interventional cath to treat achd

7/30/2019 Interventional Cath to Treat ACHD

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Interventional Catheterization

to treat Adults with

Congenital Heart DiseaseDanyal Khan, M.D, FACC, FAAP, FSCAI

Pediatric Interventional Cardiologist

Miami Children's Hospital


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Congenital Heart Disease (CHD)

Occurs in 1 in 120 newborns

Commonest congenital problem

Operative mortality is about 2% at themajor centers

Approximately 800,000 children in USA

with CHD


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Adults with Congenital Heart

Disease (ACHD)

10% of CHD is diagnosed in adulthood

In USA, there are more adults than

children with CHD

1 million adults in USA with CHD


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Historical Perspective

Heart surgery-1940s

Open heart surgery-1960s

First therapeutic catheterization-1953

Last Decade

Advanced fetal diagnosis

Explosion of interventional cath procedures

Introduction of minimally invasive surgical techniques Near extinction of the inoperable patient

Cardiac transplantation and immunosuppression


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Surgery

Interventional Catheterization


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Types of CHD

ACYANOTIC HEART

DISEASE

Pulse oximetry

normal Left to Right Shunt

Usually not

symptomatic at birth

CYANOTIC HEART

DISEASE

Pulse Oximetry may

be low Right-to-Left Shunt

Usually presents at

young age


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ACYANOTIC

HEART DISEASE

ASD

VSD

PDA

AV Canal

PS

Coarctation of the Aorta

LVOT Obstruction

CYANOTIC

HEART DISEASE

Tetralogy of Fallot

Transposition of the greatarteries

Tricuspid Atresia

Total anomalouspulmonary venous return

Tricuspid Valve, Ebsteinsanomaly

Pulmonary Atresia/VSD

Pulmonary Atresia/ IntactSeptum

Hypoplastic Left HeartSyndrome


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Adult CHD

Atrial Septal Defect (ASD)

Patent Foramen Ovale (PFO)

Coarctation Pulmonary Regurgitation


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Atrial Septal Defect

5-10 % of Congenital Heart Disease

Male : Female ratio = 1:2

Types Secundum (50-70%)

Primum

Sinus Venosus Coronary Sinus ASD


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Atrial Septal Defect

Left to Right shunt

Asymptomatic in childhood

Causes dilation of Right Atrium & Ventricle Causes symptoms in adulthood

Chest pain

Palpitations Decreased Exercise tolerance


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Diagram

S d ASD


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AORTA

Deficient antero-

superior rim

Central defect

Deficient inferior

rim

Secundum ASD

Anatomic Sub-types

Multi-fenestrated

Deficient posterior

rim

Multiple

Multiple


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Case - ASD

52 year old lady with c/o SOB & Palpitations

EKG incomplete RBBB

CXR Cardiomegaly

Echo- Severe Pulm HTN, Marked RA & RV

dilation, Severe TR

O/E- Sats 94%, decreased to 84% with exertion

Fixed split & loud S2, Flow Murmur Early clubbing & cyanosis


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Cardiac MRI

Pulmonary artery dilation


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Heterotaxy

Stomach

Transverse

Liver

No IVC


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Management

Diagnostic Cath

Treated with Oxygen via nasal cannula &

Revatio (sildenafil)

After 3 months repeat cath


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Amplatzer Device Closure


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Cardiac Cath


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Interrupted Inferior Vena Cava

IVC

IVC

SVC

RA

Azygous

Vein


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IntraCardiac Echo


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Hepatic Access


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ICE Catheter

Wire


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ASD - Echo


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ASD IntraCardiac Echo


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ASD Device


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Left disc deployment


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Left Disc


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Right Disc deployment


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Right Disc


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Device released


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18mm Amplatzer ASD Device


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Hepatic Vein- occluded with

Vascular Plug


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PFO

In Fetal circulation, presence of a PFO is

essential

PFO usually closes within the first two weeks

of life Persistant PFO is present in more than 25%

of adults


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No. 1 cause of serious disability and morbidity

Sacco RL, et al. Stroke1997

0

5

10

15

20

25

30

Heart Cancer Stroke

Causes of Death

STROKE3rd Leading Cause of Death


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Ann Neurol. 1989;25:382-90

STROKE VICTIMS

43%

PREVALENCE OF PFO IN CRYPTOGENIC STROKE

Prevalence

ofP

FO(%)

Prevalence

ofP

FO(%)

Cryptogenic Stroke

Cryptogenic Stroke

Cruz-Gonzalez I, 2009

Expert Rev Cardiovasc Ther

PFO Rates

Cryptogenic Stroke


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2.50.451.10000

26

7.1

3.25.4

0.601.90

0

10

20

30

Lausanne

(1996)

Mas2

001:(PFO

only)

DeCa

stro2

000

Mas2

001:(PFO

andA

SA)

PICS

S(2002)

Sievert(

2002)

Cujec

(surgery)

Devuyst1

966(

surgery)

Lock

(1998)

Meier

(2000)

USMultice

nter(2002)

Palac

ios(2002)

Sievert(

2002)

%o

fRecurre

ntStokeRates

MEDICAL THERAPY DEVICE CLOSURE

PFO Closure vs. Medical Therapy

REGISTRY DATA


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7.07

2.71

0

2

4

6

8

Medical

Therapy

Device

Closure

%A

djusted1YrStroke-TIA

PFO Closure vs. Medical Therapy

Landzberg Heart 2004

20 studies n=2250

5.55

4.86

2.95

0

2

4

6

8

Surgery Medical

therapy

Device

26 studies n=2534

Homma Circulation 2005

5.2

1.3

0

2

4

6

8

Medical

Therapy

Device

Closure

Whrle Lancet 2006

20 studies n=3014

Events/100patientyears

%1YearRecurrentStrokeorTIA


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PFO & Stroke

PFO are more common in patients who

have strokes or TIAs

No RCTrial has found that closure of

PFOs reduces the incidence of stroke or

death

AAN, AHA, ACC state that the benefit of

device closure therapy remains unknown


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Right-to-Left Shunt (PFO)


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To close or not to close ?


