Upload
cardiaccarecentermch
View
220
Download
0
Embed Size (px)
Citation preview
7/30/2019 Interventional Cath to Treat ACHD
1/104
7/30/2019 Interventional Cath to Treat ACHD
2/104
Interventional Catheterization
to treat Adults with
Congenital Heart DiseaseDanyal Khan, M.D, FACC, FAAP, FSCAI
Pediatric Interventional Cardiologist
Miami Children's Hospital
7/30/2019 Interventional Cath to Treat ACHD
3/104
Congenital Heart Disease (CHD)
Occurs in 1 in 120 newborns
Commonest congenital problem
Operative mortality is about 2% at themajor centers
Approximately 800,000 children in USA
with CHD
7/30/2019 Interventional Cath to Treat ACHD
4/104
Adults with Congenital Heart
Disease (ACHD)
10% of CHD is diagnosed in adulthood
In USA, there are more adults than
children with CHD
1 million adults in USA with CHD
7/30/2019 Interventional Cath to Treat ACHD
5/104
Historical Perspective
Heart surgery-1940s
Open heart surgery-1960s
First therapeutic catheterization-1953
Last Decade
Advanced fetal diagnosis
Explosion of interventional cath procedures
Introduction of minimally invasive surgical techniques Near extinction of the inoperable patient
Cardiac transplantation and immunosuppression
7/30/2019 Interventional Cath to Treat ACHD
6/104
Surgery
Interventional Catheterization
7/30/2019 Interventional Cath to Treat ACHD
7/104
Types of CHD
ACYANOTIC HEART
DISEASE
Pulse oximetry
normal Left to Right Shunt
Usually not
symptomatic at birth
CYANOTIC HEART
DISEASE
Pulse Oximetry may
be low Right-to-Left Shunt
Usually presents at
young age
7/30/2019 Interventional Cath to Treat ACHD
8/104
ACYANOTIC
HEART DISEASE
ASD
VSD
PDA
AV Canal
PS
Coarctation of the Aorta
LVOT Obstruction
CYANOTIC
HEART DISEASE
Tetralogy of Fallot
Transposition of the greatarteries
Tricuspid Atresia
Total anomalouspulmonary venous return
Tricuspid Valve, Ebsteinsanomaly
Pulmonary Atresia/VSD
Pulmonary Atresia/ IntactSeptum
Hypoplastic Left HeartSyndrome
7/30/2019 Interventional Cath to Treat ACHD
9/104
Adult CHD
Atrial Septal Defect (ASD)
Patent Foramen Ovale (PFO)
Coarctation Pulmonary Regurgitation
7/30/2019 Interventional Cath to Treat ACHD
10/104
Atrial Septal Defect
5-10 % of Congenital Heart Disease
Male : Female ratio = 1:2
Types Secundum (50-70%)
Primum
Sinus Venosus Coronary Sinus ASD
7/30/2019 Interventional Cath to Treat ACHD
11/104
Atrial Septal Defect
Left to Right shunt
Asymptomatic in childhood
Causes dilation of Right Atrium & Ventricle Causes symptoms in adulthood
Chest pain
Palpitations Decreased Exercise tolerance
7/30/2019 Interventional Cath to Treat ACHD
12/104
Diagram
S d ASD
7/30/2019 Interventional Cath to Treat ACHD
13/104
AORTA
Deficient antero-
superior rim
Central defect
Deficient inferior
rim
Secundum ASD
Anatomic Sub-types
Multi-fenestrated
Deficient posterior
rim
Multiple
Multiple
7/30/2019 Interventional Cath to Treat ACHD
14/104
Case - ASD
52 year old lady with c/o SOB & Palpitations
EKG incomplete RBBB
CXR Cardiomegaly
Echo- Severe Pulm HTN, Marked RA & RV
dilation, Severe TR
O/E- Sats 94%, decreased to 84% with exertion
Fixed split & loud S2, Flow Murmur Early clubbing & cyanosis
7/30/2019 Interventional Cath to Treat ACHD
15/104
Cardiac MRI
Pulmonary artery dilation
7/30/2019 Interventional Cath to Treat ACHD
16/104
Heterotaxy
Stomach
Transverse
Liver
No IVC
7/30/2019 Interventional Cath to Treat ACHD
17/104
Management
Diagnostic Cath
