Ventricular Outflow Tract Stenting Research Articles

Surgical versus transcatheter palliation for insufficient pulmonary blood supply in infants with cyanotic CHD.

Infants with complex cyanotic CHD can become symptomatic from insufficient pulmonary blood supply following either ductal closure or due to outflow tract obstruction. Blalock-Taussig shunt mortality remains significant and recent studies have highlighted the advantages of using transcatheter alternatives. We present here our experience in changing our primary choice of palliation from the Blalock-Taussig shunt to transcatheter palliation with either a ductal stent or, if antegrade flow is present, a right ventricular outflow tract stent.This is a retrospective, single-unit cohort study. Eighty-seven infants underwent palliation for insufficient pulmonary blood flow at under 3 months of age between 2012 and 2019. On an intention-to-treat basis, 29 underwent insertion of a Blalock-Taussig shunt, 36 duct stents, and 22 right ventricular outflow tract stents at median ages of 15, 9, and 32 days, respectively, and median weights of 3.3, 3.1, and 3.1 kg, respectively. No primary Blalock-Taussig shunts have been performed in our institution since 2017.At 30-days there had been one death in each group (univariable p = 0.93) and deaths prior to repair totalled three in the shunt group, four in the ductal stent group, and two in the right ventricular outflow tract stent group (univariable p = 0.93). Reintervention on the pulmonary circuit prior to next stage of surgery was more frequent in those undergoing transcatheter intervention, reaching statistical significance by logrank (p = 0.012).In conclusion, within this work we provide further evidence of the safety and efficacy of transition from a primary surgical to primary transcatheter palliation pathway in infants with insufficient pulmonary blood supply.

Right Ventricular Outflow Tract Stenting as Palliation of Critical Tetralogy of Fallot: Techniques and Results

Background. Despite current trends toward early primary repair, the surgical systemic-to-pulmonary shunt is still considered the first-choice palliation in patients with critical tetralogy of Fallot (TOF) and duct-dependent pulmonary circulation unsuitable for primary repair. However, stenting of the right ventricular outflow tract (RVOT) is nowadays emerging as an effective alternative to surgical palliation in selected patients. Methods and results. RVOT stenting is usually performed from a venous route, either femoral or, in selected cases, the right internal jugular vein. Less frequently, mostly in pulmonary infundibular/valvar atresia, this procedure can be performed using a hybrid surgical/interventional approach by surgical exposure of the RVOT, puncture of the atretic valve, and stent deployment under direct vision. The size and type of the most appropriate stent may be chosen, based on ultrasound measurements of the RVOT, to cover the right ventricular infundibulum completely and, at the same time, sparing the pulmonary valve, unless significant pulmonary valve annulus hypoplasia and/or supra-valvular stenosis is a significant component of the obstruction. In the large series so far published, early mortality of RVOT stenting is less than 2%, comparing favourably with either Blalock-Thomas-Taussig shunt or early primary repair. In addition, morbidity and clinical sequelae of this approach do not significantly differ from surgical palliation, even if RVOT stenting shows lesser durability and a higher rate of trans-catheter re-interventions over a mid-term follow-up. Finally, similar but more balanced pulmonary artery growth than surgical palliation following RVOT stenting is reported over a mid-term follow-up. Conclusions. RVOT stenting is a technically feasible, well-tolerated, and effective palliation in critical TOF. This approach is cost-effective with respect to surgical palliation either in high-risk neonates or whenever a short-term pulmonary blood flow source is anticipated due to the early surgical repair. It effectively increases pulmonary blood flow, improves arterial saturation, and promotes balanced pulmonary artery growth over a mid-term follow-up.

Palliative Balloon Pulmonary Valvotomy in Tetralogy of Fallot: Is There a Role in 2021?

