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