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Pediatric cardiac catheterization Part 1 balloon procedures David Shim, MD The Heart Center Children

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Coarctation of the aorta. Historical perspective ... LPA coarctation - Williams, Alagille, and rubella. Acquired - pulmonary emboli. Postsurgical ... – PowerPoint PPT presentation

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Title: Pediatric cardiac catheterization Part 1 balloon procedures David Shim, MD The Heart Center Children


1
Pediatric cardiac catheterization Part 1 -
balloon procedures David Shim, MD The Heart
Center Childrens Hospital Medical
Center Cincinnati, Ohio
2
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)

3
Balloon septostomy
  • Miller and Rashkind, 1966
  • Allows mixing in transposition of the great
    arteries
  • Inflated balloon pulled from left atrium to right
    atrium
  • Modified use with blade septostomy or static
    balloon dilation

4
Balloon septostomy pre-echo
5
Balloon septostomy the pull
6
Balloon septostomy post-echo
7
Balloon valvuloplasty
  • Originally a balloon pull-through
  • Static dilation to separate commissures
  • Success dependant on annulus size and valve
    morphology
  • Side effect valve insufficiency

8
Pulmonary stenosis
  • Kan, 1982 - 1st static balloon dilation
  • Treatment of choice in all centers (gt80
    success rate)
  • Risk of restenosis 15-20 if dilation required
    prior to a year of age, rare if over a year old

9
Pulmonary valvuloplasty
  • Indications
  • asymptomatic patients with gradients gt50 mmHg
    (Mendelsohn et al - utility of balloon
    valvuloplasty at gradients gt40 mmHg)
  • symptomatic patients
  • CHF or cyanosis in the newborn syncope, dyspnea
  • Methods
  • balloon size equal to 1.2-1.3 times the annulus
    size

10
Pulmonary valvuloplasty
11
Pulmonary valvuloplasty
12
Pulmonary valvuloplasty
13
Aortic stenosis
  • Lababidi, 1984
  • Treatment of choice of many centers
  • Palliative only
  • Methods
  • single balloon - equal aortic valve annulus (in
    general, neonates usually require 7 mm balloon)
  • double balloon - 1.2 times the aortic valve
    annulus
  • Complication
  • aortic insufficiency

14
Aortic valvuloplasty
  • Results
  • Sholler et al, 1988
  • demonstrated that balloonannulus ratio gt 1.0
    did not improve gradient relief but did increase
    regurgitation
  • Rocchini et al, 1990
  • 61 acute gradient reduction in 204 patients

15
Aortic valvuloplasty
  • Results (continued)
  • Shim et al, 1997
  • repeat balloon valvuloplasty resulted in adequate
    gradient relief in 11/15 patients (73) while
    producing worsening aortic regurgitation in 4
    patients (27)
  • - no severe regurgitation
  • - compares favorably to first dilations
  • - 3/4 patients with unsatisfactory gradient
    relief were on their third aortic valve
    intervention

16
Balloon angioplasty
  • Stretch stenotic vessels by creating a tear in
    the intima and media
  • Risks rupture or dissection of the vessel
    (balloon size and inflation pressure)
  • Ideally will grow with patient after relief of
    obstruction
  • Contraindication calcification

17
Balloon angioplasty
  • Pulmonary artery stenosis
  • Coarctation of the aorta
  • Venous (SVC) stenosis
  • Others baffles, conduits
  • Does not work with pulmonary vein stenosis

18
Coarctation of the aorta
  • Historical perspective
  • Sos et al, 1979 and Lock et al, 1982 performed
    balloon dilation on surgically removed CoA
    segments
  • Singer et al, 1982 performed balloon dilation
    on restenosis of CoA repair
  • Lababidi et al, 1983 described first balloon
    dilation on native CoA

19
Aorta angioplasty
  • Indications
  • recurrent CoA
  • - resting gradient gt20mmHg, hypertension, and/or
    symptoms (claudication)
  • native CoA
  • - greater than 1 yr old with above

20
Aorta angioplasty
  • Results (native)
  • Tynan et al, 1990 VACA study of 140 patients
    with 82 relief (4819 to 1211 mmHg)
  • Mendelsohn et al, 1994 78 immediate success
    rate and 64 positive long-term results
  • Rao et al, 1996 77 patients with gradient relief
    from 4617 to 119 mmHg with restenosis in 83 of
    neonates, 39 of infants, and 8 of children

21
Peripheral pulmonary stenosis
  • Historical perspective
  • Lock et al, 1983 - described balloon dilation of
    branch pulmonary artery stenosis in 5/7 patients
  • Rocchini et al, 1984 - described successful
    dilation in 5 and unsuccessful in 8 patients

22
Peripheral pulmonary angioplasty
  • Causes
  • Congenital
  • - TOF, low pulmonary flow
  • - LPA coarctation
  • - Williams, Alagille, and rubella
  • Acquired
  • - pulmonary emboli
  • Postsurgical
  • - shunts (Waterston, BT)
  • - Glenn/Fontan anastomosis

23
Peripheral pulmonary angioplasty
  • Indications
  • Symptoms of cyanosis, heart failure, or dyspnea
  • RV pressure of gt2/3 systemic
  • Severe pulmonary insufficiency with MPA pressure
    gt40 mmHg
  • RV pressure gt50 mmHg with unilateral obstruction
    causing marked disparity in pulmonary blood flow

24
Peripheral pulmonary angioplasty
  • Results
  • Kan et al, 1990 - VACA with 182 procedures in 156
    patients with moderate results (systolic gradient
    49 to 37 mmHg)
  • Hosking et al, 1992 - VACA follow-up with 53
    success in 72 patients
  • Gentles et al, 1993 - use of high-pressure
    balloon (17-20 atm) with success rate 63 in
    previously dilated arteries and 81 in native
    stenosis
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