RESUMEN

Perimembranous ventricular septal effects (PMVSDs) are the most common congenital cardiac defects of clinical importance. During the last decade, transcatheter closure of PMVSDs has been attempted using various occluders with variable success. This article reviews the existing literature and our experience with transcatheter closure of PMVSDs with the new Amplatzer occluder device.

Asunto(s)

Asunto(s)

RESUMEN

OBJECTIVES: To present further experience and intermediate term outcome in 30 patients with single muscular ventricular septal defects (MVSDs) who underwent transcatheter closure with the Amplatzer ventricular septal defect occluder (AVSDO). PATIENTS AND DESIGN: Thirty patients, aged 4 months to 16 years, with MVSDs underwent transcatheter closure with the AVSDO. The device consists of two low profile disks made of Nitinol wire mesh with a 7 mm connecting waist. The prosthesis size (waist diameter) was selected to be equal to the balloon "stretched" diameter of the defect. A 7-9 French sheath was used to deliver the AVSDO. Fluoroscopy and transoesophageal echocardiography guided the procedure. RESULTS: The stretched diameter of the defects ranged from 6-14 mm. The communication was completely occluded in 28 of 30 patients (93% closure rate). One patient (a 4 month old infant) with sustained complete left bundle branch block after the procedure went on to develop complete heart block one year later. No other complications were observed during a mean follow up of 2.2 years (range 0.25-4.5 years). CONCLUSIONS: The AVSDO is an efficient prosthesis that can be safely used in the majority of patients with a single MVSD. Further studies are required to establish long term results in a larger patient population.

Asunto(s)

RESUMEN

OBJECTIVE: To close perimembranous ventricular septal defects (PMVSDs) in children with the new Amplatzer asymmetric ventricular septal defect occluder (AAVSDO). PATIENTS AND DESIGN: 10 children, aged 1.5-12 years, with PMVSDs underwent transcatheter closure with the AAVSDO. The device consists of two low profile disks made of Nitinol wire mesh with a 1.5 mm connecting waist. The left disk is 5 mm towards the apex and only 0.5 mm towards the aortic valve. The right disk is 4 mm larger than the waist. The prosthesis diameter was chosen to be 1-2 mm larger than the largest diameter of the defect (determined by transoesophageal echocardiography and angled angiocardiography). A 7-8 French gauge sheath was used to deliver the AAVSDO. RESULTS: The PMVSD diameter ranged from 2-8 mm. The device diameter ranged from 4-8 mm. After deployment of the prosthesis there was no residual shunt in 9 of 10 patients (90%). In one patient there was a trivial residual shunt that disappeared at the three month follow up. Three patients developed transient complete left bundle branch block. No other complications were observed. CONCLUSIONS: The AAVSDO appears to be a promising device for transcatheter closure of PMVSDs in children. Further studies are required to document its efficacy, safety, and long term results in a larger patient population.

Asunto(s)

RESUMEN

BACKGROUND: The design of devices currently used for closure of persistent ductus arteriosus (PDA) with high pulmonary artery pressure is not ideal and there is a risk of embolisation into the aorta. OBJECTIVE: To investigate the use of the Amplatzer muscular ventricular septal defect occluder (AMVSDO) for treatment of PDA with high pulmonary artery pressure. PATIENTS AND DESIGN: Seven patients, aged 5-12 years, with large PDAs and systemic or near systemic pulmonary artery pressure underwent attempted transcatheter closure using the AMVSDO. The device consists of two low profile disks made of a nitinol wire mesh with a 7 mm connecting waist. Balloon occlusion of the duct was performed before closure from the venous side, and prosthesis size was chosen according to the measured diameter of the occluding balloon. A 7 French sheath was used to deliver the device. All patients underwent a complete haemodynamic and angiographic study one year after occlusion. RESULTS: The mean (SD) angiographic PDA diameter was 9.8 (1.7) mm (range 7-13 mm) and the mean AMVSDO diameter was 11.4 (1.8) mm (range 9-16 mm). Q(p)/Q(s) ranged from 1.9-2.2 (mean 2.0 (0.1)). Successful device delivery and complete closure occurred in all patients (100% occlusion rate, 95% confidence interval 59.04% to 100.00%). Mean systolic pulmonary artery pressures were as follows: before balloon occlusion, 106 (13) mm Hg; during occlusion, 61 (6) mm Hg; immediately after the procedure, 57 (5) mm Hg; and at the one year follow up catheterisation, 37 (10) mm Hg. Fluoroscopy time was 10.4 (4.3) min (range 7-18 min). No complications occurred. CONCLUSIONS: AMVSDO is an important adjunct for closure of large PDAs associated with high pulmonary artery pressure. Further studies are required to document its efficacy, safety, and long term results in a larger number of patients.

