, Borgmann K, Schaeffer T, Staehler H, Di Padua C, Heinisch PP, Piber N, Georgiev S, Hager A, Ewert P, Hörer J, Ono M. Eur J Cardiothorac Surg. 2024 Mar 1;65(3):ezae011. doi: 10.1093/ejcts/ezae011.PMID: 38212978 Take home points: In patients with single ventricle physiology and ductal-dependent pulmonary blood flow, initial palliation with either a surgical systemic-to-pulmonary artery shunt or interventional ductal stenting had comparable survival rates, with no significant difference in the probability of reaching stage II and III palliation. Patients undergoing ductal stenting experienced shorter ICU and hospital stays, while having higher rates of acute complications, needing more frequent reinterventions. Commentry from Dr. Milan Prsa (Switzerland, Europe), section editor of Congenital Heart Disease Interventions Journal Watch : In patients with single ventricle (SV) physiology and ductal-dependent pulmonary blood flow (DD-PBF), an initial palliation during the neonatal period is necessary to establish a stable source of PBF. This can be achieved through a surgical systemic-to-pulmonary artery shunt (SPS) or percutaneous ductal stenting (DS). The authors sought to compare survival rates between SPS and DS in patients with SV physiology and DD-PBF. Additionally, they aimed to compare the two groups in terms of hospital recovery, rate of complications, pulmonary artery (PA) development and outcomes for stage II and stage III palliation. This was a retrospective, observational study conducted at a single center from 2009 to 2022. A total of 130 patients were identified, with 81 undergoing SPS (62 modified Blalock-Taussig shunt and 19 central aortopulmonary shunt) and 49 undergoing DS as their initial palliation. The only significant difference between the groups was more patients with pulmonary atresia and intact ventricular septum were palliated with DS (22.4% vs. 9.9%, p = 0.049). The results showed comparable survival rates between the two groups, with no significant difference in reaching stage II or stage III palliation. Patients with DS had significantly shorter ICU and overall hospital stays compared to SPS (median 1 vs. 7 days in the ICU; 7 vs. 17 days in the hospital). Acute complications, including stent dysfunction and dislocation, were more common in the DS group (20.4% vs. 6.2% in the SPS group), with all 10 of these patients in the DS group needing a SPS. Pulmonary artery growth was generally similar between the two groups, though patients with DS showed a lower ratio of left-to-right PA index compared to those with SPS, indicating potentially less balanced PA development. Despite its shortcomings as a single-center retrospective review with inherent patient-level differences, this study supports the use of DS as a viable initial palliative option for patients with SV physiology and DD-PBF, particularly given the reduced hospitalization time and comparable survival rates to SPS. However, clinicians should weigh the benefits of shorter ICU and hospital stays against the potentially higher risk of reintervention associated with DS, including emergent conversion to SPS. The study also underscores the need for a prospective randomized trial to determine if one palliative approach offers a clear therapeutic advantage. Hopefully, the future large multicenter COMPASS trial will settle the debate.1 References Petit CJ, Romano JC, Zampi JD, et al. Rationale and Design of the Randomized Comparison of Methods for Pulmonary Blood Flow Augmentation: Shunt Versus Stent (COMPASS) Trial: A Pediatric Heart Network Study. World Journal for Pediatric and Congenital Heart Surgery. 2024;0(0). doi:10.1177/21501351241266110

Transcatheter Pulmonary Valve Replacement with Balloon-Expandable Valves: Utilization and Procedural Outcomes from the IMPACT Registry. Stefanescu Schmidt AC, Armstrong AK, Aboulhosn JA, Kennedy KF, Jones TK, Levi DS, McElhinney DB, Bhatt AB. JACC Cardiovasc Interv. 2024 Jan 22;17(2):231-244. doi: 10.1016/j.jcin.2023.10.065. PMID: 38267137 Take Home Points Melody valves were used more often over the entire study period (57%) though there was an evolution in valve type with Sapien valves contributing to more than 50% of implants by 2020. Melody valves were used more often in younger patients, patients with conduits and patients with RVOT stenosis whereas Sapien valves were more commonly used in patients with predominant PR and those with native/patched RVOTs Center experience with the TPVR procedure varied widely with most centers reporting <10 cases per year Commentary from Dr. Jonathon Hagel (C.S. Mott Children’s Hospital, University of Michigan) After its initial commercial approval in the United States in 2010, transcatheter pulmonary valve replacement (TPVR) has expanded and evolved. The authors sought to examine real world patient and procedural characteristics of TPVR using data from the IMPACT (Improving Pediatric and Adult Congenital Treatment) registry which includes 106 participating sites. Their secondary objectives were to describe acute hemodynamic outcomes and major adverse events (MAEs) associated with the procedure.             Patients who had a TPVR procedure entered in the IMPACT registry with an implant date between April 2016 and March 2021 were included in the study. This timeframe represents the only approved commercially available devices at the time being the Melody and Sapien transcatheter pulmonary valve (TPV). Notably, this timeframe excludes newer self-expanding TPV platforms designed specifically for large native/patched RVOTs. Those in whom a device was not implanted, were treated with a self-expanding TPV or who had no data entered for valve type were excluded from analysis. Over the 5-year study period, 4936 TPVR procedures were attempted of which 4513 met the inclusion criteria. The average yearly volume was <10 cases at more than two-thirds of centers. The median age at implant was 19 years (13, 31) with 10% of patients weighing <30 Kg and 3% of patients <20 Kg. Acute success was achieved in 95% of patients however an optimal hemodynamic outcome with peak-to-peak invasive gradient of <15 mmHg was only achieved in 83% of patients. MAEs were reported in 2.4% of cases and were significantly less common in patients with a BPV (1.4%) compared to those with a homograft (2.9%) or native/patched RVOT (3.4%) (P=0.004). In multivariable analysis, age (10-19 yrs vs. 19-40 yrs), RVOT type (BPV vs. Homograft) and femoral venous access were significantly associated with lower risk of MAEs after adjusting for valve type, year or procedure and TPVR annual center volume. Using this large national registry of children and adults with congenital heart disease there were several key findings. First, one quarter of implants were performed into native/patched outflow tracts which is an off-label application of these devices. Second, patients weighing <30Kg (who were excluded from the initial Melody and Sapien clinical trials) represented 10% of this cohort. Emergent/urgent TPVR cases were rare but more likely to be associated with MAEs and less likely to be successful. MAEs were uncommon with one reported procedural death, a small number of cardiac arrests, ECMO and unplanned cardiac or vascular surgery.