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(My) Indications for PFO Closure

Cryptogenic stroke

Rule out other obvious cause (Lipid profile,

BP, CRP, Carotid Doppler US,

HyperCoagulability w-up)

PFO with bidirectional or Right-to-Left

Shunt (on bubble study)

Age less than 55 yrs

Look for Atrial Septal aneurysm

ASD/PFO O l i D i t


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ASD/PFO Occlusion Devices at

MCH

CardioSEAL

Amplatzer

HELEX


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Case # 1

14 year old girl, who was in a car accident

and suffered a left tibial fracture

Patient was neurologically normal after the

accident

36 hours later had a stroke

TTE PFO. Bubble study positive

Confirmed with transcranial doppler

PFO closed with Sideris Button device


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Case # 2 (AS)

17 year old girl with c/o palpitations and

has had two episodes of TIA (right sided

hemiparesis + dysarthria)

Holter non sustained wide QRS

tachycardia

EPStudy no inducible Vent Tachycardia

TTE Bubble study positive

Hypercoagulability w-up: negative


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Helex


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Balloon Sizing


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Balloon Sizing


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Helex implanted


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Helex released


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ICE Image - Helex


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Case # 3 (CA)

55 yr old gentleman.

h/o two episodes of TIA

Carotid u/s normal

Hypercoag w-up Negative

No HTN or HyperLipidemia

TTE: Atrial Septal Aneurysm + PFO(positive bubble study)


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PFO


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Wire across PFO


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Balloon Sizing 14-16mm

CardioSEAL septal occluder


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CardioSEAL septal occluder

28mm


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CardioSeal snared


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Amplatzer Septal Occluder 16mm


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Amplatzer Septal Occluder 20mm


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Both disks deployed


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Final Result


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Coarctation of Aorta

8-10% of Congenital Heart Disease

Male:Female ratio = 2:1

Turners syndrome 30% incidence

85% incidence of Bicuspid Aortic Valve

Most patients present in infancy &

childhood


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Coarctation of Aorta (CoAo)

First described 1760 by Morgagni

Currently 3 modes of treatment

Surgery infants Balloon angioplasty children

Stent implantation - adults


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Coarctation in Adults

Presentation

Hypertension resistant to therapy

CXR rib notching due to collaterals

Diagnosis

BP difference between arm & leg

Echo

MRI/CT


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Case - Coarctation

21 year old with h/o Coarctaton

Repaired in infancy

c/o Hypertension 140/90

Echo coarctation with 30 mm Hg

gradient


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Cath Angiogram


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Cath Angiogram


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Cath Angiogram


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Cath Angiogram


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Cath Angiograms


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Cath Angiograms


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Cath Angiograms

C


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Cath Angiograms

Aneurysm

C d S


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Covered Stent

Fi l R lt


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Final Result

C


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Case

22 year old lady, h/o Tetralogy of Fallot

VSD closure + RV to PA homograft

Has had Aortic Valve replacement

23mm St Jude Valve

c/o decreased exercise tolerance

Echo

Severe pulmonary regurgitation

Right ventricular dilation & dysfunction

P l I ffi i


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Pulmonary Insufficiency -

The Problem Pulmonary insufficiency is common after rightventricular outflow tract reconstruction Tetralogy Fallot, Pulmonary atresia, Truncus

arteriosus Results in RV volume load

Exercise intolerance

Arrhythmia

Heart failure Traditional Rx

Surgical valve placement

Th S l ti


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The Solution

Pulmonary Valve Implantation


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Pulmonary Valve ImplantationThe Solution

Bonhoeffer P, et al, England

Bovine (cow) jugular

venous valve

CP stent mounted 18-22 mm balloon

Femoral vein access

Currently 22Fr system

Transcatheter Pulmonary Valve


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Transcatheter Pulmonary Valve

Implantation

RV

PA

M l d V l


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Melody Valve

E bl D li S t


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Ensemble Delivery System

M l d V l D l t


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Melody Valve Deployment

E h P l R it ti


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Echo Pulmonary Regurgitation

C th A i


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Cath Angiograms

Cath Angiograms


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Cath Angiograms


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Cath Angiograms


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Cath Angiograms

Balloon Angioplasty


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Balloon Angioplasty

Stenting the Pulmonary Valve


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Stenting the Pulmonary Valve

Stent


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Stent

Melody Valve


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Melody Valve

Melody Valve inner balloon


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Melody Valve inner balloon

Melody Valve outer balloon


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Melody Valve outer balloon

Melody Valve in place


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Melody Valve in place

No Pulmonary Regurgitation


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No Pulmonary Regurgitation


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Thank you


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interventional cath to treat achd

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