Asunto(s)

RESUMEN

Between May 1997 and June 2000, 69 patients, ages 0.1 to 34 years, underwent attempted anterograde transcatheter closure of a patent ductus arteriosus (PDA) using the Amplatzer Duct Occluder (ADO). The ADO is a cone-shaped, self-centering, and repositionable occluder made of nitinol wire mesh. A 5Fr to 7Fr sheath was used for the delivery of the device. The mean PDA diameter (at the pulmonary end) was 4.6 +/- 1.9 mm (range 1 mm-8.5 mm). Sixty-seven of the 69 patients had successful device placement. The mean ADO smallest diameter was 6.9 +/- 1.8 mm (range 4 mm-12 mm). Complete angiographic closure occurred in 62 (92.5%) of 67 patients (95% confidence interval, 88.22%-98.77%). In five patients, there was a trivial residual shunt immediately after the procedure. At 24 hours, color Doppler flow imaging revealed complete closure in all 67 (100%) patients. The unsuccessful attempts occurred in two patients with a small, 1-mm diameter native PDA and residual PDA after surgical occlusion. Fluoroscopy time was 7.6 +/- 1.8 minutes (4 min-18 min). No complications were observed. At a median follow-up of 1.5 years (range 0.25 to 3.2 years), all patients had complete closure without complications. We conclude that transcatheter closure using the ADO is a highly effective and safe treatment for most patients with PDA.

Asunto(s)

RESUMEN

Ascaris infection, when severe, may manifest with constitutional symptoms. The parasites penetrate the intestinal walls, reach the venules and lymphatics and, through the portal circulation, may affect the heart. To the best of our knowledge, involvement of the pericardium has yet to be reported. We describe here a case of severe pericardial effusion and cardiac tamponade in a child with ascariasis.

Asunto(s)

RESUMEN

OBJECTIVE: To report the initial and intermediate term results of stent implantation in children with coarctation of the aorta. PATIENTS AND DESIGN: 17 patients with coarctation of the aorta underwent stent implantation (median age 11 years, range 0.4-15 years); six were treated for isolated coarctation, nine for recurrent coarctation (five after surgical repair and four after balloon dilatation), and two for complex long segment coarctation. INTERVENTIONS: The procedure was guided by a second catheter placed transseptally in the left ventricle or the aorta proximal to the coarctation site, for angiographic and haemodynamic monitoring during the procedure. Twenty two stents were implanted in 17 patients. One of the patients with long segment coarctation received four stents and the other three. Palmaz 4014 stents were placed in 11 patients, Palmaz 308 in five, and Palmaz 154 in one. RESULTS: Immediately after stent implantation the peak systolic gradient (mean (SD)) fell from 50.0 (24.5) to 2.1 (2.4) mm Hg (p < 0.05). The diameter of the stenotic lesion increased from 5.1 (1.5) mm to 13.9 (2.4) mm (p < 0.05). There were no deaths or procedure related complications. At a median follow up of 33 months, no cases of recoarctation were identified, either clinically (0/17; 0%, 95% confidence interval (CI) 0% to 19%) or angiographically (0/13; 0%, 95% CI 0% to 25%). CONCLUSIONS: Stent implantation for the treatment of coarctation of the aorta appears to have very low morbidity and mortality, and reasonable intermediate term results. Long term freedom from recoarctation using this method remains to be determined in comparison with simple balloon dilatation.