The current treatment practice for Tetralogy of Fallot (TOF) is to undertake complete surgical repair between 6–9 months of age with excellent immediate and long-term results. In patients with increased cyanosis or frequent cyanotic spells, younger age of complete repair as early as 3 months is usually acceptable. Although neonatal TOF repair is reported with good immediate survival from a few centres, post-operative morbidity is significant, and the hospital stay is prolonged. Hence, in neonates and small term and preterm infants with severe cyanosis, palliative procedures such as modified Blalock-Taussig (BT) shunt, ductal stenting, right ventricular outflow tract (RVOT) stenting and balloon pulmonary valvotomy (BPV) have been reported. With the development of low-profile stents, an increasing clinician experience and more predictable outcome with both duct and RVOT stenting, these procedures have gained popularity as the preferred palliations for TOF at most centres. We reviewed the literature to analyse whether BPV for TOF palliation, a technique first reported three decades ago, still has a role in the present era of paediatric cardiac care. In this review, we have concluded that BPV has very specific indications in patients with TOF, with predominantly valvar pulmonary stenosis, and may be a preferred option over other palliative strategies in hypoxemic preterm or low-birth weight infants.

Tetralogy of Fallot: stent palliation or neonatal repair?

Surgical repair of Tetralogy of Fallot has excellent outcomes, with over 90% of patients alive at 30 years. The ideal time for surgical repair is between 3 and 11 months of age. However, the symptomatic neonate with Tetralogy of Fallot may require earlier intervention: either a palliative intervention (right ventricular outflow tract stent, ductal stent, balloon pulmonary valvuloplasty, or Blalock-Taussig shunt) followed by a surgical repair later on, or a complete surgical repair in the neonatal period. Indications for palliation include prematurity, complex anatomy, small pulmonary artery size, and comorbidities. Given that outcomes after right ventricular outflow tract stent palliation are particularly promising - there is low mortality and morbidity, and consistently increased oxygen saturations and increased pulmonary artery z-scores - it is now considered the first-line palliative option. Disadvantages of right ventricular outflow tract stenting include increased cardiopulmonary bypass time at later repair and the stent preventing pulmonary valve preservation. However, neonatal surgical repair is associated with increased short-term complications and hospital length of stay compared to staged repair. Both staged repair and primary repair appear to have similar long-term mortality and morbidity, but more evidence is needed assessing long-term outcomes for right ventricular outflow tract stent palliation patients.

Cheatham-Platinum 10-zig stents for transcatheter treatment of congenital heart diseases: A new tool to widen the spectrum of treatable conditions

ObjectivesTo report our experience using the 10-zig C-P stents in children and adults with congenital heart disease. BackgroundThe use of stents in congenital heart disease has become widespread since the 1990s and a large range of stents has been designed for a variety of indications. In many situations there is a need for stents that can be dilated to large diameters without excessive shortening. Cheatham-Platinum (10-zig C-P) (NuMED, Hopkinton, NY, USA.) stents may fulfil this requirement. MethodsBetween January 2015 and January 2020, 17 patients with congenital heart disease were treated using a 10-zig C-P stent at our center. (6 Females 13 males; (median age 33 years (range 10–69 years); median weight 85 kgs (range 25–119 kg). Indications for use of the 10-zig stents were right ventricular outflow tract (RVOT) interventions in 8 subjects and aortic coarctation in 9 patients. Results1) Right ventricular outflow tract stenting. Ten right ventricular outflow tract stents (2 also had implantation of transcatheter valves in the same procedure) were implanted in 8 patients. All the RVOT interventions were in preparation for a transcatheter pulmonary valve. Median fluoroscopy and procedure times were 41 min (range 31–131 min) and 164 min (range 152–361 min), respectively. One patient had distal perforation of a pulmonary artery due to guide-wire injury and required blood products. Two subjects showed stent fracture during follow-up needing further stent implantation. 2) Aortic Coarctation. Nine stents were implanted in 9 patients. The median fluoroscopy and procedure times were 36 min (range 11–75 min) and 164 min (range 95–225 min), respectively. The median peak systolic gradient reduced from 33 mmHg (range 15–60 mmHg) to 3 mmHg (range 0–4 mmHg) (p < 0.001). ConclusionsOur experience shows that the 10-zig Cheatham-Platinum stents can be used successfully and safely in congenital heart diseases.

Right Ventricular Outflow Tract Stenting in Infants Less Than 3.5kg to Augment Pulmonary Blood Flow Prior to Surgical Repair of Tetralogy of Fallot

Right ventricular outflow tract (RVOT) Stent angioplasty is a well described staging palliation for young infants with Tetralogy of Fallot (and morphological variants). We review our institutional outcomes of RVOT Stenting.

