Interventional Cardiac Catheterization Procedures Research Articles

A North American, single-center experience implanting fenestrated atrial devices and atrial flow regulators into a heterogeneous group of pediatric pulmonary hypertension patients.

The clinical deterioration commonly experienced by pediatric patients with pulmonary arterial hypertension (PAH) has motivated a shift in the treatment of pulmonary hypertension (PH) through innovations in surgical salvage interventions. The Occlutech fenestrated atrial septal defect (FASD) Occluder and the atrial flow regulator (AFR), which provides a protective, atrial-level shunt during hypertensive crises, have found an important role in treating pediatric patients with PAH. Other groups of pediatric patients with PH may also benefit from a similar protective physiology. The primary aim of this work is to present a single center's experience with AFR and FASD devices for managing a heterogeneous group of pediatric PH patients. A secondary goal is to identify hemodynamic changes and complications following device implantation. We performed a retrospective review of all pediatric PH patients who, after being found suitable, either successfully or unsuccessfully received an FASD or AFR device between January 2015 and December 2021 at the Stollery Children's Hospital in Edmonton, Canada. Fourteen patients (eight female) with a median age of 4.6 (range 0.3-17.9) years and a median body mass index of 15.1 (Q1 = 13.8, Q3 = 16.8) kg/m2 underwent device implantation: five received FASDs, eight received AFRs, and one was ultimately unable to receive an implant due to thrombosed iliac vessels and required surgical intervention. Of the fourteen patients, seven were in group 1 (PAH), one was in group 3 (lung disease), and six were in group 5 (primarily pulmonary hypertension vascular disease) under the World Symposium PH classification. All patients were on mono-, dual-, or triple-drug PH therapy. Device stabilization was not possible for two patients, who then required a repeat catheterization. Of the group 1 patients, three AFR and three FASD implants were successful, while one FASD implant was unsuccessful due to thrombosed vessels. At a six-month clinical assessment, all group 1 patients had patent devices and improved WHO FCs. This work presents a single center's experience with AFR and FASD implants in a heterogeneous group of fourteen pediatric patients with severe PH. This treatment strategy is novel in the pediatric population and so this work provides momentum for future studies of interventional cardiac catheterization procedures for pediatric patients with PH. Further collaborations are required to develop criteria to identify ideal pediatric candidates and optimally time interventions in order to maximize the benefits of this treatment.

Interventional cardiac magnetic resonance imaging: current applications, technology readiness level, and future perspectives.

Background:Cardiac magnetic resonance (CMR) provides excellent temporal and spatial resolution, tissue characterization, and flow measurements. This enables major advantages when guiding cardiac invasive procedures compared with X-ray fluoroscopy or ultrasound guidance. However, clinical implementation is limited due to limited availability of technological advancements in magnetic resonance imaging (MRI) compatible equipment. A systematic review of the available literature on past and present applications of interventional MR and its technology readiness level (TRL) was performed, also suggesting future applications.Methods:A structured literature search was performed using PubMed. Search terms were focused on interventional CMR, cardiac catheterization, and other cardiac invasive procedures. All search results were screened for relevance by language, title, and abstract. TRL was adjusted for use in this article, level 1 being in a hypothetical stage and level 9 being widespread clinical translation. The papers were categorized by the type of procedure and the TRL was estimated.Results:Of 466 papers, 117 papers met the inclusion criteria. TRL was most frequently estimated at level 5 meaning only applicable to in vivo animal studies. Diagnostic right heart catheterization and cavotricuspid isthmus ablation had the highest TRL of 8, meaning proven feasibility and efficacy in a series of humans.Conclusion:This article shows that interventional CMR has a potential widespread application although clinical translation is at a modest level with TRL usually at 5. Future development should be directed toward availability of MR-compatible equipment and further improvement of the CMR techniques. This could lead to increased TRL of interventional CMR providing better treatment.

Interpreting Quality Improvement When Introducing New Technology: A Collaborative Experience in ASD Device Closures.