Asunto(s)

RESUMEN

OBJECTIVE: The aim of this study was to report further experience with transcatheter closure of the patent ductus arteriosus (PDA) using the Amplatzer duct occluder (ADO). BACKGROUND: The design of previously used devices is not ideal for this purpose, and their use has been associated with several drawbacks, especially in large PDAs. METHODS: Forty-three patients, aged 0.3 to 33 years (mean 6.4+/-6.7 years), with a moderate to large, type A to E PDA, underwent attempted transcatheter closure using the ADO. The device is a plug-shaped repositionable occluder made of 0.004-in. nitinol wire mesh. It is delivered through a 5F to 6F long sheath. The mean PDA diameter (at the pulmonary end) was 3.9+/-1.2 mm (range 2.2 to 8 mm). All patients had color flow echocardiographic follow-up (6 to 24 months) at 24 h, 1 and 3 months after closure, and at 6-month intervals thereafter. RESULTS: The mean ADO diameter was 6.1+/-1.4 mm (range 4 to 10 mm). Complete angiographic closure was seen in 40 of 43 patients (93%; 95% confidence interval [CI] 85.4% to 100%). The remaining three patients had a trivial angiographic shunt through the ADO. At 24 h, color flow mapping revealed no shunt in all patients. A 9F long sheath was required for repositioning of a misplaced 8-mm device into the pulmonary artery. The mean fluoroscopy time was 7.9+/-1.6 min (range 4.6 to 12 min). There were no complications. No obstruction of the descending aorta or the pulmonary artery branches was noted on Doppler follow-up studies. Neither thromboembolization nor hemolysis or device failure was encountered. CONCLUSIONS: Transcatheter closure using the ADO is an effective and safe therapy for the majority of patients with patency of the arterial duct. Further studies are required to establish long-term results in a larger patient population.

Asunto(s)

RESUMEN

OBJECTIVES: The aim of this study was to close muscular ventricular septal defects (MVSDs) in children, with a new device, the Amplatzer ventricular septal defect occluder (AVSDO). BACKGROUND: The design of previously used devices for transcatheter closure of MVSDs is not ideal for this purpose and their use has been limited by several drawbacks. METHODS: Six patients, aged 3 to 10 years, with MVSDs underwent transcatheter closure using the AVSDO. The device is a modified self-centering and repositionable Amplatzer device that consists of two low profile disks made of Nitinol wire mesh with a 7-mm connecting waist. The prosthesis size (connecting waist diameter) was chosen according to the measured balloon stretched VSD diameters. A 6-F or 7-F sheath was used for the delivery of the AVSDO. Fluoroscopy and transesophageal echocardiography were utilized for optimal guidance. RESULTS: The location of the defect was midmuscular in five patients and beneath the pulmonary valve in one. The balloon stretched MVSD diameter ranged from 6 to 11 mm. Device placement was successful in all patients, and complete occlusion occurred in all six patients (95% confidence interval 54.06% to 100%). Two patients developed transient complete left bundle branch block. No other complications were observed. CONCLUSIONS: This encouraging initial clinical success indicates that the AVSDO is a promising device for transcatheter closure of MVSDs in children. Further clinical trials and longer follow-up are needed before the widespread use of this technique can be recommended.

Asunto(s)

RESUMEN

Anomalous origin of the right pulmonary artery from the ascending aorta (AORPA) with severe right ventricular dysfunction in a neonate was completely diagnosed by echocardiography. Cardiac catheterization was performed to explore further right ventricular dysfunction, which is extremely rare at this age. Following cardiac catheterization, the patient died. We suggest that in critically ill infants with the aforementioned condition surgical repair guided by modern echocardiography must be the chosen management.

