Pediatric Cardiac Interventions Research Articles

Long-term Outcomes After Interrupted Aortic Arch Repair

BackgroundInterrupted aortic arch (IAA) is associated with left ventricular outflow tract obstruction (LVOTO) and DiGeorge syndrome. High-risk infantile surgery is required to address IAA, with limited data available on long-term outcomes. We used the Pediatric Cardiac Care Consortium, a multicenter US-based registry for pediatric cardiac interventions, to assess long-term outcomes after IAA repair by patient characteristics and surgical approach. MethodsThis is a retrospective cohort study of patients undergoing IAA repair between 1982 and 2003. Kaplan-Meier plots and Cox proportional hazards regression were used to examine associations with postdischarge deaths tracked by matching with the US National Death Index. ResultsOf 390 patients meeting inclusion criteria, 309 (79.2%) survived to discharge. During a median follow-up of 23.6 years, 30-year survival reached 80.7% for patients surviving hospital discharge after initial IAA repair. Adjusted analysis revealed higher risk of death for type B vs type A (adjusted hazard ratio [aHR], 3.32; 95% CI, 1.48-7.44), staged repair (aHR, 2.50; 95% CI, 1.14-5.50), and LVOTO interventions during initial hospitalization (aHR, 4.12; 95% CI, 1.83-9.27) but not for LVOTO without need for interventions or presence of DiGeorge syndrome. There was a trend toward improved in-hospital and long-term survival over time during the study period. ConclusionsStaged repair, type B IAA, and need for LVOTO intervention during initial hospitalization for repair are associated with high risk of death out to 30 years. Survival outcomes are improving, but further efforts need to minimize staged approach and risks associated with LVOTO relief procedures.

Long-Term Outcomes of Cardiovascular Operations in Children With Connective Tissue Disorders

Connective tissue disorders can be associated with significant cardiovascular morbidity needing cardiac surgery during childhood. In this retrospective study, we used the Pediatric Cardiac Care Consortium, a multicenter United States-based registry of pediatric cardiac interventions, to describe the long-term outcomes of patients who underwent their first surgery for connective tissue-related cardiovascular conditions aged <21 years. Between 1982 and 2003, a total of 103 patients were enrolled who underwent cardiac surgery for a connective tissue-related cardiovascular disorder, including 3 severe infantile cases operated on within the first year of life. Most patients underwent aortic site surgery (n = 85) as a composite graft (n = 50), valve-sparing (n = 33), or other aortic surgery (n = 2). The remaining patients underwent atrioventricular valve surgery (mitral 17, tricuspid 1). Of the 99 patients surviving to discharge, 80 (including the 3 infantile) had adequate identifiers for tracking long-term outcomes through 2019 through linkage with the National Death Index and the Organ Procurement. Over a median period of 19.5 years (interquartile range 16.0 to 23.1), 29 deaths and 1 transplant occurred in the noninfantile group, whereas all 3 infantile patients died before the age of 4 years. The postdischarge survival for the noninfantile group was 92.2%, 68.2%, and 56.7% at 10, 20, and 25 years, respectively. Cardiovascular-related pathology contributed to all deaths in the infantile and 89% (n = 27) of deaths for the noninfantile cases after hospital discharge. The significant late attrition from cardiovascular causes emphasizes the need for close monitoring and ongoing management in this population.

Generative learning approach for radiation dose reduction in X-ray guided cardiac interventions.