Stenting of the right ventricular outflow tract as an initial intervention in Tetralogy of Fallot with pulmonary stenosis and major aortopulmonary collateral arteries.

To assess the role of right ventricular outflow tract stenting as the primary intervention in Tetralogy of Fallot with pulmonary stenosis and major aortopulmonary collateral arteries. The management of a subset of infants with Tetralogy of Fallot with pulmonary stenosis and major aortopulmonary collateral arteries requires a staged approach including rehabilitation of diminutive native pulmonary arteries, conventionally using an aortopulmonary shunt. We share our experience of pulmonary artery rehabilitation with right ventricular outflow tract stenting. Retrospective review of all patients with Tetralogy of Fallot with pulmonary stenosis who underwent right ventricular outflow tract stenting as primary intervention over an 8-year period. Ten patients underwent right ventricular outflow tract stent insertion at a median age of 61 days (interquartile range (IQR) 8.3-155 days). Median weight at stent deployment was 4.2 kg (IQR 3.2-5.7 kg). Oxygen saturations improved from a median of 79% (IQR 76-80%) to 92% (IQR 90-95%), p = 0.012. The median right and left pulmonary artery z score increased from -3.51 (IQR -4.59 to -2.80) and -2.07 (IQR -3.72 to 0.15) to a median of -1.17 (IQR -2.26 to 0.16) p < 0.05, and 0.24 (IQR -1.09 to 1.84) p < 0.05, respectively, at subsequent angiogram. Nine patients underwent further catheterisation. Four patients underwent complete anatomical repair. Only one patient required unifocalisation, as most patients had a native supply to all-important lung segments. Right ventricular outflow tract stenting is a useful procedure in the subset of patients with Tetralogy of Fallot with pulmonary stenosis and major aortopulmonary collateral arteries, where native pulmonary arterial growth is required to facilitate repair.

Hybrid Subxiphoid Perventricular Approach as an Alternative Access in Neonates and Small Children Undergoing Complex Congenital Heart Interventions.

The hybrid subxiphoid perventricular approach provides direct access through the heart and may alleviate the technical limitations of complex percutaneous interventions particularly in infants with low body weight. We present the outcomes from a tertiary cardiology center using this approach. We performed a retrospective review of all patients less than 15kg who underwent a hybrid perventricular approach via a small subxiphoid incision. Medical records were reviewed to obtain clinical, demographic and outcome data. Seventeen patients underwent 18 hybrid perventricular procedures using a subxiphoid approach. Median age at time of procedure was 4.6months (IQR = 1.6 to 18months) and median weight was 6.2 kgs (IQR = 3.4 to 8.6 kgs). Six patients underwent hybrid pulmonary valve replacement (PVR), 5 patients underwent pulmonary outflow stenting, and 5 infants underwent hybrid ventricular septal defect (VSD) device closure. One patient with a single ventricle who did not tolerate a percutaneous approach underwent left pulmonary artery (LPA) stenting for severe LPA coarctation with subsequent right ventricular outflow tract (RVOT) stenting. One further patient underwent implantation of a larger diameter stent for pulmonary artery bifurcation stenosis. Procedure success rate was 89% with two of the VSD cases reverted to open surgical repair. There were no intra-procedural complications; however, one patient died within 72h. Minor adverse events occurred in 2 patients including a wound infection in one patient with an immunodeficiency syndrome. Hybrid subxiphoid perventricular approach provides an excellent alternative access to the heart especially in low birth weight infants to prevent hemodynamic instability or in small children requiring large delivery sheaths.

Are early palliative procedures providing an adequate long-term benefit in young cyanotic infants from developing countries, despite advances in surgery and interventions?

