Holzer R, Batlivala SP, Boe B, Goldstein B, Gudausky T, Hasan B, O’Byrne M, Quinn B, Sathanadam S, Shahanavaz S, Trucco SM, Zampi JD, Bergersen L. Pediatr Cardiol. 2023 Apr;44(4):795-805. doi: 10.1007/s00246-023-03126-9. Epub 2023 Feb 20.
Take home points:
- Life-threatening adverse events occur very rarely during cardiac catheterization in CHD, but not infrequently result in serious adverse outcomes.
- Adverse events following radiofrequency perforation of the pulmonary valve, atrial septal interventions, and procedures in non-elective cases, in neonates and early after surgery are associated with the highest risk of serious adverse outcomes.
- Case-specific rather than routine surgical backup may be more appropriate for interventional cardiac catheterization in CHD.
Commentary from Dr. Milan Prsa (Switzerland, Europe), section editor of Congenital Heart Disease Interventions Journal Watch:
Surgical interventions are rarely required for life-threatening adverse events (AEs) occurring during cardiac catheterization. Nevertheless, expert consensus recommends that surgical backup be available for therapeutic procedures in adult and pediatric CHD.1 As there are no published reports on the odds or outcomes of such interventions, the authors sought to examine the relationship between significant traumatic (tear with flow obstruction, unconfined tear, aneurysm, and/or heart perforation) or technical (coil/device/stent embolization or migration) AEs and adverse outcome (surgery, ECMO, or death).
Data from the Congenital Cardiac Catheterization Project on Outcomes (C3PO), collected from 14 centers between January 2014 and December 2017, was analyzed (Table 1).
Traumatic AEs were seen in 92 cases or 0.4% of C3PO registered cases and resulted in an adverse outcome in 26% (24/92) or 0.1% of all cases. Surgery was required in 20%, ECMO in 9%, and death occurred in 10% (9/92) of cases with traumatic AEs. Radiofrequency perforation of the pulmonary valve was most likely to result in traumatic AEs (7/69 or 10%), with 57% (4/7) of cases having an adverse outcome. Atrial septal interventions were responsible for 29% of adverse outcomes due to traumatic AEs.
Technical AEs were seen in 176 cases or 1.3% of C3PO registered interventional cases and resulted in an adverse outcome in 14% (25/176) or 0.2% of all interventional cases. Surgery was required in 13%, ECMO in 2%, and death occurred in 2% (3/176) of cases with technical AEs.
Predictably, adverse outcomes were more likely to occur after traumatic AEs, especially in non-elective/emergent cases (OR 7.1), in neonates (OR 4.8), and in those who had surgery in the previous 30 days (OR 4.2).
This multicenter cohort study shows that significant AEs are very rare during cardiac catheterization in CHD, suggesting that immediate surgical or ECMO backup may only be needed for specific cases associated with a high rate of serious adverse outcomes if these AEs occur. Updated expert consensus recommendations should address appropriate backup provisions more specifically.
Table 1. Demographic and clinical data.
- Bashore TM, Balter S, Barac A et al. 2012 American College of Cardiology Foundation/Society for Cardiovascular Angiography and Interventions expert consensus document on cardiac catheterization laboratory standards update: A report of the American College of Cardiology Foundation Task Force on Expert Consensus documents developed in collaboration with the Society of Thoracic Surgeons and Society for Vascular Medicine. J Am Coll Cardiol. 2012 Jun 12;59(24):2221-305. doi: 10.1016/j.jacc.2012.02.010. Epub 2012 May 8. PMID: 22575325.
