interventional opportunities interventional opportunities
TRANSCRIPT
Pediatric Interventional Cardiology: Pediatric Interventional Cardiology: Current and New InterventionsCurrent and New Interventions
October 17, 2006October 17, 2006
James P. Kyser, M.D.Interventional Pediatric CardiologyChildren’s Cardiac Center of OregonLegacy Emanuel Children’s Hospital
Interventional OpportunitiesInterventional Opportunities
Holes: make them; close them– Atria, ventricles, arteries, veins
Blockages: balloon them, stent them– valves, arteries, veins
Arrhythmias: ablate their cause– atrial, ventricular
Surgery or Surgery or CathCath??
Consider best long term solution to problemBalance risks and benefitsEffective treatment may be a combination of both catheterization and surgeryBalanced presentation to family is important when either option is safe and effective
The The AtrialAtrial Septum: InterventionSeptum: Intervention
1966: William Rashkind and balloon atrialseptostomy – life-saving for newborns with transposition of the great arteries.2001: FDA approves Amplatzer SeptalOccluder for closure of secundum ASDs –nearly 50 years after first surgical ASD closure
DD--TGA: 1200 gram infantTGA: 1200 gram infant HypoplasticHypoplastic Left Heart SyndromeLeft Heart Syndrome
HLHSHLHS--Restrictive Restrictive AtrialAtrial SeptumSeptum AtrialAtrial SeptostomySeptostomy--RF PerforationRF Perforation
Pulmonary AtresiaPulmonary Atresia--RF PerforationRF Perforation ValvularValvular PulmonicPulmonic StenosisStenosis
TetralogyTetralogy of of FallotFallot, Cyanotic, Cyanotic1.4 Kg, Sat = 60% RA1.4 Kg, Sat = 60% RA Critical Aortic Critical Aortic StenosisStenosis: :
Vascular ApproachesVascular Approaches
RetrogradeUmbilicalAntegrade (IVC-RA-LA-LV-Aao)Trans-carotid
Critical Aortic Critical Aortic StenosisStenosis1.9 kg male1.9 kg male
ValvularValvular Aortic Aortic StenosisStenosis
Total Anomalous Pulmonary Total Anomalous Pulmonary Venous Return vs. Pulmonary Venous Return vs. Pulmonary
Hypertension?Hypertension?
Obstructed TAPVRObstructed TAPVR
Vertical Vein Vertical Vein StentStent SecundumSecundum AtrialAtrial SeptalSeptal DefectDefect
AmplatzerAmplatzer ASD deviceASD device
Approved by the FDA in 2001/2002Double Umbrella designLA disc 7 mm greater radius than central discRA disc 5 mm greater than central discSizes up to 38 mm (LA disc 52 mm dia.)
TranscatheterTranscatheter ASD ClosureASD Closure
ASD SizingASD Sizing LA Disc releaseLA Disc release
PrePre--deploymentdeployment ReleaseRelease
AmplatzerAmplatzer ASD ASD ®® OccluderOccluder ResultsResults
Multicenter non-randomized study comparing surgical closure versus device closure, 29 centers, 1998 – 2000442 patients device closure; 154 surgical closureMedian age – 9.8 (0.6-82) yrs for device group– 4.1 (0.6-38) yrs for surgical group
Du et al. JACC Vol 39 2002
ASD: Device vs. SurgeryASD: Device vs. SurgeryASD size not different between groups – (13 mm versus 14 mm)
Procedural success rate - immediate– 95.7 % for device group– 100 % for surgical group
Procedural success – 6 months– Device - 97.2 %– Surgery - 100 %
Length of Stay– Device - 1.0 +/- 0.3 days– Surgery - 3.4 +/- 1.2 days
Du et al. JACC Vol 39 2002
Device vs. Surgery:Device vs. Surgery: ComplicationsComplications
Device Group (n = 442)– 1.6 % Major – embolization, stroke– 6.1% Minor – arrhythmias, headaches
Surgical group (n = 154)– 5 % major - tamponade, re-operation, wound
complication – 19 % minor – effusions, wound infection,
arrhythmia
Du et al. JACC Vol 39 2002
Costs: Device versus surgeryCosts: Device versus surgery
Hughes et al. Heart 2002– Similar procedure costs– Lower hospital costs – Procedure times/LOS significantly longer in
surgical group– No ICU services/blood products required in
device group
PDA Coil ClosurePDA Coil Closure
PDAs represent 10-18% of all CHD.Ivalon plug (1967) was successful in 90% of cases, however delivery apparatus (12-27F sheaths) precluded use in small children.Gianturco coil for PDA closure first described in 1993.