Ductal stents, right ventricular outflow tract stents, and aortopulmonary shunts are used to palliate newborns and infants with reduced pulmonary blood flow. Current long-term outcomes of these palliations from resource-restricted countries are unknown. This single-centre, retrospective, observational study analysed the technical success, immediate and late mortality, re-interventions, and length of palliation in infants ≤5 kg who underwent aortopulmonary shunts, ductal, and pulmonary outflow stents. Patients were grouped by their anatomy. There were 69 infants who underwent one of the palliations. Technical success was 90% for aortopulmonary shunts (n = 10), 91% for pulmonary outflow stents (n = 11) and 100% for ductal stents (n = 48). Early mortality within 30 days in 12/69 patients was observed in 20% after shunts, 9% after pulmonary outflow stents, and 19% after ductal stents. Late mortality in 11 patients was seen in 20% after shunts, 18% after outflow stents, and 15% after ductal stents. Seven patients needed re-interventions; two following shunts, one following outflow stent, and four following ductal stents for hypoxia. Among the anatomical groups, 10/12 patients with pulmonary atresia, intact ventricular septum survived after valvotomy and ductal stenting. Survival to Glenn shunt after ductal stent for pulmonary atresia, intact ventricular septum and diminutive right ventricle was very low in two out of eight patients, but very good (100%) for other univentricular hearts. Among 35 patients with biventricular lesions, 22 survived to the next stage. Cyanotic infants, despite undergoing technically successful palliation had a high inter-stage mortality irrespective of the type of palliation. Duct stenting in univentricular hearts and in pulmonary atresia with an intact ventricular septum and adequate sized right ventricle tended to have low mortality and better long-term outcome. Completion of biventricular repair after palliation was achieved only in 63% of patients, reflecting unique challenges in developing countries despite advances in intensive care and interventions.

Stenting of the right ventricular outflow tract with subsequent radical correction in a child with a tetralogy of Fallot: results of six-year follow-up

Tetralogy of Fallot (ToF) is the most common cyanotic congenital heart defect. Since the first radical correction in 1954, treatment strategy has been constantly improving. Current treatment of ToF ensures the long-term survival (30-year survival ranges from 68.5% to 90.5%), yet it is still challenging in underweight patients. Here we present a clinical case of two-step surgery which included right ventricular outflow tract (RVOT) stenting and further radical correction in an underweight child who was then followed-up for six years. RVOT stenting is an appropriate alternative to the bypass surgery which has higher risk of perioperative complications. RVOT stenting significantly reduces hypoxia, enhances the development of the pulmonary vasculature and increases end-diastolic index ultimately permitting efficient radical correction after 4 months. The described approach resulted in a favorable outcome and quality of life after 6 years of follow-up.

Hybrid Approach for Embolized Right Ventricular Outflow Tract Stent.

Displacement and embolization of the stent is one of the major complications of right ventricular outflow tract (RVOT) stenting. Since embolized stents cannot be retrieved percutaneously as they cannot be crimped into pre-stenting state (unlike duct occluders and septal devices, which can be pulled back into the sheath), surgery remains the gold standard treatment. We describe a hybrid approach for the retrieval of the embolized RVOT stent, which will decrease morbidity when compared to the standard surgical approach that is otherwise required.

Stenting of Right Ventricular Out Flow Tract: Analysis of 32 Cases from Catheterization Laboratory of a Paediatric Cardiac Centre

Introduction: The objectives of the present study are to describe the institutional experience, technical aspects and outcome of right ventricular outflow tract (RVOT) stenting in Tetralogy of Fallot type lesions as the initial palliation in a Bangladeshi centre.&#x0D; Methods: This is a retrospective, single-center study of nonrandomized, consecutive 32 patients over a 12-year period. Selected patients underwent cardiac catheterization for implanting a stent into an obstructed RVOT to improve pulmonary blood flow.Statistical data analysis was performed using SPSS 20.&#x0D; Results: Thirty cases had stenting in RVOT and two cases were postponed. Median age was 8.1 (3-40) months, median weight was 4.8 (3.3-11.4)kg, median procedure time was 65 (26-210) minutes and fluoroscopy time was 16 (10-75) minutes.Stents were implanted through 5F Judkins coronary guide catheter and 5F or 6F delivery sheath of ADOII device. Median stent diameter was 6 (4-7) mm. Stent length varies from 12-22 mm with median 14 mm. Oxygen saturation of the patients increased from median 60 (30 - 75)% to 91 (85-98)%. In one patient stent was embolized to aorta and was fixed to descending aorta. Two cases were postponed for short infundibular length. One patient died from non cardiac cause two months after palliation. No procedure related mortality recorded.&#x0D; Conclusion: Right ventricular outflow tract stenting is a good option of palliation for small babies with reduced pulmonary blood flow. In our setting we did most of the palliation to offer better quality of life who could not afford surgery or who was detected late.&#x0D; Bangladesh Heart Journal 2020; 35(1) : 1-5

Right ventricular outflow tract stenting during neonatal and infancy periods: A multi-center, retrospective study.

