Interventional Cardiology for Congenital Heart Disease

Abstract

Congenital heart interventions are now replacing surgical palliation and correction in an evolving number of congenital heart defects. Right ventricular outflow tract and ductus arteriosus stenting have demonstrated favorable outcomes compared to surgical systemic to pulmonary artery shunting, and it is likely surgical pulmonary valve replacement will become an uncommon procedure within the next decade, mirroring current practices in the treatment of atrial septal defects. Challenges remain, including the lack of device design focused on smaller infants and the inevitable consequences of somatic growth. Increasing parental and physician expectancy has inevitably lead to higher risk interventions on smaller infants and appreciation of the consequences of these interventions on departmental outcome data needs to be considered. Registry data evaluating congenital heart interventions remain less robust than surgical registries, leading to a lack of insight into the longer-term consequences of our interventions. Increasing collaboration with surgical colleagues has not been met with necessary development of dedicated equipment for hybrid interventions aimed at minimizing the longer-term consequences of scar to the heart. Therefore, great challenges remain to ensure children and adults with congenital heart disease continue to benefit from an exponential growth in minimally invasive interventions and technology. This can only be achieved through a concerted collaborative approach from physicians, industry, academia and regulatory bodies supporting great innovators to continue the philosophy of thinking beyond the limits that has been the foundation of our specialty for the past 50 years.

Keywords: Congenital; Pulmonary valve replacement; Stenting; Transcatheter.

Figure 1

Series of images outlining retrograde perimembranous VSD closure via a left common carotid cutdown in a 6.8 kg infant. (A, B) Patient positioning with feet pointing towards the head of the table to facilitate access to the left common carotid artery. (C) Insertion of 7 Fr short sheath following left common carotid cutdown. (D) Transesophageal echocardiography image demonstrating a 10 mm Occlutech membranous VSD occluder across the VSD. (E, F) Final LV and ascending aortic angiogram confirming the VSD device in position without residual leak or aortic incompetence. LV = left ventricular; VSD = ventricular septal defect.

Figure 2

Series of images demonstrating transcatheter VSD closure in a patient with prolapse of the RCC of the aortic valve. (A) LV angiography demonstrating a moderate sized perimembranous VSD (white arrow). (B) Initial aortography demonstrating RCC prolapse (white arrow). (C) Short axis TOE image confirming the defect. (D) TOE image following deployment of 10 mm Lifetech eccentric membranous VSD occluder using a deflectable sheath to deploy from the LV cavity. (E) Final aortogram confirming no aortic incompetence and buffering of the RCC prolapse with the VSD device (white arrow). (F) Final colour Doppler TOE image in the short-axis confirming no residual leak across the ventricular septum. LV = left ventricular; VSD = ventricular septal defect; RCC = right coronary cusp; TOE = transoesophageal echocardiography; VSD = ventricular septal defect.

Figure 3

Series of images demonstrating transcatheter pulmonary valve replacement with Venus P valve in a patient with a previous transannular patch. (A) Initial MPA angiogram in the lateral projection confirming a dilated RVOT with free pulmonary incompetence. (B) Balloon sizing demonstrated waisting at 33 mm. (C) Angiography with valve deployment within the left pulmonary artery. (D) Post valve deployment angiography in the main pulmonary artery confirming valvar competence. (E) En-face view of the valve demonstrating near circularity of the valve with no distortion of the aorta seen with aortic angiography. (F) Transthoracic echocardiography with color Doppler confirming no pulmonary incompetence. MPA = main pulmonary artery; RVOT = right ventricular outflow tract.

Figure 4

Series of images demonstrating transcatheter creation of a reverse Pott's shunt. (A) Initial simultaneous angiography in the descending aorta and main pulmonary artery confirming the proximity of the dilated left pulmonary artery to the descending aorta (white arrows). (B) Deflectable sheath used to advance RF wire (white arrow) towards goose-neck snare in the pulmonary artery. (C) Repeat simultaneous angiography in the descending aorta and pulmonary artery demonstrating separation of the 2 vessels following RF perforation (white arrows). (D) Aortic angiography following implantation of 10×37 mm covered stent and post dilation with 14 mm balloon (white arrow). (E) Pulmonary artery angiography demonstrating right-to-left shunt across the newly created reverse Pott's shunt (white arrow). RF = radiofrequency.

Figure 5

Cartoon illustrating possible future strategies for the surgical management of newborns with CHD. If CHD is diagnosed prenatally, fetal cells may be harvested and iPS generated; as an alternative, umbilical cord stem cells can be isolated at the time of birth. When diagnosis of CHD is made after birth or in babies who require a palliative surgical operation soon after birth, stem cells may be isolated from surgical cardiac leftovers. All these types of cells will allow the generation of a tissue-engineered graft endowed with growth and remodeling potential, necessary for the definitive correction of cardiac defects. Taken from Avolio et al. CHD = congenital heart disease; iPS = induced pluripotent stem cells.