Elnur Imanov¹, Surkhay Musayev¹, Farida Hajyeva¹, Samir Allahverdiyev¹, Sabina Hasanova¹, Leman Rüstemzade¹, Fuad Abdullayev², Vasiliy Lazoryshynets³, Oleksandr Pliska⁴

¹Health Ministry of Republic of Azerbaijan Education Therapeutic Clinic of Azerbaijan Medical University, Baku, Azerbaijan. ²4Health Ministry of Republic of Azerbaijan Scientific Center of Surgery Named After M.A. Topchubashov Pediatric Cardiac Surgery and Neonatal Surgery center, Baku, Azerbaijan. ³Amosov National Institute of Cardiovascular Surgery, Kiev, Ukraine. ⁴Dragomanov National Pedagogical University, Kiev, Ukraine

Critical aortic stenosis is a complex pathology in newborns requiring emergency care. The treatment of such patients is a complex and complicated problem. Treatment methods include balloon valvuloplasty and open surgical valvuloplasty. The aim of the study was to analyze our own experience in surgical treatment and balloon valvuloplasty of critical aortic stenosis in newborns.

From 2006 to 2019, the State Institution “National Institute of Cardiovascular Surgery named after N. M. Amosova of the NAMS of Ukraine” and Ministry of Health of Azerbaijan, Scientific-Research Surgical Institute named after M.A. Topchubashov Pediatric Cardiac Surgery Center treated 58 infants with aortic stenosis. At the same time, 47 (81%) patients (group I) underwent X-ray endovascular balloon valvuloplasty of aortic stenosis, and 11 (19%) patients (group II) underwent surgical treatment.

After balloon valvuloplasty, a significant decrease in the gradient on the aortic valve was observed in group I patients and an increase in the ejection fraction of the left ventricle. However, in a mid-term observation, the pressure gradient on the aortic valve in most patients increased, and aortic insufficiency began to increase. After surgical correction, good immediate and mid-range results were noted with respect to the gradient on the aortic valve and the degree of insufficiency.

Both surgical valvuloplasty and balloon valvuloplasty are effective treatments for aortic stenosis in newborns with good immediate results. The study indicates that balloon valvuloplasty is an acceptable alternative to surgical treatment in patients with signs of severe heart failure, but tends to increase aortic insufficiency in the long term. The length of stay of patients with balloon valvuloplasty is twice shorter for such surgical valvuloplasty, which significantly reduces the economic costs of treatment.

Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China, Beijing, China

UMAE T1 IMSS, Leon Gto, Mexico

This is the case of a 43-year-old male with a history of hypertension in treatment with Telmisartan/HCTZ 80/25 mg OD, Amlodipine 10 mg OD, Metoprolol 100 mg BID.

He was referred to our center as a case of uncontrolled secondary hypertension due to aortic coarctation. Physical examination revealed a systolic murmur II/IV in the left sternal border, in the left infraclavicular area, and under the left scapula. A supine arm–leg blood pressure gradient of 30 mmHg (upper limbs 180/100 mmHg). ECG denotes left ventricular hypertrophy. Echocardiography findings in the suprasternal view showed coarctation of aorta after the left subclavian artery with no flow through aortic lumen.

Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China

Result: Twenty-two patients (17 Males/5 Females) with severe PR (grade 4 +) were enrolled in this study with mean age of 28.8 ± 10.5 years and weight of 58.6 ± 10.7 kg. All patients had previous surgery for tetralogy of Fallot (TOF)/double ventricular outflow tract (DORV). Thirteen patients were symptomatic with New York Heart Association (NYHA) heart function III/IV and 9 with NYHA II at baseline. The mean diameter of distal main pulmonary artery (MPA), sub-local residual pulmonary leaflet, and RVOT aneurysm measured in Computed tomography angiography (CTA) were 33.6 ± 6.1 mm, 34.7 ± 6.0 mm, and 41.9 ± 9.3 mm. The landing zone lied usually within these three levels. Mean devices size used was 25.3 ± 1.3 mm waist/39.1 ± 4.9 mm flare. Successful valve implantation was achieved in all patients. No device malposition, coronary obstruction, reduced flow to the PA branches, or paravalvular leak were noted during the procedures. Mean pulmonary artery diastolic pressure increased from 5.8 ± 3.1 mmHg to 11.3 ± 2.5 mmHg (P < 0.05). In one month’s follow-up, Magnetic Resonance Imaging (MRI) revealed regression of right ventricle remodeling with right ventricle end-diastolic volume index (RVEDVI) decreased from 182.7 ± 27.5 ml/m² to 121.9 ± 27.5 ml/m² after intervention (P < 0.05). After successful valve implantation, the mean transpulmonary valve pressure gradient measured with echocardiography was 7.1 ± 2.9 mmHg.

Singhealth, Singapore, Singapore

Device closure of Secundum ASD has become the standard of care in most countries. Success of the procedure lies in understanding the atrial septal anatomy. Abnormal septal anatomy adds to the complexity of the procedure and could increase the complication rates especially embolization.

We describe the imaging planes in a case of secundum ASD with juxtaposed atrial appendage that was successfully closed using an Amplatzer septal occluder.

An 11-year-old female with a diagnosis of secundum ASD and juxtaposition of the atrial appendage underwent successful deployment of a 18-mm Amplatzer septal occluder with the help of TEE guidance. The atrial septal orientation was clearly ascertained using orthogonal planes and 3D data sets as there is a great potential to misconstrue the mouth of the juxtaposed appendage to be the defect thereby minimizing the risk of embolization.

Mansoura University, Mansoura, Egypt

Results: The mean age of patients was 9.6 ± 3.7 years, the median bodyweight of the patients was 30.5 (21.25–44.5) kg, 38 (55.9%) were males, and 67(98.5%) cases were successful procedures. The median follow-up duration was 37 months (range 3–83 months). The mean defect diameter was 3.5  ±  1.4 mm. The most common type was perimembranous VSD (33 cases), one of them was associated with PDA which was closed in the same setting, 6 cases had muscular outlet VSD, 17 cases with mid muscular VSD, and 11 cases had residual postsurgical closure. The devices used were as follows 30 (44.1%) pfm Nit-Occlud^® Lê VSD Coil, 21 (30.9%) Hyperion™ VSD Muscular Occluders, 5(7.4) Amplatzer muscular occlude, 11(16.2%) Amplatzer Duct Occluder ADO I, and 1 (1.5%) ADO II. One ADO I device embolized in perimembranous VSD, which was retrieved successfully. No significant difference in the success rate between groups. A complete heart block was detected in 2 cases immediately post procedure and resolved with steroid intake. Residual flow after the device insertion was seen immediately in 9 cases, which resolved in 6 cases within 6 months of follow-up. No cardiac erosion was detected in any of the followed cases and no mortality occurred during the intermediate-term follow-up.

University of Rochester Medical Center, Rochester, USA

Methods: Catheterization, echocardiogram, and progress notes were retrospectively reviewed for all patients following balloon pulmonary valvuloplasty for critical PS between 1/1/2000 and 3/1/2019. Patients with additional congenital heart disease (apart from PFO or small ASD) were excluded. Supplemental oxygen was continued post procedure to maintain resting oxygen saturation > 88% by pulse oximetry, though intermittent, self-resolved desaturations to 80% were not treated with additional oxygen. Data were reported as n (%) and median (IQR or range). Continuous variables were compared using Wilcoxon ranked-sum test. Categorical variables were compared using Fisher’s exact test. p < 0.05 was considered statistically significant.

Results: Twenty-six infants had balloon pulmonary valvuloplasty at age 2 (1–5) days with weight 3.4 (2.8–3.8) kg. Four (15%) were premature. Eleven (42%) needed supplemental oxygen pre-catheterization including 4 (15%) that were intubated. By echocardiogram, baseline right ventricle (RV) to pulmonary artery (PA) peak gradient (PG) was 82 (69–93) mmHg, pulmonary valve diameter 7 (6.5–7.9) mm and Z-score − 1.6 (− 1.9 to − 0.5), and tricuspid valve diameter 12.1 (10.5–13.2) mm and Z-score +0.3 (− 1 to +0.8). Seven (37%) had ≥ mild RV systolic dysfunction, 2 (8%) had mild RV hypoplasia, and 11 (42%) had ≥ mild RV enlargement. The baseline RV-PA PG by catheter was 61 (45–73) mmHg and baseline RV/systemic pressure ratio 1.5 (1.3–1.8). Following valvuloplasty, RV-MPA PG was reduced to 15 (12–20) mmHg and RV/systemic pressure ratio 0.8 (0.6–0.9). Prostaglandin duration post procedure was 1 (0–2.3) days and oxygen supplementation was 1 (range: 0–15) day, with 8 patients receiving ≥ 5 days supplemental oxygen prior to hospital discharge. Two (8%) patients were discharged home with supplemental oxygen. Infants with ≥ 5 days supplemental oxygen post-procedure had smaller tricuspid valve diameter (10.4 vs. 13 mm, p = 0.03), and increased baseline RV/systemic pressure ratio (1.7 vs. 1.4, p = 0.04). There were no other statistically significant differences between groups and specifically lower gestational age, need for oxygen or intubation pre-valvuloplasty, smaller pulmonary valve diameter, greater post-procedure RV-PA PG, and RV dysfunction were not associated with longer duration of supplemental oxygen post-valvuloplasty. No patient had additional transcatheter or surgical procedures prior to discharge.

Benisuef University, Cairo, Egypt

Patent Ductus Arteriosus (PDA) is a common form of congenital heart disease. It has been estimated to occur in 1 in 2500–5000 live births. As an isolated lesion, it represents 9–12% of all congenital heart diseases. The benefits of the transcatheter closure of PDA compared to surgical closure seem obvious in terms of shorter in-hospital stay, high success rates, no scar, and insignificant morbidity.

Results: There were significant decrease in left ventricular dimensions in both groups, the procedure time, fluoroscopy time, and residual shunt rates were similar between the two groups. Procedural success rate was 100% in both groups. Although the residual shunt rate was higher in the PDA-R group immediately after the procedure, the difference was not statistically significant (16.0% vs. 12.0%; p value 0.762). No deaths occurred in any of the groups, and there were no differences in complication rates during the short- and mid-term follow-up periods.

Benisuef University, Cairo, Egypt

Objectives: To investigate the safety, effectiveness, and hemodynamic effects of percutaneous atrial septal defect (ASD) closure using the Occlutech^® devices in a prospective trial.

Results: Median age and ASD sizes were 7.8 years (8 months–59 years) and 16.5 mm (4.8–38 mm), respectively. Deficient or absent retro-aortic rim was observed in 30 patients (27%). All patients had dilated right-side chambers. Pulmonary artery systolic pressure > 35 mmHg was observed in 57 (51%) patients who had significantly larger ASDs (p = 0.009) and larger RV lengths (p = 0.006). Implantation of an Occlutech device (mean size of 19.4 ± 8 mm) with successful closure was reported in 95.5%. Closure success was linked to larger IVC rims (p = 0.009). An IVC rim ≥ 7.2 mm is 97.1% sensitive, while IVC rim ≥ 11.2 mm is 100% specific for closure success. Median follow-up of 6 months was obtained in all patients. Successful closure leads to significant regression of RV and pulmonary artery dimensions at 1, 3, and 6 months of follow-up (p < 0.001).

Benisuef University, Cairo, Egypt

Aortic root pathology has been described in patients with Tetralogy of Fallot, although the most common reason for repeat surgery in the adult after TOF repair relates to problems in the right ventricular outflow tract, the aortic root is often forgotten.

Methods and Results: A multicenter observational study which enrolled 100 patients (50 surgically repaired and 50 before surgical repair of nTOF) with standardized reassessment of echocardiographic parameters and multislice CT angiography of the heart and great vessels data. The data were reviewed and analyzed according to the demographic, morphological, surgical, and clinical details. We used standard nomograms and Z-score for aortic root dimensions at the level of aortic annulus, sino-tubular junction and sinus of Valsalva based on body surface area. For surgically repaired patients, all the measured diameters across aortic annulus, STJ, and sinus of Valsalva were larger in the dilated unrepaired group with mean and median of 24.63 (3.99) and 25 (15–35), 27.2 (4.26) and 27 (17–40), 35.97 (4.59) and 36 (24–45) mm, respectively, compared to a mean and median of 13.2 (2.62) and 13 (9–17), 14.53 (2.90) and 14 (10–19), 20.53 (3.40) and 21 (14–25) mm, respectively, in the not dilated unrepaired group with significant statistical difference (p value < 0.0001). Also Z-score among unrepaired dilated TOF patients was larger in comparison to the non-dilated unrepaired group with significant statistical difference (p value < 0.0001). For unrepaired patients, all the measured diameters across aortic annulus, STJ, and sinus of Valsalva were larger in the dilated unrepaired group with mean and median of 24.63 (3.99) and 25 (15–35), 27.2 (4.26) and 27 (17–40), 35.97 (4.59) and 36 (24–45) mm, respectively, compared to a mean and median of 13.2 (2.62) and 13 (9–17), 14.53 (2.90) and 14 (10–19), 20.53 (3.40) and 21 (14–25) mm, respectively, in the not dilated unrepaired group with significant statistical difference (p value < 0.0001). Also Z-score among unrepaired dilated TOF patients at the level of annulus, STJ, and sinus of Valsalva was larger in comparison to the non-dilated unrepaired group with significant statistical difference (p value < 0.0001).

Children’s National Hospital, Washington, USA

Results: The median radiation exposure for an x-ray guided RHC was 0.4 uGy*m²/kg (range 0.05–3.3). When converted to effective dose, the median total dose was 0.07 mSv (0.006–0.4). In the MR-guided RHC cohort, where patients underwent EMB only (n = 9), a median of 1.06 uGy*m²/kg (0.2–12) or 0.2 mSv (range 0.02–2) of exposure occurred. In the same cohort for patients who underwent EMB with coronary angiography (n = 15), there was a median of 26.0 uGy*m²/kg (9–82) or 4.0 mSv (range 1.3–10.6) of exposure.

Takeshi Sasaki^1,2, Tomas Forbes¹, Robert Ross¹, Yuki Kawasaki^1,2, Daisuke Kobayashi¹

¹Division of Cardiology, Children’s Hospital of Michigan, Detroit, USA. ²Department of Pediatric Cardiology, Osaka City General Hospital Pediatric Medical Center, Osaka, Japan

Results: Twenty-one patients underwent 28 cardiac catheterizations. The median age was 17.4 years (range 0.3 to 60.0), and the underlying cardiac diagnoses were normal heart n = 3, pulmonary hypertension 1, heart transplant 1, pulmonary arteriovenous malformation 1, pulmonary vein disease 3, biventricular congenital heart diseases 5, and single ventricles 7. The diagnostic utility of catheterization was 81% (17/21). At two-thirds (18/28) of catheterizations, transcatheter interventions were performed in 14/21 (67%) patients: aortopulmonary collateral embolization 14, aortopulmonary and venovenous collateral embolization 1, and pulmonary arteriovenous malformation embolization 3. Although recurrent hemoptysis was frequent (50%) post intervention, the final effectiveness of transcatheter interventions was 79% (11/14 patients). Overall mortality was 19% (4/21), all in those presenting with massive hemoptysis.