Navigation guidance in cardiac interventions is provided by X-ray angiography. Cumulative radiation exposure is a serious concern for pediatric cardiac interventions. A generative learning-based approach is proposed to predict X-ray angiography frames to reduce the radiation exposure for pediatric cardiac interventions while preserving the image quality. Frame predictions are based on a model-free motion estimation approach using a long short-term memory architecture and a content predictor using a convolutional neural network structure. The presented model thus estimates contrast-enhanced vascular structures such as the coronary arteries and their motion in X-ray sequences in an end-to-end system. This work was validated with 56 simulated and 52 patients' X-ray angiography sequences. Using the predicted images can reduce the number of pulses by up to three new frames without affecting the image quality. The average required acquisition can drop by 30% per second for a 15 fps acquisition. The average structural similarity index measurement was 97% for the simulated dataset and 82% for the patients' dataset. Frame prediction using a learning-based method is promising for minimizing radiation dose exposure. The required pulse rate is reduced while preserving the frame rate and the image quality. With proper integration in X-ray angiography systems, this method can pave the way for improved dose management.

Unusual transcathetar pediatric cardiac interventions in infancy: A single tertiary care centre experience

Unusual transcathetar pediatric cardiac interventions in infancy: A single tertiary care centre experience

Abstract 11511: Long-Term Outcomes of Transcatheter Aortic Valvuloplasty in Infants: A Study from the Pediatric Cardiac Care Consortium

Introduction: Long-term outcomes of aortic stenosis (AS) after balloon aortic valvuloplasty (BAV) in infancy are scarce. Here, we report the 25-year outcomes after the first BAV in infants enrolled in the Pediatric Cardiac Care Consortium (PCCC), a US-based registry of pediatric cardiac interventions. Methods: We queried the PCCC for patients undergoing BAV in infancy between 1982 and 2003. Outcomes were tracked through 2019 in the PCCC and by linkage with the National Death Index and the Organ Procurement and Transplantation Network. Cases dependent on ductus arteriosus at the time of BAV were deemed critical and procedural outcomes were defined as optimal if residual valve gradient was &amp;lt30mmHg and no more than mild insufficiency reported. Reinterventions were tracked in PCCC through 2011. Transplant-free survival (TFS) post initial BAV is described by Kaplan-Meier plots . Results: The cohort included 316 patients: males 75.3%, median age 0.6 months (IQR: 0.1 - 2) at the time of the BAV. Of them, 95 had critical AS and 187 had optimal procedural outcome. A total of 289 (91.5%) survived to hospital discharge. Over a median follow-up time of 21.7 years (IQR: 18.9, 24.6), 3 patients underwent transplantation and 17 died, with a 25-year TFS of 92.4% (95%CI: 89.0-96.0%). Presence of critical AS and procedural outcome did not affect long-term outcomes (Figure 1). One hundred thirteen patients underwent at least one transcatheter or surgical reintervention through 2011: 48 (42%) had critical AS and 59 (52%) had suboptimal outcome after the first BAV (relative risk of reintervention 1.26 (95%CI: 0.94, 1.69) and 1.98 (95%CI: 1.48, 2.64) respectively). Conclusions: Infants undergoing BAV have favorable 25-year survival independent of the critical nature of the AS and the lack of optimal outcome at discharge. Patients with suboptimal result were more likely to require reintervention.

Abstract 10672: Long-Term Need for Heart Transplantation and Post-Transplantation Survival After Fontan Palliation

Introduction: Fontan palliation for single ventricle frequently leads to heart failure and need for transplant; timing and factors associated with post-Fontan transplant, as well as post-transplant outcomes are not well understood. Methods: This is a retrospective cohort study of patients undergoing Fontan in the Pediatric Cardiac Care Consortium (PCCC), a large US-based registry of pediatric cardiac interventions. Deaths and transplants were captured in the PCCC and by linkage with the National Death Index and the Organ Procurement Transplant Network through 2019. Results: Between 1982 and 2003, 2,071 patients were enrolled in the PCCC and had their Fontan between 1988 and 2011. During Fontan hospitalization 151 deaths and 6 transplant listings occurred; 201 additional deaths and 148 listings occurred after discharge (Figure A). Cumulative incidence of transplant listing was 7.1% (95% CI 6.0-8.3) with the median time post Fontan being 11.1 years (IQR 5.3 - 13.8). After adjustment for risk factors, systemic right ventricle (HR 2.69; 95% CI 1.87 - 3.88) and &gt;30-day length of stay after Fontan (HR 2.29; 95% 1.51 - 3.48) were associated with transplant listing. Among listed patients, 112 (73%) underwent isolated heart transplant, 2 (1%) underwent heart-liver transplant, 20 (13%) died on the waitlist, and 20 (13%) are alive without transplant. One-year post-transplant survival was 70% for transplants before 2010 and 95% after 2010 (Figure B). Graft failure was associated with transplant before 2010 (HR 6.34; 95% CI 2.21-18.2), diagnosis of hypoplastic left heart syndrome (HR 3.71; 95% CI 1.38 - 9.92), and bilirubin &gt;2mg/dl at time of transplant (HR 2.79; 95% CI 1.03 - 7.58). Conclusion: Need for heart transplant is frequent post Fontan, but many die without listing. With significant improvements in post-transplant outcomes in recent years, timely transplant evaluation before significant end-organ dysfunction may improve survival for patients with single ventricle.

