Page 49 - Journal of Structural Heart Disease - Volume 1 Issue 2

Meeting Abstracts
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armamentarium for catheter closure of atrial septal defects in chil- dren and adults. Further studies are required document its long-term safety in a larger patient population.
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NOVEL ACCESS TO THE NATIVE ATRIA FOLLOWING TOTAL CAVOPULMONARY ANASTOMOSIS
Robert Petersen1, Saadeh Al-Jureidini1, Saar Danon1, Beth Price2, Jodi Hundley2, Kathy Tinker2, Lisa Bade2
1Saint Louis University School of Medicine, Saint Louis, MO, USA 2Cardinal Glennon Children's Medical Center, Saint, Louis, MO, USA
Accessing the atria following total cavopulmonary anastomosis (Fon- tan) with the extra-cardiac conduit or intra-cardiac baffle can be a challenging task. Rare reports describing both per-thoracic access and conduit trans-septal puncture for a limited scope have been pub- lished. We present the use of these approaches for various therapeu- tic aims. Between 2009 and 2014, 5 patients ages 7 to 28 underwent one of these techniques; three per-thoracic and 2 trans-septal Fontan puncture (one lateral baffle and one extra-cardiac Fontan): 1. A 28 year old with lateral baffle Fontan and sick sinus syndrome under- went trans-septal puncture of the lateral tunnel via the superior vena cava for successful left atrial lead placement and pacing. This patient previously had a failed attempt at surgical placement of a pacing wire on pace receptive tissue. 2. Two patients ages 7 and 14 years with ex- tra cardiac Fontan underwent per-thoracic access of the right atrium for device occlusion of a re-canalized left superior vena cava to the coronary sinus. This resulted in significant improvement of their sat- urations. 3. An 8 year old with an extra-cardiac Fontan and history of embolic stroke underwent per-thoracic access of the left atrium, thus providing a route for device closure of a patent native pulmonary ar- tery. This was performed to reduce the risk of future embolic events. 4. A 27 year old with revised classic Fontan to an extra-cardiac Fontan, underwent trans-septal puncture of the conduit. This provided access to the native atria for ablation of incessant atrial flutter. All 5 cases were technically successful. Complications occurred in only one pa- tient who had blood loss through a fractured sheath and required a blood transfusion. This patient also had temporary heart block, likely due to device placement, which self-resolved. Removal of the sheath following per-thoracic approach in all 3 patients was uncomplicated, with no difficulty achieving hemostasis with direct pressure.
Conclusions: Per-thoracic and trans-septal techniques are alternative approaches to provide access to the left and right native atria follow- ing total cavopulmonary anastomosis. These techniques may allow for therapeutic procedures which mitigate the need for further open heart surgery.
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RIGHT VENTRICLE TO PULMONARY ARTERY (RV-PA) CONDUIT DISRUPTION DURING TRANSCATHETER PULMONARY VALVE REPLACEMENT (TPVR) AND THE PARCS* TRIAL. *PULMONARY ARTERY REPAIR WITH COVERED STENTS
Ram Bishnoi1, Matthew Minahan2, Bryan Goldstein1, Richard Ringel3
1Cincinnati children's hospital medical center, Cincinnati, USA
2Boston Children's Hospital, Boston, USA 3johns Hopkins University, Baltimore, USA
Introduction: On 1/25/2010 the Melody TPV was approved for re- placement of the pulmonary valve for patients with CHD who have dysfunctional right ventricle to pulmonary artery conduits. RV-PA ho- mograft conduits are frequently calcified and rigid. Dilation of these conduits prior to TPVR, poses a significant risk of conduit tearing or rupture. The NuMED Covered Cheatham-Platinum Stent (CCPS) has been used in the prevention or treatment of aortic wall injury in coarctation of the aorta stent trial (COAST II) and during TPVR proce- dures into RV-PA conduits under Emergency Use (EU) or Compassion- ate Use (CU) conditions.
Aims: The aim of this study is to prospectively assess the effectiveness and safety of the NuMED Covered Cheatham-Platinum Stent (CCPS) for the treatment of RV-PA conduit disruption, occurring during car- diac catheterizations aimed at enlarging the conduit or making the conduit competent by the implantation of a transcatheter pulmonary valve.
Methods: PARCS has collected CCPS implant information on 50 pro- spectively enrolled patients with conduit disruptions from multiple institutions around the country between 1/1/2013 and 9/11/2014. Catheterization records and 6 months follow up visit data were col- lected. Outcomes of the valve implant associated with CCPS use were compared to the effectiveness and safety of the TPV implants without CCPS use.
Results: From January 2013 (1/1/2013) to September 2014 (9/11/2014), 50 patients received CCPS during TPV implant proce- dures. Patient age ranged from 6 to 44 years (median 17 years). 27 (54%) patients had TOF/PA and PA/IVS spectrums. 45 (90%) patients had pulmonary or aortic homografts, 2 had Contegra conduits, 2 had dacron conduits and the conduit was not specified in the remaining one patient. Conduit size ranged from 7 to 28 mm (Median 19 mm). 31 patients had pulmonary stenosis, 9 had pulmonary regurgitation and the remaining 10 had mixed disease. The mean preintervention minimum angiographic conduit diameter ranged from 5.1 to 20.5 mm (10.6 ± 3.2). 4 patients had pre-existing tears, and 46 patients developed tears during balloon dilations. Median largest balloon size used for dilation prior to tear recognition was 18 mm. The average ratio of the largest balloon prior to conduit tear to minimum conduit diameter ranged from 1.1 to 2.8 (1.8 ± 0.5). The average ratio of the largest balloon to initial conduit diameter ranged from 0.8 to 1.5 (1.0 ± 0.2). 42 patient had contained tears, 4 had partially contained tears and the remaining 4 had non-contained tears. Conduit tears were re- paired by covered stents in 48 out of 50 patients. A total of 63 covered stents were used (single CPSS for 40 patients, two each for 7 patients and three each for the remaining three). After CCPS therapy, 4 pa- tients developed new, small, contained peri-vascular leaks. 3 were left untreated without any sequelae and 1leak was closed with Melody implantation. The mean pre-implant peak-to-peak RVOT gradient ranged from 5 to 96 mmHg (39.3 ± 17.1 mmHg) compared to 1 to 28 mmHg (10.85 ± 6.1) postimplant. One patient had somewhat serious CCPS related complication. On echo at 6 months, peak Doppler RVOT gradient ranged from 2-49 mmHg (21.88 ± 11.2) and mean gradient 4.5-23 mmHg (12.6 ± 5.4). Valve competence was maintained during follow-up, with no patients having more than no/trivial PR.
Conclusions: In this prospective multicenter study the CCPS was suc- cessful in treating RV-PA conduit disruption occurring during TPV im-
Journal of Structural Heart Disease, August 2015
Volume 1, Issue 2: 36-111