Cairo University, Cairo, Egypt

Results: The median age of 96 patients was 22 (2–120) days and their median weight was 3 (2–5.5) kg. The procedure was successful in 81.25% of patients, 72.92% has tortuous PDA. The femoral artery approach was used in 75% of procedures, axillary access in 19.79%, carotid access in 3.8%, and femoral vein approach in 2.6%. Seventy-nine coronary stents were deployed in 78 patients. One patient needs two stents to cover total ductal length, and drug-eluting stent was used in 17 (21.8%) patients. Median right PA (RPA) and left PA (LPA) Z-scores were − 0.79 (− 1.91 to 0.12) and − 1.02 (− 1.82 to − 0.38), respectively. The success rate was higher in straight PDA and in relatively younger patients. Post-stenting mean oxygen saturation (SO₂) increased significantly from baseline. No mortality was reported during the procedure. Minor complications in seven patients, while stent thrombosis in two patients and stent embolization in another two. At a median follow-up (4–6) month for 43 patients, MSCT was done for 37 patients, median RPA and LPA Z-scores, [0.93 (0.28–1.82), 0.40 (0.24–1.01)], respectively, were significantly increase compared to baseline. Four patients required reinterventions. Eighteen patients underwent cardiac surgery during the follow-up period. Urgent BT shunt was done for six patient, palliative surgery was done for nine, and corrective surgery for three patients.

Rush University Medical Center, Chicago, Illinois, USA

Results: Fifteen patients were included. Ten patients (~ 67%) had non-audible hemodynamically insignificant PDAs, and five patients (~ 33%) had audible hemodynamically insignificant PDAs. There were no statistical differences between flow velocities, aortic, and pulmonic diameters of non-audible PDAs versus audible PDAs (p value = 0.12, 0.07, and 0.52, respectively).

Cairo University Children Hospital, Cairo, Egypt

Pulmonary Hypertension is defined by a threefold condition: a mean PAP of 20 mmHG, a LAP lower than 15 mmHG, and a PVR of 3 Wood units. A lot of progress has been achieved when it comes to medications allowing for longevity and a better quality of life for PH patients; however, these medications are not curative. Interventions are also palliative as patients would eventually need lung or heart–lung transplants. Interventions include septostomies or stenting the interatrial septum. More recently, reversed Potts shunts—both surgical and transcatheter—have also been performed on PH patients. Other PH interventions can be applied for cases of univentricular repair such as Glenn and Fontan procedures. These may include blocking extra-pulmonary blood supply, or interrupting forward flow, using plugs or other devices. For Fontan cases, circulation opening and stenting the closed fenestration can also help, especially when Fontan intervention fails.

Interventions in PH in children and adolescents are not common. We report 20 cases who experienced different interventions for PH, with an age range of 9–25 years old and 75% female patients. Of the 20, 10 had idiopathic Ph, 4 were post Glenn, 2 post PA band, and 4 post Fontan. Interventions include balloon dilatation of IAS (6), stent IAS (3), Stent ASD device (1), Shunt occlusion (2), Stent PDA coil (1), PDA occlusion (1), and forward flow interruption (6). Follow-up of idiopathic PH group revealed an overall improvement in symptoms and an increased desaturation. As for the univentricular heart group, symptoms also improved and more prominently, these cases exhibited a drop in PH. Through these cases, we conclude that intervention for PH in children and adolescents is a safe and feasible palliative procedure, which improves symptoms in PH for both idiopathic and post-surgery univentricular heart patients.

Helwan University, Cairo, Egypt

Herein we report successful device closure of large-sized OS ASD in 59 children with less than 1 year of age done over the period of 9 years. The study population age and weight ranged from 7½ to 12 months and 5.7 to 10.3 kg. Symptomatic children with dilated right heart were taken as criteria for the device closure. The sizes of the devices used were from 10 to 22 mm with high rate of successful deployment (97%). All patients who underwent successful device closure tolerated the procedure well without any major complications

Advantages in early closure:

Jacek Kusa^1,2, Pawel Czesniewicz², Magdalena Slupska²

¹Pediatric Cardiology Department, Medical University of Silesia, Katowice, Poland. ²Pediatric Cardiology Department, Regional Specialized Hospital-Research and Development Centre, Wroclaw, Poland

The procedure was performed under general endotracheal anesthesia, through femoral vein access. The right coronary Judkins catheter was used to enter to the ostium of fistula. The manual angiography was performed to confirm the previous diagnosis and establish the morphology precisely. Then the catheter was inserted deeper, but just before the coronary sinus. Through the same catheter the Amplatzer Vascular Plug 4–7 mm was introduced and released from delivery system. The right position of the implant was confirmed. Over the next 3 days the infusion of heparin was maintained, and then acenocoumarol was introduced with the recommendation lifetime use.

Nicklaus Children’s Hospital, Miami, USA

Patients were divided into two groups with (group A) and without (group B) early postoperative catheterization. Group A had longer post-stage 1 LOS (mean 43 vs 28 days, p = 0.05), additional catheterizations in the interstage period (43% vs 22.7%, p = 0.01), and lower pre-SCPA SVC saturation (mean 46% vs 51%, p < 0.01). At the time of SCPA, group A was younger (mean 162 vs 199 days, p < 0.01) with lower weight (mean 5.8 vs 6.4 kg, p = 0.03) and longer cardiopulmonary bypass time (126.9 vs 91.6 min, p < 0.01).

Division of Pediatric Cardiology. University of Texas McGovern Medical School at Houston, Houston, USA

Patient 2 is 5-week-old ex-28-week preterm boy. Current weight 1.26 kg. Multiple dysmorphic features led to diagnosis of Cornelia de Lange syndrome. By angiogram, PDA was type F (Hockey-stick shape) with diameter 4 mm. Amplatzer Piccolo Occluder (5-2) device was deployed. After echocardiographic confirmation, the device was released. Upon release, the device was noted to move back into main pulmonary artery (MPA). Therefore, attempts were made to retrieve the device using gooseneck snare. During these attempts, the device dislodged to LPA and pericardial effusion occurred. After pericardiocentesis, there was immediate recurrence. Sternotomy was performed and a perforation in RVOT was repaired. Next morning, echocardiogram showed no PDA, device in proximal LPA with mild LPA stenosis only. At 4 months after procedure, device is still in MPA/LPA junction with mild LPA stenosis.

Discussion: We are presenting two preterm babies who had unsuccessful attempts at transcatheter device closure of PDA and subsequently found to have spontaneous closure in both babies—one in 5 days and the other within 24 h. We speculate that mechanical stimulation of wall of PDA by the devices may initiate a process of spontaneous PDA closure. Other mechanisms for spontaneous closure of the PDA after birth including high pO₂ and low circulation prostaglandin have been proposed. Further studies are required to delineate the mechanism of spontaneous closure.

University Medicine Goettingen, Goettingen, Germany

Transcatheter valve-in-valve (ViV) implantation has emerged as an alternative treatment option to repeat surgical replacement in high-risk patients for degenerated bioprosthetic valves. But data regarding these procedures in adults with congenital heart disease (ACHD) remain limited.

We present the case of a 60-year-old lady born with a partial atrioventricular septal defect that was surgically corrected at the age of 7 years. Left-sided AV-valve replacement was performed for significant left-sided AV-valve stenosis and moderate regurgitation with a bioprosthetic valve (CE Perimount Modell Magna Mitral ease (25 mm) at the age of 54 years. The bioprosthesis was favored over mechanical valve replacement because of systemic lupus erythematosus with cerebral vasculitis and increased risk for cerebral bleeding to avoid long-term anticoagulation with a vitamin K antagonist. The patient was kept on 100 mg ASS once daily. Comorbidities included arterial hypertension, chronic renal insufficiency, moderate aortic stenosis, and regurgitation.

Five years later, the patient complained about dyspnea and decreased exercise tolerance due to severe stenosis of the bioprosthesis with a mean echocardiographic gradient of 12 mmHg. Because of high-risk for open-heart surgery transcatheter ViV implantation was favored.

Cardiac catheterization was performed under general anesthesia, heparin was given to achieve an ACT > 200 ms and cephazolin was administered intravenously as prophylaxis. Transseptal puncture guided by TEE was followed by balloon dilation of the intraatrial septum with an 8 mm Atlas balloon. Under 3D-TEE guidance the stenotic mitral valve was crossed, and a ‘Safire’ wire was placed into the LV apex. To allow unhindered ViV implantation, the stenotic calcified bioprosthetic valve was predilated with the ES balloon. By previous CT evaluation and using the App ‘ViV Mitral,’ it was decided to implant a 26 mm ES 3 valve. This was subsequently performed without any problems. The 26 mm ES 3 valve was placed in good position, there was no insufficiency and the mean gradient was reduced to 3 mmHg post implant. Postinterventional atrial fibrillation was successfully cardioverted and gastric bleeding required gastroscopic clipping and transfusion. Anticoagulation was changed from initial dual antiplatelet therapy to apixaban 5 mg bid. At 3 months of follow-up, the patient’s clinical status has improved significantly and the mean gradient across the ES 3 valve remained between 3 and 4 mmHg.

Yale University, New Haven, USA

Patient two was a 13-year-old patient with complete atrioventricular canal defect with tetralogy of Fallot who underwent complete surgical repair in the newborn period with VSD closure and a transannular patch. He subsequently developed recurrent stenosis in his right ventricular outflow tract and had repeat surgical intervention at 4 months old. He developed progressive stenosis across his RV outflow tract patch and underwent successful TPVR with 18 mm Medtronic Melody valve at 7 years old following pre-stenting with 5 mmHg residual gradient at end of procedure. Four years later he was noted to have severe stenosis across the Melody valve (peak 70 mmHg, mean 38 mmHg). The Melody valve was subsequently balloon dilated using a 20 mm high-pressure balloon with resultant 2 mmHg gradient and mild Melody valve insufficiency. There were no complications.

Indiana University, Indianapolis, USA

Results: 401 patients under 12 months old were analyzed. The prevalence of clinical pulse loss was 14.9%; 6.5% were treated with a heparin bolus, 11.2% had an ultrasound performed for persistent pulse loss, and 7.5% were diagnosed with a femoral arterial thrombus by ultrasound. Of these 401 patients, 82 had a 3.3F sheath, 298 had a 4F sheath, and 21 had a 5F sheath. The prevalence of pulse loss in patients with 3.3F sheaths was 8.5%, compared to 16.8% in patients with 4F sheaths, and 14.2% with 5F sheaths. Fisher’s exact test showed no statistically significant difference among the groups for incidence of pulse loss (p value 0.170) or heparin treatment (p value 0.379). However, when multiple logistic regression were performed, sheath size was significantly associated with pulse loss; odds ratio for pulse loss was 2.92 (95% CI 1.23–6.95) for 4 Fr catheters compared to 3.3 Fr catheters (p value = 0.015). A similar trend was found for treatment with heparin; odds ratio for administration was 2.46 (95% CI 0.69–8.69) for 4 Fr catheters compared to 3.3 Fr catheters, however, this did not meet our threshold for significance (p value 0.164).

University of Minnesota, Minneapolis, USA

A 4-month-old female, former 24 weeks, weighing 4.0 kg, with moderate secundum atrial septal defect (ASD) in the setting of severe respiratory disease of prematurity and pulmonary hypertension (on inhaled nitric oxide and sildenafil). Baseline hemodynamics were significant for moderately elevated pulmonary artery pressures (mPAp 27 mmHg) and normal PVR 2.3 iWU improved with vasoreactivity testing. Due to a small patient size and a tortuous thin IVC, a decision was made to close the ASD per-atrially through a hybrid anterior mini-thoracotomy approach. A regular mini TEE probe could not be passed and a ‘micro TEE’ probe was used which limited the ability to get good images. By TEE, the defect measured 0.6–0.7 cm with adequate rims all around except the retro-aortic rim (2 mm).

Surgical right anterior mini-thoracotomy through a 5th intercostal space was performed and purse string suture was placed in the right atrium. An 18 gauge needle and a 0.035″ Emerald J tip wire was advanced through the purse string across the ASD and positioned tip in the left lower pulmonary vein using echo guidance. A 6 Fr short sheath, hand shaped to provide torque capability, was advanced over the wire and tip positioned in the left atrium. An 8-mm Amplatzer Septal Occluder (ASO) (St Jude Medical Inc.), prepped in usual fashion, was deployed under TEE guidance with no residual atrial level shunting although the images were suboptimal with the micro TEE probe.

At follow-up, the occluder was appeared to have missed catching the superior and posterior rim, 2 days later it was malpositioned and had unbuttoned with the right atrial disc partly in the left atrium. The child was taken back to the cath lab, under TEE guidance, an 8 fr sheath was introduced through the same anterior mini-thoracotomy incision and through the right atrial purse string suture. A 10-mm Amplatz Gooseneck Snare (eV3 Endovascular, Inc.) was positioned over the microscrew and snared. The right atrial disc was partially recaptured, and device redeployed across the atrial septum. Epicardial echocardiography was used in conjunction with TEE which confirmed good capture of all rims. Child was extubated after 6 days and was weaned off CPAP 12 days later. At 3 weeks of follow-up, the device was well seated with small residual shunt through the waist and was discharged home.

Dislocation of ASO placed by hybrid approach through mini-thoracotomy has been previously described in two adult studies. Occluder dislodged into the right atrium in all five cases and underwent immediate surgical repair with cardiopulmonary bypass (CPB). In our case, detection of malposition was early when the occluder was still partially attached to the septum. This enabled us to attempt hybrid snare retrieval through mini-thoracotomy which is a novel and feasible approach for malpositioned ASO devices that has not been previously reported. It could be considered as a good alternative to transcatheter percutaneous or surgical retrieval techniques whenever possible given limited exposure to fluoroscopy and avoiding CPB.

All India Institute of Medical Sciences, Delhi, India

Reid Ponder¹, Hannah El-Sabrout¹, Soraya Sadeghi¹, Arpine Davtyan², Jamil Aboulhosn³, Howaida El-Said², Daniel Levi³

¹University of California, Los Angeles, Los Angeles, USA. ²Rady’s Children Hospital, San Diego, USA. ³Ronald Reagan UCLA Medical Center, Los Angeles, USA

Results: Since 2010, there were 399 Melody valve and 124 Sapien valve TCPVRs performed between UCLA and UCSD. Of the Melody valve implants, there were 27 performed after placement of a PTFE-covered CP stent. There were no cases of endocarditis with Melody valve implants after use of covered pre-stents and only one case of Sapien valve endocarditis. The Kaplan–Meier curves shown below demonstrate the divergence of endocarditis incidence in valves covered by PTFE or implanted within PTFE stents.

UCLA, Los Angeles, USA

Conclusion: Self-expanding stents implanted in the aorta are able to expand in the aorta without inhibiting growth or causing vascular injury. This strategy could have promise in the treatment of neonatal coarctations and pulmonary artery stenoses.