The objective of this study was to evaluate the impact of the regular introduction of new technologies into interventional cardiac catheterization procedures, in this case new atrial septal defect (ASD) closure devices, while conducting a multi-center collaborative initiative to reduce radiation usage during all procedures. Data were collected prospectively by 8 C3PO institutions between January 1, 2014 and December 31, 2017 for ASD device closure procedures in the cardiac catheterization lab during a quality improvement (QI) initiative aimed at reducing patient radiation exposure. Radiation exposure was measured in dose area product per body weight (µGy*m2/kg). Use of proposed practice change strategies at the beginning and end of the QI intervention period was assessed. Radiation exposure was summarized by institution and by initial type of device used for closure. This study included 602 ASD device closures. Without changes in patient characteristics, total fluoroscopy duration, or number of digital acquisitions, median radiation exposure decreased from 37 DAP/kg to 14 DAP/kg from 2014 to 2017. While all individual centers decreased overall median DAP/kg, the use of novel devices for ASD closure correlated with a temporary period of worsening institutional radiation exposure and increased fluoroscopy time. The introduction of new ASD closure devices resulted in increased radiation exposure during a QI project designed to reduce radiation exposure. Therefore, outcome assessment must be contextualized in QI projects, hospital evaluation, and public reporting, to acknowledge the expected variation during innovation and introduction of novel therapies.

Radiation Dose Reduction in Congenital Heart Disease Patients During Cardiac Catheterization by a Novel Protocol.

Objective:Cardiac catheterization remains a major source of radiation exposure for patients with congenital heart disease. This study reports the magnitude of radiation with a 3.75 frame per second (fps) pulse fluoroscopy rate and compares the reduction with the previous 15 fps protocol during cardiac catheterization for pediatric and adult congenital heart disease.Material and Methods:All diagnostic and interventional cardiac catheterization procedures from a single tertiary center were analyzed from January 1, 2014 to December 31, 2015, one year before and after implementing lower starting pulse fluoroscopy rates. The radiation dose was quantified as air kerma dose (mGy) and dose-area product (DAP; µGy/m2). Radiation exposure was analyzed for diagnostic and interventional procedures; the diagnostic group was subdivided into cyanotic and acyanotic patients, whereas the interventional group was subdivided according to the most common indications.Results:A total of 786 procedures were analyzed. The median fluoroscopy times and contrast amounts did not show a statistically significant difference between both periods (487 vs. 456 seconds and 42.5 vs. 45.3 cm3). The median air kerma for all procedures showed an 88% reduction after implementing lower pulse fluoroscopy rates (340-41 mGy). The doses were reduced significantly for diagnostic and interventional angiograms from 470 mGy and 162 mGy to 40 mGy and154 mGy. Among all patient groups, the most striking decrease was observed in the diagnostic procedures we use, of which fluoroscopy is more prominent than cine angiography.Conclusion:We claim that novel radiation dose reduction protocols could be easily applied without increasing fluoroscopy time or losing image quality.

A comparative study of intravenous combination of Dexmedetomidine and ketamine versus fentanyl and ketamine as sedative agents in children undergoing interventional Cardiac Catheterization procedures

Fentanyl is a highly selective mu-agonist (or MOP agonist); the MOP receptor appears to be specifically involved in the mediation of analgesia. Opioids appear to exert their effects by interacting with presynaptic Gi-protein receptors, leading to hyperpolarization of the cell membrane by increasing K+ conductance. Inhibition of adenylate cyclase, leading to reduced production of cAMP, and closure of voltage-sensitive calcium channels also occur. After institutional scientific and ethical committee approval, a written informed consent was obtained from parents. 70 paediatric patients, American Society of Anesthesiologists (ASA) physical status II and III, aged between 4 to 12 yrs with acyanotic congenital heart disease admitted for elective interventional cardiac catheterization procedures are included in this study. There is significant difference in the mean duration of sedation attained by group D and group F both statistically and clinically. The sedation time does include the procedure duration and duration from end of procedure to attainment of the steward score of 7.

Cardiac Catheterization in the Early Post-Operative Period after Congenital Heart Surgery.