Percutaneous Common Carotid Artery Access for Cardiac Interventions in Infants Does Not Acutely Change Cerebral Perfusion.

Pediatric cardiac interventions via percutaneous common carotid artery (CCA) access have been shown to be safe and effective. However, the impact of placement of a sheath in the carotid artery for interventions on cerebral perfusion is unknown. In this study we used cerebral near-infrared spectroscopy (NIRS) to analyze the effects of percutaneous CCA access for cardiac interventions on cerebral perfusion. This study is a retrospective chart review carried out at a tertiary care center on all pediatric patients who underwent percutaneous cardiac catheterization via carotid artery access from January 2010 to January 2020. All patients who had ipsilateral NIRS recorded on the side of carotid artery access were included. Patients with only partial or no ipsilateral NIRS data were excluded. The primary outcome measure was the change in NIRS upon CCA access; the mean NIRS for 15min before obtaining access was compared to the mean NIRS during the procedure and to the mean NIRS 15min after removal of the CCA sheath. We hypothesized that there would be a significant drop in NIRS values on the side of CCA access. There were 48 catheterizations in the study period where percutaneous CCA was accessed. Of those, 21 catheterizations had complete data and were included in the study. 13 (62%) were of males. The median age was 23days (IQR 7-79). The indications for CCA access were patent ductus arteriosus stent implantation (n = 13; 62%), aortic valvuloplasty (n = 5; 24%), balloon angioplasty of coarctation of aorta (n = 2; 10%), and renal artery angioplasty (n = 1; 4%). In 16 patients (72%), the left common carotid artery was accessed. The median weight of the patients was 3.3kg (IQR 2.8-2.9). The most common sheath size used was 4F, in 16 patients (72%). The mean NIRS prior to the procedure was 67 ± 15%, during the procedure was 68 ± 20%, and after removal of sheath was 68 ± 21%. Paired t test of cerebral NIRS before, during, and after the procedure showed no significant change with CCA access (P = 0.08). No patient in the series had a documented neurologic deficit following the procedure. Percutaneous CCA access was not associated with a decrease in NIRS on the side of the access during the procedure, suggesting there was no significant acute change in cerebral perfusion with CCA access.

Neurological Sequelae Following Pediatric Cardiac Interventions

AIM: The aim of the present study was to assess neurological sequelae within 30 days of surgical or cardiac catheter interventions in infants and children.&#x0D; METHOD: In this cross-sectional study, we evaluated all patients who developed neurological problems after cardiac interventions either by surgery or by catheter by clinical evaluation, brain imaging, and electrophysiological studies.&#x0D; RESULTS: Among 1200 procedures were performed; 895 (74.6%) were cardiac catheterizations either diagnostic or intervention, 167 (13.9%) were open-heart surgery, and 138 (11.5%) were closed heart surgery. The overall incidence of post-procedure neurological dysfunction in the studied population was 3.4%. The differences between the three groups were statistically significant (p &lt; 0.0001(. In our series, the neurological complications were in the form of disturbed conscious level in 2/41 (4.9%), impaired motor function in 11/41 (26.8%), impaired mental functions in 6/41(14.6%), hyperreflexia in 27/41 (65.9%), and seizures in 38/41 (92.7%). The most common presentation of seizures was in the form of focal fits 21/41 (51.2%), followed by generalized fits in 15/41(36.6%) and then myoclonic fits 2/41 (4.9%).&#x0D; CONCLUSION: Seizures are the most common complication following cardiac interventions in pediatric age and the highest percentage following open heart surgery.

