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PERCUTANEOUS INTERVENTIONS IN OBSTRUCTIVE CHD Dr.Tahsin.N Jan 2012.

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Presentation on theme: "PERCUTANEOUS INTERVENTIONS IN OBSTRUCTIVE CHD Dr.Tahsin.N Jan 2012."— Presentation transcript:

1 PERCUTANEOUS INTERVENTIONS IN OBSTRUCTIVE CHD Dr.Tahsin.N Jan 2012

2 Overview 1. Endovascular Stents 2. Balloon Aortic Valvuloplasty 3. Balloon Pulmonary Valvuloplasty 4. Perforation of the Atretic Pulmonary Valve 5. Mitral Valve Dilation 6. Tricuspid Valve Dilation 7. Coarctation, Recoarctation and Aortic Arch Obstructions 8. Branch Pulmonary Artery Stenoses 9. Pulmonary Vein Stenoses 10. Systemic Vein Stenoses

3 Endovascular Stents Low profile that allows introduction through small delivery sheaths Easy crimp ability or availability as premounted stents Possibility for re-expansion to adult size High degree of flexibility for placement around curved structures Allowance for rehabilitation of vessels that are overlapped by the placed stent through the stent meshwork/cells (e.g., open-cell design) High radial force to accommodate very tight and scarred lesions

4 Rounded atraumatic edges that avoid damage to the vessel and the balloon Nonexisting or low degree of stent-shortening during expansion Stent material - MRI compliant, noncorrosive, and does not lead to increased blood levels of metal Low risk of neointimal proliferation, possibly through internal coating Possibility of biodegradable material with a platform to sustain drug coating to minimize tissue reaction

5 Balloon Aortic Valvuloplasty Indications Peak-to-peak gradient >60 mm Hg Asymptomatic patients Peak-to-peak gradient > 50 mm Hg Symptomatic patient or ECG changes - ischemic AS in the critically ill neonate Dilated left ventricle and poor left ventricular function

6 Retrograde - Less traumatic Antegrade - Better balloon position, No arterial injury Single balloon - Antegrade Double balloon - More dilation older patients Cross aortic valve ; most difficult step JR / JL /Multipurpose Catheter Balloon across valve; Rapid inflation & deflation Longer balloons Adenosine – Cardiac standstill Rapid RV pacing

7 Balloon size Single-balloon technique - 80% of the measured aortic annulus diameter Double-balloon technique - combined diameters 1.2 times the measured diameter of the aortic annulus

8 Complications  Femoral artery complications – Avoided by Antegrade approach Carotid approach Double balloon  Aortic regurgitation with AVR

9 Outcome Gradient by 60% to 70% or to a gradient of 30 to 40 mm of Hg Long-term results surgical valvotomy – palliative without a sternotomy or cardiopulmonary bypass In pediatric patients and young adults is now the standard initial procedure in most centers

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11 Balloon Pulmonary Valvuloplasty First introduced by Kan et al. in 1982 December centers - reporting to VACA - successful and safe technique in >680 cases Standard therapeutic procedure for pulmonary valvar stenosis in all ages from the newborn period throughout adult life Maximum instantaneous systolic echo gradients of 35 mm Hg with evidence of right ventricular hypertrophy

12 Long exchange wire to LPA or Duct – Desc. aorta Optimum balloon diameter - between 1.2 and 1.3 times the size of the pulmonary valve annulus for a single-balloon dilation Low pressure balloons Tyshak II (NuMED, Hopkinton, NY) with a lower profile Smaller size High-pressure balloons ZMed II (NuMED, Hopkinton, NY) or the double-balloon technique Larger size – older pts Dysplastic, thickened pulmonary valves Associated supravalvar narrowing Smaller coronary balloons can facilitate predilating the valve

13 Gradient across the nondysplastic pulmonary valve to <10 mm Hg Reduction in the RV-to-systemic pressure ratio Relief of the valvar stenosis may unmask infundibular obstruction Infundibular obstruction - dynamic - regress with time Dysplastic valves higher-pressure gradient reduction less Immediate results Good immediate results >95% pts Very Low mortality rates Improved Rv fn Decrease in TR

14 Complications Arrhythmia Hypotension / collapse Blood loss RV / Tricuspid valve injury Pulm valve / annulus disruption VACA registry Death 0.24% Major complications 0.35%

15 Long term results Restenosis - 5% to 11% within 10 years Risk factors Infancy Very dysplastic pulmonary valves Undersized balloon No evidence of increased PV replacement

16 Perforation of the Atretic Pulmonary Valve Pulmonary atresia with intact ventricular septum (PA/IVS) Palliative Acutely decompresses the right ventricle Facilitate growth of an initially hypoplastic right ventricle Suitability by 2D echocardiography Minimal criteria Tripartite right ventricle Membranous atretic pulmonary valve Well formed infundibulum

17 Measure right ventricular and systemic arterial pressures RV angiography with 20-degree cranial angulation & lateral projection Measure pulmonary valve plate diameter Exclude of RV-dependent coronary circulation LV angiography - same projection – Assess Valve plate Nykanen RF perforation wire and the Baylis radiofrequency puncture generator Power setting of 5 W/s Balloon dilation performed Low-profile balloon valvuloplasty catheter- Mini-Tyshak Diameter of about 130% of the valve plate annulus Ductal stenting / surgical shunt – 50%