We report successful device closure of OS ASD in 58 patients (male 23, Female 35) with age ranged from 8 months to 75 years (median age 4 years) and weight ranged from 5.5 to 84 kg (median weight 14.6 kg) done between 15.10.19 and 20.3.20 with success rate of 95% and no major complications.

R. Allen Ligon MD¹, Steve Bibevski MD, PhD¹, Mark M. Ruzmetov MD, PhD¹, Kak-Chen Chan MD¹, Todd Roth MD¹, Immanuel I. Turner², Frank G. Scholl MD¹, Larry A. Latson MD¹

¹Joe DiMaggio Children’s Hospital - Memorial Healthcare System, Hollywood, USA. ²Joe DiMaggio Children’s Hospital - Memorial Healthcare System, Hollywood, USA

Results: PVR was indicated in 55 pts. Primary transcatheter PVR was attempted in 37, a hybrid procedure was performed in 11, and on-pump surgical PVR was performed in 9. Median age at PVR was 27 years (6–65 years) and the most common diagnosis was tetralogy of Fallot (n = 39). Primary transcatheter PVR was successful in 35/37, with 2 converted to surgical PVR for stent/valve migration. Surgical valve implantation on cardiopulmonary bypass was utilized for positive CC testing (n = 4), stent/valve system migration (n = 2), or patient preference over the newer hybrid approach (n = 3). The hybrid group had a mean RVOT diameter of 34 mm (32–38 mm) by balloon-sizing pre-RVOT plication and then 25 mm (22–27 mm) post plication. All hybrid procedures were performed without CPB, except for one patient who underwent surgically-guided delivery of the transcatheter PVR due to change in RVOT anatomy/orientation pre and post plication. Median length of stay following procedure was 1 day for transcatheter PVR, 5 days for surgical, and 3 days for hybrid (p = 0.02). Median follow-up period was 1.5 years and there have been no reported episodes of endocarditis. There have been 3-valve reinterventions to date including one balloon valve dilation in the transcatheter PVR cohort, one balloon valve dilation, and a subsequent transcatheter valve-in-valve PVR in the surgical cohort. One hybrid patient expired (11 months post-index procedure) for multiple reasons, but including a coronary artery insult possibly occurring at the time of RVOT plication.

UCLA, Los Angeles, USA

Background: Use of a microbraiding technology has been used to produce the WEB, a neurovascular aneurysm treatment recently approved by FDA. Novel, patented HDBraid technology has been used to produce the LOBO (Okami Medical, Aliso Viejo), an FDA-cleared peripheral occlusion device. HDBraid technology has also been used to produce a device design specifically for closure of PDAs in preterm infants using a microcatheter for device delivery.

Methods: Two-disk PDA devices were manufactured from 144 wires using the previously described and proprietary braiding technology and traditional shape setting. The device has two discs (4 mm and 7 mm) designed to elongate in a tubular fetal-type PDA (Figure 1). The PDA device is compatible with most commercially available 0.027″ microcatheters. The ductus of three newborn piglets was recannulized using balloon angioplasty with a 5 or 6 mm Tyshak Mini balloon (NuMed, Hopkinton, NY) in order to create 3 mm PDAs. The PDAs were occluded in both antegrade and retrograde fashion with the PDA device using ECHO and fluoroscopic guidance (Figure 2). Angiograms and ECHOs were performed to document occlusion and devices were examined postmortem as well. The ability to deliver, visualize, and release the device was assessed as well as time to complete angiographic occlusion.

Conclusion: Initial animal testing of the new microcatheter-based PDA device justifies further investigation of this device as a possible new device for occlusion of tubular PDAs in low birth weight infants.

Rainbow Babies & Children’s Hospital, Cleveland, USA

All coils were successfully delivered through the Lantern microcatheter. Post-release angiograms demonstrated complete occlusion in 15 vessels, with near complete occlusion in two. There were no procedural complications. Follow-up angiography was not performed in any patients except for the patient with CAF, which was recanalized at six-month follow-up. The patient returned to the cath laboratory for successful occlusion using an additional POD followed by a packing coil.

Amjad Mahmood¹, Khurram Akhtar²

¹AFIC@NIHD, Rawalpindi, Pakistan. ²AFIC&NIHD, Rawalpindi, Pakistan

A 12*40 mm balloon-mounted peripheral stent was deployed at RVOT to rescue severely stenosed infundibulum in a lady of 18 years with TOF who had failing RV extreme desaturation and declared unfit for surgical correction. During final deployment, the stent embolized into LPA. The fully expanded stent was successfully dragged and redeployed with the help of balloon inflation within the stent. After successful redeployment of the same stent, RVOT was adequately expanded and the patient saturated well to avoid further hypercyanotic spells.

Check angiogram shows final position of stent

John Cheatham¹, Matt Gillespie², Lee Benson³, Shicheng Weng⁴, Lisa Bergersen⁵

¹Nationwide Children’s Hospital, Columbus, OH, USA. ²Children’s Hospital of Philadelphia, Philadelphia, PA, USA. ³The Hospital for Sick Children, Toronto, ON, Canada. ⁴Medtronic, Mounds View, MN, USA. ⁵Boston Children’s Hospital, Boston, MA, USA

Howaida El-Said¹, Kanishka Ratnayaka¹, Stephen Nageotte², John W Moore¹, Peter Guyon¹, Krishna Bhandari¹, Rachel Weber³, Jesse W Lee⁴, Hyeri You¹, Danica Griffin¹, Rohit P Rao⁵, John J Nigro¹

¹UCSD, San Diego, USA. ²St. Louis Children’s Hospital, St Louis, USA. ³Rady Children’s Hospital, San Diego, USA. ⁴The Children’s Hospital of San Antonio, san Antonio, USA. ⁵UCSD, san, USA

Results: Eighty-three patients [Blalock–Taussig Shunt (BTS), n = 41; PDA stent, n = 42] met inclusion criteria. In Era 1, most received BTS [62% (41/66)]. In Era 2, all received PDA stents [100% (17/17)]. There were no demographic differences between eras. There were no differences in mortality, treatment failures, complications, or reinterventions between eras. Post-procedure length of stay was shorter in Era 2 (8 vs 22 days, p < 0.05). There were less surgical revisions for PDA stent patients (2% vs 20%, p < 0.05). Post-procedure recovery surrogate endpoints favored Era 2 and PDA stenting. Additional analysis revealed PDA stent (compared to BTS) patients had shorter overall (18 vs 43 days, p < 0.05) and post-procedure (11 vs 29 days, p < 0.05) length of stay and more symmetric branch pulmonary arteries (0.9 vs 0.7, p < 0.05) at subsequent surgery.

University of Texas Southwestern/Children’s Medical Center, Dallas, USA

Conclusions: Neonatal PDA stenting is a safe and feasible alternative to MBTS for ductal-dependent pulmonary blood flow. Anticoagulation strategies using ASA therapy alone were adequate with no appreciable benefit from adding enoxaparin as it relates to rate of unplanned reintervention or PA growth for jailed/non-jailed PAs. Future studies are needed to assess rates of ASA resistance in the neonatal PDA stenting for ductal-dependent pulmonary blood flow cohort.

Doff McElhinney¹, Dan Levi², Matthew Gillespie³, Thomas Jones⁴, Robert Gray⁵, Tomoyuki Fujita⁶, Jeremy Asnes⁷, Shicheng Weng⁸, John Cheatham⁹

¹Stanford University, Stanford, CA, USA. ²UCLA, Los Angeles, CA, USA. ³Children’s Hospital of Philadelphia, Philadelphia, PA, USA. ⁴Seattle Children’s Hospital, Seattle, WA, USA. ⁵University of Utah, Salt Lake City, UT, USA. ⁶National Cerebral and Cardiovascular Center, Osaka, Japan. ⁷Yale University, New Haven, CT, USA. ⁸Medtronic, Mounds View, MN, USA. ⁹Nationwide Children’s Hospital, Columbus, OH, USA

Results: Forty patients underwent TPVR with either the TPV22 (n = 21) or TPV25 (n = 19), followed by 10 additional patients receiving a modified TPV25, for a total of 50 study patients. The mean age was 28.7 ± 11.3 years. Thirty-one patients (62%) were male, 46 (92%) had an original diagnosis of tetralogy of Fallot, and the median number of prior open-heart surgeries was 1 (Q1, Q3: 1, 2). Primary safety and performance outcomes were previously reported for the TPV22 and TPV25 cohort, along with 30-day performance of the modified TPV25. The current presentation will include complete data for 6-month endpoints in all patients, including those who received the modified TPV 25.

Jenny Zablah^1,2, Salvador Rodriguez¹, Ryan Leahy¹, Gareth Morgan^1,2

¹Children’s Hospital Colorado, Aurora, USA. ²University of Colorado Hospital, Aurora, USA

Results: When the traditional protocol group was compared with the multimodality protocol group, a significant reduction was described for total fluoroscopy time (31.6 min vs. 26.2 min), dose of contrast per kilogram (1.8 mL/Kg vs. 0.9 mL/Kg), DAP/kg (26.6 µGy·m²/kg vs. 19.9 µGy·m²/kg), and Air Kerma (194 mGy vs. 99.9 mGy). Interestingly, a reduction for procedure time was noted (140 min vs. 116.5 min), but no statistical difference was described. No differences were found for clinical outcomes or the presence of complications between groups.

Gareth Morgan^1,2, Salvador Rodriguez¹, Ryan Leahy¹, Jess Randall¹, Jenny Zablah^1,2

¹Children’s Hospital Colorado, Aurora, USA. ²University of Colorado Hospital, Aurora, USA

Baylor College of Medicine, Houston, USA

Results: There were 48 catheterizations in the study period where carotid artery was accessed. Out of those, 22 catheterizations with complete data were included in the study. Thirteen (50%) were males. Median age was 23 (IQR 7,79) days. The indications for carotid artery access were PDA stent implantation (n = 13,48%), aortic valvuloplasty (n = 5,22%), balloon angioplasty of coarctation of aorta (n = 2,10%), and renal artery angioplasty (n = 1,4%). In 16 patients (72%), the left common carotid artery was accessed. The median weight of the patients was 3.3 kg (IQR 2.8, 2.9). The most common sheath size used was 4F in 16 patients (72%). The average cNIRS prior to the procedure was 67 ± 15 (mean ± SD), during the procedure was 68 ± 20 (mean ± SD), and after removal of sheath was 68 ± 21 (mean ± SD). Paired t test of cerebral cNIRS before and during the procedure showed no significant change with carotid artery access (p = 0.08). Paired t test of means of cNIRS during and after procedure showed no significant change with removal of carotid artery sheath. No patient in the series had a documented neurologic deficit following the procedure.

Darren Berman^1,2, Thomas Jones³, Doff McElhinney⁴, Julie Vincent⁵, William Hellenbrand⁶, John Cheatham², Evan Zahn⁷, Danyal Khan⁸, John Rhodes⁹, Shicheng Weng¹⁰, Lisa Bergersen¹¹

¹The Ohio State University College of Medicine, Columbus, USA. ²Nationwide Children’s Hospital, Columbus, USA. ³Seattle Children’s Hospital, Seattle, USA. ⁴Stanford University, Stanford, USA. ⁵Columbia University Medical Center, New York, USA. ⁶Yale School of Medicine, New Haven, USA. ⁷Cedars-Sinai Heart Institute, Los Angeles, USA. ⁸Miami Children’s Hospital, Miami, USA. ⁹Medical University of South Carolina, Charleston, USA. ¹⁰Medtronic, Mounds View, USA. ¹¹Children’s Hospital, Boston, USA

Results: Among the 171 enrolled patients, a total of 150 patients underwent transcatheter valve implantation (TPVI) with the Melody valve. Median age at TPVI was 19 years (range 7–53). Fifty-one percent of enrolled patients had tetralogy of Fallot. As previously published, mean RVOT Doppler gradient was 17 mmHg at discharge. Five-year freedom from reintervention and freedom from explant were 76 ± 4% and 92 ± 3%, respectively. Thirty-two patients underwent RVOT reintervention at a median 4.5 years of follow-up. The majority of reinterventions were for RVOT obstruction (n = 27), while two patients underwent reintervention for endocarditis, and one patient for RV dysfunction. The current encore presentation will review 10-year outcomes as previously presented at SCAI 2020.

UH Rainbow Babies & Children’s Hospital, Cleveland, USA

Optimal angiographic imaging angles are essential in transcatheter interventions. However, achieving ideal views of complex or unique cardiovascular structures can be challenging. We sought to develop a tool to assist in obtaining optimal imaging angles using the mathematics of vectors. For a given vector v₁, there exists a plane defined as the set of all vectors that are perpendicular to v₁. This concept may be useful in cardiac angiography: if the “down-the-barrel” viewing angle of a vessel or structure is known, then many orthogonal camera angles could be derived to provide optimal “profile” views. Further, if two profile viewing angles of a structure are known, then the down-the-barrel angle can be derived.

To test the formulas, an X-ray phantom was designed and 3D printed.

One hundred trials were performed to assess formula 1. Mathematically, formula 1 generated high-quality solutions, with a mean angle of 90.01 degrees (range 89.52 to 90.42 degrees) between the down-the-barrel view and the calculated profile angles. Fluoroscopically, 99 of the calculated profile angles appeared perpendicular, while one appeared to be one degree off perpendicular (mean fluoroscopic angle 0.01 ± 0.1 degrees off perpendicular).

Ten trials were performed to assess formula 2, which also generated high-quality mathematical solutions. The mean angle between the known profile angles and the calculated down-the-barrel angles was 89.93 degrees (range 89.45 to 90.53 degrees). Fluoroscopically, nine of the calculated down-the-barrel angles appeared perpendicular, while one appeared to be one degree off perpendicular (mean fluoroscopic angle 0.1 ± 0.3 degrees off perpendicular).

São Paulo Federal University, São Paulo, Brazil. Synthetic Heart Institute, São Paulo, Brazil

Results: Physical tests. Result of study of surface scanning of pre and post crimp stent showed no structural modification of the PU. Hydrodynamic test showed a pressure gradient oscillation between 5 and 20 mm, in basal or stress conditions, respectively. Experimental studies. Sheep were subjected to 3D echo-Doppler study, in 6th follow-up months, which showed satisfactory hemodynamic performance, with low transvalvular gradient (M = 6.60 mmHg).

Ultrastructural Study: Six stents were explanted after 20 days to 21 months of follow-up to Ultrastructural analysis. All of which revealed no presence of calcium growth and prostheses structure was intact.

