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Devices.
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1. Pediatric cardiac catheterizationPart 2 - device proceduresDavid Shim, MDThe Heart CenterChildren’s Hospital Medical CenterCincinnati, 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