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Interventions and innovations in pipeline for paediatric cardiology Shakeel A Qureshi Evelina Children’s Hospital London


Upcoming interventions • Not much change in interventional procedures over the last 5 years • Interventions in next 5 years will be similar • However, there will be more registry or other data to provide evidence • More adult congenital heart interventions • More new device changes e.g biodegradable stents • There will be increasing hybrid procedures


Earlier inventions • Catheter pulmonary valvotomy (in Mexico in 1953) • Rashkind septostomy in 1966 • Catheter ASD closure (King & Mills in 1976 • Some fell out of favour whilst others survived (BAS) because: – The inventors did not pursue – Technology was not good – Industry support was lacking


Established interventions today •

Balloon dilation: – Pulmonary valve stenosis at all ages – Aortic valve stenosis at all ages

Catheter closure: – PDA by coils or devices – ASD by devices – VSD by devices – Coil occlusion of MAPCAs, AV malformations etc

Stent dilation: – Peripheral PS – Aortic coarctation in adolescents and adults.


Palmaz stent

Palmaz Genesis stent

Stainless steel balloon-expandable


Stent : Extra Large:

Andrastent (Andramed) CP (Numed)


Stent implantation for pulmonary artery stenosis Open cell stents


More recent trends • Stenting of RVOT in tetralogy of Fallot in neonates • Stenting of PDA in duct-dependent cyanotic CHD


RVOT stenting in tetralogy of Fallot Whole of RVOT should be covered


RVOT stenting in tetralogy of Fallot


Ductal stenting Originally, a novel but risky approach, but with improvement in stent design & delivery platforms it is considered today as an alternative to surgical shunts


Tricuspid atresia, PDA PDA stenting via femoral artery route

Alwi M, IJN, Kuala Lumpur


Pulmonary artery growth PDA stent vs BT shunt

Uniform growth after duct stents

Santoro et al


Covered Stents in Paediatric Cardiology


Stent for aortic coarctation


Aortic interruption

Treated with a covered stent


Trends in interventions • Fetal balloon dilation of aortic and pulmonary valves • Fetal atrial septostomy • Catheter replacement of pulmonary valve • Catheter replacement of other valves • MRI based catheterisation and interventions • Hybrid procedures (eg. Completion of Fontan)


Balloon dilation of aortic valve in fetus

Wayne Tworetzky


Fetal intervention Pulmonary atresia/IVS

Gurleen Sharland


Fetal interventions in future • The evidence base for these will increase • These techniques likely to continue although currently they may have questionable benefit • Improved technology may allow much earlier interventions and so may influence the outcome


Hybrid theatres and procedures Hybrid Cardiac Operative Suite, Columbus, Ohio


Hybrid Therapy for CHD • Provide surgical access for interventions • Extremely premature neonates • Hybrid for HLH • Aortic stenosis with poor LV function or borderline LV size • Perventricular closure of MVSD • Intraoperative stents • Exit diagnostic angiography • Hybrid valve implantation


Successful balloon pulmonary valvoplasty in 700 gm baby RV fx improved, ascites resolved, baby discharged

Hybrid approach essential for success

Courtesy: John Cheatham


Stage I Palliation

Comprehensive stage I & II

Transcatheter Fontan


Hybrid procedure for HLH with absent left lung

Now age 6 years after single lung Fontan


Hybrid procedures for VSDs 4 month old, 4 kg; large anterior muscular VSD


Hybrid LPA stenting

Dilated RVOT with tortuous LPA origin


Hybrid stent implantation for disconnected LPA

This collaborative hybrid approach reduces the risk of procedure


Exit Angiography


Catheter valve replacement • Pulmonary valve - clinical • Aortic valve – clinical • Tricuspid valve - clinical • Mitral valve - experimental


Percutaneous implantation of the pulmonary valve

Melody valve Sapien valve


Introducer sheaths for percutaneous pulmonary valves Melody introducer: 22 Fr OD Sapien sheaths: 25 to 28 Fr OD 25 F