Adult and Paediatric Cardiac Intervention in Timor-Leste: Disease Burden, Demographics and Clinical Outcomes

The East Timor Hearts Fund (ETHF) is a charitable organisation of Australian cardiologists providing outreach screening in Timor-Leste. For patients requiring intervention, ETHF arranges logistics, procedures, and postoperative care. The aim of this project is to evaluate outcomes of patients requiring intervention. The ETHF database of all patients was utilised to identify patients with disease warranting surgical or percutaneous intervention. Both patients who underwent intervention and those who did not proceed to intervention were included in this study. Patients who had intervention arranged by other organisations but have then had follow-up with ETHF were also included. Overall demographics and pre and postoperative factors were assessed, with sub-group analysis of adult and paediatric patients to identify any differences in care. Of 221 patients requiring intervention, 101 patients underwent intervention, receiving 22 different operations or procedures. Patients were predominantly young (median age 17.5 years) and female (64.7%), with rheumatic heart disease (63.8%). Twenty-four (24) (33.3%) women aged 15-45 years old with cardiac disease warranting intervention were documented as pregnant or breastfeeding at time of clinic assessment. Of patients who did not proceed to intervention, adults were more likely to be lost to follow-up (42.4% vs 18.5%) while paediatric patients were more likely to experience progression of disease (18.5% vs 7.5%, p=0.005). Median waitlist time was 5 months, with no significant difference between adults and children, correlating with a preoperative mortality rate of 5.4%. For patients who underwent intervention, post-procedure mortality was extremely low (0.9%) and attendance of at least one post-procedure review was excellent (99.0%). Eleven (11) (10.9%) patients have required repeat intervention, with no difference in rates between adult and paediatric patients. Length of follow-up extends up to 20 years for some patients. The Timor-Leste interventional cohort was predominantly a young female population with rheumatic and congenital cardiac disease. There were also high rates of pregnancy amongst female patients with severe cardiac disease. Delayed access to intervention may result in preoperative adverse events and mortality, and is a key target for improvement. Patients who undergo intervention have very low post-procedural mortality, good adherence to early medical follow-up and good long-term outcomes.

Use of percutaneous carotid artery access for performing pediatric cardiac interventions: Single-center study

Background:Carotid artery (CA) access allows a more straight route for many left heart lesions. This has previously been achieved via a surgical cut-down approach in certain pediatric cardiac interventions. However, there are little data considering CA access in pediatric cases, percutaneously.Aim:We hypothesized that there would be notable improvements in efficiency as well as overall success when using the CA for access in selected cases.Methods:Between November 2016 and January 2019, records of patients undergoing attempted percutaneous CA access under ultrasound guidance for cardiac catheterization were reviewed.Results:Thirty patients underwent 36 catheterizations; median age 17 days (range, 6 days–9 months) and median weight 3.2 kg (1.2–7.8). Procedures performed were stenting or stent redilatation of the patent ductus arteriosus in 23, stenting or angioplasty of modified Blalock–Taussig shunts in four, aortic valvuloplasty in three, angioplasty for coarctation of the aorta in four, renal angioplasty in one, and diagnostic catheterization in one case. The intended intervention was unsuccessful in two patients despite successful CA access. Follow-up imaging showed a normal carotid in 28 of 30 (94%), with mild luminal narrowing with normal Doppler velocities in two instances. No patient had clinically apparent neurological sequelae attributable to CA access.Conclusions:Our data indicate that CA access should be employed when dealing with a select group of infants requiring vertical approach for left-sided cardiac lesions. Percutaneous CA access, even in very small preterm infants, is safe and feasible with negligible vascular injury and no neurological adverse events.

