Percutaneous Structural Interventions in Adult Congenital Heart Disease: State-of-the-Art Review

Abstract

Structural interventions play a crucial role in the management of adult congenital heart disease (ACHD). In recent years, this field has seen significant advancements in catheter-based procedures despite limited investment from industry and lack of device development specific to this population. Because each patient is unique in their anatomy, pathophysiology, and surgical repair, many devices are used off-label with a "best fit" strategy. Therefore, continuous innovation is needed to adapt what is available to ACHD and to increase collaboration with industry and regulatory bodies to develop dedicated equipment. These innovations will further advance the field and offer this growing population less invasive options with fewer complications and faster recovery times. In this article, we summarize some of the contemporary structural interventions performed in adults with congenital defects and present cases performed at Houston Methodist to better illustrate them. We aim to offer a greater understanding of the field and stimulate interest in this rapidly growing specialty.

Keywords: adult congenital heart disease; percutaneous interventions; structural heart disease.

Figure 1

Patent ductus arteriosus (PDA) closure. (A) Angiography demonstrating 5.5-mm calcified PDA. (B,C) Amplatzer 10-8 Occluder (Abbott) with aortic disc in descending aorta with aortography demonstrating no further shunting. (D) Stable position of PDA occluder device following release.

Figure 2

Patent foramen ovale (PFO) occlusion. (A) Amplatzer PFO Occluder with left disc deployed in left atrium. (B) Right disc deployed against right atrium. (C) Amplatzer PFO Occluder deployed. (D) Lateral view of Amplatzer PFO Occluder in place.

Figure 3

Three-dimensional reconstruction of computed tomography angiograms. (A) Coarctation of the aorta at aortic arch preintervention (triangle showing calcified coarctation). (B) Postintervention view with covered stent in place (arrow showing stent).

Figure 4

Aortic coarctation angioplasty. (A) Pre-stent angiography demonstrating coarctation of aortic arch. (B) Expansion of inner balloon during angioplasty with Cheatham platinum covered stent 24 mm × 3 cm. (C) Full deployed stent with significant waist due to calcified coarctation. (D) 24 × 4 Atlas Gold balloon (Becton, Dickinson and Company) used for post-dilation. (E) Post-stent digital subtraction angiography demonstrating patent stent with no residual stenosis, dissection, or extravasation.

Figure 5

Right ventricular outflow tract and valvuloplasty. (A,B) Hancock bioprosthetic valve (Medtronic) with previous Melody valve (Medtronic). (C) Valvuloplasty and deployment of Palmaz 3110 XL stent (Cordis) with NuMED balloon-in-balloon device (NUMED, INC). (D) Post-dilation using Atlas Gold balloon {Becton, Dickinson and Company).

Figure 6

Cardiac magnetic resonance imaging post scimitar repair showing the scimitar vein baffle draining into the left atrium through a surgically created atrial septal defect (ASD). (A) Left atrium; (B) surgical ASD. Arrow: scimitar vein baffle

Figure 7

Intervention for stenosis of reattached right pulmonary vein in scimitar syndrome. (A) Venography demonstrating stenotic right pulmonary vein. (B) Inflation of Medtronic drug-eluting balloon. (C) Post-intervention with Genesis Palmaz 29- × 10-mm stent (Cordis).

Figure 8

Fontan fenestration closure. (A) Left disc of 4-mm Amplatzer ventricular septal defect closure device deployed in common atrium (triangle). (B) Right disc now also deployed in Fontan (arrow). (C) Intracardiac echocardiography showing device deployment (arrow) across fenestration from common atrium (star) to Fontan (x).

Figure 9

Percutaneous pulmonary valve replacement. (A) Anterior-posterior view of Edwards Alterra pre-stent in right ventricular outflow tract. (B) Lateral view of Alterra. (C) AP view of Edwards SAPIEN 3 valve deployed in Alterra. (D) Lateral view of SAPIEN 3 valve in position.

Figure 10

Bioprosthetic tricuspid valvuloplasty. (A) 26-mm Vida valvuloplasty balloon inflated showing 20.6 mm at waist. (B) 28-mm True balloon inflated for intentional value fracture (green markers showing landmarks created using 2D/3D registration from computed tomography angiography). (C) Post valve fracture measurement with improvement. (D) SAPIEN 3 Ultra 26-mm valve successfully deployed.