Sheath Set

Internal Diameter

Outside Diameter

Length

23 mm

22F

8.4 mm

35 cm

26 mm

24F

9.2 mm

35 cm 28 F


Melody valve implantation Prestenting with covered stent in calcified RVOT


Implantation of Melody valve in a prosthetic tricuspid valve


Hybrid Perventricular Melody valve off CPB

Courtesy: John Cheatham


Delivery of the Melody valve

Courtesy: John Cheatham


Catheter valve replacement Pulmonary valve • Challenges of large RVOT remain • Techniques being evaluated to reduce the RVOT dimension


Surgical implantation of Melody valve • Surgical Melody Valve Implantation in Infancy • Using Melody valve as surgical conduit for RVOT • With growth of patient, Melody valve can be dilated with a balloon • Experience of 7 babies so far

Pedro del Nido, Boston


RV-PA conduit • Implantation Technique – Attach sewing cuff of stretch PTFE – In situ implantation within native RVOT PA

RV

• Late evaluation for effect of redilation Pedro del Nido, Boston


Melody RVOT conduit • Patients

8

• Age (median)

8mo (1.6mo-6.6yrs)

• Diameter at implant 12mm (9-18mm) • Follow-up (18mo) • Replacement in 2 • Re-dilation in 5 (mild PR)


Account for growth RV Outflow Reconstruction


Mitral Valve Replacement •

N=

7

Age

3mo (1-12)

Pathology

– MR

6

– MS

1

Technique – Crimped to 10mm, sewn to native leaflets, expanded in situ – Cuff of autologous pericardium for annulus fixation

Follow up – 1 death (slavage procedure from ECMO) – 2 redilated (3 and 4mo post implant) – 1 explanted at Tx


Mitral valve replacement using Melody valve

• 6 months post implant presented with para prosthesis leak


Evolution of the Integration


Roadmapping • Image modalities for EP • Image Fusion/Registration Techniques • Applications • Image-based guidance • Image-based predictive modelling


Advances in imaging which help interventions • • • •

3-D and 4-D echocardiography 3-D CT angiography 3-D MRI Rotational angiography

DynaCT: 3-D reconstruction


3D Rotational Angiography (3DRA) 240O acquisition over 4 sec No standards for technique Room set-up

- Monitoring - Anesthesia/airway

Contrast injection

- Amount - Initiation / Duration - Dilution

Patient related issues

- Anatomy - Breath-hold - Artifact

Tom Fagan, Denver, 2013


Rotational Angiography

Coronary artery assessment prior to Melody valve


Imaging pulmonary arteries in patients with TCPC

In TCPC pts, PAs should be unobstructed With 3DRA, subtle abnormalities may be seen


Pulmonary valve balloon with 3D reconstruction and roadmapping. A - 3D rendering of a non-gated right-sided cardiac C-arm CT reconstruction B - Overlay of the 3D pulmonary artery from A (red outline) onto live fluoroscopy during balloon valvuloplasty of the pulmonary valve

Schwartz et al, 2011


Interventional Guidance 3DRA Roadmapping

6 yo HLHS post Fontan with RPA Stenosis


Interventional Guidance 3D RA Roadmapping

a

b

c

Melody and pre-Melody stent placement Schwartz, Int J Cardiovasc Imaging. 2011 Dec;27(8):1205-22


TOE registration with fluoro for transseptal puncture

Courtesy: Kawal Rhode., KCL


Current / Near Future Projects Echo Navigator (EchoNav) Para-valvar mitral leak closure

Courtesy:John Carroll, Denver


MRI image overlay Stenting of aortic coarctation


MRI guided interventions without fluoroscopy

Balloon dilation of coarctation


MRI guided interventions without fluoroscopy

Balloon dilation of PVS


True Overlay


Future directions •

Many techniques and technologies are being developed

If suturing inside the heart becomes practical, then perhaps ASDs could be closed without devices

Hybrid suites (surgeons and interventionalists working together) will develop

Catheter lab and theatres will combine

Exit angiography will assume importance

MRI compatible catheters and devices will reduce the need for radiation for interventional procedures

SHA24/071003  
SHA24/071003  

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