The number of diagnostic and interventional cardiac catheterization procedures are increasing in the post-operative period of congenital heart diseases (CHD). The aim of this study was to evaluate data of patients who underwent cardiac catheterization in the early post-operative period after congenital heart surgery (CHS). We retrospectively evaluated the data of patients who underwent cardiac catheterization within 30 days after CHS. Between 2010 and 2016 in our hospital, 2584 children had operations, and 2911 children underwent cardiac catheterization due to CHD. Cardiac catheterization was performed in 50 (1.9% of the surgeries) of these patients during the early post-operative period. Twenty-nine (58%) of the patients were males. The median age was 7.5 months (range: 15 days-12.5 years), and the median body weight was 6 kg (range: 3-35 kg). Twenty-eight (56%) of the patients had two-ventricle, and 22 (44%) had single ventricle physiology. The median RACHS-1 score was 3 (range: 1-6). Cardiac catheterization was performed under extracorporeal membrane oxygenation (ECMO) support in 16 of the patients. Twenty-four (48%) patients underwent diagnostic catheterization, while 26 (52%) had interventional procedures. Fifteen (30%) patients had a reoperation due to anatomic problems identified during catheterization. Major complications developed in 4 (8%) patients. There was no cases of procedural mortality due to catheterization. Cardiac catheterization should be performed in post-operative cardiac patients without hesitation, even under ECMO, if significant hemodynamic or clinical problems cannot be identified clearly by other non- interventional diagnostic techniques.

Cardiac catheterization and percutaneus catheter in grown-up congenital heart diseases: single center experience at developing country

Background: Grown-up congenital heart disease (GUCH) patients are unique and challenges especially at developing country. The numbers of diagnostic as well as interventional cardiac catheterization procedures in GUCH patients are growing. The aim of this study was to report the outcome of cardiac catheterization including intervention procedure in GUCH.Methods: The descriptive study was conducted at Sanglah Hospital, Denpasar, Bali, Indonesia. All patients (age of more than 12 years) who underwent cardiac catheterization from 2011 until 2017 were included in this study. Patients, characteristic, types of catheter procedures, immediate complications, and outcomes were documented.Results: A total 54 subjects were included with median age of 23 years and 70% were female. The first symptom that brought patients to hospital is dyspnea 46% and palpitation 32%. Five subjects underwent a diagnostic catheter procedure and 49 (91%) diagnostic and catheter based interventions. Transcatheter interventions procedures included atrial septal defect (ASD) (success rate of 20 per 21), patent ductus arteriosus (PDA) (success rate of 16 per16), ventricular septal defect (VSD) (success rate of 9 per 9), pulmonal stenosis (PS) (success rate of 1 per 2), and aortic stenosis (AS) (success rate of 1 per 1). The complications encountered were transient dysrhythmias in 15 subjects, device embolization in 4 subjects, massive bleeding in 1 subject, and overall mortality in 2 subjects.Conclusion: The number of the catheterization interventions in GUCH was 91% and ASD device closure was the most common procedure. Transcatheter intervention has a high procedural success rates (96%) and low procedural-related complications.

Arrhythmia during diagnostic cardiac catheterization in pediatric patients with congenital heart disease.

Diagnostic and interventional cardiac catheterization procedures for congenital heart diseases (CHD) are becoming increasingly more popular, and arrhythmia is a well-known complication. This study was an evaluation of the incidence and causative agents of arrhythmia and the subsequent treatment strategies applied during cardiac catheterization. The catheterization data of all of the patients who underwent diagnostic cardiac catheterization for CHD between January 2012 and 2018 at a single center were examined retrospectively. A total of 1316 children underwent diagnostic cardiac catheterization due to CHD. The median age and body weight was 18 months (6 days-21 years) and 9.9 kg (2.2-135 kg), respectively. Patients with ventricular septal defect (281 patients) and those with tetralogy of Fallot (257 patients) represented 2 major groups of the study population. In 93 (7%) patients, arrhythmia developed during cardiac catheterization. Among them, there were 58 (62%) cases of bradyarrhythmia and 35 (38%) cases of tachyarrhythmia. Arrhythmia was classified as low, high, or major, according to the adverse event severity score; the rates were 2.7%, 4.3%, and 1.2%, respectively. In 36 (39%) patients, there was no need for therapy, whereas 57 (61%) required treatment to eliminate the arrhythmia. Treatment modalities included catheter manipulation in 15, pharmacological therapy in 24, and cardioversion in 3 patients. Eleven patients required cardiopulmonary resuscitation. Temporary pacemaker implantation was required in 2 patients, while 2 others underwent permanent pacemaker implantation secondary to catheterization-related arrhythmia. There were no cases of mortality secondary to catheterization-related arrhythmia. Diagnostic cardiac catheterization in CHD may result in various types of cardiac arrhythmias. The proper management of arrhythmias may reduce morbidity and mortality related to cardiac catheterization.

Utility and Safety of Combined Interventional Catheterization and Electrophysiology Procedures in a Children's Hospital.