Adult and Paediatric Cardiac Intervention in Timor-Leste: Disease Burden, Demographics and Clinical Outcomes

Background: The East Timor Hearts Fund (ETHF) is a charitable organisation involving Australian cardiologists who provide outreach screening in Timor-Leste, and cardiac interventions in Australia/New Zealand. Methods: The ETHF database was utilised to identify patients with disease warranting surgical or percutaneous intervention. Overall demographics and pre- and post-operative factors were assessed, with sub-group analysis of adult and paediatric patients to identify any differences in care. Results: Of 221 patients requiring intervention, 101 patients received intervention. Patients were predominantly young (median age 17.5 years) and female (64.7%), with rheumatic heart disease (63.8%). 24 (33.3%) women aged 15–45yo were documented as pregnant with severe cardiac disease. Of patients not proceeding to intervention, adults were more likely to be lost to follow-up (42.4% vs 18.5%) while paediatric patients were more likely to experience progression of disease (18.5% vs 7.5%, p = 0.005). Median waitlist time was 5 months, with no difference between adults and children, correlating with pre-operative mortality of 5.4%. Post-procedure mortality was extremely low (0.9%) and attendance of at least one post-procedure review excellent (99.0%). 11 (10.9%) patients have required repeat intervention, with no difference in rates between adult and paediatric patients. Conclusions: The Timor-Leste interventional cohort are predominantly a young female population with rheumatic and congenital cardiac disease. Delayed access to intervention may result in pre-operative adverse events and mortality, and is a key target for improvement. Patients who undergo surgery have very low post-procedural mortality, excellent adherence to medical follow-up and good long-term outcomes.

Recent advances in pediatric interventional cardiology.

During the last 10 years, there have been major technological achievements in pediatric interventional cardiology. In addition, there have been several advances in cardiac imaging, especially in 3-dimensional imaging of echocardiography, computed tomography, magnetic resonance imaging, and cineangiography. Therefore, more types of congenital heart diseases can be treated in the cardiac catheter laboratory today than ever before. Furthermore, lesions previously considered resistant to interventional therapies can now be managed with high success rates. The hybrid approach has enabled the overcoming of limitations inherent to percutaneous access, expanding the application of endovascular therapies as adjunct to surgical interventions to improve patient outcomes and minimize invasiveness. Percutaneous pulmonary valve implantation has become a successful alternative therapy. However, most of the current recommendations about pediatric cardiac interventions (including class I recommendations) refer to off-label use of devices, because it is difficult to study the safety and efficacy of catheterization and transcatheter therapy in pediatric cardiac patients. This difficulty arises from the challenge of identifying a control population and the relatively small number of pediatric patients with congenital heart disease. Nevertheless, the pediatric interventional cardiology community has continued to develop less invasive solutions for congenital heart defects to minimize the need for open heart surgery and optimize overall outcomes. In this review, various interventional procedures in patients with congenital heart disease are explored.

Percutaneous Common Carotid Artery Access for Pediatric Interventional Cardiac Catheterization.