The aim of this study was to evaluate the outcomes of right ventricular outflow tract stenting for palliation during the newborn and infancy periods. Between January 2013 and January 2018, a total of 38 patients (20 males, 18 females; median age 51 days; range, 3 days to 9 months) who underwent transcatheter right ventricular outflow tract stenting in three centers were retrospectively analyzed. Demographic characteristics, cardiac pathologies, angiographic procedural, and clinical follow-up data of the patients were recorded. The diagnoses of the cases were tetralogy of Fallot (n=27), double outlet right ventricle (n=8), complex congenital heart disease (n=2), and Ebstein"s anomaly (n=1). The median weight at the time of stent implantation was 3.5 (range, 2 to 10) kg. Five cases had genetic abnormalities. The median pre-procedural oxygen saturation was 63% (range, 44 to 80%), and the median procedural time was 60 (range, 25 to 120) min. Acute procedural success ratio was 87%. Reintervention was needed in seven of patients due to stent narrowing during follow-up. During follow-up period, seven cases died. Total correction surgery was performed in 26 patients without any mortality. While a transannular patch was used in 22 patients, valve protective surgery was implemented in two patients, and the bidirectional Glenn procedure was performed in two patients. Based on our study results, right ventricular outflow tract stenting is a form of palliation which should be considered particularly in cases in whom total correction surgery is unable to be performed due to morbidity.

Catheter-based palliation for infants with tetralogy of Fallot.

The optimal management of symptomatic tetralogy of Fallot in neonates and younger infants with unfavourable anatomy is unclear and is further constrained by resource limitations in low and middle income countries. Retrospective medical record review of infants with tetralogy of Fallot undergoing corrective or palliative procedures between January 2016 and June 2019. The study included 120 infants; of whom 83 underwent primary complete repair, four underwent surgical palliation, and 33 underwent catheter-based palliation, including balloon pulmonary valvuloplasty (n = 18), right ventricular outflow tract stenting (n = 14), and stenting of the patent arterial duct (n = 1). Infants undergoing catheter-based procedures were younger in age (median 32 days; inter-quartile range (IQR) 7-144 versus 210 days; IQR 158-250), with lower baseline saturation (65 ± 12% versus 87 ± 7%) and had smaller pulmonary artery z-scores compared to the complete repair cohort. Follow-up was available for 31/33 (94%) infants (median 7 months [IQR 4-11]) who underwent trans-catheter palliation; 12 underwent complete repair, 10 are well, awaiting repair, eight required further palliation (catheter: 6; surgical: 2), and one died post-discharge from non-cardiac causes. Catheter-based palliation is a safe and effective alternative in infants with tetralogy of Fallot who are at high risk for primary surgical repair.

Staged Treatment Using Right Ventricular Outflow Tract Stenting for Effective Augmentation of Native Pulmonary Arteries in a Case of Tetralogy of Fallot with Major Aortopulmonary Collateral Arteries

Staged Treatment Using Right Ventricular Outflow Tract Stenting for Effective Augmentation of Native Pulmonary Arteries in a Case of Tetralogy of Fallot with Major Aortopulmonary Collateral Arteries

Right Ventricular Outflow Tract Stenting as an Option to Blalock-Taussig Shunt for Tetralogy of Fallot

Right Ventricular Outflow Tract Stenting as an Option to Blalock-Taussig Shunt for Tetralogy of Fallot

Anesthesia for high-risk procedures in the catheterization laboratory.