Interventional cardiac catheterization (cath) and electrophysiology (EP) procedures are not routinely performed together. There are several perceived barriers affecting this practice, though there are also advantages for both the patient and practitioner to a combined approach. This was a single-center retrospective study reviewing combined cath and EP procedures with a preprocedural intention to intervene at Texas Children's Hospital from 2001 to 2014. We excluded procedures in which the intended procedure was purely diagnostic in nature. A total of 121 patients requiring 125 procedures were identified, of which 61 patients underwent 62 procedures that met our inclusion criteria. Potential subgroups of interest included adult congenital heart disease patients (26% of cohort), single ventricle anatomy (34%), and heterotaxy (19%) and collectively 58% of procedures involved a patient in one of these groups. The combined nature of the procedure did not preclude a cath or EP intervention in any patient. There were no mortalities. There were three adverse events, affecting 4.8% of procedures. Combined interventional cardiac cath and EP procedures in pediatric patients and those with congenital heart disease can be performed safely in a high-volume center. These combined procedures save patients the risk and inconvenience of multiple procedures, and further investigation into cost savings is warranted.

Early Cardiac Catheterization Leads to Shortened Pediatric Extracorporeal Membrane Oxygenation Run Duration.

Cardiac catheterization in patients receiving extracorporeal life support (ECLS) has previously been shown to be safe and, in many cases, therapeutic. However, the influence of cardiac catheterization on clinical outcomes in this patient population has not been clearly defined. A single institution, retrospective review of all pediatric cardiac ECLS patients who underwent cardiac catheterization between January 2006 and September 2015 was performed. Eighty-two interventional cardiac catheterization procedures were performed on 74 patients. Catheterization findings directly led to catheterization-based or surgical intervention in 54 (73%) patients. One (1.2%) catheterization-related complication occurred (pulmonary artery rupture), which ultimately resulted in death. Patients who underwent early catheterization (≤72 hours of ECLS initiation) required shorter total duration of ECLS than patients who underwent catheterization >72 hours after ECLS initiation (136 hours vs. 227 hours, P < 0.01). The groups experienced similar rates of interventions based on catheterization findings (72% early cath vs. 74% late cath, P = 0.81). Survival to hospital discharge was higher in the early catheterization group (74% vs. 51%, P = 0.04). In multivariate models adjusting for covariates, early catheterization was associated with a reduction in ECLS duration by approximately 150 hours (P < 0.01). Cardiac catheterization is safe in pediatric ECLS patients and an earlier catheterization is associated with shorter duration of ECLS and improved hospital survival. Diagnostic cardiac catheterization should be considered in patients who remain dependent on ECLS after several days of support.

Clinical Manifestation, Diagnosis, and Surgical Treatment of Chronic Radiation Ulcers Related to Percutaneous Coronary Intervention.

Chronic radiation ulcers that develop after cardiac catheterization have become common recently because of the rapid increase in the use of diagnostic and interventional cardiac catheterization procedures. However, their diagnosis and treatment remain difficult. We encountered 10 patients with National Cancer Institute grade 4 radiation ulcers related to prolonged percutaneous coronary intervention. Data of these 10 patients, including clinical presentations and treatments, were collected and analyzed. A quality-of-life questionnaire was administered to the patients preoperatively and postoperatively. Most of the lesions (8/10 patients) were located on the back. All of the patients received prolonged cardiac catheterization lasting for more than 3 hours, at least once, and all of the coronary artery lesions showed chronic total or near-total occlusion. The surgical procedures included complete resection of the lesion followed by fasciocutaneous flap coverage (9/10) or skin grafting (1/10). The mean ± SD follow-up time was 23.3 ± 19.79 months, and the wounds in all the patients healed well without complications. After the surgery, the symptoms reduced and the quality of life improved significantly according to the scores in the quality-of-life questionnaire. In conclusion, the early diagnosis of chronic ulcers related to prolonged percutaneous coronary intervention depends on careful history taking and a highly suspicious clinical presentation. For National Cancer Institute grade 4 radiation ulcers, complete resection and immediate reconstruction with flaps or grafts may improve the symptoms and achieve reliable wound coverage without complications.

