Confirmed CCHD What next?

(1)

2/11/2013 Dell Children's Pediatric Care Conference VI 2/11/2013

Confirmed CCHD … What next?

Herbert J. Stern MD, FACC, FSCAI

Children’s Cardiology Associates and

Dell Children’s Hospital

(2)

Catheter Based Therapy: Spectrum

of Procedures

• Tear PFO to enhance “mixing” (D-TGA)

• Dilate and/or stent narrowed valves

(valvuloplasty) and vessels (angioplasty)

• Close abnormal vessels (PDA’s, collaterals, etc)

• Close septal defects

• Open atretic valves, create fenestrations

• Implant transcatheter valves

(3)

Spectrum of Age – Birth til…

(4)

Balloon Septostomy

(5)

Valvuloplasty

Mechanism of dilatation:

commissural splitting

• Semilunar Valves

most commonly(A-V

valves rarely)

• Use oversize balloons

for pulmonic valve

• Use 80-100% annulus

size for aortic valve

(6)

Valvuloplasty-Critical PS

(7)

Valvuloplasty-Critical PS

(8)

2/11/2013 Dell Children's Pediatric Care Conference VI

RF Perforation of Pulmonary

Atresia in 1500 gm Infant

(9)

Valvuloplasty-Critical AS

(10)

Valvuloplasty-Critical AS

(11)

Angioplasty

Mechanism of dilatation:

Does NOT stretch the

vessel, but purposely tears

the

intima/media(hopefully

not the adventitia)

• Vessel heals in open

position

• Critical to properly size

lesion to chose proper

balloon size

(12)

Angioplasty-Coarctation of the

Aorta

(13)

Endovascular Stents

• Wire mesh cylinders

which must be hand-

crimped on balloon

catheters or come

premounted

• Indicated for vessel

stenosis in: coarctation of

the aorta, conduits,

Mustard baffles,

(14)

(15)

Coarctation of the Aorta

(16)

Endovascular Stents-RV to PA

Conduits

(17)

Left Pulmonary Artery Stenosis

(18)

(19)

Poiseulle’s Law (flow in rigid

tubes)

(20)

Occlusion Devices

(21)

2/11/2013 Dell Children's Pediatric Care Conference VI 2/11/2013 Dell Children's Pediatric Care Conference VI

(22)

Gianturco Coil Occlusion

(23)

(24)

Amplatzer Vascular Plug

(25)

(26)

Coil Occlusion Aortopulmonary

Collaterals (APCs)

(27)

Amplatzer Occlusion ASD

(28)

Balloon Sizing Both Defects

(29)

ASD Closure with two devices

(30)

TEE post delivery

(31)

Creating Fenestrations

(32)

Combination Lesions

(33)

Combination Lesions

Usually occur in context of Single Ventricle

Physiology

• Recoarctation of the Aorta (balloon and/or stent)

• Stenosis @ SVC anastomosis or branch PA’s

(balloon and/or stent)

• Aortic and /or venous collaterals (vessel

occlusion)

(34)

Angioplasty of Thrombosed LPA

(35)

Access to Vessel via

Floppy-Tipped Wire

(36)

Stent of LPA and Coarcatation

(37)

Emerging Technologies

(38)

Transcatheter Valve Replacement

(Bonhoeffer:Circ.2000;102:813-16)

• Bovine jugular vein containing native

biological valve harvested, fixed and

sterilized

• Sutured to interior of pre-expanded C-P

stent

• Re-formed and crimped onto 18-22mm

balloons

(39)

Bovine Valve Sutured in Stent

• Valved stent placed

successfully in 7/11

lambs; 5/7 placed

correctly across native

pulmonary valve

• All 5 lambs with

normal neo-pulmonic

valve function after

two months follow-up

(40)

Competent Valve Following

Explantation

Applications:

• Free PI with RV volume

overload (e.g. TOF with

transannular patch)

• RV-PA valved homograft

deterioration (TOF/PA,

Truncus, Ross procedure)

(41)

Transcatheter Valve Implantation

(42)

2/11/2013 Dell Children's Pediatric Care Conference VI 2/11/2013 Dell Children's Pediatric Care Conference VI

(43)

Hybrid Procedures

(44)