Treated with Oxygen via nasal cannula &
Revatio (sildenafil)
After 3 months repeat cath
7/30/2019 Interventional Cath to Treat ACHD
18/104
Amplatzer Device Closure
7/30/2019 Interventional Cath to Treat ACHD
19/104
Cardiac Cath
7/30/2019 Interventional Cath to Treat ACHD
20/104
Interrupted Inferior Vena Cava
IVC
IVC
SVC
RA
Azygous
Vein
7/30/2019 Interventional Cath to Treat ACHD
21/104
IntraCardiac Echo
7/30/2019 Interventional Cath to Treat ACHD
22/104
Hepatic Access
7/30/2019 Interventional Cath to Treat ACHD
23/104
ICE Catheter
Wire
7/30/2019 Interventional Cath to Treat ACHD
24/104
ASD - Echo
7/30/2019 Interventional Cath to Treat ACHD
25/104
ASD IntraCardiac Echo
7/30/2019 Interventional Cath to Treat ACHD
26/104
ASD Device
7/30/2019 Interventional Cath to Treat ACHD
27/104
Left disc deployment
7/30/2019 Interventional Cath to Treat ACHD
28/104
Left Disc
7/30/2019 Interventional Cath to Treat ACHD
29/104
Right Disc deployment
7/30/2019 Interventional Cath to Treat ACHD
30/104
Right Disc
7/30/2019 Interventional Cath to Treat ACHD
31/104
Device released
7/30/2019 Interventional Cath to Treat ACHD
32/104
18mm Amplatzer ASD Device
7/30/2019 Interventional Cath to Treat ACHD
33/104
Hepatic Vein- occluded with
Vascular Plug
7/30/2019 Interventional Cath to Treat ACHD
34/104
7/30/2019 Interventional Cath to Treat ACHD
35/104
PFO
In Fetal circulation, presence of a PFO is
essential
PFO usually closes within the first two weeks
of life Persistant PFO is present in more than 25%
of adults
7/30/2019 Interventional Cath to Treat ACHD
36/104
7/30/2019 Interventional Cath to Treat ACHD
37/104
7/30/2019 Interventional Cath to Treat ACHD
38/104
No. 1 cause of serious disability and morbidity
Sacco RL, et al. Stroke1997
0
5
10
15
20
25
30
Heart Cancer Stroke
Causes of Death
STROKE3rd Leading Cause of Death
7/30/2019 Interventional Cath to Treat ACHD
39/104
Ann Neurol. 1989;25:382-90
STROKE VICTIMS
43%
PREVALENCE OF PFO IN CRYPTOGENIC STROKE
Prevalence
ofP
FO(%)
Prevalence
ofP
FO(%)
Cryptogenic Stroke
Cryptogenic Stroke
Cruz-Gonzalez I, 2009
Expert Rev Cardiovasc Ther
PFO Rates
Cryptogenic Stroke
7/30/2019 Interventional Cath to Treat ACHD
40/104
2.50.451.10000
26
7.1
3.25.4
0.601.90
0
10
20
30
Lausanne
(1996)
Mas2
001:(PFO
only)
DeCa
stro2
000
Mas2
001:(PFO
andA
SA)
PICS
S(2002)
Sievert(
2002)
Cujec
(surgery)
Devuyst1
966(
surgery)
Lock
(1998)
Meier
(2000)
USMultice
nter(2002)
Palac
ios(2002)
Sievert(
2002)
%o
fRecurre
ntStokeRates
MEDICAL THERAPY DEVICE CLOSURE
PFO Closure vs. Medical Therapy
REGISTRY DATA
7/30/2019 Interventional Cath to Treat ACHD
41/104
7.07
2.71
0
2
4
6
8
Medical
Therapy
Device
Closure
%A
djusted1YrStroke-TIA
PFO Closure vs. Medical Therapy
Landzberg Heart 2004
20 studies n=2250
5.55
4.86
2.95
0
2
4
6
8
Surgery Medical
therapy
Device
26 studies n=2534
Homma Circulation 2005
5.2
1.3
0
2
4
6
8
Medical
Therapy
Device
Closure
Whrle Lancet 2006
20 studies n=3014
Events/100patientyears
%1YearRecurrentStrokeorTIA
7/30/2019 Interventional Cath to Treat ACHD
42/104
PFO & Stroke
PFO are more common in patients who
have strokes or TIAs
No RCTrial has found that closure of
PFOs reduces the incidence of stroke or
death
AAN, AHA, ACC state that the benefit of
device closure therapy remains unknown
7/30/2019 Interventional Cath to Treat ACHD
43/104
Right-to-Left Shunt (PFO)
7/30/2019 Interventional Cath to Treat ACHD
44/104
To close or not to close ?