Circulation : Clinical Summaries

<i>Circulation</i> : Clinical Summaries

The establishment of comprehensive cardiac care centre

Salman Abdulla Aldabbous Cardiac Centre in Aladan hospital was inaugurated in February 2010. Constructed with generous grant from Mr. Salman Abdulla Aldabbous, the centre was a progression for the cardiology division services at Aladan hospital which till then was part of the internal medicine department. The centre serves a population of 1.3 million in the Governorates of Ahmadi and Mubarak Alkabeer in the State of Kuwait. The centre includes of 20 bed coronary care unit, 40 beds for inpatients, 2 catheterization suites, 2 operating room suites and 3 bed cardiac surgical intensive care unit. Tremendous amount of work went into staffing it before and after its opening in 2010. Our vision was to equip it in a way to become a standalone centre of excellence in the country to be able to provide all types of cardiac services including diagnostic and interventional cardiac catheterization procedures, electrophysiology procedures and cardiac surgery. This was a huge challenge that involved employing trained human resources from nurses, technicians and doctors as well as …

Virtual-Reality Simulator System for Double Interventional Cardiac Catheterization Using Fractional-Order Vascular Access Tracker and Haptic Force Producer.

This study proposes virtual-reality (VR) simulator system for double interventional cardiac catheterization (ICC) using fractional-order vascular access tracker and haptic force producer. An endoscope or a catheter for diagnosis and surgery of cardiovascular disease has been commonly used in minimally invasive surgery. It needs specific skills and experiences for young surgeons or postgraduate year (PGY) students to operate a Berman catheter and a pigtail catheter in the inside of the human body and requires avoiding damaging vessels. To improve the training in inserting catheters, a double-catheter mechanism is designed for the ICC procedures. A fractional-order vascular access tracker is used to trace the senior surgeons' consoled trajectories and transmit the frictional feedback and visual feedback during the insertion of catheters. Based on the clinical feeling through the aortic arch, vein into the ventricle, or tortuous blood vessels, haptic force producer is used to mock the elasticity of the vessel wall using voice coil motors (VCMs). The VR establishment with surgeons' consoled vessel trajectories and hand feeling is achieved, and the experimental results show the effectiveness for the double ICC procedures.

日本小児循環器学会所属施設における心臓カテーテル検査・インターベンションの深鎮静に関する全国調査

目的：日本小児循環器学会所属施設における心臓カテーテル検査・インターベンション（心カテ）の深鎮静の実態を把握すること．方法：心カテ時の全身麻酔・深鎮静の概要につき対象施設にアンケート調査を行った．結果：対象の60施設における年間の心カテ件数は9,942件で，麻酔科医による全身麻酔・深鎮静は3,694件（37％），小児科医による深鎮静は4,979件（50％）に行われていた．小児科医による深鎮静の体制では，心電図モニタとパルスオキシメータは52/52施設（100％），呼気二酸化炭素モニタは8/52施設（15％）で用いられていた．経時的なバイタルサインを5分以下の間隔で記録している施設は15/37施設（41％）であった．結論：小児科医による深鎮静は，全国の心カテの半数に行われているが，呼気二酸化炭素モニタの使用やバイタルサインの測定間隔は十分ではなかった．心カテの深鎮静に関し，本学会が指針を示し，診療報酬改定により体制整備が進むことが望まれる．

The IMPACT Registry™: IMproving Pediatric and Adult Congenital Treatments

Tremendous advances have occurred in catheter-based interventions for congenital heart disease. Multicenter trials of these advances are either out of date or have been limited in scope. As such little is known on the application of these techniques in the current era. The IMPACT Registry (IMproving Pediatric and Adult Congenital Treatments) will allow us to measure variability in the performance and outcomes of both diagnostic and interventional cardiac catheterization procedures in all children and adults with congenital heart disease. The IMPACT Registry will be harmonized with the Society of Thoracic Surgeons Congenital Heart Disease Database, thereby allowing us to compare catheter-based interventions with surgical interventions when appropriate. The initial release of the registry will only include hospital-based outcomes, but ultimately it will transition to a longitudinal registry. The IMPACT Registry will provide the necessary benchmark tools for quality improvement activities for cardiac catheterization procedures in congenital heart disease.