Professor of pediatric cardiology Manoura University, Mansoura, Egypt

Method: Between April 2005 and June 2018, all consecutive patients with CAS treated with balloon valvuloplasty in our hospital were analyzed retrospectively. Patients were followed up from 18 months to 13 years (mean 100.8 months [8.4 years]) by clinical examination and echocardiography. RESULT: Sixty-seven consecutive patients were analyzed. Their gestational age was 37.53 ± 1.37 weeks. Eleven patients (16.4%) were preterm newborn. Postnatal age 8.5  ±  7.6 days, range 4–35 days. Weight 2.75 ± 0.43 kg. 58.5% was male and 41.5% was female. Fifty-seven of patient (85.07%) received PGE1 infusion before the procedure to maintain the ductal patency in a dose of 0.05 to 0.1 µg/kg/min. Balloon valvuloplasty was accomplished in 65 (97.01%) of 67 interventions. The procedural approaches, success, early outcome, complication rates, mid-term results, and aortic regurgitation were retrospectively studied. Pre-dilatation by Brio coronary balloon was used in 19 patients (28.35%) followed by TAYSHAk^® mini balloon. TAYSHAk^® mini balloon was used from the start in 48 patients (71.6%) with balloon annulus ratio 0.85. In nineteen patients, antegrade approach was used through the patent foramen ovale, in 21 patients, trans-femoral retrograde approach was used, whereas, in 25 patients, trans-carotid approach was used. Peak-to-peak pressure gradient across the valve fell from (85.4 ± 14.0) to (24.7 ± 14.0) (P < 0.001). Left ventricular pressure fell from (101.4 ± 16.0) mmHg to (45.5 ± 10.5) mmHg (P < 0.001). Two patients had very difficult aortic valve cannulation with the wire then referred for surgical valvotomy. Two patients lost follow-up. Echocardiography on follow-up revealed a mean trans-aortic systolic gradient of < 30 mmHg, none to grade I aortic. On follow-up 6 children (9.2%) required a second balloon dilatation with good results.

Sharib Gaffar^1,2, Sanjay P. Sinha^2,1,3, Michael R. Recto²

¹University of California Irvine, Irvine, USA. ²CHOC Children’s Hospital of Orange County, Orange, USA. ³University of California Los Angeles, Los Angeles, USA

Manipal Hospital, Bangalore, India

Thoracic central venous system comprises deep venous system continuing from the head, neck, upper limb to the heart through the thoracic inlet corresponding to the level of T1 vertebra. These include the superior vena cava (SVC), Brachiocephalic vein (BCV), subclavian vein (SCV), intrathoracic segment of Internal Jugular Vein (IJV), and suprahepatic Inferior Vena Cava (IVC). Stenoses of these vessels are not infrequent with most common cause being multiple punctures while cannulating the IJV or SCV. The other causes include turbulent flow secondary to AV shunts, thrombin sheath formation within the indwelling catheters. Clinically they present with ipsilateral arm or face swelling, increased venous pressure during hemodialysis(HD) and failed access. Rather than the conventional treatment options, endovascular management remains as a standalone promising treatment option. In this pictorial exhibit, we present 4 patients with central venous stenosis who were referred to Interventional Radiology department for endovascular management.

Case Series:

Adrian Sanchez Flores¹, Bryan Barrera Ruvalcaba²

¹Hospital General Tijuana, Tijuana, Mexico. ²IMSS Clínica 1, Tijuana, Mexico

A 10-month-old female patient with a medical history of Down syndrome, at 1 month of age reported with tachypnea and diaphoresis during feedings. Assessed by paediatric cardiologist: reported physical examination an III/VI holosystolic murmur and a single and loud S2 sound, diagnosed with: 6 mm PM VSD, 5 mm ASD, small PDA and pulmonary hypertension (45 mmHg). In class III Ross classification, stared treatment with double diuretic. Assessed monthly for clinical and hemodynamic repercussion: with failure to thrive, throughout de following months with poor weight gain and pulmonary hypertension. Its decided at 10 months old to be taken to the cath lab, due to her failure to thrive and very low weight and to avoid open heart surgery to try to benefit her with a PDA closure due to hemodynamic repercussion: dilated left cavities and pulmonary hypertension, and clinical repercussion: weight under 1% percentile for her current age. In the procedure reported with moderate pulmonary hypertension with 55 mmHg (mean: 40 mmHg) of systolic pulmonary pressure: 20 mmHg under systemic pressure. The PDA (type C) was successfully closed through retrograde approach with an Amplatzer AVP II 6 mm device. A left ventricular angiography on four chambers view was made to investigate the VSD defect, which measured 8 mm. It was decided during the procedure for maximum benefit and to avoid open-heart surgery to close the VSD. The PM VSD was closed through a retrograde approach using a 5Fr Judkins right guiding catheter and a 0.035-inch guide wire to cross the VSD. Using the same guide catheter a 8 mm AVP II Amplatzer device was loaded and deployed successfully, only with angiography without eco guidance. Proper device position was confirmed with LV angiography, only noticing a minimal residual shunt and pulmonary pressure dropping 10 mmHg (mean: 40 mmHg). At her two-month post procedure check up: reported in Class I Ross classification, and 1.1 kg weight gain. Her transthoracic echocardiogram with the device in proper position with a 1.5 mm residual shunt generating a 55 mmHg gradient, LVDD: 28 mm (Z score: 1.1), and normal pulmonary pressure: 25 mmHg. An electrocardiogram reported in normal sinus rhythm. Using different devices such as the Amplatzer AVP II for transcatheter closure of perimembranous VSD defects is feasible and safe in small infants, with low weight, due to the fact that this devices can be deployed through smaller delivery catheters making it possible to close larger PM VSD defects, without causing rhythm disturbances or aortic/tricuspid regurgitation due to the softer material and design characteristics of this devices adapting well.

Evan Zahn¹, Vivian Dimas², Vasilis Babaliaros³, Dennis Kim³, D. Scott Lim⁴, Gareth Morgan⁵, Thomas Jones⁶, Aimee Armstrong⁷, Jamil Aboulhosn⁸, Vaikom Mahadevan⁹, Matthew Gillespie¹⁰, David Balzer¹¹, Girish Shirali¹², Anitha Parthiban¹², Jonathan Leipsic¹³, Philipp Blanke¹³, Yanjun Chen¹⁴, Shabana Shahanavaz¹¹

¹The Smidt Heart Institute and the Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, USA. ²Division of Cardiology, Department of Pediatrics, University of Texas Southwestern Medical Center, Children’s Health System of Texas, Dallas, USA. ³Division of Cardiology, Structural Heart and Valve Center, Emory University, Atlanta, USA. ⁴University of Virginia, Charlottesville, USA. ⁵Children’s Hospital, University of Colorado, Aurora, USA. ⁶Seattle Children’s Hospital, Seattle, USA. ⁷Nationwide Children’s Hospital, Columbus, USA. ⁸Ahmanson/UCLA Adult Congenital Heart Center, Los Angeles, USA. ⁹University of California, San Francisco, San Francisco, USA. ¹⁰Children’s Hospital of Philadelphia, Philadelphia, USA. ¹¹Washington University in St. Louis School of Medicine, St. Louis, USA. ¹²Children’s Mercy Hospital, Kansas City, USA. ¹³St. Paul’s Hospital, Vancouver, Canada. ¹⁴Edwards Lifesciences, Irvine, USA

Multicenter Pivotal Study of Alterra Adaptive Prestent and SAPIEN 3 Transcatheter Heart Valve in Congenital Pulmonic Valve Dysfunction.

Results: Enrolled patients (N = 60) were a mean age of 29.5 years; 50% were ≤ 21 years old. The cohort was 56.7% male with a mean weight of 73.1 kg, and 92% New York Heart Association class I/II. Fifty-nine patients had the Alterra and SAPIEN 3 THV devices concomitantly implanted; 1 patient had a staged procedure. All devices were implanted in the intended location. Acute device success was 93.3%: a single Alterra Adaptive Prestent implanted in the desired location (100%), a single THV implanted in the desired location within the Alterra Adaptive Prestent (96.7%), RV-PA peak-to-peak gradient < 35 mmHg post implantation (98.3%), < moderate PR by discharge (98.3%), free of explant at 24 h post implantation (100%). At 30 days, < moderate total PR was 98.3%; 1.7% (n = 1) had moderate PR (Fig. 1). At 30 days, TR was ≤ mild in 83.4% of patients. No death, pulmonary embolism, RVOT reintervention, endocarditis, clinically relevant arrythmia, or coronary artery compression were reported at 30 days. Alterra frame fracture was 1.7% at 30 days and 10% at 6 months. Frame fracture was not associated with a change in valve function and no patient has required an intervention.

The 6-month primary endpoint data will be available at the time of the presentation.

Conclusion: Early results demonstrate the safety and effectiveness of the Alterra Adaptive Prestent and SAPIEN 3 THV in patients with dysfunctional RVOT/PV.

Silvia Cecilia Britton Robles¹, Jesús Manuel Yañez Sánchez¹, Gloria Cristina Aguilar Arredondo^1,2, Otoniel Salinas Lozano¹, Abraham Patricio Garza Castro¹, Rosemberg Albores Figueroa^1,2, Juan Alberto Quintanilla Guitérrez¹, Mario Castro Medina^3,1

¹ITESM, Monterrey, Mexico. ²UMAE, Monterrey, Mexico. ³Children’s Hospital of Pittsburgh, Pittsburgh, USA

A 7-month-old boy, Jehovah Witness, diagnosed with a 11-mm ventricular septal defect complicated with pulmonary hypertension was admitted to the ER with decompensated congestive heart failure, oxygen saturation of 92% at room air, bilateral crackles, and evident shortness of breath. The patient was stabilized with supplementary oxygen, diuretics, and inotropic support. Pulmonary infection was ruled out. Seven days after the admission, the patient was subject to a perventricular VSD closure. The procedure was guided by transesophageal echocardiogram, placing a 12-mm Amplatzer^® VSD device to fully close the defect, without cardiopulmonary bypass support. The procedure terminated successfully, extubating the patient in the OR, without the need for blood transfusion with no other immediate complications. The patient was admitted to the PICU with minimal respiratory and inotropic support, with a stable and favorable evolution. No arrythmias nor bleeding presented within the first days after the procedure. Hemodynamic improvement was evidenced with echocardiogram which showed decreased tricuspid regurgitation and decreased pulmonary pressure. The patient was discharged eight days post surgery with minimal diuretics, aspirin, and phosphodiesterase inhibitors dose. This case is relevant, because it shows how religious beliefs can change the management of congenital heart defects. The surgical closure of the defect with a patch would be the first approach to resolve the defect, but the need for blood transfusion limited this possibility. The placement of a VSD device occluder with a hybrid approach was a suitable alternative considering the location of the defect and the borders for the correct implant of a metallic device by a perventricular puncture without the need of blood transfusions nor cardiopulmonary bypass; giving the family a relative low-risk procedure with physical, psychological, and spiritual safeness.

Rajeev Anchan¹, Diane Weibeler¹, AbdulRahman Dia¹, Joseph Venturini¹, Daniel Gruenstein², Sajid Shahul³, Rohan Kalathiya¹, John Blair¹, Stephanie Besser¹, Jonathan Paul¹, Sandeep Nathan¹, Atman Shah¹

¹University of Chicago Medical Center, Section of Cardiology, Chicago, USA. ²University of Chicago Medical Center, Department of Pediatrics, Chicago, USA. ³University of Chicago Medical Center, Department of Anesthesia and Critical Care, Chicago, USA

Results: Nineteen patients underwent TPVI, eight of which received CS. The procedure success rate was not statistically different between GA and CS cohorts; one case in the GA-TPVI group had an elevated transvalvular gradient of 24 mmHg. The CS-TPVI 90-day all-cause mortality and 30-day hospital readmission rates were 0%. Median in-room procedure time was less with CS than GA (132 min (92–170, IQR) versus 196 min (179–234, IQR), p = 0.008). There were no differences in procedure or valve delivery durations, contrast use, radiation exposure, length of stay, or periprocedural complications between groups.

Conclusions: In a single-center experience, the use of CS for TPVI was safe, less-invasive, and more efficient than GA. Our study demonstrates the importance of a multidisciplinary approach in complex congenital heart disease patients and underscores the need for larger studies investigating CS-TPVI.

Carolinas Medical Center, Charlotte, USA

Results: Forty-two patients were included with a mean weight of 72.4 kg ± 19.5, mean age of 26.3 years ± 8.5, and a mean BMI of 25.6 kg/m² ± 6.2 at the time of catheterization. Ten (23.8%) patients had a systemic right ventricle (RV) and 5 (11.9%) had undergone a Norwood operation. The mean SVEDP was 11.1 mmHg ± 3.5 and mean pulmonary artery pressure was 16 mmHg ± 4.0. On univariate analysis, SVEDP was positively associated with BMI (p < 0.01), age > 25 yo (p = 0.04), taking diuretics at time of catheterization (p < 0.01), taking sildenafil at time of catheterization (p < 0.01), symptoms of heart failure(p < 0.01), systemic ventricular systolic pressure (p = 0.03), pulmonary artery mean pressure (p < 0.01), and systemic vascular resistance (p < 0.01). The SVEDP was negatively associated with aortic saturation (p < 0.01). On multivariate analysis, SVEDP was positively associated with age > 25 yo at catheterization (p < 0.01), BMI (p = 0.04), and symptoms of heart failure (p = 0.05).

Kristie Barras¹, Hannah Reese¹, Miguel Behrhorst¹, Kiran Mallula²

¹Children’s Hospital of New Orleans, New Orleans, USA. ²LSU Health, New Orleans, USA

Kishore Raja¹, Satinder Sandhu²

¹Jackson Memorial Hospital, Miami, USA. ²University of Miami, Miami, USA

Methods: A retrospective chart review was undertaken of patients who underwent TVIVI at our institution between 2016.and 2020. Baseline clinical characteristics, procedural details, and outcomes at 1 month, 6 months, and 1 year were reviewed. Statistical analyses (dependent t test) to assess tricuspid valve gradients before and after TVIVI and at 1, 6, 12, 24 months of follow-up were performed. A p value < 0.05 was considered significant.

Results: Four patients, ages 17 to 66 years (37.5 + 10.2; mean + SEM), identified to have severe stenosis of a previously placed bioprosthetic valve in the tricuspid position underwent TVIVI with a 22-mm Melody valve. Three patients were NYHA functional class 4 and 1 patient was class 3 prior to intervention. All patients had multiple associated comorbidities and were considered high risk for cardiac surgery. Cardiac catheterization data obtained prior to and after TVIVI demonstrated that the peak-to-peak gradient across the tricuspid valve decreased from 14.5 + 3.3 to 5.25 + 1.25 mmHg (mean + SEM; p value = 0.02). By echocardiogram the mean gradient across the tricuspid valve decreased from 12.0 + 1.41 to 5.0 + 1.08 mmHg (mean + SEM; p value = 0.007). The mean transvalvar gradient by echocardiogram was unchanged at a follow-up of 3–25 mo (5 + 4.3; mean + SEM). One patient underwent Melody valve placement in the pulmonary valve position during the same procedure. The only complication was transient complete heart block in one patient, which resolved within 12 h. No other complications were identified at a mean follow-up of 5 months. Hospital length of stay ranged from 1 to 13 days, with a mean of 4.5 days (SEM + 2.8). Cardiovascular symptoms resolved in 3 patients and 2 patients had improvement in NYHA functional class. One patient, with a functional single ventricle (unbalanced AV septal defect, severe AV bioprosthetic valve stenosis) had liver cirrhosis, chronic ascites, and deteriorating renal function. Following TVIVI, he had improvement in renal function and is now listed for heart and liver transplant.

