Nonsurgical Cardiac Interventions in Children

Dr Anil S.R

Consultant Pediatric Cardiologist

MIMS, Calicut

Estimates of Congenital Heart Disease (CHD) Prevalence Among Live-born

Infants in India*

• Total CHD at birth ~130-270,000• Critical CHD (requiring intervention in infancy):

~ 80,000• Infant mortality: India- 63/ 1000

Kerala- 13/ 1000 Andhrapradesh-33/1000

• CHD mortality as a fraction of infant mortality: 3-20% (10-12% in AP?)

*Based on available data of CHD prevalence at birth in developed countries and present birth rates in India

Timing for CHD

• Early correction of congenital heart disease is desirable because it avoids a number of adverse cardiac, neurodevelopment and other consequences

• Early correction of a variety of congenital heart lesions is feasible and realistic with excellent results in most of the developed nations and selected Indian centers

What Happens if Congenital Heart Disease is Untreated?

• Majority of them succumb to death in infancy and early childhood

• The rest live a turbulent and truncated life

Timing of Intervention in CHD

• Surgical intervention• Trans-catheter intervention

Congenital Heart Disease:

RV LV

PA

MPA

Ao

AoPA

Pediatric Cardiac Interventions

1960s: Rashkind Balloon Septostomy

1970s: King and Mills ASD

Device, Rashkind PDA occluder

1980s: Balloon valvotomy

1990s: Devices, coils and stents, RF wire

2000…: Implantable valves, Percutaneous PA band, Percutaneous shunts, Transcatheter Fontan, transcatheter gene therapy

60s

80s

90s

2000…

Interventions in CHD: Well Accepted

• Coil and device closure of PDA*• ASD device closure*• Coil / device closure of coronary cameral

fistulas• Balloon dilation / stenting of native

coarctation in older children and adults• Balloon dilation / stenting of baffle obstruction• Static balloon dilation of atrial septum

Interventions in CHD: Performed in Few Selected Centers

• VSD device closure• Recanalization (laser/RF assisted) of

valvar pulmonary atresia• RVOT dilation for TOF• Stenting of PDA • Balloon dilation and stenting of conduits• Closure of paravalvar leaks

Transcatheter PDA Closure

Patent Arterial Duct: Transcatheter Closure

Ao

LPA

Ampulla

The High Parasternal or “Ductal View”

MPA

Ao

The two small white arrows indicate the points where the duct is measured at its PA insertion. The white line indicates the ampulla.

Methods: Echo Assessment

Duct diameter at PA insertion defined by echo in the high parasternal view

MPA

LPAA

mpulla

PDA Coil Closure; Closure of Large Ducts Using Coils

AortaPulmonaryArtery

Coil Closure of a Patent Arterial Duct

Bioptome-assisted Single Coil Delivery

The Amplatzer PDA Occluder

• Greater ease, better control and precision during deployment

• Size of the duct and shape of the duct is less of an issue (as against coils)

• Concerns regarding protrusion of parts of the device in the aorta or PA

• Some reluctance to use the device < 4-5 kg

5.4mm PDA: Device 10mm/8mm

PDA Closure

• Most PDAs can potentially be closed in the catheterization lab

• The role of surgery is now essentially limited to large ducts with short ampullae in small infants

• There is scope for further improvements in the coil / device technology

Case Scenario DAY-2

Deep Cyanosis

Critical PS

Stabilized on PGE1

Underwent BPV

Case Scenario DAY-3• Persisting Cyanosis

• On Ventilator-

• ABG-pO2 23mmHg

• PGE1-Max Dose

• Echo

No residual PS

PDA, L-R

ASD, R-L

What Next ???

Day 5

Day 5

Day 5

Day 5

Day 5

Transcatheter ASD Closure

TEE, horizontal plane

TEE, vertical plane

The STARFlex Device

The Amplatzer Device

The Gore Helex Device

• All fossa ovalis type defects < 30 –35 mm with at least 5 mm margin all around (except anterior margin which can be absent altogether): 40-60% of all fossa ovalis ASDs

• Stricter criteria for younger children• “Safe” distance from mitral valve,

pulmonary vein, coronary sinus, SVC

Transcatheter ASD Closure: Scope (Amplatzer ASD

occluder)

Transcatheter VSD Closure

nishant

Chenna raja

Sai teja

Sai teja

Conclusions

• Today, by just stretching, tearing and plugging alone 20-30% of children with CHD can be treated in the cath lab

• The future is exciting because we are the threshold of going beyond the paradigm of “stretching, tearing and plugging”– Creation of new channels: covered stents, special

devices– Transcatheter gene therapy, biodegradable

devices