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Transcript
Interventional Pediatric Cardiology - a spectrum of possibilities D. Scott Lim, M.D. Division of Pediatric Cardiology Departments of Pediatrics & Medicine University of Virginia Tuesday, March 19, 2013 Relevant Disclosures WL Gore Medical GSO ASD and REDUCE trials Primary Investigator Consultant & Research Grant Support St. Jude Medical Amplatzer ASD & VSD trials Primary Investigator Consultant & Research Grant Support Abbott Vascular Primary Investigator for EVEREST/REALISM/COAPT (MitraClip) trials Proctor, Consultant, & Research Grant Support Edwards Lifesciences Primary Investigator for PARTNER 1 & 2 trials (Sapien TAVR) Steering committee - PARTNER II trial Proctor, Consultant, & Research Grant Support Mitralign Consultant Tuesday, March 19, 2013 Milestones in congenital heart disease “Congenital affections of the heart have only a limited clinical interest, as in a large proportion of the cases the anomaly is not compatible with life, and in others nothing can be done to remedy the defect or even relieve symptoms.” Sir William Osler 1892 Tuesday, March 19, 2013 Milestones & Early Contributions 1936: Maude Abbott - Atlas of Congenital Heart Disease 1938: Ashton Graybiel - ligated PDA in 22 yo with BE 1938: Robert Gross - ligated PDA in child 1944 Clarence Crafoord - first Coarctation resection 1944 Helen Taussig - aortopulmonary shunt Tuesday, March 19, 2013 Helen Taussig MD 1898 - 1986 As a pediatric cardiologist in Baltimore she observed that cyanotic neonates often died after spontaneous closure of the ductus arteriosus Robert Gross scoffed at her idea of a surgically constructed “artificial ductus” Alfred Blalock and Vivian Thomas had created a brachiocephalic to aorta anastomosis in the canine for coarctation 1941: “Why not put the subclavian artery into the pulmonary artery?” Helen Taussig 1944: First classic Blalock-Taussig shunt in a cyanotic newborn with Tetralogy of Fallot Tuesday, March 19, 2013 Vivian Thomas and the Blalock-Taussig Shunt Blalock and Park “Why not bypass the coarctation with a carotid artery?” Helen Taussig “If you can do that, why not connect the subclavian artery to the pulmonary artery?” Tuesday, March 19, 2013 Progress in Congenital Heart Disease The “Blalock Clamp” for the pulmonary artery designed by Vivian Thomas and William Longmire 1976: Vivian Thomas and Helen Taussig recognized by Johns Hopkins President Steven Muller Tuesday, March 19, 2013 Milestone in Congenital Heart Disease 1953: John Gibbon’s novel heart-lung bypass machine used to close an ASD next 2 patients expired and he never used it again 1955: C. Walton Lillihei controlled cross circulation using parent as “oxygenator” 1955: Kirklin revisits the Gibbon mechanical pump oxygenator at the Mayo Clinic 1982: Jean Kan performed the first transcatheter intervention pulmonary balloon valvuloplasty Tuesday, March 19, 2013 Talk outline - Pediatric Interventional Cardiology ASD VSD Pulmonary stenosis Pulmonary insufficiency Branch PS Pulmonary vein stenosis Mitral stenosis Aortic stenosis Patent ductus arteriosus Coarctation of the aorta Tuesday, March 19, 2013 Atrial Septal Defect Anatomy Physiology Imaging Indications for therapy Intervention Tuesday, March 19, 2013 ASD Devices Helex CardioSEAL Sideris Button ASD Star Amplatzer DAS-Angel Wings ASDOS Tuesday, March 19, 2013 Currently available devices Amplatzer ASO Nitinol mesh 4-38mm : Small to large defects Self-centering Rare risk of cardiac erosion Gore Helex ePTFE with nitinol wire Non-self-centering 15 - 35mm : small to medium defects Soft; no reports of cardiac erosion Tuesday, March 19, 2013 Currently available devices Amplatzer ASO Nitinol mesh 4-38mm : Small to large defects Self-centering Rare risk of cardiac erosion Gore Helex ePTFE with nitinol wire Non-self-centering 15 - 35mm : small to medium defects Soft; no reports of cardiac erosion Tuesday, March 19, 2013 the Next Generation: GSO Gore Septal Occluder ePTFE with 5 nitinol petals 15 - 30mm : Small to medium defects Partially Self-centering Soft; no reports of cardiac erosion Tuesday, March 19, 2013 the Next Generation: GSO Tuesday, March 19, 2013 Talk outline - Pediatric Interventional Cardiology ASD VSD Pulmonary stenosis Pulmonary insufficiency Branch PS Pulmonary vein stenosis Mitral stenosis Aortic stenosis Patent ductus arteriosus Coarctation of the aorta Tuesday, March 19, 2013 Ventricular Septal Defect Anatomy Physiology Imaging Indications for therapy Intervention Tuesday, March 19, 2013 Ventricular Septal Defect Anatomy