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Pediatric cardiac catheterization Part 2 - device procedures David Shim, MD The Heart Center Children s Hospital Medica

Devices.

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Pediatric cardiac catheterization Part 2 - device procedures David Shim, MD The Heart Center Children s Hospital Medica

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    1. Pediatric cardiac catheterization Part 2 - device procedures David Shim, MD The Heart Center Children’s Hospital Medical Center Cincinnati, Ohio

    2. Devices “a piece of equipment designed to perform a special function” (Noah Webster) “contrived”, “fanciful” quickly evolving with new uses for old ideas careful patient selection endothelialization of device

    3. Pediatric interventional catheterization diagnosis redirected from catheterization suite to the echocardiography suite therapy redirected from the surgical suite to the catheterization suite neonatal caths (Shim et al, 1999) 1984-5 - 18% interventional (BAS) 1994-5 - 38% varied interventions (p=0.003)

    4. Coil occlusion of the persistently patent ductus arteriosus

    5. Coil occlusion of the persistently patent ductus arteriosus

    6. Coil occlusion of the persistently patent ductus arteriosus

    7. Methods left heart catheterization with aortogram measure “minimum ductal diameter” coil selection: helical diameter at least twice the ductal diameter and enough length to produce 3-4 loops intravenous antibiotics at time of coil delivery and oral antibiotics for 24-48 hours SBE prophylaxis for 6 months following documented complete occlusion and indefinitely if residual shunt Coil occlusion of the persistently patent ductus arteriosus

    8. Coil occlusion of the persistently patent ductus arteriosus

    9. Complications coil embolization 16.0% pulmonary artery PDA systemic artery failure to implant coil 5.0% coil embolization not retrieved 2.3% vascular injury 2.0% fever 0.5% Coil occlusion of the persistently patent ductus arteriosus

    10. Results Moore et al, 1994, 80% immediate success and 90% long-term success in 30 patients Shim et al, 1996, 58% immediate success and 87% at 20 months in 75 patients PDA coil registry, 77% immediate success in 800 patients and 93% long-term success in 577 patients with follow-up Coil occlusion of the persistently patent ductus arteriosus

    11. Indications Conditions for which there is general agreement that coil occlusion is appropriate: aortopulmonary collaterals with dual supply small PDA (<4.0 mm) surgical aortopulmonary shunts intrapulmonary arteriovenous fistulas anomalous venovenous connections (esp s/p Glenn or Fontan procedure) Coil embolization therapy

    12. Indications (continued) Conditions for which coil occlusion may be indicated: moderate PDA (4-7 mm) clinically silent PDA coronary arteriovenous fistulas Conditions for which there is general agreement that coil occlusion is inappropriate: AP collateral w/o dual supply nonrestrictive PDA (VSD) Coil embolization therapy

    13. Complications occlusion of wrong vessel embolization of coil pulmonary infarction subtotal vessel occlusion hemolysis infection Coil embolization therapy

    14. Device occlusion of atrial septal defects Historical perspective King and Mills, 1976, occluded 5/10 ASD with an interlocking double-umbrella device made of stainless steel and Dacron via 22 Fr sheath Rashkind ASD occluder, 1987, single umbrella with 3 barbed hooks Clamshell septal occluder, 1989, double umbrella design placed in over 800 patients

    15. Device occlusion of atrial septal defects Indications Clinical right ventricular volume overload paradoxical embolism Investigational single secundum ASD sufficient rim of septum

    16. Device occlusion of atrial septal defects Investigational devices Angel wings ASDOS Clamshell (Cardioseal) Buttoned device Amplatzer device Helex device

    17. Device occlusion of atrial septal defects Amplatzer, 1997 2 round disks made of nitinol mesh which are connected directly by a short connecting waist 6-7 French venous advantages self-centering extremely retrievable disadvantages high profile device

    18. Device occlusion of atrial septal defects Methods balloon “sizing” of atrial septal defect (ie, stretched diameter) antibiotics/heparin device deployment under TEE oral antibiotics for 24 hours and ASA (3-5 mg/kg) for 3 months

    19. Device occlusion of atrial septal defects Results Taeed, 2000, 100% complete occlusion at one year follow-up in 18 patients

    20. Stents Historical perspective Dotter and Judkins, 1964, discussed the “temporary use of a Silastic endovascular splint” Dotter, 1969, implanted tubular coil-spring endovascular prostheses to support previously dilated arteries Palmaz and Schatz, 1985-87, used a stainless steel mesh stent in numerous vessels

    21. Stents Indications Conditions for which there is general agreement that stenting is appropriate: pulmonary artery stenosis superior or inferior vena caval stenosis systemic venous obstruction at the superior or inferior baffle limb after atrial repair of transposition

    22. Stents Indications (continued) Conditions for which stenting may be indicated: stenotic RV to PA conduit stenotic aortopulmonary collateral vessels coarctation of the aorta PDA in infants with ductal-dependent pulmonary or systemic flow Conditions where stenting is inappropriate: pulmonary vein stenosis

    23. Stents

    24. Future pediatric interventions stent valves VSD closure devices absorbable stents percutaneous aortopulmonary shunts ethanol ablation for hypertrophic cardiomyopathy

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