Interventional cardiac catheterization procedures in pediatric cardiac transplant patients: Transplant surgery is not the end of the road

The objectives of this study are to report the spectrum of cardiac lesions in pediatric patients post-orthotopic heart transplantation (OHT), the characteristics of patients who develop these lesions, and the feasibility of transcatheter intervention in treating these lesions. Indications for OHT in the pediatric population range from cardiomyopathy to complex congenital heart defects with and without prior palliation. These patients may have residual vascular access and great vessel abnormalities. Data was collected through retrospective review of all OHT patients at our institution from 1988 to 2005. During the study period, 276 heart transplants were performed. Forty-seven patients, age 1.6 [0.1-26] years with a weight of 9.5 [3.5-96.0] kilograms, underwent 69 procedures. Patients with original diagnoses of hypoplastic left heart syndrome and failed palliations required intervention most frequently. Sixteen patients, all with a history of left sided disease, developed aortic arch obstruction. Fifteen were successfully treated with balloon angioplasty while one has recurrent supravalve aortic obstruction. Fourteen patients had superior vena cava obstruction treated with balloon angioplasty and/or stent placement. Twelve patients required no further intervention and two required further stent placement. Ilio-femoral vein occlusion was treated with balloon angioplasty alone in 4 patients and stent placement in 10 patients to achieve vessel patency. Other procedures included treatment of branch pulmonary artery and pulmonary vein stenosis. Anastomotic aortic arch and venous obstructive lesions should be sought following pediatric OHT as they occur in almost 20% of patients and can be successfully addressed using interventional techniques.

Angiographic predictors of femoral access site complications: Implication for planned percutaneous coronary intervention

This study examined the relationship between the femoral arteriotomy location and the risk of femoral access site complications after diagnostic and interventional cardiac catheterization procedures. One of the most common complication of cardiac catheterization and percutaneous coronary intervention (PCI) involves the vascular access site. The femoral approach is the most frequent site of vascular access during invasive cardiac procedures. This approach is associated with vascular complications, such as retroperitoneal bleeding, which can be life-threatening. If angiographic predictors of retroperitoneal bleeding can be identified, this complication could be avoided. A prospective cohort of 33 patients with femoral access site complications was subgrouped based on the angiographic arteriotomy site. Concurrent patients without complications were randomly selected to form a control group. Study and control patients were compared on presenting risk factors and outcomes. Logistic regression analysis was used to identify independent predictors for femoral access site complications. Arteriotomy location above the most inferior border of the inferior epigastric artery in patients undergoing PCI was associated with 100% of all retroperitoneal bleeds (P < 0.001). Low, high middle, and high femoral arteriotomy sites were associated with 71% of all vascular access complications. The combination of these locations for the femoral arteriotomy was an independent predictor of adverse vascular access site complications beyond traditional risk factors (odds ratio = 28.7; CI = 6.73-122.40; P < 0.0001). Vascular complications occurred more frequently in patients who were of older age (72 vs. 66 years; P < 0.001). The location of the femoral arteriotomy site assessed by a femoral angiogram is predictive of life-threatening complications. Patients undergoing PCI with an arteriotomy above the most inferior border of the inferior epigastric artery are at an increased risk for retroperitoneal bleeding. This complication may be avoided by risk-stratifying patients prior to intervention with a femoral angiogram.

Pericardial access using the perDUCER and flexible percutaneous pericardioscopy

The results of this study suggest that lead groin shielding may be used during cardiac catheterization or electrophysiologic procedures in an attempt to minimize radiation dose to the lower abdominal or groin regions. Although the dose of radiation received by unshielded patients is low using current generation fluoroscopy devices, shielding further decreased the dose without increasing radiation in adjacent measured regions. No evidence was found of patients being exposed to increased radiation scatter due to the lead groin shield. 1. Bakalyar DM, Castellani MD, Safian RD. Radiation exposure to patients undergoing diagnostic and interventional cardiac catheterization procedures.

Advances in pediatric cardiac surgery

Interventional cardiac catheterization offers increased therapeutic options to many patients with congenital heart disease. Over the past year encouraging results have been reported in hundreds of patients with interatrial communications, patent ductus arteriosus, and pulmonary artery stenosis requiring stenting. The Amplatzer (AGA Medical Corporation, Golden Valley, MN, USA) family of atrial septal, ventricular septal, and ductus occluding devices shows particular promise. Other studies support the efficacy and safety of established procedures such as balloon valvuloplasty and coarctation angioplasty. In some areas, such as transcatheter perforation of atretic pulmonary valves and endovascular stenting for coarctation of the aorta, our technical abilities may be advancing faster than our understanding of the ultimate clinical impact of our treatment. As interventional cardiac catheterization procedures continue to develop, they must be evaluated carefully against alternative treatments.