CONGENITAL HEART DEFECTS IN ADULTS
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2 CONGENITAL HEART DEFECTS IN ADULTS THE ROLE OF CATHETER INTERVENTIONS Mario Carminati
3 CONGENITAL HEART DEFECTS IN ADULTS CHD in natural history CHD with post-surgical sequelae
4 PULMONARY VALVE STENOSIS First choice procedure: Balloon valvuloplasty Indications and results comparable with pediatric population
5 Pulmonary valvuloplasty in adults Double balloon technique
6 VALVULAR AORTIC STENOSIS Balloon valvuloplasty Rare indications in adolescents and adults
7 PULMONARY BRANCHES STENOSIS (usually post-surgery) First choice procedure: Stent implantation
8 Palmaz stents
9 LPA stenosis (post Tetralogy repair) Pre- Post-
10 Multiple RPA stenosis Pre- Post-
11 COARCTATION AND RECOARCTATION First choice procedure: Stent implantation
12 Large Stents
13 Eur Heart J Sept 2005
14 G.A. m, 30 y Grad. 45 mmhg
15 Stent implantation
16 G.A. m, 30 y Grad. 0 mmhg
17 L.M. m 52y Native Coarctation Grad. 83 mmhg P mm. Grad. 0 mmhg
18
19 L.M. m 52y 4 years follow-up
20 F.L. f 65y Transverse Arch stenosis Grad. 100 mmhg P mm Grad. 0 mmhg
21 F.L. f 65y 3 years follow-up Grad. 0 mmhg
22 STENTING NATIVE COARCTATION Pressure Gradient (mmhg) Pre Post Vessel Diameter (mm) Pre Post
23 STENTING RECOARCTATION Pressure Gradient (mm Hg) Vessel Diameter (mm) 0 Pre Post Pre Post
24 Early Major Complications * wall rupture: 25 yrs, aortic recoarctation+aneurysm (Palmaz 5014) * periaortic-hematoma: 32 yrs, severe coarctation (Palmaz 5014)
25 P.M., 32 y. Early Complication with Periaortic-hematoma BS
26 Periaortic-hematoma Early Complication with BS
27 Spontaneous resolution
28 Background Stents implantation has gained increased popularity for the treatment of aortic arch obstructions in adolescents/adults Some problems/complications cannot be avoided completely (aneurysms, dissections, wall rupture.) Can covered stents improve the results/avoid complications?
29 CP covered stent
30 Stenting of subatretic coarctation
31 Aneurysm
32 CP covered stent
33 Covered stent
34 Stenting Aortic Arch Obstructions San Donato Experience (Jan 2000 Jul 2007) 123 pts age: 15 years (6-66) Native Coarctation 85 Recoarctation 38
35 Stents Used Bare Stents (BS) 77 Palmaz 42 Genesis 24 CP 11 Covered Stents (CS) 46 CP 46
36 Results Successful implantation in all pts in both groups No differences for age, weight, gender, type of coarctation (native/recoarctation), procedure and fluoroscopy time
37 Subatretic aortic isthmus
38 Interruption of Aortic isthmus
39 Follow-up Complications BS: aneurysm formation 2 (10 and 12 months after stent implant) CS: none
40 Major Advantages of CS vs BS Less risk of unwanted damage of the aortic wall
41 Results Distribution of stent used during the period of study BS CS
42 PDA First choice procedure: device closure
43 PDA Amplatzer device
44 PDA Amplatzer device
45 SECUNDUM ASD First choice procedure: device closure
46 Amplatzer 92% Starflex 4% Intrasept-Cardia 2% Helex 2%
47
48 Early Complications:34 pts (3,8%) Complete AVB : 1 (0.1 %) Transient SV Arrhythmias: 8 (0.9 %) A.F. needing ECV: 6 (0.7%) Thrombus formation on the device: 1 (0.1 %) Groin hematoma: 6 (0.7 %) Retropharingela hematoma: 1 (0.1 %) Medical treatment Device malposition/embolization: 7 (0,8%) Erosion of atrial wall: 2 (0,2%) Pericardial effusion: 1 (0,1%) Need for Surgery
49
50 Follow-up 32±15 months (range 1-68) Long -term complications (> 4 months post procedure) (0.3 %) Thrombus formation (medical therapy): Device malposition (elective surgery): Ao -RA fistula (elective surgery): 1 pt 1 pt 1 pt
51 Aorta-RA fistula
52 Total ASD s: (%) perc clos surg 1115 (80%) 272 (20%) 20 0 Policlinico San Donato
53 ASD closure (%) perc clos surgery Policlinico San Donato
54 VENTRICULAR SEPTAL DEFECTS VSD s in natural history much less common than in pediatric age Residual post-surgery VSD s
55 VSD s percutaneous closure (up to May 2006) N Total 145 < 18 y 104 (72%) > 18 y 41 (28%) Perimembranous 27 Muscular 7 Residual post-surg. 7
56 Muscular VSD
57 Amplatzer muscular VSD occluder
58 Amplatzer muscular VSD occluder
59 Perimembranous VSD
60 Amplatzer membranous VSD occluder
61 Amplatzer membranous VSD occluder
62 Perimembranous VSD with aneurysm Muscular VSD device implantation IRCCS Policlinico San Donato
63 Residual VSD after DORV surgical repair
64 Device closure
65 Complete VSD Closure Immediate 40 % Discharge 65 % Follow-up 93 % 7% trivial residual shunt IRCCS Policlinico San Donato
66 Complications Aortic regurgitation 6 (4%) (trivial) Tricuspid regurgitation 12 (8%) (trivial) Complete Heart Block: 6 (4%) (requiring PM implantation) Only perimembranous VSD s Device embolization 3 (2%) ( cath retrieval in all) IRCCS Policlinico San Donato
67 Post-surgical RVOT disfunction
68 Transcatheter pulmonary valve implantation Melody
69 September 2000 Bonhoeffer P, et al. Lancet 2000
70 Melody Valve and delivery system Bovine jugular venous valve in Platinum-Iridium (CP) stent Balloon-In-Balloon (BIB) delivery system Three balloon sizes: 18, 20, 22 mm 22Fr size
71
72 Predominant RVOT lesion RVOT obstruction Pulmonary Regurgitation 40% 30% 30%
73 Clinical Criteria RV outflow tract obstruction (RVOTO) RV systolic pressure 2/3 of systemic Moderate to severe regurgitation (PR) Impaired exercise capacity (<65% of predicted) Significant RV dilatation / dysfunction Lurz P, et al. Circulation 2008
74 Morphological Criteria RVOT dimensions > 16 mm and < 22 mm
75 Procedure Pre-dilatation 30% Pre-stenting 50%
76 Procedure Melody implanted 18mm: 23% 20mm: 28% 22mm: 45%
77 Procedure Post-dilatation 70%
78 Global experience with Melody up to May 2008 Implantations worldwide 550 Europe 399 Canada 68 U.S. 57 Saudi Arabia 26 M Carminati Euro PCR 2008
79 Acute results Melody successfully implanted: 294/305 (96,4%) Residual gradient < 25mmHg: 88% Absent / trivial pulmonary regurgitation: 99%
80 The impact of Interventional Cardiology for the management of GUCH patients Reasons for hospitalisation Fron Jane Sommerville Database
81
82 Thank you for your attention! Mario Carminati
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