Yuki Kawasaki^1,2, Takeshi Sasaki^1,2, Thomas Forbes¹, Robert Ross¹, Daisuke Kobayashi¹

¹Children’s Hospital of Michigan, Detroit, USA. ²Osaka City General Hospital, Osaka, Japan

The objective of this study was to describe the hemodynamic data with test occlusion of the Fontan fenestration between closure and non-closure patients along with subsequent development of Fontan-associated diseases (FAD) at follow-up.

Results: Among the 38 patients who were brought to the catheterization laboratory, 33 received fenestration closure and 5 did not. On a median follow-up of 3.4 years (range 1 month to 12.6 years), the incidence of primary adverse outcomes was 13% (5/38). The incidence of primary outcome was significantly higher in the non-closure group (60% vs. 6%, p < 0.01). The non-closure group had a higher incidence of moderate or severe atrioventricular valve regurgitation, NYHA class III symptoms, use of ACEI/ARB, furosemide, and sildenafil. Multivariable logistic regression model showed that the hemodynamic variables associated with non-closure group were mean left atrial pressure (odds ratio 1.74, p < 0.05) and change of mean Fontan pressure at the balloon occlusion (2.2, p < 0.05).

National Medical Center “20 de Noviembre” ISSSTE, Mexico City, Mexico

Under general anesthesia and mechanical ventilation, we obtain femoral access. There were no obstructions in any site of the Fontan circuit but the mean pressure was 25 mmHg, in the angiography with no evidence of the surgical fenestration, so with a Brockenbrough needle advanced through a 6 Fr long sheath to the selected perforation site of the extracardiac conduit, a PT choice 0.014 coronary wire was advances through the needle and the right atrium and positioned in the left atrium, next, the needle, and the dilator of the long sheath were carefully exchanged for a 5-mm balloon catheter to pass and dilate the conduit and the atrial wall. Afterwards, the balloon catheter was exchanged for a 7-mm and then a 10-mm balloon catheter to further gradually dilate the initially established communication.

In the subsequent days, the patient presented a complete AV block, with the indication of colocation of a pacemaker, because of the risks, we decided a transcatheter implantation and the only access was the recent perforation, but the cables would obstruct almost the whole fenestration. The second procedure was performed in similar conditions, the previous fenestration was permeable, also with a Brockenbrough needle the second perforation was made above the first one, and the balloons catheters used to dilate were 6, 8, and 10 mm. We left the coronary wire to advance de pacemaker and position it at the atrium and left ventricle. After the procedure the patient’s clinical condition improved considerably, the control EKG demonstrated the normal function of the pacemaker.

Peter W. Guyon Jr.¹, Caitlin M. Heyden¹, Robert J. Lederman², Howaida G. El-Said¹, John W. Moore¹, Kanishka Ratnayaka¹

¹Division of Pediatric Cardiology, Rady Children’s Hospital| University of California San Diego, San Diego, USA. ²Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, USA

In an adult congenital heart disease patient, superior vena cava exit and right pulmonary artery entry followed by subsequent endografts created a permanent superior cavopulmonary anastomosis with anastomotic diameter of 20.7 mm. In a second (pediatric) patient, transcatheter rescue re-anastomosis was performed after inadvertent right pulmonary artery occlusion following transcatheter pulmonary valve insertion. Distal endograft wire perforation from the main pulmonary artery followed by balloon angioplasty created a 7.0 mm anastomosis with 6 mmHg residual pressure gradient into the right pulmonary artery while preserving implanted valve function. In a third case, transcatheter electrosurgery established temporary (“transcaval”) vascular access between the inferior vena cava and abdominal aorta (spaced 20 mm apart) in a patient with insufficient arterial vascular access. This facilitated temporary 20 French arterial access for endograft placement to dilate a stenotic surgical interposition graft and exclude a compressive seroma.

There were no procedural transcatheter electrosurgery complications. All three patients were extubated immediately after their procedures. The superior cavopulmonary anastomosis patient was hospitalized for 112 h (4.6 days) while the other two patients were hospitalized for 36 and 37 h, respectively. At time of most recent follow-up (576 ± 458 days), there were no complications.

Conclusions: Transcatheter electrosurgery can be used safely for large vessel end-to-side anastomosis, rescue re-anastomosis, and temporary anastomosis for vascular access. We demonstrated success in directly adjacent vessels as well as more remote vessels requiring traversal of extra-vascular space. Wire traversal was performed through native, naïve vessels, and synthetic material (Melody, Medtronic, Minneapolis, Minnesota).

NewYork Presbyterian Morgan Stanley Children’s Hospital, New York, USA

Results: There were 52 catheterization procedures performed on 50 patients. Endomyocardial biopsies were the most common procedure (n = 27, 52%). Interventional and diagnostic procedures represented 27% (n = 14) and 21% (n = 11) of cases, respectively. Two emergent procedures (3.8%) were performed on patients with positive COVID-19 testing. Most cases were performed on patients with negative COVID-19 testing (n = 33, 94%).

Cedars-Sinai Medical Center, Los Angeles, USA

Methods: The Minima stent is a balloon expandable, cobalt-chromium stent that comes pre-mounted on a proprietary 4F covered delivery system designed to track over a standard 0.014″ or 0.018″ guidewire. Bench-top expandable diameter ranges from 4 to 22 mm. This study was performed in 6 infant pigs to examine 1) deliverability and implant performance, 2) early histopathologic pathologic response, 3) in vivo re-dilation potential and stent behavior, and 4) chronic histopathologic pathologic response in both re-expanded and non-re-expanded stents.

This study utilized final stent designs, however, some manufacturing processes were modified between experiments.

Results: Twenty-four stents (22 Minima and 2 control) were implanted into the aorta (n = 13), branch pulmonary arteries (n = 6), and central veins (n = 5) of 6 infant piglets with an average weight of 4.6 kg. One piglet had an LPA stent which migrated to the MPA and underwent no further instrumentation and is not included in subsequent analyses. The remaining piglets were divided into 3 categories: 1) Early feasibility, single re-expansion, and sacrifice at 1 month (n = 2 piglets, 10 stents); 2) Serial re-dilation performed at 2–3 mos and 5 mos after implant (2 piglets, 9 stents); and 3) Single dilation 5 months after implant (1 piglet, 4 stents). All stents were successfully deployed into the target vessel, excluding 1 branch pulmonary artery stent, which utilized an early delivery system prototype. There were 2 early instances of proximal LPA stent migration following successful deployment during removal of the delivery balloon. Median implant diameter was 7.5 mm (2.6–8.8 mm). Stents were re-expanded at 34, 64, 82, and 154 days, corresponding to average animal weights of 14, 35, 44, and 107 kg. All Minima stents regardless of location could be re-dilated to keep pace with somatic growth (Figure). There was a single Minima stent that appeared incompletely opposed to the abdominal aortic vessel wall 64 days after implant. Histopathology at 34 and 146 days (3 animals, 8 vessels) demonstrated widely patent stented vessel lumens with uniform stent apposition to vessel wall, early (1 mos) mild inflammatory response surrounding stent struts, typical progressive vascular healing response, and a progressive smooth neointimal growth pattern covering stent struts over time (2–3 mos).

Conclusions: This early work suggests that the Minima stent and 4F delivery system may be well suited for treatment of a variety of vascular stenoses in young infants and neonates. This is a unique device in that it can be enlarged in vivo, from neonatal to adult diameters while maintaining structural integrity. Further laboratory and clinical testing will be needed to determine the safety and efficacy of this novel device in humans.

Do you think we need to add a blurb like this about the varying manufacturing processes—which led to the inability to grow past 18 mm and accounted for higher recoil in some stents?

I like it

This stent was one that was left in the vessel for 5 months without re-expansion

Fixed this…I think

Rajesh Kumar Ramaswamy¹, Sivakumar Kothandam²

¹Madras Medical Mission, Chennai, India. ²Madras Medical Mission, Chennai, India

Robert Petersen¹, Beth Price², Chetena Reddy¹

¹St. Louis University, St. Louis, USA. ²SSM Health Cardinal Glennon Children’s Hospital, St. Louis, USA

Case Presentation: Fetal care Institute patient with pregnancy complications including monozygous/diamniotic pregnancy, NIPT positive for Trisomy 21 in both twins, gestational diabetes, and growth restriction of Twin A. The fetal ECHO on both twins showed suspected Tetralogy of Fallot and with arch hypoplasia in Twin A. They were born at 30 weeks of gestation due to preterm labor. Postnatal Trisomy 21 was confirmed on both twins. Postnatal echocardiogram for Twin A showed a moderate perimembranous ventricular septal defect (VSD) (3.7 mm) with bidirectional flow, small-to-moderate PDA with bidirectional shunting, mostly left to right. Patent foramen ovale with left-to-right flow. No left heart enlargement. Mild tricuspid regurgitation, estimated RVSP 52 mmHg + RAp. Normal biventricular systolic function. The findings on twin B after delivery found moderate perimembranous VSD (3.5 mm) with bidirectional flow, mostly left to right, partially covered by tricuspid valve tissue. Moderate PDA with bidirectional shunting, mostly left to right. Patent foramen ovale with mostly left-to-right flow. No left heart enlargement. Mild tricuspid regurgitation, with estimated RVSP 54 mmHg + RAp. Normal biventricular systolic function. Both spent 3 months in the NICU due to feeding difficulties resulting in a G-tube placement and respiratory failure. Both required Lasix while in the NICU for clinical signs of pulmonary overcirculation. Both failed weaning from respiratory support and were sent home on 1/8L nasal cannula. At their first outpatient clinic visit, both had low velocity flow across their VSD and a soft murmur on exam concerning for elevated right heart pressures. Prior to undergoing repair, both underwent a cardiac catheterization. The catheterization findings on Twin A showed a moderate perimembranous VSD, moderate secundum ASD, mildly elevated RVEDP (11 mmHg), elevated PA pressure (40–42 mmHg), normal PVR (1.92 iWU), upper normal LVEDP (10 mmHg), Qp:Qs = 4.25:1. The findings on Twin B showed a large perimembranous VSD with baseline Qp:Qs 2.27:1, elevated pulmonary vascular resistance at baseline 5.7 Woods units × m², pulmonary vasodilator testing with iNO 40 ppm and FiO₂ 60% demonstrated improvement in PVR to high normal level 2.7 iWU and decreased cardiac output 2.4 L/min/m2. Based on the information found during the catheterization twin A underwent surgical closure of VSD, closure of ASD, and ligation of the PDA. Based on the information found during the cardiac catheterization, Twin B was started on Tadalafil prior to repair. Twin B underwent closure of an ASD and VSD and ligation of PDA. The post-operative course for both twins was uncomplicated.

Children’s Hospital of Michigan, Detroit, USA

Results: A total of 127 patients underwent 153 pericardiocentesis procedures. The mean age was 6.5 ± 6.7 years with weight of 27.8 ± 28.6 kg. Most common etiology was post-pericardiotomy syndrome (n = 56, 44%), followed by Infectious (12%), Malignant (10%), and Iatrogenic (9%). Clinical and echocardiographic cardiac tamponade were present in 53% (80/153). Pericardiocentesis was performed primarily in the catheterization laboratory (n = 86, 59%) and in the high acuity (emergent 9%/urgent 91%). Concurrent pericardial drain placement was performed in 67 patients (53%) at the initial pericardiocentesis. Acute procedural success was 93%. Repeat intervention was performed in 33 patients (26%). The incidence of SAE was 5% (7/149): hemopericardium requiring emergent surgery (n = 2), hemopericardium with hypotension (n = 2), seizure with anesthesia induction (n = 1), right ventricle puncture with needle (n = 2). No identifiable risk factors were associated with SAE.

Children’s Hospital of Michigan, Detroit, USA

Results: A total of 13 PBP’s were performed in 11 children at the median age of 12 years (range 1.8 to 19). The etiologies of pericardial effusion were post-pericardiotomy syndrome (n = 4), restrictive cardiomyopathy (n = 1), autoimmune diseases (n = 3), malignancy (n = 2), and idiopathic (n = 1). Two patients received two PBP. The technical success of PBP was 100% with no acute adverse events (balloon rupture or local bleeding). Five (45%) required reintervention and ultimately 3 required a surgical pericardial window 6 to 35 days after the PBP. As a result, ultimate procedural success rate was 73% (8/11).

Boston Children’s Hospital, Boston, USA

Conclusion: Our in vitro study identifies the histologic correlates to IVUS-defined areas of intraluminal PVS. IVUS may provide further understanding of the anatomy and mechanisms of pediatric pulmonary vein obstruction.

Hannah El-Sabrout¹, Justin Ryan², Sanjeet Hegde³, Howaida El-Said³, John Nigro³, John Moore³, Kanishka Ratnayaka³

¹University of California, Los Angeles, Los Angeles, USA. ²Rady Children’s Hospital San Diego, San Diego, USA. ³Rady Children’s Hospital San Diego/University of California, San Diego, San Diego, USA

Conclusions: Ideal transcatheter cavopulmonary shunt device for the typical patient would be 10 mm in diameter and 20–25 mm in length.

Najib AlRawahi¹, Ghaliah Al Muhaini¹, Mohammed AlRawahi^1,2

¹National Heart Center, Muscat, Oman. ²Sultan Qaboos University Hospital, Muscat, Oman

Since 2008 implantable Cardiac Resychronization devices have been implanted exclusively in our center. We describe our experience in successful implantation of the left ventricular lead from 2015 to 2019. Our approach is using EGMs from a quad electrophysiology catheter which is successful in 96% of the cases. For the remaining cases, our approach is using different shapes of conventional diagnostic coronary catheters in localization of the Os then advancing a guide wire into the coronary sinus. Our stepwise approach was successful in 99% of the cases. For the remaining 1% complication of CS dissection was done which warrants a second procedure during which the implantation is done. We would like to share our approach to the world.

Cohen Children’s Hospital, Zucker School of Medicine, New York, USA

Results: Seventeen premature infants underwent successful transcatheter PDA closure during our study period. The mean gestational age at birth was 25.6 + 1.8 weeks and the mean corrected age at time of PDA closure was 32.1 + 4 weeks. Mean weight at the time of closure was 1674.3 + 925 g. The mean minimum diameter of the PDA was 2.5 + 0.6 mm. After closure, we found the indexed left ventricular end-diastolic diameter significantly decreased from 12.9 + 2.7 mm at baseline to 11.4 + 1.7 mm at 1 week, and 10.1 + 1.2 mm at 1 month (p = 0.04, p < 0.001, respectively). The left ventricular ejection fraction and shortening fraction remained within normal limits pre and post closure with no significant difference. ASb pre closure was highest in the TransAo (mean of 6617 + 3071). Post closure there was no significant statistical difference in the ASb at AscAo or PLXAscAo. There was a statistically significant decrease in ASb at TransAo (mean of 3550 + 1434, p = 0.0010) and DistAo (mean of 2892.8 + 1632.5, p = 0.0092) one month post closure. The average ASb post closure also demonstrated significant improvement at 1 month (mean of 3553.2 + 994.5, p = 0.0005) compared to the cumulative baseline (5256 + 1478).