Combining ProceduresCombining Procedures
Pulmonary Atresia with intact ventricular septum– Surgical valvotomy– Modified BT shunt
Pulmonary Atresia with IVSPulmonary Atresia with IVS
Pulmonary Atresia with IVSPulmonary Atresia with IVS Tricuspid Atresia, with Tricuspid Atresia, with Fenestrated Fenestrated FontanFontan
Cyanosis with saturations in the low 70’sIncreasing exercise intoleranceBrought to cath lab to assess for venous collaterals
Fenestrated Fenestrated FontanFontan with with CyanosisCyanosis
Fenestrated Fenestrated FontanFontan with with CyanosisCyanosis
Fenestrated Fenestrated FontanFontan with with CyanosisCyanosis
Fenestrated Fenestrated FontanFontan with with CyanosisCyanosis
Fenestrated Fenestrated FontanFontan with with CyanosisCyanosis
Fenestrated Fenestrated FontanFontan with with Cyanosis: Sat = 95%Cyanosis: Sat = 95%
Vascular PlugVascular Plug 9 month old with Pulmonary AVM9 month old with Pulmonary AVM
9 month old with Pulmonary AVM9 month old with Pulmonary AVMSatsSats improved from 75% to 95%improved from 75% to 95% Endovascular Endovascular StentsStents
Endovascular Endovascular StentsStentsAvoid need for creating intimal tearsAvoids restenosis due to vessel recoilAllows for staged dilation if desiredDoes not completely eliminate risks of aneurysm formation/vascular trauma Original indications for adult ileo-femoral artery and biliary duct obstructions.Currently applied to arterial as well as venous stenoses unresponsive to conventional balloon therapy
LPA LPA stenosisstenosis, S/P BT shunt for PA/VSD, S/P BT shunt for PA/VSD
LPA LPA stenosisstenosis LPA LPA stenosisstenosis, post, post--stentstent
CoarctationCoarctation StentStent Cutting Edge / Future DirectionsCutting Edge / Future DirectionsRemarkable imagination and innovations have removed many former limitationsPercutaneous valve placementVentricular septal defect closure Laser valvotomy of atretic valvesFetal interventionPercutaneous Fontan completionMolecular interventional therapy – Veg-F angiogenesis
Fetal Aortic Fetal Aortic StenosisStenosis InterventionIntervention
Tworetzky et al Circuation 2004; 110:2125
Fetal Aortic Fetal Aortic StenosisStenosis InterventionIntervention
Tworetzky et al Circuation 2004; 110:2125
VSD DevicesVSD Devices
Muscular VSD devices expected to be widely available in the USA later this year
Perimembranous VSD devices still with unacceptable amount of heart block, aortic valve regurgitation and procedure complications
– Hybrid opportunity
AmplatzerAmplatzer Closure Muscular VSDClosure Muscular VSD
Piechaud Heart 2004:90:1505
New ASD Device:New ASD Device:CribriformCribriform DeviceDevice
Designed for fenestrated ASDs– Thin central waist– Equal sized and flat
left and right atrialdiscs
PercutaneousPercutaneous VSD IssuesVSD Issues
Patient selection– Patient size– Defect location and size
Potential for surgical closureAdequacy of closureDamage to adjacent structures
Stage I Norwood Hybrid Stage I Norwood Hybrid ProcedureProcedure
Stage I Norwood Hybrid Stage I Norwood Hybrid ProcedureProcedure
PercutaneousPercutaneous Pulmonary ValvePulmonary Valve
Andrews and Tulloh ADC 2004 89:1168Copyright ©2005 Elsevier Science B.V.
Coats, L. et al.; Eur J Cardiothorac Surg 2005;27:536-543
Percutaneous pulmonary valve stent insertion
Exciting Time and FutureExciting Time and Future