7/30/2019 Interventional Cath to Treat ACHD
45/104
(My) Indications for PFO Closure
Cryptogenic stroke
Rule out other obvious cause (Lipid profile,
BP, CRP, Carotid Doppler US,
HyperCoagulability w-up)
PFO with bidirectional or Right-to-Left
Shunt (on bubble study)
Age less than 55 yrs
Look for Atrial Septal aneurysm
ASD/PFO O l i D i t
7/30/2019 Interventional Cath to Treat ACHD
46/104
ASD/PFO Occlusion Devices at
MCH
CardioSEAL
Amplatzer
HELEX
7/30/2019 Interventional Cath to Treat ACHD
47/104
Case # 1
14 year old girl, who was in a car accident
and suffered a left tibial fracture
Patient was neurologically normal after the
accident
36 hours later had a stroke
TTE PFO. Bubble study positive
Confirmed with transcranial doppler
PFO closed with Sideris Button device
7/30/2019 Interventional Cath to Treat ACHD
48/104
Case # 2 (AS)
17 year old girl with c/o palpitations and
has had two episodes of TIA (right sided
hemiparesis + dysarthria)
Holter non sustained wide QRS
tachycardia
EPStudy no inducible Vent Tachycardia
TTE Bubble study positive
Hypercoagulability w-up: negative
7/30/2019 Interventional Cath to Treat ACHD
49/104
Helex
7/30/2019 Interventional Cath to Treat ACHD
50/104
Balloon Sizing
7/30/2019 Interventional Cath to Treat ACHD
51/104
Balloon Sizing
7/30/2019 Interventional Cath to Treat ACHD
52/104
Helex implanted
7/30/2019 Interventional Cath to Treat ACHD
53/104
Helex released
7/30/2019 Interventional Cath to Treat ACHD
54/104
ICE Image - Helex
7/30/2019 Interventional Cath to Treat ACHD
55/104
Case # 3 (CA)
55 yr old gentleman.
h/o two episodes of TIA
Carotid u/s normal
Hypercoag w-up Negative
No HTN or HyperLipidemia
TTE: Atrial Septal Aneurysm + PFO(positive bubble study)
7/30/2019 Interventional Cath to Treat ACHD
56/104
PFO
7/30/2019 Interventional Cath to Treat ACHD
57/104
Wire across PFO
7/30/2019 Interventional Cath to Treat ACHD
58/104
Balloon Sizing 14-16mm
CardioSEAL septal occluder
7/30/2019 Interventional Cath to Treat ACHD
59/104
CardioSEAL septal occluder
28mm
7/30/2019 Interventional Cath to Treat ACHD
60/104
CardioSeal snared
7/30/2019 Interventional Cath to Treat ACHD
61/104
7/30/2019 Interventional Cath to Treat ACHD
62/104
7/30/2019 Interventional Cath to Treat ACHD
63/104
Amplatzer Septal Occluder 16mm
7/30/2019 Interventional Cath to Treat ACHD
64/104
Amplatzer Septal Occluder 20mm
7/30/2019 Interventional Cath to Treat ACHD
65/104
Both disks deployed
7/30/2019 Interventional Cath to Treat ACHD
66/104
Final Result
7/30/2019 Interventional Cath to Treat ACHD
67/104
Coarctation of Aorta
8-10% of Congenital Heart Disease
Male:Female ratio = 2:1
Turners syndrome 30% incidence
85% incidence of Bicuspid Aortic Valve
Most patients present in infancy &
childhood
7/30/2019 Interventional Cath to Treat ACHD
68/104
Coarctation of Aorta (CoAo)
First described 1760 by Morgagni
Currently 3 modes of treatment
Surgery infants Balloon angioplasty children
Stent implantation - adults
7/30/2019 Interventional Cath to Treat ACHD
69/104
Coarctation in Adults
Presentation
Hypertension resistant to therapy
CXR rib notching due to collaterals
Diagnosis
BP difference between arm & leg
Echo
MRI/CT
7/30/2019 Interventional Cath to Treat ACHD
70/104
Case - Coarctation
21 year old with h/o Coarctaton
Repaired in infancy
c/o Hypertension 140/90
Echo coarctation with 30 mm Hg
gradient