Physiology Imaging Indications for therapy Intervention Tuesday, March 19, 2013 Intervention for muscular VSD Amplatzer mVSD Occluder Nitinol mesh 4 - 18mm No erosion risk ?arrhythmic risk Tuesday, March 19, 2013 VSD Case 18 m/o male with multiple mVSDs and CHF High surgical risk due to VSD location Tuesday, March 19, 2013 Tuesday, March 19, 2013 Talk outline - Pediatric Interventional Cardiology ASD VSD Pulmonary stenosis Pulmonary insufficiency Branch PS Pulmonary vein stenosis Mitral stenosis Aortic stenosis Patent ductus arteriosus Coarctation of the aorta Tuesday, March 19, 2013 Pulmonary valve stenosis Anatomy Physiology Imaging Indications for therapy Intervention Tuesday, March 19, 2013 Pulmonary insufficiency Anatomy Physiology Imaging Indications for therapy Intervention Tuesday, March 19, 2013 Percutaneous Pulmonary Valve Replacement Tuesday, March 19, 2013 Talk outline - Pediatric Interventional Cardiology ASD VSD Pulmonary stenosis Pulmonary insufficiency Branch PS Pulmonary vein stenosis Mitral stenosis Aortic stenosis Patent ductus arteriosus Coarctation of the aorta Tuesday, March 19, 2013 Branch Pulmonary Stenosis Anatomy Physiology Imaging Indications for therapy Intervention Tuesday, March 19, 2013 Imaging for branch PS Tuesday, March 19, 2013 Indications and Intervention for Branch PS Marked flow imbalance in a developing lung Contralateral pulmonary hypertension RV hypertension Pulmonary regurgitation Tuesday, March 19, 2013 Talk outline - Pediatric Interventional Cardiology ASD VSD Pulmonary stenosis Pulmonary insufficiency Branch PS Pulmonary vein stenosis Mitral stenosis Aortic stenosis Patent ductus arteriosus Coarctation of the aorta Tuesday, March 19, 2013 Pulmonary Vein Stenosis Anatomy Physiology Imaging Indications for therapy Intervention Tuesday, March 19, 2013 Tuesday, March 19, 2013 Talk outline - Pediatric Interventional Cardiology ASD VSD Pulmonary stenosis Pulmonary insufficiency Branch PS Pulmonary vein stenosis Mitral stenosis Aortic stenosis Patent ductus arteriosus Coarctation of the aorta Tuesday, March 19, 2013 Mitral Valve Stenosis Anatomy Physiology Imaging Indications for therapy Intervention Tuesday, March 19, 2013 Mitral Valve Stenosis Anatomy Physiology Imaging Indications for therapy Intervention Tuesday, March 19, 2013 Talk outline - Pediatric Interventional Cardiology ASD VSD Pulmonary stenosis Pulmonary insufficiency Branch PS Pulmonary vein stenosis Mitral stenosis Aortic stenosis Patent ductus arteriosus Coarctation of the aorta Tuesday, March 19, 2013 Aortic Valve Stenosis Anatomy Physiology Imaging Indications for therapy Intervention Tuesday, March 19, 2013 Aortic Valve Stenosis Indications for Intervention: Severe AS peak-to-peak gradient > 70mmHg (cath) if asymptomatic AVA < 0.5cm2/m2 in presence of LV dysfunction Moderate/severe AS if: symptomatic competitive athlete Contra-indications: Significant aortic insufficiency (3+ or 4+) Tuesday, March 19, 2013 Interventions for Pediatric Aortic Stenosis Balloon aortic valvuloplasty Tuesday, March 19, 2013 Future Interventions for AS Transcatheter Aortic Valve Replacement (TAVR) Tuesday, March 19, 2013 Talk outline - Pediatric Interventional Cardiology ASD VSD Pulmonary stenosis Pulmonary insufficiency Branch PS Pulmonary vein stenosis Mitral stenosis Aortic stenosis Patent ductus arteriosus Coarctation of the aorta Tuesday, March 19, 2013 Patent ductus arteriosus Anatomy Physiology Imaging Indications for therapy Intervention Tuesday, March 19, 2013 Intervention for PDA Small PDA (<2mm) Retrograde approach with Gianturco coil Moderate/large PDA Nitinol occluder device Tuesday, March 19, 2013 Talk outline - Pediatric Interventional Cardiology ASD VSD Pulmonary stenosis Pulmonary insufficiency Branch PS Pulmonary vein stenosis Mitral stenosis Aortic stenosis Patent ductus arteriosus Coarctation of the aorta Tuesday, March 19, 2013 Coarctation of the Aorta Anatomy Physiology Imaging Indications for therapy Intervention Tuesday, March 19, 2013 Coarctation Interventions Balloon angioplasty Percutaneous from femoral artery High pressure tubular balloon Goal is to tear intimal and medial layers of coarctation Intramural blood pressure causes expansion and beneficial remodeling Stent Tuesday, March 19, 2013 Coarctation Interventions Balloon angioplasty Stent Percutaneous from femoral artery Moderate pressure tubular balloon Goal is to stretch layers of coarctation Stent structure maintains expansion and beneficial remodeling Con: Stent, being metal, doesn’t grow! Tuesday, March 19, 2013 Thank you Tuesday, March 19, 2013