Recent advances in catheterization and imaging technology allow for more complex procedures to be performed in the catheterization laboratory. A number of lesions are now amenable to a percutaneous procedure, eliminating or at least postponing the need for a surgical intervention. Due to the increase in the complexity of the procedures performed, the involvement of anesthesiologists and their close collaboration with the interventional cardiologists have increased. It is important to understand the physiology and pathophysiology of the patients and to anticipate the plans and the potential complications in order to manage them. We are witnessing a rise in the number of complex interventions in newborns and infants, such as balloon valvotomy (critical aortic stenosis, pulmonary stenosis), radio frequency perforation (of pulmonary atresia and intact ventricular septum), right ventricular outflow tract stenting (in Tetralogy of Fallot), ductal stenting (in some ductus-dependent pulmonary circulation), and combined with a surgical procedure (hybrid procedure for hypoplastic left heart syndrome). Multiple registries have been created in order to understand and improve outcomes of patients with congenital heart disease undergoing catheterization procedures and to develop performance and quality metrics, from which data regarding anesthetic-related risks can be extrapolated. Experienced personnel and a multidisciplinary team approach with direct communication among the team members is a must to ensure anticipation and management of critical events when they occur.

Atrioventricular septal defect and tetralogy of Fallot - A single tertiary center experience: A retrospective review.

Background:Complete atrioventricular septal defect (CAVSD) in association with tetralogy of Fallot is a rare and complex disease that makes its repair more difficult than repair of either lesion alone. We reviewed retrospectively our experience in managing this lesion.Patients and Methods:Between February 2006 and May 2017, 16 patients who underwent repair of CAVSD/tetralogy of Fallot (TOF) were reviewed retrospectively. Fifteen patients had trisomy 21. Five patients underwent primary repair while eleven patients went for staged repair in the form of right ventricular outflow tract (RVOT) stenting (n = 9) or systemic to pulmonary (S-P) surgical shunt (n = 2). RVOT stenting has replaced surgical shunt since 2012 in our center. Early presentation with cyanosis was the main determinant factor for staged versus primary repair.Results:The median age at first palliation was 46 days (range 15–99 days). The median age at total repair for both groups was 6 months (range 3–18 months); the median age for the palliated patients was 6.5 months (range 5–18 months) while the median age for primary repaired patients was 5 months (range 3–11 months). The median weight at final repair was 6.9 kg (3.7–8.2 kg). The pulmonary valve was preserved in five patients (31%), four of them had no prior palliation. Chylothorax occurred in 50% of the patients. One late mortality occurred after final repair due to sepsis.Conclusion:CAVSD/TOF can be repaired with low mortality and morbidity. The use of RVOT stent has replaced the surgical (S-P) shunt with acceptable results in our center.

Evolution of Approach to Right Ventricular Outflow Tract Stenting in Infants ≤ 2Kgs

Evolution of Approach to Right Ventricular Outflow Tract Stenting in Infants ≤ 2Kgs

Atrioventricular Septal Defect and Tetralogy of Fallot, a Single Tertiary Center Experience: A Retrospective Review

Background: Complete atrioventricular septal defect (CAVSD) in association with tetralogy of Fallot is a rare and complex disease that makes its repair more difficult than repair of either lesion alone. We reviewed retrospectively our experience in managing this lesion. Patients and Methods: Between February 2006 and May 2017, 16 patients who underwent repair of CAVSD/tetralogy of Fallot (TOF) were reviewed retrospectively. Fifteen patients had trisomy 21. Five patients underwent primary repair while eleven patients went for staged repair in the form of right ventricular outflow tract (RVOT) stenting (n = 9) or systemic to pulmonary (S-P) surgical shunt (n = 2). RVOT stenting has replaced surgical shunt since 2012 in our center. Early presentation with cyanosis was the main determinant factor for staged versus primary repair. Results: The median age at first palliation was 46 days (range 15–99 days). The median age at total repair for both groups was 6 months (range 3–18 months); the median age for the palliated patients was 6.5 months (range 5–18 months) while the median age for primary repaired patients was 5 months (range 3–11 months). The median weight at final repair was 6.9 kg (3.7–8.2 kg). The pulmonary valve was preserved in five patients (31%), four of them had no prior palliation. Chylothorax occurred in 50% of the patients. One late mortality occurred after final repair due to sepsis. Conclusion: CAVSD/TOF can be repaired with low mortality and morbidity. The use of RVOT stent has replaced the surgical (S-P) shunt with acceptable results in our center.