Asunto(s)

RESUMEN

OBJECTIVES: This study reports our clinical experience with transcatheter closure of secundum atrial septal defects (ASDs) in children, using the Amplatzer, a new occlusion device. BACKGROUND: None of the devices previously used for transcatheter closure of interatrial communications has gained wide acceptance. METHODS: We examined the efficacy and safety of the Amplatzer, a new self-centering septal occluder that consists of two round disks made of Nitinol wire mesh and linked together by a short connecting waist. Sixteen patients with secundum ASD met established two- and three-dimensional echocardiographic and cardiac catheterization criteria for transcatheter closure. The Amplatzer's size was chosen to be equal to or 1 mm less than the stretched diameter. The device was advanced transvenously into a 7F long guiding sheath and deployed under fluoroscopic and ultrasound guidance. Once its position was optimal, it was released. RESULTS: The mean ASD diameter by transesophageal echocardiography was 14.1+/-2.3 mm and was significantly smaller (p < 0.001) than the stretched diameter of the ASD (16.8+/-2.4 mm). The mean device diameter was 16.6+/-2.3 mm. No complications were observed. After deployment of the prosthesis, there was no residual shunt in 13 (81.3%) of 16 patients. In three patients there was trivial residual shunt immediately after the procedure that had disappeared in two of them at the 3-month follow-up. CONCLUSIONS: The Amplatzer is an efficient prosthesis that can be safely applied in children with secundum ASD. However, a study including a large number of patients and a longer follow-up period are required before this technique can be widely used.

Asunto(s)

RESUMEN

To evaluate the safety and efficacy of pericardial window creation by percutaneous balloon dilation in children with recurrent, symptomatic, nonmalignant pericardial effusion, 6 boys and 4 girls, age 5-12 yr, underwent the procedure using the subxiphoid approach. The procedure was successful in 9 patients. There was one case with rupture of the balloon and entrapment of its distal part within the pericardium. During follow-up (mean 14.6 mo) there was reaccumulation of fluid only in the patient in whom rupture of the balloon had occurred. No other complications were noted. Thus, percutaneous balloon pericardiotomy appears to be a safe and effective technique for the creation of a pericardial window in children with nonmalignant pericardial effusions, and may be used as an alternative to surgical window creation.

Asunto(s)

RESUMEN

OBJECTIVES: To assess the effectiveness of atrial septostomy by percutaneous balloon dilatation in patients with congenital heart defects or primary pulmonary hypertension. PATIENTS AND DESIGN: Twenty three patients (15 boys, eight girls; aged 10 days to 10 years; 17 with congenital heart defects and six with primary pulmonary hypertension), all haemodynamically unstable under optimal medical treatment, underwent atrial septostomy by percutaneous balloon dilatation. INTERVENTIONS: The balloon catheter entered the left atrium through a patent foramen ovale (n = 14) or via transseptal puncture in cases with an intact atrial septum (n = 9). The size of the balloons used ranged from 13 to 18 mm. RESULTS: There were no complications. The interatrial communication (mm) increased (P < 0.05) after dilatation and remained unchanged (P = NS) during a 16.6 (13.8) month follow up (2 (1.7) v 8.8 (1.4) v 8.2 (1.1), respectively). Transatrial gradient (mm Hg) fell and arterial oxygenation (%) improved both in patients with transposition (6.3 (0.8) v 0.8 (1) (P = 0.0001) and 40.6 (4.2) v 76.5 (4.8) (P = 0.0001), respectively) and in those with mitral atresia (13.4 (1.9) v 2 (1.4) (P = 0.0001) and 77.1 (3.9) v 81.5 (4.2) (P = 0.008), respectively). There were two failures, one early and one late, both in the group of patients with mitral atresia or stenosis. A decrease in arterial oxygenation (94.8 (1.5) v 83 (2.4), P = 0.004) and an increase in left atrial pressure (6.8 (0.9) v 8.3 (1.2), P = 0.02) and cardiac index (2.3 (0.2) v 3.1 (0.2) l/min/m2, P = 0.002) was observed in patients with primary pulmonary hypertension. CONCLUSIONS: Percutaneous balloon dilatation is an effective and safe procedure for creating an adequate interatrial communication that can be used as an alternative to blade septostomy.