LeBonheur Children’s Hospital, University of Tennessee Health Science Center, Memphis, USA

Results: Fifty-one patients, underwent a total of 62 procedures. There was a significant difference in post-procedure troponin I level between groups (p < 0.001). Diagnostic cardiac catheterization (n = 7) demonstrated minimal troponin release with no values exceeding upper threshold post procedure (median 0.012, IQR 0.012–0.012). Endomyocardial biopsies (n = 31) were associated with the highest elevation in troponin I level (median 0.2, IQR 0.114–0.259) compared to interventional cardiac catheterization procedures (n = 24, median 0.064, IQR 0.026–0.154). No procedure-related complications occurred during this study.

Stephen Clark¹, Santiago Borasino¹, Jeffrey Alten², Mark Law¹

¹University of Alabama at Birmingham, Birmingham, USA. ²University of Cincinnati College of Medicine, Cincinnati, USA

Conclusions: This large cohort of pediatric PC patients demonstrates that standard ECHO technique is safe and effective; the PLANE technique appears equally safe and may offer potential advantages in smaller, more critically ill patients. Additionally, this novel technique may be more easily mastered as suggested by its use in non-interventional cardiology trained practitioners.

Diana Herrera-Valenzuela¹, Camila Castro-Páez¹, Juan Carlos Briceño¹, Alberto García-Torres²

¹Department of Biomedical Engineering, Universidad de los Andes, Bogotá, Colombia. ²Congenital Heart Disease Institute, Fundación Cardioinfantil, Bogotá, Colombia

Results: Eight (8) patients were analyzed. Ages ranged from 1 to 55 days (median = 6), and weight ranged from 2.4 to 4 kg (median = 2.95). Arterial blood oxygen saturation previous to the procedure ranged from 60 to 99% (median = 93.75). Two patients had a diagnosis of pulmonary stenosis, two had pulmonary atresia with ventricular septal defect, three had pulmonary atresia with intact ventricular septum, and one had pulmonary atresia with single ventricle morphology. Only one patient had a procedure prior to stenting. Four DA had aortic insertions at the aortic arch and four at the descending aorta. Six DA had a type 2 shape, one a type 3 shape, and one a type 1 shape according to the Qureshi et al. classification scheme. Angiography images of the eight ductus are presented in Figure 1. DA minimum diameter ranged from 1.6 to 5.11 mm (median = 2.41). Transductal gradient previous to procedure ranged from 13 to 90 mmHg (median = 41.5). Pulmonary arteries size ranged from 2.9 to 5.1 mm for the left pulmonary artery (median = 3.80) and 2.83 to 5 mm for the right pulmonary artery (median = 4.22). McGoon indexes ranged from 1.13 to 1.91 (median = 1.41). Femoral artery access was used in all the patients, however, the shape of the ductal guide catheter can be used for alternative vascular accesses that will be used in future interventions. No concomitant procedures were performed. The procedure was successfully completed in all patients and only two patients had minor complications, which were successfully controlled. Procedure time ranged from 59 to 262 min (median = 77). Patients required from 1 to 4 stents (median = 2). A total of 17 stents with either 3.5 or 4 mm diameter were used. All patients were monitored 4 to 207 days (median = 15) after the procedure was performed. Only one patient evidenced non-restrictive flux through the stent at follow-up.

Texas Children’s Hospital/Baylor College of Medicine, Houston, USA

Basil (Vasileios) D. Thanopoulos^1,2, George Tsaousis³, Nicholaos Eleptherakis⁴, Evangelos Karanasios⁴, Andreas Giannopoulos⁵

¹Agios Loukas Clinic, Thessaloniki, Greece. ²Iatrikon Medical Center, Athens, Greece. ³Agia Sophia Children’s Hospital, Athens, Greece. ⁴Agia Sophia Children’s Hospital, Athens, Greece. ⁵AHEPA University General Hospital, Thessaloniki, Greece

Joshua Quinones¹, Duraisamy Balaguru¹, Amilcar Avendano², Salman Arain¹

¹University of Texas McGovern Medical School, Houston, Texas, USA. ²Memorial Hermann Hospital, Houston, Texas, USA

Introduction: Transcatheter closure of coronary fistula is an established procedure. However, closure of coronary fistula approaching from pulmonary artery side is considered difficult. We report transcatheter closure of coronary fistula via pulmonary artery using a double-guide wire technique.

Medtronic, Mounds View, USA

Louisiana State University, New Orleans, USA

Complex infradiaphragmatic venovenous collaterals following Fontan palliation in the setting of inferior vena caval obstruction.

(1) Patient 1 had a large VVC from the right internal jugular vein (RIJV) to the left atrium fed by tributaries from the azygous vein formed by collaterals from the paravertebral plexus inferiorly. Due to severe RIJV stenosis, bilateral femoral venous occlusion, and difficult access to the collateral, he underwent hybrid procedure for closure of the VVC with a 14-mm Amplatzer vascular plug II (AVP II).

(2) Patient 2 had severe stenosis of the IVC. This resulted in the formation of paravertebral venous collaterals that drained into the azygous vein and eventually into the right upper pulmonary vein. VVC was closed by deployment of two 14-mm AVP II devices in the azygous vein that was accessed through a paravertebral venous collateral followed by placement of seven stents in the IVC.

(3) Patient 3 had complete obstruction of infrarenal IVC. The paravertebral venous collaterals coalesced and drained into the left upper pulmonary vein. Percutaneous closure of VVCs in these patients was complicated by infrarenal IVC obstruction and difficult access to the VVC. After considering the complexity of the procedure to eliminate the collateral, weighing the risks and benefits of closing the VVC, a decision was made not to intervene.

The most recent follow-up of patients 1 and 2 were 11 and 1 months after the procedure. They reported a 10% increase in the baseline saturations and improved exercise tolerance.

Rady Children’s Hospital/UCSD, San Diego, USA

Methods and Results: A retrospective chart review of all pediatric patients that underwent IVUS during cardiac catheterization to evaluate the cross-sectional lumen of non-coronary vessel(s) at Rady Children’s Hospital from January 2018–December 2019 was performed. Mean patient age 1076 days ± 1182 days with mean weight 12.1 kg ± 9 kg. A total of 26 vessels were interrogated with IVUS. Pathology evaluated included pulmonary venous stenosis (n = 8), coarctation (n = 5), branch pulmonary artery stenosis (n = 6), systemic shunts and conduits (n = 3), and other peripheral vasculature (n = 4). IVUS added value in 100% of the cases in which it was utilized. Use of IVUS guided intervention in 88% of the procedures and defined the endpoint in 62% of the procedures.

Asimina Courelli¹, Arpine Davtyan², Bryan Mosher², Peter Guyon², Kanishka Ratnayaka², Howaida El-Said²

¹University of California, San Diego School of Medicine, San Diego, USA. ²Division of Cardiology, Rady Children’s Hospital, San Diego, USA

Methods: Patients having undergone transcatheter pulmonary valve implantation (Melody, Medtronic, Minneapolis, MN) with weight at implantation of less than 25 kg at Rady Children’s Hospital in San Diego between January 2011 and December 2019 were identified. Patient profiles, short-term outcomes, and mid-term outcomes were reviewed.

Results: Thirty-four patients were identified who had undergone Melody valve implantation. The mean age was 6.8 ± 1.7 yrs and the mean weight was 20.7 ± 2.9 kg. Most patients were initially diagnosed with Tetralogy of Fallot (n = 16), which had been surgically repaired. The right ventricular outflow tract (RVOT) substrate was either native RVOT (trans-annular patch) (n = 17), conduit (n = 14), or bioprosthetic valve (n = 3). The indication for the Melody valve implantation was either regurgitation only (RO, n = 19), stenosis only (SO, n = 5), or both regurgitation and stenosis (R + S, n = 10). Implanted valve sizes were 22 mm (n = 14), 18 mm (n = 12), 20 mm (n = 6), 16 mm (n = 1), and 14 mm (n = 1). Immediately after implantation, no pulmonary regurgitation was noted on angiography or echocardiography for all patients and a significant decrease in RV-PA gradient (pre: 28 ± 7 mmHg, post: 15 ± 4 mmHg, p < 0.01) was observed. 3/34 patients had a complications: vascular access (n = 1), RPA jailing (relieved during same procedure) (n = 1), and conduit pseudo-aneurysm that required placement of vascular plug (n = 1). 5/34 patients developed transient non-sustained ventricular ectopy, none of which resulted in hemodynamic instability. Three of those five patients were treated with Nadolol and all arrhythmias resolved within 3 months. To date, only 2/34 patients required reintervention. One required reintervention 2 years post implantation for stenosis due to interval growth, which was treated with angioplasty, and the other required reintervention 6 years post implantation for stenosis due to interval growth and Melody frame fracture, which was treated with re-stenting, and Melody valve placement. 2/34 experienced Type I stent fractures, only one of which required intervention. At the time of most recent follow-up, on average 2.5 years (range 6 ms–6.6 ys), none of the patients required surgical intervention or developed Melody valve endocarditis. Echocardiography showed an average maximum RVOT gradient of 17 ± 9 mmHg in RO patients and 11 ± 8 mmHg in R + S patients with mild pulmonary regurgitation in only 3/34 patients. There was no patient mortality.

Sharib Gaffar^1,2, Joanne P Starr¹, Roy Ramirez¹, Danny Lam¹, Michael R Recto¹

¹CHOC Children’s Hospital of Orange County, Orange, USA. ²University of California Irvine, Irvine, USA

Republican Scientific and Practical Centre Cardiology, Minsk, Belarus

We studied 96 patients aged 70.6 (66.0; 73.0) years old, 32 (33.3%) were men, 64 (66.7%)—women. Grades 1–3 hypertension were present in 87 (91%), myocardial infarction—8 (8%), angina pectoris—23 (24%), PCI (6) (7%). Chronic heart failure Class I-II NYHA had 78 (81%). All included patients were statin-naïve. Computed tomography angiography of the coronary arteries (CTA CA) and estimation of Coronary Calcium Index (CCI) were performed on a dual-energy, 384-slice CT scanner of the premium class Siemens Somatom Force from General Electric Medical Systems (Germany). Standard biochemical blood test with determination of the lipid spectrum of blood, glucose, uric acid, determination of apolipoprotein A-1 (ApoA-1), and apolipoprotein B (ApoB) in blood serum was carried out by immunoturbidimetric method on a biochemical analyzer “ARCHITECTPLUS: 4000,” USA. Serum coenzyme Q levels were determined using the Human Coenzyme Q10 (CoQ10) Elisa kit reagent using an enzymatic method to determine the optical density at a wavelength of 450 nm (high-performance liquid chromatography).

The results of a biochemical blood test are presented in Table 1.

Data of heart CT presented in Table 2.

We found positive moderate correlation between the levels of LDL and the CCI (r = 0.66, p < 0.), between the levels of TC and the CCI (r = 0.52, p < 0.), between the levels of LDL and CA significant stenosis (r = 0.29, p < 0.05). CCI was higher in smokers (r = 0.33, p < 0.), patients with diabetes mellitus (r = 0.30, p < 0.), and in alcohol abusers (r = 0.57, p < 0.r = 0.29, p < 0.).

Shanique Sterling¹, Yuen Y. Lo Yau Leung¹, Alejandra Bueno¹, Satinder Sandhu²

¹Jackson Memorial Hospital, Miami, USA. ²University of Miami, Miami, USA

Cardiac Catherization is an invaluable diagnostic and interventional tool in the management of patients with congenital and acquired heart disease. The CRISP Score is an essential pre- procedural risk scoring tool to stratify pediatric patients and identify those at risk for serious adverse events (SAE). We aim to internally validate this scoring tool at our institution in both our pediatric and adult patients with congenital heart disease.

A total of 2031 procedures between January 2008 to December 2018 were reviewed retrospectively and the CRISP Score calculated based on pre- and intraprocedural data. Complications documented within the immediate 24 h post procedure were identified. A SAE was defined as any adverse event causing mortality, permanent morbidity, need for further interventions, or extended length of stay. Microsoft Excel and SPSS were then utilized to facilitate performance of basic measures of descriptive analysis and binary logistic regression.

The cohort consisted of 1004 (49%) females and 1027 (51%) males with 66% being children (age < 18 years) and 34% being adults (> 18 years). Mean age for children was 7 years with a SD of 6.4 years, while for adults it was 30.3 years with a SD of 13.4 years. The age range for the cohort was 0–82.6 years.

There were 29 SAE (1.43% of total procedures). Children accounted for 82.7% of the SAE. The rate of SAE in children was 1.79% (24/1342) and in adults was 0.73% (5/689). The rate of SAE in children increased as age of the child decreased with neonates (< 1 month old) having a rate of SAE of 16.4% while children > 5 years had a rate of < 0.5%.

The mortality rate of this entire cohort of patients was 0.2% which accounted for 8.7% of all SAE (4/29). It should be noted that all deaths occurred in the pediatric age group with 3 of the 4 deaths being in neonates.

Our results have internally validated the utility and accuracy of the CRISP Scoring System in predicting the risk of a SAE both in our pediatric and adult population which both showed that there was a statistically significant increase in the odds of having a SAE for every 1 unit increase in their CRISP Score. We conclude that CRISP Score should be used pre- procedurally and intraprocedurally to risk stratify patients with congenital heart disease undergoing cardiac catheterization.

Stanford University School of Medicine, Palo Alto, USA

Conclusions: In TOF/MAPCAs, the distribution of MAPCAs is highly variable and essentially unique for each patient. Though each pulmonary segment can be supplied by a MAPCA, central PA, or both, in our analysis the type of supply was not associated with surgical outcome, and all anatomic combinations were conducive to a good repair. Of the variables we studied, total cross-sectional area of central PA and MAPCA material (TNPAI) was an important driver of outcome, with those having a paucity of total material being the most challenging patients to manage.

Data presented as n (%) or median (Q1, Q3). PA pulmonary artery, PDA ductus arteriosus, Qp:Qs ratio of pulmonary to systemic blood flow, MAPCA major aortopulmonary collateral artery, TNPAI total neo-pulmonary artery index, RV:Ao ratio of right ventricle to aortic pressure.

Ricardo Ortega¹, Donovan Espriu¹, Marco Solorzano², Oscar Medina³, Gutierrerez Marai¹, Hayde Estrada⁴, Cristian Villar¹, Roman Garcia¹

¹Departamento de Cardiologia del Centro Medico Nacional del Bajio IMSS T1, Guanajuato, Mexico. ²Departamento de Cardiologia/Intervencionismo en Cardiopatias Congenitas del Centro Medico Nacional del Bajio IMSS T1, Guanajuato, Mexico. ³Departamento de Cardiologia/Ecocardiografia del Centro Medico Nacional del Bajio IMSS T1, Guanajuato, Mexico. ⁴Departamento de Cardiocirugia del Centro Medico Nacional del Bajio IMSS T1, Guanajuato, Mexico

Case Report: This is a 21-year-old male patient with a significant history of diagnosis of systemic arterial hypertension and post-ductal aortic coarctation both diagnosed at 17 years of age a month later under endovascular treatment with Advanta V12 16 × 61 mm aortic covered stent placement without complications. He began his condition 1 month before admission with unquantified fever, myalgia, arthralgia, and chills with management with multiple antibiotic regimens without improvement. Physical examination revealed heart murmurs with mesosystolic murmur in aortic focus intensity III/VI Levine with irradiation to the neck without s3 s4, limbs with decreased pulses and erythematous lesions, rest of normal physical examination. With studies: Hemoglobin: 8.7 g/dl, Leukocytes 15.8 ul, Creatinine 1.2 mg/dl, and positive blood cultures for streptococcus pyogenes. Transesophageal echocardiogram image of a mixed, irregular, mobile echogenicity mass is observed, with multiple ramifications of approximately 10 × 9 mm on its short axis (Fig. 1), concluding intra-aortic stent with image suggestive of thrombus (Fig. 2). Angiotomography with 3D reconstruction aortic stent in ascending aorta with collapse in the proximal end (Fig. 3) and in sagittal slice image in relation to thrombosis of stent and collapse (Fig. 4). Therefore, it was decided to undergo a surgical emergency treatment to remove a thrombosed stent and place a 10-cm polytetrafluoroethylene graft without complications, culture report of a positive surgical specimen for pyogenes streptococcus.

