PROF. DR. ALPAY ÇELIKER

Complication is destiny of the every pediatric cardiologist who is working at interventional area.

Patient related Intervention related Operator related Catheter & device related Miscellaneous

Age and BW Severity of

underlying heart disease

Previous intervention and operation

General status of the patient

• Heart Failure• Hypoxia• Acidosis• Electrolyte imbalance• Bleeding diathesis• Neurologic status• Other conditions related with syndromic patients

Type of InterventionDuration of interventionDifficulty of procedure

Supply of Needed DevicesEnough number and typeAppropriate alternativesBeware of “reuse” catheters

and devices

First and second operatorExperince levelCompetence at alternative

methods

AnesthesiaIntervention familiar

EchocardiographistCompetent associated personal:

Nurse, technicianSurgical back-up when needed

Not appropriate“Reuse”Not indicated Very stiff or floopy; short-long, small

internal diameter Newer catheter and devices

Relatively safe; but carries risk at small ages/body weight; and bad hemodynamic condition

May occur any phase from the beginning to a few weeks

Small age and body weight Complex procedures Severe underlying heart disease

•Large VSD in an infant•Hybrid procedures•Patients at CICU

Beginners may have more complications Personal first interventions Beginning of a new method

More experience may lead less complications.

High degree difficulty regarding the

Manipulation Imaging Alternative routes

Unique complications Rhythm problems Semilunar (aortic valve) regurgitation Av valve (Tricuspid>mitral) LV perforations

Preoperative planning Previous operations & interventions Latest clinical&echocardiographic evaluation

(>1 week) Indivudialized planning for each patient Continuous monitoring for the

complications Do not lean any body (including nurses and

anesthesia team) Intervene before the final phase of the

complication Prepare to solve for the possible

complications at the cath lab.

Brachial plexsus injury

Usually temporary Treatment: Time and physical rehabilitation

May occur direct puncture, local anesthesic infiltration

Specifically in small kids Stiff and large catheters and sheaths Vigorous and uncontrolled manipulation

Close follow-up during manipulation Correct equipment/technique and

meticulous work

Inadvertent catheterization of coronary arteries

Emboli (air, clot) at coronary circulation

Sinus bradicardia: May occur secondary to catheter manipulation, anesthesia >>> controlled respiration, atropine IV

Bundle branch blocks: Catheter or wire travma to the conduction system

Tachycardia (VT>SVT)

Stop the catheter movement or pull back

Pullback or reposition the

catheter

Kardiyoversiyon 0.5 joule/kg

Complete AV block

Catheter/wire/ sheath/ device trauma to the conduction system

It is very important since it may be related with the early or late permanent AV block

Pull-back or reposition the catheter. If it recurs with unforced and appropriate catheter manipulation consider to abandone the procedure

Blood loss, anemia, shock Hemolysis Hypotermia Hypoxia, acidosis Allergic reactions Malign hypertermia Infection

The most common reasons are incorrect device size/type selection and imaging problems

May cause hemodynamic problems LV, RV, ascending aorta

Percutaneous extraction tolls should be on the shelf

Surgical backup may be needed

General Measures: Hemodynamic status Cardiac rhythm Blood and blood products Surgical backup Another cardiologist (if needed)

Equipment Sheaths Snares Bioptome Various catheters

Gooseneck Snare

Endomyocardial Biopsy Forceps

Embolization site is very important Echocardiographic imaging is very important

ıf embolizations would occur to the ventricles. Generally, there is no rhythm problems, and

hemodynamic deterioriation at aortic and pulmonary embolization

Planning of device capture and extraction route

Always monitor the arterial pressure

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> 2F form the delivery sheath

Braided sheaths should be used

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Must have appropriate inner lumen diameter/lenght for the capture device/snare

High torque capability. Longer than the sheath Usually Judkins right coronary artery

catheter

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Capture of the device Devices embolized to the ventricles should be

expelled to the great vessels to prevent AV valve chordae or semilunar valve damage.

Device should be catched from the delivery hub One may try to capture the delivery hub as

proximal as possible to facilitate to extraction Pullback of the device inside the sheath

Do not move the device before the pullback of the device inside the sheath

If there would be a diffculty for pulbback one can move the catheter very cautiously.

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Detailed history, clinical, laboratory, ECHO, , catheter and surgical data of the patient

Anticipate the possible complications Usage of appropriate equipment Do not force the catheter, test injections Continuous monitoring for the complications Working careful and patience Knowing how do you solve the complication.

• Every effort should be instituted to prevent complications

• This measures may be paramount importance in sick/small children

Prepare for unexpected complications in every patients.

Appropriate equipment and surgical back-up is very important to manage the complications.