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19 Outcome Most series are very small - include fewer than five patients Overall procedural mortality - 8% Incidence of procedural complications -15% 75% - biventricular or one-and-a-half ventricle circulation

20 Mitral Valve Dilation Anatomy of congenital MS Variable Less favorable for balloon dilation than rheumatic Femoral veins - transseptal approach – LA - LV Single or double balloon Inoue Two balloon diameters = the measured or estimated maximal normal mitral valve diameter for the patient

21 Transseptal Puncture Transseptal needle Brockenbrough needle with a transseptal Mullins introducer set (Cook)

22 Radiofrequency energy Minimal force and a much lower risk of injuring adjacent structures Toronto transseptal catheter with the 8 Fr TorFlex transseptal sheath and dilator Curved at the end by about 210 degrees - avoid continued perforation of adjacent structures Increased stiffness Larger patients

23 In small infants 4 or 5 French Judkins right (JR) catheter A 180-cm inch outer diameter coaxial injectable catheter (Baylis) is loaded over a 260-cm inch Nykanen RF perforation wire

24 McElhinney et al. 108 patients with congenital MS Median age - 18 months BMV - reduction of the mean gradient by - 38% Significant MR - 28% Overall 5-year survival - 69% Later stages of the institutional experience - 87% The early mortality BMV = surgical mitral valvuloplasty

25 Initial procedure - typical congenital MS or double-orifice mitral valve Surgical approach - supra valve mitral ring and parachute mitral valve Parachute MV Not a contraindication to BMV Less effective - single papillary muscle or severe shortening or virtual absence of the chordal apparatus

26 Tricuspid Valve Dilation Congenital TS Associated with other cardiac lesions Less amenable to balloon valvuloplasty than rheumatic Similar to BMV Balloon size equal to estimated TV diameter A successful dilation should eliminate any transvalvar gradient Limited experience

27 Coarctation, Recoarctation and Aortic Arch Obstructions 1979 Sos et al. native coarctation in postmortem specimens 1980 Dr. James Lock et al excised human coarctations as well as experimentally induced coarctations in lambs Dr. Ronald Grifka and Dr. Charles E. Mullins et al., - Texas Children's Hospital - endovascular stent therapy to treat coarctation 1995, Suarez de Lezo reported the first large series of stent implantation to treat native and recurrent coarctation in humans using the Palmaz stent 1999 Cheatham first reported on a new stent design, the Cheatham- Platinum (CP) stent - also available in a PTFe-covered variety

28 Cylindrical fixed maximal-diameter dilating balloons- high pressures Goal of the procedure – Reduction in the gradient to <10 mm Hg or 90% relief of the obstruction angiographically Zabal et al. - cohort of 54 pts - observational study Residual gradient of >10 mm Hg was associated with a significantly higher failure index (heart-related death, a gradient on follow-up of >20 mm Hg, and the need for reintervention or complications such as aneurysm formation)

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30 Balloon Dilation in CoA

31 Stents in CoA

32 Bare or Covered Stent

33 In smaller patients with an expected diameter below average adult size, the Genesis XD or the Mega LD stents with a maximum expandable diameter of 18 mm. If larger maximum diameters are required, the Max LD, the Cheatham- Platinum, or older Palmaz XL (Cordis, Warren, NJ) stents with maximum expandable diameters >25 mm Cheatham-Platinum covered stent

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35 Balloon angioplasty alone for native coarctation in smaller children and infants - 66% recoarctation rate. Interventions for native coarctation - greater incidence of aortic aneurysm formation Catastrophic events as a direct result of aneurysms are rare Dilation of native coarctation more reasonable for discrete lesions in patients >7 to 12 months of age In the larger child, primary stent therapy for native coarctation - gradual conservative expansion of stents over two or three procedures to reduce the incidence of dissection or aneurysm formation

36 Branch Pulmonary Artery Stenoses Accepted standard procedure - not amenable to surgical repair Reduction in the RV -to-systemic pressure ratio - good indicator for a successful outcome. Individual pressure gradients to branch pulmonary arteries may be less meaningful IJV or transhepatic approaches eliminates some of the double-S curves that have to be traversed from a femoral venous approach – better pushability Balloon should preferably between 2 to 3 times the stenotic area High pressure balloons & Cutting balloons may be required Intravascular stents have become the primary mode of therapy for branch pulmonary artery stenoses (except infants)

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38 Pulmonary Vein Stenoses Surgical & transcatheter interventions for pulmonary vein stenoses - uniformly bad long-term outcome Performed as a last resort before considering heart - lung transplantation Restenosis is observed in most cases Stents – No better medium- or long-term results than (cutting) balloon angioplasty alone Short-term results may be superior than angioplasty High percentage of complications - systemic stent embolization

39 Systemic Vein Stenoses Successful and carries little risk - even in freshly operated lesions Surgical alternative for these lesions is poor to nonexistent Stenosis recurs in most cases The balloon size between 2 & 3 times the diameter of the stenosed segment Primary therapy for long-standing venous lesions - intravascular stents RF energy with covered stents may allow the recanalization of even completely obstructed venous structures Results of central venous stent implantations - excellent. No adverse reactions or long-term complications of the stents Venous restenoses when stents were overdilated

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41 Conclusion Treatment of choice in many conditions Evidence to prove superiority over Sx is lacking No randomised Trials, only institutional series More dedicated hardwares are required Number of centres offering expert Rx increased recently

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