Renelle George^1,2, Mohammad Khan^1,2, John Lozier^1,2, Martin Bocks^1,2

¹UH Rainbow Babies & Children’s Hospital, Cleveland, USA. ²Case Western Reserve University School of Medicine, Cleveland, USA

Case Description: A 3-week-old female born at 31 weeks of gestation developed new systemic desaturations requiring escalation of respiratory support. Echocardiogram demonstrated infradiaphragmatic TAPVR with a descending vertical vein draining to the portal vein and a small accessory pulmonary vein draining to the left innominate vein. Given that she was clinically stable and weighed only 1775 g, consensus opinion following our case management conference was to defer surgical repair until a minimum of 36 weeks of gestation to allow for improved maturation and weight gain prior to undergoing cardiopulmonary bypass. In the interim, however, she developed Klebsiella pneumoniae and worsening hypoxemia which did not respond to 100% FiO2. She became progressively hemodynamically unstable and suffered bradycardic arrest for which she was successfully resuscitated. Echocardiogram demonstrated a newly narrowed DV and new severe pulmonary hypertension (PH). Due to her critical status with guarded neurological prognosis, she was considered too high risk for surgical repair or palliation with ECMO. Therefore, she was emergently brought to the catheterization laboratory for DV stenting to relieve the obstruction. Using ultrasound guidance, transhepatic access was obtained in the portal vein with a 5/4 Merit sheath. Angiogram demonstrated a severely stenotic DV. The DV was crossed using a Maestro microcatheter through a 4 Fr JR 2.5 catheter over a 0.014″ Choice PT wire, which was exchanged for an 0.018″ Steelcore wire. A pre-mounted 4-mm × 16-mm Formula 418 stent was advanced over the wire into the DV, where it was implanted with balloon inflation to 12 atm. Angiogram demonstrated excellent stent placement with vigorous flow into the hepatic venous system and the atria (Figure 1). The balloon, wire, and sheath were removed. Coiling of the transhepatic tract was unsuccessful due to the short distance between liver capsule and the accessed portal vein, so manual compression was performed. Ultrasound demonstrated a small amount of blood in the abdomen, which remained stable on subsequent evaluation.

The patient tolerated the procedure well with acutely improved oxygenation. Despite adequately decompressing the anomalous venous connection, however, her PH did not abate. Due to her small size and hemodynamic instability, her surgical candidacy did not improve. Her parents elected to withdraw life-sustaining measures.

Neeraj Awasthy¹, Romilla Chemoriya², Gaurav Kumar²

¹Max Hospital, Saket, Delhi, India. ²Max Hospital, Delhi, India

Tricuspid valve atresia with severe pulmonary stenosis is one of the common cyanotic diseases in neonate. Child can succumb due to profound cyanosis and arterial hypoxemia after closure of PDA. Evolving procedure of Right ventricular outflow tract (RVOT) stenting may be considered as a palliative procedure in such vulnerable group, destined for a later definitive management. The RVOT stenting is described essentially for TOF physiology with a catheter course across tricuspid valve. We describe a case of successful RVOT stenting in 5-day-old symptomatic neonate. We discuss the possible routes and the tips to facilitate RVOT stenting in such a case. This happens to be the first reported case description with successful stenting of neonate with tricuspid atresia with critical pulmonic stenosis.

Max Hospital, Delhi, India

Percutaneous device closure of a left ventricular (LV) pseudoaneurysm have been rarely reported. We describe the case of a 60-year-old woman with a history closed mitral valvotomy at 18 years of age, Mitral Valve (MV) replacement at 53 year of age in Feb 2016 at 60 year of age. She presented with shortness of breath and chest pain since for 2 weeks. Echocardiography (Echo) revealed LV pseudoaneurysm with neck size of 12 mm. Cardiac MRI showed a large LV pseudoaneurysm (36 × 32 mm) that was filling from a small leak in the anterolateral aspect of the ventricle. Considering high-risk candidate for surgical treatment in view of three previous sternotomies, the pseudoaneurysm was closed percutaneously with use of a 16-mm AMPLATZER muscular VSD occlude successfully. The patient was discharged from the hospital the next day and was asymptomatic on follow-up.

Juan Samayoa¹, Dana Boucek¹, Elisa McCarthy¹, Michelle Riley¹, Lloyd Tani¹, Arvind Hoskoppal², Robert Gray¹, Mary Martin¹

¹University of Utah, Salt Lake City, USA. ²University of Pittsburgh Schools of the Health Sciences, Pittsburgh, USA

Results: During the study period, 246 patients underwent successful TPVR (Melody n = 181, SAPIEN n = 65). Groups had similar baseline age, weight, and diagnosis. The most common indications were stenosis (31.5%) or mixed disease (47.5%) in the Melody group and insufficiency in the SAPIEN group (49.2%) (p < 0.001). SAPIEN valves were more often placed in native RVOT (60% vs. 17%, p < 0.001). The mean final measured valve size on fluoroscopy was 20.9 mm (± 2 mm) in the Melody group and 24.5 mm (± 2.7 mm) in the SAPIEN group. Discharge and follow-up mean and peak Doppler gradients were similar between groups (Table). The patients in the native RVOT group had significantly lower post-implantation gradients in both the Melody and SAPIEN groups (Table). Only 1 patient in the entire cohort (SAPIEN in conduit) had > mild pulmonary regurgitation at follow-up.

Conclusion: In our cohort, post-procedure and short-term follow-up Doppler gradients were similar after Melody or SAPIEN TPVR. When groups were subdivided by RVOT type, lower post-procedure gradients were noted after TPVR into a native RVOT. Long-term follow-up is needed to further assess valve function over time.

Hannah El-Sabrout¹, Reid Ponder², Arpine Daytyan¹, Peter Guyon², Ryan Reeves³, Kanishka Ratnayaka¹, John Moore¹, Jamil Aboulhosn², Daniel Levi², Howaida El-Said¹

¹Rady Children’s Hospital San Diego/UCSD, San Diego, USA. ²Mattel Children’s Hospital/UCLA, Los Angeles, USA. ³Salpizio Medical Center/UCSD, San Diego, USA

Results: There were 507 TPV, 113 of which had native RVOT and 394 of which had non-native RVOT. Out of these patients, 385 received Melody valves and 122 received Sapien valves. The incidence of endocarditis was 1.8% (n = 2) for native versus 9.4% (n = 37) for non-native. Of the two native RVOT patients that developed endocarditis, one received a Melody valve, and one received an Edwards Sapien 3 valve. All of the patients who developed endocarditis with non-native RVOT received a Melody valve. The Kaplan–Meier curves below display the incidence of endocarditis between the two RVOT substrates over time, factoring for valve type.

Conclusion: The intermediate-term incidence of endocarditis post TPV is low for native RVOT. In this study, there was a trend towards a lower incidence of endocarditis in native versus non-native RVOT. This however did not meet statistical significance (p = 0.63).

Kiran Mallula¹, Nathaniel Taggart², Gurumurthy Hiremath³, Sarosh Batlivala⁴, Bryan Goldstein⁵, Kurt Schumacher⁶, Jeffrey Zampi⁶

¹Louisiana State University, New Orleans, USA. ²Mayo Clinic, Rochester, USA. ³University of Minnesota, Minneapolis, USA. ⁴University of Cincinnati, Cincinnati, USA. ⁵University of Pittsburgh, Pittsburgh, USA. ⁶University of Michigan, Ann Arbor, USA

Célia Silva¹, Juliana Taguchi¹, Gustavo Feitosa¹, José Aguiar Jr², Jorge Durante², Yan Sasaki¹, Ana Faccinetto¹, Renata Mazzini², Camila Silveira²

¹Federal University of São Paulo, São Paulo, Brazil. ²General Hospital of Pirajussara, São Paulo, Brazil

Congenital heart disease (CHD) with ductal-dependent pulmonary circulation are still a challenge because there is necessity of early intervention to maintain the pulmonary flow, either by surgery to have a modified Blalock–Taussig shunt (mBTS) performed or percutaneous by implanting a stent in the ductus arteriosus.

Istanbul Marty Prof. Dr. Ilhan Varank Sancaktepe Research and Training Hospital, Istanbul, Turkey

A 72-year-old male patient was admitted to the emergency department with a speech disorder and weakness on the right side. In his medical history, he did not have chronic drug use or additional disease except two package/year smoking.

On physical examination, his blood pressure was 142/82 mmHg and his pulse was 72 bmp.

Sinus rhythm and left bundle branch block were seen on the patient’s ECG.

The patient was conscious and cooperative in his neurological examination. He evaluated as right hemiplegic due to loss of strength in his right arm and dysarthric.

Dilated cerebral sulcus secondary to diffuse atrophy and bilateral periventricular chronic ischemic gliotic changes were reported as pathological findings in brain CT.

The patient was admitted to the neurology department with the diagnosis of acute ischemic cerebral vascular event.

In laboratory tests, hemogram, renal, and liver function tests were normal. The patient’s LDL value was measured as 172 mg/dl and HbA1C was measured as 6.4% mmol/mol.

In echocardiographic evaluation, hypertrophy and impairment systolic function of the left ventricle were observed. Ejection fraction was measured as 35% by Simpson’s method.

Carotid vertebral doppler USG was performed for embolic focus etiology. Irregular fibrofatty-calcified plaque was observed extending from the left CCA bulbus level to the left ECA proximal segment. More than 90% stenosis was reported.

In CT angiography, it was stated that this lesion did not cause significant stenosis. Carotid angiography was planned due to conflicting results between imaging methods. In the carotid angiography, thrombus image was detected in the left ICA proximal segment. Carotid endarterectomy was planned for the patient. After the successful endarterectomy operation he was discharged with medical therapy.

PS: CT angiographic and carotid angiographic images of the patient are available if you request we can send.

Cardiology Specialist in Istanbul Marty Prof. Dr. Ilhan Varank Sancaktepe Research and Training Hospital, Istanbul, Turkey

A 72-year-old male patient was admitted to the emergency department with a speech disorder and weakness on the right side. In his medical history, he did not have chronic drug use or additional disease except two package/year smoking.

On physical examination, his blood pressure was 142/82 mmHg and his pulse was 72 bmp.

Sinus rhythm and left bundle branch block were seen on the patient’s ECG.

The patient was conscious and cooperative in his neurological examination. He was evaluated as right hemiplegic due to loss of strength in his right arm and dysarthric.

Dilated cerebral sulcus secondary to diffuse atrophy and bilateral periventricular chronic ischemic gliotic changes were reported as pathological findings in brain CT.

The patient was admitted to the neurology department with the diagnosis of acute ischemic cerebral vascular event.

In laboratory tests, hemogram, renal and liver function tests were normal. The patient’s LDL value was measured as 172 mg/dl and HbA1C was measured as 6.4% mmol/mol.

In echocardiographic evaluation, hypertrophy and impairment systolic function of the left ventricle. Ejection fraction was measured as 35% by Simpson’s method.

Carotid vertebral doppler USG was performed for embolic focus etiology. Irregular fibrofatty-calcified plaque was observed extending from the left CCA bulbus level to the left ECA proximal segment. More than 90% stenosis was reported.

In CT angiography, it was stated that this lesion did not cause significant stenosis. Carotid angiography was planned due to conflicting results between imaging methods. In the carotid angiography, thrombus image was detected in the left ICA proximal segment. Carotid endarterectomy was planned for the patient. After the successful endarterectomy operation he was discharged with medical therapy.

PS: CT angiographic and carotid angiographic images of the patients are available. If you request, we can send.

The Children’s Hospital of Philadelphia, Philadelphia, USA

There were no procedural complications or mortality. Twelve patients underwent subsequent selective glue embolization of abnormal hepatoduodenal/periduodenal lymphatic networks identified and two underwent glue embolization of lymphatic networks leaking into the peritoneum.

UH Rainbow Babies and Children’s Hospital, Cleveland, USA

Brian Boe¹, Aimee Armstrong¹, Darren Berman¹, Sharon Cheatham¹, John Cheatham², Kan Hor¹

¹Nationwide Children’s Hospital, Columbus, USA. ²Nationwide Childrens Hospital, Columbus, USA

Results: From 2012 to 2018, 33 patients met study inclusion criteria. Patients were a median (range) age of 19.4 (10.6–62.1) years and weight of 60 (32.1–134) kg. The majority of patients were born with tetralogy of Fallot (n = 20) and had undergone a surgical repair with a transannular patch (n = 23) at a median (range) time of 18.5 (9.4–51.2) years prior to attempted PPVI. Indication for PPVI included pulmonary regurgitation (n = 26) and mixed RVOT disease containing stenosis and regurgitation (n = 7). PPVI was successful in 24 patients using the available BE TPVs implanted at the following diameters: 20 mm (n = 1); 22 mm (n = 8); 23 mm (n = 2); 26 mm (n = 6); 29 mm (n = 7). Nine procedures were unsuccessful secondary to large RVOT size (n = 3), coronary/aortic root compression (n = 4), and inability to technically implant the valve (n = 2). There was moderate correlation between the RVOT diameter by cMRI of 23.4 ± 4.6 mm (mean ± standard deviation) compared to the balloon-sizing waist of 23.5 ± 2.3 mm, with a Spearman’s correlation coefficient of 0.53. Based on cMRI data, the imaging team predicted 24/24 (100%) of successful BE PPVI. The imaging team predicted 4/9 (44%) unsuccessful procedures which included the three patients with a RVOT too large for BE PPVI.

