Pediatric cardiac catheterization Part 2 device procedures David Shim, MD The Heart Center Childrens

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Pediatric cardiac catheterizationPart 2 -
device proceduresDavid Shim, MDThe Heart
CenterChildrens Hospital Medical
CenterCincinnati, Ohio
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Devices

• a piece of equipment designed to perform a
  special function (Noah Webster)
• contrived, fanciful
• quickly evolving with new uses for old ideas
• careful patient selection
• endothelialization of device

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Pediatric interventional catheterization

• diagnosis redirected from catheterization suite
  to the echocardiography suite
• therapy redirected from the surgical suite to
  the catheterization suite
• neonatal caths (Shim et al, 1999)
• 1984-5 - 18 interventional (BAS)
• 1994-5 - 38 varied interventions (p0.003)

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Coil occlusion of the persistently patent ductus
arteriosus

• Historical perspective
• Gross and Hubbard, 1939, first surgical ligation
• Porstmann plug, 1967, first occlusion device
• Rashkind PDA occluder, 1987
• Sideris buttoned device, 1991

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Coil occlusion of the persistently patent ductus
arteriosus
Cambier et al, 1992 first use of Gianturco steel
coil in 3 small PDAs advantages - cheap and
widely available
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Coil occlusion of the persistently patent ductus
arteriosus

• Indications
• left ventricular volume overload
• congestive heart failure
• subacute bacterial endarteritis

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Coil occlusion of the persistently patent ductus
arteriosus

• Methods
• left heart catheterization with aortogram
• measure minimum ductal diameter
• coil selection helical diameter at least twice
  the ductal diameter and enough length to produce
  3-4 loops
• intravenous antibiotics at time of coil delivery
  and oral antibiotics for 24-48 hours
• SBE prophylaxis for 6 months following documented
  complete occlusion and indefinitely if residual
  shunt

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Coil occlusion of the persistently patent ductus
arteriosus
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Coil occlusion of the persistently patent ductus
arteriosus

• Complications
• coil embolization 16.0
• pulmonary artery
• PDA
• systemic artery
• failure to implant coil 5.0
• coil embolization not retrieved 2.3
• vascular injury 2.0
• fever 0.5

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Coil occlusion of the persistently patent ductus
arteriosus

• Results
• Moore et al, 1994, 80 immediate success and 90
  long-term success in 30 patients
• Shim et al, 1996, 58 immediate success and 87
  at 20 months in 75 patients
• PDA coil registry, 77 immediate success in 800
  patients and 93 long-term success in 577
  patients with follow-up

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Coil embolization therapy

• Indications
• Conditions for which there is general agreement
  that coil occlusion is appropriate
• aortopulmonary collaterals with dual
  supply
• small PDA (lt4.0 mm)
• surgical aortopulmonary shunts
• intrapulmonary arteriovenous fistulas
• anomalous venovenous connections (esp s/p
  Glenn or Fontan procedure)

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Coil embolization therapy

• Indications (continued)
• Conditions for which coil occlusion may be
  indicated
• moderate PDA (4-7 mm)
• clinically silent PDA
• coronary arteriovenous fistulas
• Conditions for which there is general agreement
  that coil occlusion is inappropriate
• AP collateral w/o dual supply
• nonrestrictive PDA
• (VSD)

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Coil embolization therapy

• Complications
• occlusion of wrong vessel
• embolization of coil
• pulmonary infarction
• subtotal vessel occlusion
• hemolysis
• infection

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Device occlusion of atrial septal defects

• Historical perspective
• King and Mills, 1976, occluded 5/10 ASD with an
  interlocking double-umbrella device made of
  stainless steel and Dacron via 22 Fr sheath
• Rashkind ASD occluder, 1987, single umbrella with
  3 barbed hooks
• Clamshell septal occluder, 1989, double umbrella
  design placed in over 800 patients

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Device occlusion of atrial septal defects

• Indications
• Clinical
• right ventricular volume overload
• paradoxical embolism
• Investigational
• single secundum ASD
• sufficient rim of septum

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Device occlusion of atrial septal defects

• Investigational devices
• Angel wings
• ASDOS
• Clamshell (Cardioseal)
• Buttoned device
• Amplatzer device
• Helex device

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Device occlusion of atrial septal defects

• Amplatzer, 1997
• 2 round disks made of nitinol mesh which are
  connected directly by a short connecting waist
• 6-7 French venous
• advantages
• self-centering
• extremely retrievable
• disadvantages
• high profile device

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Device occlusion of atrial septal defects

• Methods
• balloon sizing of atrial septal defect
  (ie, stretched diameter)
• antibiotics/heparin
• device deployment under TEE
• oral antibiotics for 24 hours and ASA (3-5
  mg/kg) for 3 months

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Device occlusion of atrial septal defects

• Results
• Taeed, 2000, 100 complete occlusion at one year
  follow-up in 18 patients

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Stents

• Historical perspective
• Dotter and Judkins, 1964, discussed the
  temporary use of a Silastic endovascular splint
• Dotter, 1969, implanted tubular coil-spring
  endovascular prostheses to support previously
  dilated arteries
• Palmaz and Schatz, 1985-87, used a stainless
  steel mesh stent in numerous vessels

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Stents

• Indications
• Conditions for which there is general agreement
  that stenting is appropriate
• pulmonary artery stenosis
• superior or inferior vena caval stenosis
• systemic venous obstruction at the superior or
  inferior baffle limb after atrial repair of
  transposition

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Stents

• Indications (continued)
• Conditions for which stenting may be indicated
• stenotic RV to PA conduit
• stenotic aortopulmonary collateral vessels
• coarctation of the aorta
• PDA in infants with ductal-dependent pulmonary or
  systemic flow
• Conditions where stenting is inappropriate
• pulmonary vein stenosis

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Stents
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Future pediatric interventions

• stent valves
• VSD closure devices
• absorbable stents
• percutaneous aortopulmonary shunts
• ethanol ablation for hypertrophic cardiomyopathy