Asunto(s)

Asunto(s)

RESUMEN

Percutaneous balloon valvuloplasty was performed in 16 children, 1 1/2 to 14 years old, with congenital pulmonary stenosis with teh use or trefoil balloons. These balloons, which consist of 3 identical angioplasty balloons, do not interrupt completely the blood flow during inflation. The size of the trefoil balloons used was 30 to 50% larger than the valve anulus. A obtain an effective pulmonary valvuloplasty in two patients with large valve anulus. The mean prevalvuloplasty systolic gradient fo 78.2 +/- 28.9 mmHg (range 40 to 140 mmHg) was reduced to 20.3 +/- 5.7 (range 10 to 30 mmHg) after valvuloplasty. No patient developed significant hypotension or bradycardia or other complications as a result of the procedure. The findings demonstrate that percutaneous balloon valvuloplasty with oversized trefoil balloons effectively treated congenital pulmonary stenosis without complications in the cases studied. The use of large trefoil instead of single balloons of a similar diameter is advantageous since they cause no significant compromise of the cardiac output during valvuloplasty.

Asunto(s)

RESUMEN

Two cases of rubella myocarditis are reported: a 6-year-old boy who developed a complete, distal to His, atrioventricular block, during the third day of illness; and a 12-year-old boy who developed myocarditis with congestive heart failure 20 days following rubella infection. Although permanent pacing was required in the first patient, six years later he showed a normal growth and maintained normal activity. The second patient has deteriorated markedly and 6 months after the initial illness he had severe heart failure. It should be noted that myocarditis with abnormalities of the conduction system or congestive heart failure may be a complication to postnatal rubella.

Asunto(s)

RESUMEN

Hypersplenism is a frequent complication of Gaucher disease requiring splenectomy. A patient with Gaucher disease and severe hypersplenism was treated with partial splenic embolization to avoid the increased risk of serious infectious complications and deterioration of the disease associated with splenectomy. A first embolization (25% ablation) was performed at 4 years. Because of persisting abdominal discomfort, failure to thrive and signs of hypersplenism a second embolization (40-50% ablation) was performed 18 months later. Subsequently, the patient's health improved remarkably and 4 years later he achieved normal growth, maintains normal haematologic parameters, is free of symptoms and has no skeletal abnormalities. No serious infections have occurred. The size of the liver and the spleen has not changed appreciably. It appears that partial splenic embolization may be preferable to splenectomy in patients with Gaucher disease, especially in those of young age.

Asunto(s)

RESUMEN

Prostaglandin E2 was administered to 22 newborns with ductus-dependent cyanotic congenital heart disease. Twelve patients had pulmonary atresia and ten simple dextrotransposition of the great arteries. Patients were classified into two groups: group 1 (n = 11) received prostaglandin E2 by the intravenous route (dose: 0.01-0.05 microgram/kg per min); group 2 (n = 11) received prostaglandin E2 by the oral route (dose: 35-65 micrograms/kg per 1-4 h). Treatment lasted for 1-90 days. All infants except one of group 2 showed a significant (greater than 10 Torr) increase in PaO2 following PGE2 administration. The mean increase in PaO2 was higher (P less than 0.01) in group 1 (21.8 +/- 1.7, Torr) than in group 2 (15.8 +/- 1.5, Torr). PaO2 fell significantly (P less than 0.01) in five patients of group 1 who continued treatment orally with satisfactory (greater than 30 Torr) levels in four of them. Severe side effects were observed only in group 1. The data show that similarly to prostaglandin E1 infusions, prostaglandin E2, given i.v. or orally, is useful in the management of infants with ductus-dependent cyanotic congenital heart disease. Oral prostaglandin E2, administration is less effective than i.v. infusions, but can be used for long-term, therapy being more convenient and causing minimal morbidity.

Asunto(s)

RESUMEN

Clinical, haemodynamic, angiocardiographic, and necropsy findings are reported in a newborn infant who presented with typical findings of the severe form of the syndrome of absent pulmonary valve. In addition to the usual findings of aneurysmal dilatation of the pulmonary arteries, pulmonary insufficiency, and stenosis, this patient had an intact ventricular septum and large ductus arteriosus. The former is a rare finding and the latter is not known to have been reported in a patient with the severe form of this syndrome.

Asunto(s)