Arpine Davtyan¹, Peter Guyon¹, Hannah El-Sabrout², Reid Ponder², John Bradley¹, Caitlin Heyden¹, Linda Drake³, Kanishka Ratnayaka¹, John Moore¹, Asimina Courelli⁴, Bryan Mosher¹, Holly Bauser-Heaton³, Daniel Levy², Jamil Aboulhosn², Henri Justino⁵, Howaida El-Said¹

¹UC San Diego/Rady Children’s Hospital, San Diego, USA. ²UCLA, Los Angeles, USA. ³Emory/Children’s Healthcare Atlanta, Atlanta, USA. ⁴UC San Diego School of Medicine, San Diego, USA. ⁵Texas Children’s Hospital, Houston, USA

Abhishek Chakraborty¹, Ranjit Philip¹, Ronak Naik¹, Mimily Harsono², Huma Abdulmajeed¹, Rush Waller¹, Shyam Sathanandam¹

¹Division of Pediatric Cardiology, University of Tennessee Health Sciences Center, LeBonheur Children’s Hospital, Memphis, USA. ²Division of Neonatology, University of Tennessee Health Sciences Center, LeBonheur Children’s Hospital, Memphis, USA

Results: During the study period, TCPC was attempted on 241 infants that satisfied the inclusion criteria, with 99.1% success rate. There was no difference in success rates based on the age at TCPC (99.3% vs. 99% for procedural age < 28 days vs. > 28 days, respectively; P = 0.82). Overall, 140 infants underwent TCPC at < 28 days of age, 29 of whom were < 14 days, and 54 infants underwent TCPC between 15 and 21 days of age. The median age at TCPC progressively decreased from 60 days of life (14–211 days) between January 2012 and December 2014 to 18 days (8–38 days) between August 2019 and May 2020 (P < 0.00001). Similarly, the weight at TCPC decreased over the same time periods (median 1985 g vs. 900 g; P < 0.00001). Procedure-related complication rates were similar for those < 28 days vs. > 28 days of age at the time of TCPC (2.8% vs. 4.9% respectively; P = 0.42).

Conclusions: It is feasible and safe to perform TCPC after the first week of life for infants born < 28 weeks’ gestation. As experience grows, more infants are referred earlier after birth which translates to performing TCPC on smaller infants. Benefits of early TCPC have to be determined in order for this therapy to be advocated routinely for all premature infants (Table 1).

Abhishek Chakraborty¹, Cihangir Buyukgoz², Hitesh Sandhu², Samir Shah², Shyam Sathanandam¹

¹Division of Pediatric Cardiology, University of Tennessee Health Sciences Center and LeBonheur Children’s Hospital, Memphis, USA. ²Division of Pediatric Critical Care Medicine, University of Tennessee Health Sciences Center and LeBonheur Children’s Hospital, Memphis, USA

Results: Six patients were included, of which three were female. One of the patients was cannulated twice. Three patients had history of congenital heart disease. Mean age was 13.5 (6–18) years. Mean weight was 68 (17–109) kg. Five patients (71%) were cannulated due to cardiogenic shock and two (29%) patients were cannulated due to cardiorespiratory arrest. Three patients (43%) were cannulated from right femoral vein, right internal jugular vein, and left femoral artery; whereas four patients (57%) were cannulated from right femoral vein and left femoral artery. Median venous cannula size was 21 (15–25) French and median arterial cannula size was 17 (15–17) French. Mean cannulation start time to ECMO flow time was 45 (18–112) min. No cannula repositioning or replacement required. 30-day survival and survival at ECMO decannulation were 86% (n = 6). One patient (14%) developed ECMO cannulation-related complication. No patient had loss of limb circulation. Mean ECMO duration was 3.7 (0.3–8) days. Cardiovascular surgeon was present during all ECMO cannulations.

Abhishek Chakraborty¹, Ranjit Philip¹, Ronak Naik¹, Rush Waller¹, Mimily Harsono², Shyam Sathanandam¹

¹Division of Pediatric Cardiology, University of Tennessee Health Sciences Center and LeBonheur Children’s Hospital, Memphis, USA. ²Division of Neonatology, University of Tennessee Health Sciences Center and LeBonheur Children’s Hospital, Memphis, USA

UNIFESP, São Paulo, Brazil

She was then referred for a cardiac catheterization for better evaluation and surgical plan. The diagnosis of the superior vena cava (SVC) draining into the left atrium was confirmed, in addition an anomalous drainage of the right upper pulmonary vein into the SVC was seen. The patient was then sent for surgery. At the surgery the distal portion of the right SVC with the right upper pulmonary vein was left in place and the remaining portion was then anastomosed to the right atrium. The PFO was closed. Her postoperative period was uneventful, with the oxygen saturation of 98% in room air. She was discharged on oral anticoagulation and has been followed up on the outpatient clinic.

Conclusion: Anomalous drainage of the superior vena cava in the left atrium is extremely rare, as the lesion causes an obliged right-to-left shunt, surgical repair is necessary. It can be isolated or associated to anomalous pulmonary venous drainage and interatrial communication. Cyanosis, heart failure, and brain abscess should draw attention for the possibility of this diagnosis.

UNIFESP, São Paulo, Brazil

Introduction: The persistence of the fifth arch arteries is extremely rare. The bilateral fifth arch arteries have never been documented, unilateral partial fifth arch artery has been demonstrated only once in a developing human embryo, dorsal collateral channels connecting the fourth and sixth arches are common, to qualify as the fifth arch artery any channel must arise from the ascending aorta proximal to the brachiocephalic artery, take a serpentine course and lie extrapericardially and terminate in the dorsal aorta, or through the sixth arch into pulmonary artery or arteries. The use of echocardiography for diagnosis alone is difficult, with percutaneous angiography (or both) considered as reference methods. However, cardiac computed tomography and magnetic resonance imaging can more accurately outline the anatomy of the arch and its variation. Case report: Male neonate 12 days old, born in another service, term, first child, mother with non-insulin-dependent gestational diabetes, presented with choking and cyanosis on the first day of life, being referred to a neonatal intensive care unit, where, after hearing a heart murmur, he performed echocardiography and was diagnosed with tricuspid atresia and pulmonary valve stenosis. Maintained with prostaglandin and referred for evaluation by pediatrics cardiology and therapeutic procedure. The echocardiogram confirmed tricuspid atresia, pulmonary valve stenosis, and aortic arch to the right. Cardiac catheterization has been programed for stent placement in the ductus arteriosus. During examination, previous diagnoses were confirmed and anomalous origin of the vessels in the base was observed. There was a right subclavian with usual origin and other vessels originating from a common trunk (5th arch) that emitted the right and left carotid arteries, left subclavian, and tortuous artery canal (Figure 1). Through a puncture through the left axillary artery (Figure 2), two coronary stents were positioned, the first Nexgen 3.5 × 19 mm in the distal segment, and the second Nexgen 4.0 × 13 mm in the proximal segment of the canal, in overlapping nails with the first. Procedure performed successfully and without complications (Figure 3). The patient evolved with 89% saturation, discharge from the ICU on the 2nd postoperative day, and referred for outpatient follow-up using anti-aggregation. Conclusion: The presence of the 5th arch artery is rare and when associated with other complex heart diseases, it needs the evaluation of physicians specialized in congenital heart diseases for the proper diagnosis and treatment.

Krishna Kishore Umapathi¹, Aravind Thavamani², Joshua Murphy¹

¹Rush University, Chicago, USA. ²Rainbow Babies and Children’s Hospital, Cleveland, USA

Results: A decreasing trend in the use of TC for ASD was noted with a noticeable drop in TC-ASD since 2011–2012 (Figure 1). SC was more common in the younger cohort (1–4 years), males and Caucasians (all p < 0.001)—Table 1. While hemopericardium, infective endocarditis, and ventricular arrhythmias were significantly more common in SC (all, p < 0.001), arterial thrombus, stroke, device embolization (all, p < 0.001), and severe sepsis (p = 0.01) were significantly more common in TC. No significant differences were noted in cardiac tamponade, complete heart block, cardiac arrest, sepsis, and death between the groups. Among procedures, blood transfusion, cardiopulmonary resuscitation (both p < 0.001), and pacemaker insertion (p = 0.013) were significantly associated with SC with no significant difference noted in ECMO use between the groups (Table 2). Mean length of stay (LOS) and mean hospitalization charges (HC) are significantly higher in the SC group (3.93 ± 0.04 vs 1.87 ± 0.06 and 90,421 ± 835 vs 62728 ± 1200, both p < 0.001). Mean inflation-adjusted HC and LOS show an overall uptrend in both groups during the study period (Figure 2).

Dr. Martha Elizabeth Rubio Hernandez¹, Dr Carlos Escobedo Uribe¹, Dr Luis Fernando Perez Gonzalez perez¹, Dr Mario Martinez¹, dra Veronica vasquez²

¹Hospital Dr Ignacio Morones Prieto, San Luis Potosi, Mexico. ²Hospital Especialidades Jose Carrasco Arteaga, Cuenca, Ecuador

Three-month-old female infant, who was admitted for 40-degree fever of 10 days of evolution, in poor general irritability, with 5 days of diarrheal stools, was treated with antipyretic and antimicrobial with no improvement on the two recent days vomiting, irritability, rejection of the oral route, with a punctate rash, erythematosus, in the chest, upper limbs as well as dry cough, dehydration, for which reason he entered the pediatric acute respiratory care unit in isolation at the risk of infection by SARCOV-2 due to suspicion.

Upon admission to the hospital, the patient had leukocytosis, anemia, decreased platelets and altered liver enzymes.

During her hospitalization with fever of 40 degrees of difficult handling, systematic desaturation of 50–60%. in paraclinics with elevated Ferritin 569, low hemoglobin 5.7 g, platelets 70,000, elevation of dimer D: 2.3.

Chest thorax with apical right infiltrate, light cardiomegaly.

Heart echocardiogram without congenital anatomical malformations, light pericardial effusion, mitral regurgitation, and light tricuspid, LVEF 65% Simpson, TAPSE 12 mm, PSAP 25 mmHg, both right dilated coronaries with rosary image measuring 2.5 mm in origin and 5 × aneurysm 7 mm diameter. Left coronary artery with an 8-mm-diameter aneurysm.

EKG sinus rhythm without data on ischemia or arrhythmia, Troponin I 0.001.

Immunoglobulin was started at 2 g/kg/dose to pass in 24 to 36 h, aspirin 80 mg/kg/day, continued with antibiotic.

Infant Febrile persists, 2 peaks of 38 and 39.2 C despite 72 h of antibiotic and immunoglobulin dose.

It was decided to administer a second bolus of immunoglobulin at 2 g/kg/dose, continue ASA and clopidogrel, and Methylprednisolone bolus of 30 mg/kg for 3 days.

Without improvement with persistent fever, a second dose of immunoglobulin was administered.

With good response to the afebrile patient treatment, without data of respiratory distress, tolerates the oral route, is adequately fed.

An angiotomography was performed, showing giant aneurysmal lesions in both coronaries, aneurysms in the left subclavian artery, mammary arteries, and a large aneurysm in the abdominal aorta.

At discharge, the patient was on enoxaparin 5 mg every 12 h, aspirin 5 mg/kg/day, Clopidogrel 0.2 mg/kg/day, prednisone, and weekly methotrexate.

Heidi Kim¹, Sushmita Yallapragada¹, Rashmin Savani¹, Vedanta Dariya¹, Sana Ullah¹, Kate Mangona¹, Timothy Pirolli¹, Larry Brown², Surendranath Reddy¹

¹University of Texas Southwestern Medical Center, Dallas, USA. ²Parkland Health and Hospital System, Dallas, USA

Children’s Health Ireland Crumlin, Dublin, Ireland

Results: Sixty-seven RVOT stents were deployed during 56 procedures into 47 patients (tetralogy of Fallot (n = 25), atrioventricular septal defects and tetralogy of fallot (n = 8), double outlet right ventricle (n = 5), and other conditions with right ventricular outflow tract obstruction (n = 9). The median age and weight at insertion were 41 days (range 2–204) and 3.67 kg (range 1.59–7.1), respectively. Thirty-one procedures were semi-elective and 25 were emergencies. Stent positioning was confirmed with transthoracic echocardiogram and/or RV angiography across the VSD from an aortic approach. The median total procedure and fluoroscopy times were 67.5 (range 15–145) and 19 min (1–107), respectively. The median radiation dose was 136cGY/cm² (range 5–2002). Thirty-five patients were either admitted in ICU pre-procedure or required ICU admission post procedure with a median ICU length of stay of 3 days (range 1–48). The median length of stay was 8 days (range 1–258). There were 3 major complications and 2 minor complications. There were two deaths (included in the 3 major complications) within 30 days of the procedure. A patient with Cornelia de Lange Syndrome (1.8 kg) died following stent embolization and inability to wean from emergency cardiopulmonary bypass for stent retrieval and the second infant had an unexplained asystole arrest post procedure while awaiting transfer to ICU.

Mohamed Al-Nasef^1,2,3, Doaa Shahbah⁴, Sarosh Batlivala⁵, Colm R Breatnach¹, Nial Linnane¹, Kevin P. Walsh¹, Paul Oslizlok¹, Brian McCrossan¹, Athar M Qureshi⁴, Bryan H. Goldestein⁵, Damien Kenny¹

¹Children Health Ireland, Dublin, Ireland. ²Prince Sultan Cardiac Center, Riyadh, Saudi Arabia. ³Salmaniya Medical Complex, Manama, Bahrain. ⁴Texas Heart Institute, Houston, USA. ⁵Cincinnati Children Hospital, Cincinnati, USA

Patent Ductus Arteriosus (PDA) stenting has evolved as a valid alternative to surgical systemic-pulmonary shunts in patients with duct-dependent pulmonary circulation facilitating improved saturations and pulmonary artery growth. This may be more compelling for neonates ≤ 2.5 kg, in whom surgical palliation may be challenging. The objective of this study is to evaluate outcomes following PDA stenting in patients ≤ 2.5 kg from three large tertiary centers.

Results: Forty-two PDA stents were implanted in a total of 31 patients (16 female) at median age of 8 days (IQR 5–15) and median weight of 2.1 kg (IQR 2–2.4 kg). Thirteen patients (41%) had femoral artery access, 8 patients (25%) had carotid artery access, and the remaining had axillary or umbilical cord artery access. Two patients developed femoral artery thrombosis, while one patient developed right carotid artery aneurysm, and another had intracranial thrombosis. Twenty-one patients (68%) had tortuosity indices of II or III. Oxygen saturations improved from median of 73% (IQR 62.5–79.5) to 88% (IQR 80–93%, p < 0.001). Two patients proceeded to emergency surgical shunts and one patient underwent a surgical shunt 74 days post PDA stenting. The median ICU stay was 3.5 days (IQR 2–6 days) and the median hospital stay was 25 days (IQR 14.5–70). Twenty patients (65%) required reintervention with either balloon dilation or re-stenting at a median age of 86.5 days (IQR 67.5–115.5). At 6-month follow-up, the median z-score for the left and right pulmonary artery diameters increased from − 1.1 (IQR − 1.71 to − 0.2) to − 0.7 (IQR − 1.27 to 0.1) (p 0.35) and − 1.31 (IQR − 1.8 to − 0.6) to − 0.09 (IQR − 1.2 to 0.33) (p 0.05), respectively. There was one procedure-related death and 4 interstage mortalities not directly related to the PDA stent.

Mohamed Al-Nasef¹, Donnchadh O Sullivan¹, Li Yen Ng¹, Colm R Breatnach¹, Kevin Walsh¹, Paul Oslizlok¹, Brian McCrossan¹, Damien Kenny¹, Shyam Sathanandam²

¹Children Health Ireland, Dublin, Ireland. ²Heart center of Memphis, Memphis, USA