7/30/2019 Interventional Cath to Treat ACHD
71/104
Cath Angiogram
7/30/2019 Interventional Cath to Treat ACHD
72/104
Cath Angiogram
7/30/2019 Interventional Cath to Treat ACHD
73/104
Cath Angiogram
7/30/2019 Interventional Cath to Treat ACHD
74/104
Cath Angiogram
7/30/2019 Interventional Cath to Treat ACHD
75/104
Cath Angiograms
7/30/2019 Interventional Cath to Treat ACHD
76/104
Cath Angiograms
7/30/2019 Interventional Cath to Treat ACHD
77/104
Cath Angiograms
C
7/30/2019 Interventional Cath to Treat ACHD
78/104
Cath Angiograms
Aneurysm
C d S
7/30/2019 Interventional Cath to Treat ACHD
79/104
Covered Stent
Fi l R lt
7/30/2019 Interventional Cath to Treat ACHD
80/104
Final Result
C
7/30/2019 Interventional Cath to Treat ACHD
81/104
Case
22 year old lady, h/o Tetralogy of Fallot
VSD closure + RV to PA homograft
Has had Aortic Valve replacement
23mm St Jude Valve
c/o decreased exercise tolerance
Echo
Severe pulmonary regurgitation
Right ventricular dilation & dysfunction
P l I ffi i
7/30/2019 Interventional Cath to Treat ACHD
82/104
Pulmonary Insufficiency -
The Problem Pulmonary insufficiency is common after rightventricular outflow tract reconstruction Tetralogy Fallot, Pulmonary atresia, Truncus
arteriosus Results in RV volume load
Exercise intolerance
Arrhythmia
Heart failure Traditional Rx
Surgical valve placement
Th S l ti
7/30/2019 Interventional Cath to Treat ACHD
83/104
The Solution
Pulmonary Valve Implantation
7/30/2019 Interventional Cath to Treat ACHD
84/104
Pulmonary Valve ImplantationThe Solution
Bonhoeffer P, et al, England
Bovine (cow) jugular
venous valve
CP stent mounted 18-22 mm balloon
Femoral vein access
Currently 22Fr system
Transcatheter Pulmonary Valve
7/30/2019 Interventional Cath to Treat ACHD
85/104
Transcatheter Pulmonary Valve
Implantation
RV
PA
M l d V l
7/30/2019 Interventional Cath to Treat ACHD
86/104
Melody Valve
E bl D li S t
7/30/2019 Interventional Cath to Treat ACHD
87/104
Ensemble Delivery System
M l d V l D l t
7/30/2019 Interventional Cath to Treat ACHD
88/104
Melody Valve Deployment
E h P l R it ti
7/30/2019 Interventional Cath to Treat ACHD
89/104
Echo Pulmonary Regurgitation
C th A i
7/30/2019 Interventional Cath to Treat ACHD
90/104
Cath Angiograms
Cath Angiograms
7/30/2019 Interventional Cath to Treat ACHD
91/104
Cath Angiograms
7/30/2019 Interventional Cath to Treat ACHD
92/104
Cath Angiograms
7/30/2019 Interventional Cath to Treat ACHD
93/104
Cath Angiograms
Balloon Angioplasty
7/30/2019 Interventional Cath to Treat ACHD
94/104
Balloon Angioplasty
Stenting the Pulmonary Valve
7/30/2019 Interventional Cath to Treat ACHD
95/104
Stenting the Pulmonary Valve
Stent
7/30/2019 Interventional Cath to Treat ACHD
96/104
Stent
Melody Valve
7/30/2019 Interventional Cath to Treat ACHD
97/104
Melody Valve
Melody Valve inner balloon
7/30/2019 Interventional Cath to Treat ACHD
98/104
Melody Valve inner balloon
Melody Valve outer balloon
7/30/2019 Interventional Cath to Treat ACHD
99/104
Melody Valve outer balloon
Melody Valve in place
7/30/2019 Interventional Cath to Treat ACHD
100/104
Melody Valve in place
No Pulmonary Regurgitation
7/30/2019 Interventional Cath to Treat ACHD
101/104
No Pulmonary Regurgitation
7/30/2019 Interventional Cath to Treat ACHD
102/104
7/30/2019 Interventional Cath to Treat ACHD
103/104
Thank you
7/30/2019 Interventional Cath to Treat ACHD
104/104