Surgical cutdown for access to the common carotid artery provides a more direct route for certain pediatric cardiac interventions and avoids femoral artery injury in small infants. The safety of percutaneous carotid access (PCA) in children is unknown. Retrospective review of PCA at Texas Children's Hospital and Children's Healthcare of Atlanta. From July 2006 to November 2014, 42 patients underwent 47 attempts at catheterization via PCA. Median (range) age was 20 days (0 days-2.9 years) and weight was 3.2 kg (1.1-12.2). Two patients had failed PCA with no sequelae. Of the 45 catheterizations with successful PCA and sheath placement, 44 interventions were performed, the most common being stenting or stent redilation of the ductus arteriosus, balloon aortic valvuloplasty, and stenting or angioplasty of Blalock-Taussig shunts. After sheath withdrawal, hemostasis was achieved with manual compression, with no need for surgical control of bleeding. Follow-up carotid imaging was performed in all. Acutely, 3 patients developed carotid thrombosis with resolution in 1 and mild residual narrowing in 2 after anticoagulation therapy. At follow-up, 40 of 42 patients (95%) had a normal carotid artery, with 2 instances of mild stenosis. There were no neurological sequelae attributable to PCA. PCA is safe even in small infants, and hemostasis can be achieved without surgical repair, with a carotid patency rate superior to published data after surgical cutdown. Surgical cutdown is not routinely required for pediatric cardiac catheterization via the carotid artery.

The First Ten of Everything: A Review of Past and Current Practice in Pediatric Cardiac Percutaneous Interventions.

This study was designed to compare outcomes of the most common pediatric cardiac interventions from the time of implementation with the current era. Since the introduction of semilunar valve balloon dilation and device closure of the arterial duct and septal defects, development of interventional techniques and devices has been rapid. However, few studies have compared outcomes between those initial interventions and those in the current era. Five validated common catheter-based therapies were chosen for analysis, including atrial and duct device closure, balloon dilation of the aortic and pulmonary valves, and native coarctation of the aorta. A retrospective review of the first and most recent 10 consecutive patients in each group was performed. There was a high mortality (30%) among neonates who underwent aortic valve (AV) dilation in the early era, but no mortality noted in other groups. In the early era, transcatheter atrial defect closure and AV dilations were associated with a low success rate (60% for both lesions) and a high complication rate (40% for atrial septal defect, 30% for AV dilations). Among the last 10 children, the atrial defect occlusion was successful in 100% without complications and AV dilations where successful in all children with a 30% complication rate (one major, two minor). A learning curve with device development plays a significant role in the evolution of transcatheter techniques. These data provide baseline estimates of success and may be used as a template in the future when new techniques are adapted into practice.

Transoesophageal echocardiography using the miniaturised multiplane probe during paediatric cardiac intervention in children below 5.5 kg – an initial experience

IntroductionUntil recently intra-operative transesophageal echocardiography (TOE) has not been feasible in neonates and small infants. TOE is routinely used intra-operatively at our institution in children >5.0 kg, below this weight...

Cardiac Interventions in Pediatric Cardiology: The Future

Pediatric Cardiac interventions have come a long way from the initial intervention in the 1950's. Balloon angioplasty has been accepted as the procedure of choice in several congenital anomalies. Apart from balloon angioplasties/valvuloplasties, Atrial Septal Defect, Ventricular Septal Defect (muscular) device closure have been FDA approved with adequate world wide clinical experience and long-term follow-up. In addition, newer procedures are under clinical trial for perimembranous VSD device closure in the catheterization lab; per operative closed heart procedure in the operation theatre or as a hybrid procedure. Palliative procedures like flow restriction to lungs with devices to equate with surgical pulmonary artery banding; stenting of the patent ductus arteriosus in duct dependent cyanotic heart disease in the newborn or a combination of these form transcatheter Norwood stage I in the cath lab. Experience and technology will also help make transcatheter Fontan operation possible and that does not seem too far. The emphasis in pediatric cardiac interventions shall always remain that the decision, procedure, and management of their complications is a joint effort of the surgeon and the interventionalist.

Repetitive Paroxysms of Supraventricular Tachyarrhythmias Triggered During Pediatric Cardiac Interventions: Suppression After Short Infusion of Amiodarone

Arrhythmias are the most common major complications encountered during pediatric cardiac catheterizations. This report describes the management of repetitive paroxysms of supraventricular tachyarrhythmias triggered by catheter manipulation during interventional procedures in two children. After 15 minutes, amiodarone infusion (25 microg/kg/min) eliminated further paroxysms in both patients, allowing both interventions to be completed safely and effectively.