Confirmed CCHD What next? Herbert J. Stern MD, FACC, FSCAI Children s Cardiology Associates and Dell Children s Hospital
Catheter Based Therapy: Spectrum of Procedures Tear PFO to enhance mixing (D-TGA) Dilate and/or stent narrowed valves (valvuloplasty) and vessels (angioplasty) Close abnormal vessels (PDA s, collaterals, etc) Close septal defects Open atretic valves, create fenestrations Implant transcatheter valves
Spectrum of Age Birth til
Balloon Septostomy
Valvuloplasty Mechanism of dilatation: commissural splitting Semilunar Valves most commonly(a-v valves rarely) Use oversize balloons for pulmonic valve Use 80-100% annulus size for aortic valve
Valvuloplasty-Critical PS
Valvuloplasty-Critical PS
RF Perforation of Pulmonary Atresia in 1500 gm Infant
Valvuloplasty-Critical AS
Valvuloplasty-Critical AS
Angioplasty Mechanism of dilatation: Does NOT stretch the vessel, but purposely tears the intima/media(hopefully not the adventitia) Vessel heals in open position Critical to properly size lesion to chose proper balloon size
Angioplasty-Coarctation of the Aorta
Endovascular Stents Wire mesh cylinders which must be handcrimped on balloon catheters or come premounted Indicated for vessel stenosis in: coarctation of the aorta, conduits, Mustard baffles, pulmonary arteries, etc.
Endovascular Stents
Coarctation of the Aorta
Endovascular Stents-RV to PA Conduits
Left Pulmonary Artery Stenosis
LPA stenosis
Poiseulle s Law (flow in rigid tubes)
Occlusion Devices
Gianturco Coil Occlusion
Amplatzer Ductal Occluder
Amplatzer Vascular Plug
Intralobar Pulmonary Sequestration
Coil Occlusion Aortopulmonary Collaterals (APCs)
Amplatzer Occlusion ASD
Balloon Sizing Both Defects
ASD Closure with two devices
TEE post delivery
Creating Fenestrations
Combination Lesions
Combination Lesions Usually occur in context of Single Ventricle Physiology Recoarctation of the Aorta (balloon and/or stent) Stenosis @ SVC anastomosis or branch PA s (balloon and/or stent) Aortic and /or venous collaterals (vessel occlusion)
Angioplasty of Thrombosed LPA
Access to Vessel via Floppy- Tipped Wire
Stent of LPA and Coarcatation
Emerging Technologies
Transcatheter Valve Replacement (Bonhoeffer:Circ.2000;102:813-16) Bovine jugular vein containing native biological valve harvested, fixed and sterilized Sutured to interior of pre-expanded C-P stent Re-formed and crimped onto 18-22mm balloons
Bovine Valve Sutured in Stent Valved stent placed successfully in 7/11 lambs; 5/7 placed correctly across native pulmonary valve All 5 lambs with normal neo-pulmonic valve function after two months follow-up
Competent Valve Following Explantation Applications: Free PI with RV volume overload (e.g. TOF with transannular patch) RV-PA valved homograft deterioration (TOF/PA, Truncus, Ross procedure)
Transcatheter Valve Implantation
Hybrid Procedures
Thank You!