Nonsurgical Cardiac Interventions in Children
Dr Anil S.R
Consultant Pediatric Cardiologist
MIMS, Calicut
Estimates of Congenital Heart Disease (CHD) Prevalence Among Live-born
Infants in India*
• Total CHD at birth ~130-270,000• Critical CHD (requiring intervention in infancy):
~ 80,000• Infant mortality: India- 63/ 1000
Kerala- 13/ 1000 Andhrapradesh-33/1000
• CHD mortality as a fraction of infant mortality: 3-20% (10-12% in AP?)
*Based on available data of CHD prevalence at birth in developed countries and present birth rates in India
Timing for CHD
• Early correction of congenital heart disease is desirable because it avoids a number of adverse cardiac, neurodevelopment and other consequences
• Early correction of a variety of congenital heart lesions is feasible and realistic with excellent results in most of the developed nations and selected Indian centers
What Happens if Congenital Heart Disease is Untreated?
• Majority of them succumb to death in infancy and early childhood
• The rest live a turbulent and truncated life
Timing of Intervention in CHD
• Surgical intervention• Trans-catheter intervention
Congenital Heart Disease:
RV LV
PA
MPA
Ao
AoPA
Pediatric Cardiac Interventions
1960s: Rashkind Balloon Septostomy
1970s: King and Mills ASD
Device, Rashkind PDA occluder
1980s: Balloon valvotomy
1990s: Devices, coils and stents, RF wire
2000…: Implantable valves, Percutaneous PA band, Percutaneous shunts, Transcatheter Fontan, transcatheter gene therapy
60s
80s
90s
2000…
Interventions in CHD: Well Accepted
• Coil and device closure of PDA*• ASD device closure*• Coil / device closure of coronary cameral
fistulas• Balloon dilation / stenting of native
coarctation in older children and adults• Balloon dilation / stenting of baffle obstruction• Static balloon dilation of atrial septum
Interventions in CHD: Performed in Few Selected Centers
• VSD device closure• Recanalization (laser/RF assisted) of
valvar pulmonary atresia• RVOT dilation for TOF• Stenting of PDA • Balloon dilation and stenting of conduits• Closure of paravalvar leaks
Transcatheter PDA Closure
Patent Arterial Duct: Transcatheter Closure
Ao
LPA
Ampulla
The High Parasternal or “Ductal View”
MPA
Ao
The two small white arrows indicate the points where the duct is measured at its PA insertion. The white line indicates the ampulla.
Methods: Echo Assessment
Duct diameter at PA insertion defined by echo in the high parasternal view
MPA
LPAA
mpulla
PDA Coil Closure; Closure of Large Ducts Using Coils
AortaPulmonaryArtery
Coil Closure of a Patent Arterial Duct
Bioptome-assisted Single Coil Delivery
The Amplatzer PDA Occluder
• Greater ease, better control and precision during deployment
• Size of the duct and shape of the duct is less of an issue (as against coils)
• Concerns regarding protrusion of parts of the device in the aorta or PA
• Some reluctance to use the device < 4-5 kg
5.4mm PDA: Device 10mm/8mm
PDA Closure
• Most PDAs can potentially be closed in the catheterization lab
• The role of surgery is now essentially limited to large ducts with short ampullae in small infants
• There is scope for further improvements in the coil / device technology
Case Scenario DAY-2
Deep Cyanosis
Critical PS
Stabilized on PGE1
Underwent BPV
Case Scenario DAY-3• Persisting Cyanosis
• On Ventilator-
• ABG-pO2 23mmHg
• PGE1-Max Dose
• Echo
No residual PS
PDA, L-R
ASD, R-L
What Next ???
Day 5
Day 5
Day 5
Day 5
Day 5
Transcatheter ASD Closure
TEE, horizontal plane
TEE, vertical plane
The STARFlex Device
The Amplatzer Device
The Gore Helex Device
• All fossa ovalis type defects < 30 –35 mm with at least 5 mm margin all around (except anterior margin which can be absent altogether): 40-60% of all fossa ovalis ASDs
• Stricter criteria for younger children• “Safe” distance from mitral valve,
pulmonary vein, coronary sinus, SVC
Transcatheter ASD Closure: Scope (Amplatzer ASD
occluder)
Transcatheter VSD Closure
nishant
Chenna raja
Sai teja
Sai teja
Conclusions
• Today, by just stretching, tearing and plugging alone 20-30% of children with CHD can be treated in the cath lab
• The future is exciting because we are the threshold of going beyond the paradigm of “stretching, tearing and plugging”– Creation of new channels: covered stents, special
devices– Transcatheter gene therapy, biodegradable
devices