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• W2608552260 abstract "EditorialBalloons, Blades, Plugs and Umbrellas in the Treatment of Heart Disease in Infants and Children P. Syamasundar RaoMD, FAAP, FACC P. Syamasundar Rao Consultant Pediatric Cardiologist, Chairman, Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, P. O. Box 3354, Riyadh 11211, Saudi Arabia Search for more papers by this author Published Online:1 Apr 1987https://doi.org/10.5144/0256-4947.1987.85SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutIntroductionUntil recently, surgery has been preferred for the correction of abnormalities of the heart and blood vessels, whether congenital or acquired, but during the last decade transcatheter techniques have become increasingly useful in this field.Although transcatheter treatment by balloon dilatation of stenotic lesions was first described by Rubio and Limon-Lason in 1954,1 and Dotter and Judkins in 1964,2 until recently only the transcatheter balloon atrial septostomy described by Rashkind in 19663 for palliation of transposition of the great arteries had become widely used. However, following Gruntzig's description of transcatheter techniques to dilate coronary artery stenotic lesions,4 balloon dilatation techniques have been used in all vascular and valvular stenoses, both in adults and children.Transcatheter treatment can be discussed under seven arbitrary subheadings: 1] transcatheter balloon and blade atrial septostomy, 2] catheter closure of patent ductus arteriosus and atrial septal defects, 3] balloon dilation of stenotic lesions, 4] selective embolization of abnormal blood vessels, 5] transcatheter removal of foreign bodies, 6] transcatheter His bundle ablation, and 7] transcatheter laser applications. In this review, balloon dilatation of stenotic lesion will be discussed in detail, and the others mentioned briefly.Rashkind's balloon atrial septostomy has been extensively used in the initial palliation of transposition of the great arteries, allowing the neonate to grow to an age when surgical correction by venous switch procedures can be performed safely. Enlargement of the atrial defect by this technique which allows easy egress of blood from one atrium to the other has also been useful in the palliation of mitral atresia, tricuspid atresia, pulmonary atresia with intact ventricular septum, and total anomalous pulmonary venous connection. In older infants and children the lower margin of the patent foramen ovale is thick and muscular and cannot be torn by the balloon. To circumvent this problem, Park5 developed a catheter with a built- in retractable blade to cut the lower margin of the patent foramen ovale, which can then be enlarged by balloon atrial septostomy. We6 and others7 have used this technique successfully in the palliation of complex congenital heart disease in older infants and children.Several types of devices (plugs and umbrellas) have been developed by Porstman,8 King9 and Rashkind10 for transcatheter closure of patent ductus arteriosus and atrial septal defect. The technique is quite attractive, but because of the bulky size of the catheter delivery system and the extremely low mortality and morbidity rates in surgical closure of these defects, it has not gained wide popularity. Further refinement and miniaturization of these devices and additional clinical trials are necessary prior to general use.There has been limited but successful experience in selective embolization of abnormal blood vessels in pediatric patients. The materials used for embolization may be absorbable biodegradable materials or nonabsorbable particulate materials. Pediatric applications include occlusion of Blalock-Taussig shunts, blocking of collateral vessels to the lung in tetralogy of Fallot and pulmonary atresia, embolization of pulmonary atriovenous malformations, therapeutic obliteration of arterial supply to the sequestered portion of lung in infants with scimitar syndrome and congestive heart failure, patent Glenn anastomosis, and other types of arteriovenous malformations.Removal of embolized foreign bodies, including inadvertently embolized polyethylene and pacing catheters, fragments of guide wires and catheters dislodged during cardiac catheterizar tion, and detached cerebral ventriculo-atrial shunts is possible with several catheter techniques. Prevention by meticulous attention to inserting and securing the intravenous catheters, use of radiopaque catheters so that they can be located easily in the event of inadvertent embolization, and prompt removal once embolized (because of high incidence of serious complications) are recommended.Transcatheter His bundle ablation for controlling junctional automatic ectopic tachycardias unresponsive to conventional measures and the use of similar techniques to ablate the Kent bundle is also feasible in pediatric patients, but more clinical experience and further refinement of the technique are required.Transcatheter laser techniques have been used to produce atrial septal defects and to relieve stenotic lesions experimentally in postmortem hearts and in animals. This technique requires further development in animal models, to be followed by clinical studies.Balloon dilatation of valvular stenotic lesions by a pullback or dynamic technique was described by Rubio and Limon-Lason in 1954,1 and by Semb in 1979,11 but static dilatation is now used more commonly, as described by Kan and associates in 1982.12 This technique has been used in infants, children and adults to relieve congenital, acquired and postoperative stenotic lesions of the pulmonary valve, peripheral or main pulmonary artery, pulmonary vein, aortic valve, mitral valve, descending aorta (coarctation of the aorta), interatrial baffle after Mustard's operation for transposition of the great arteries, and the superior vena cava.The relief of obstruction is seen by sudden disappearance of ‘waisting’ of the balloon, fall in trans-stenotic pressure gradient and increase in the size of the stenotic area by angiography. In general, valvular stenotic lesions can be relieved by balloon dilatation, while central arterial (pulmonary artery and aorta) stenotic lesions have a variable result, and venous (pulmonary or systemic venous) stenotic lesions have least favorable results.Direct visual observations of pulmonic and aortic valves in a few patients immediately following balloon dilatation show tearing of the valve raphae, and tearing or avulsion of the valve leaflet. The mechanism for relief of arterial stenotic lesions appears to be tearing of the intima and media of the vessel wall.The risks of surgical relief of most of the stenotic lesions are low, but open-heart operations still have many disadvantages, including prolonged hospitalization, scars of the operation, and greater cost. For these reasons alone, catheter techniques may be more attractive. Successful immediate results in pulmonary valve stenosis with indications that relief persists suggest that percutaneous balloon dilatation is the treatment of choice for moderate to severe pulmonary valve stenosis.13Although the long-term results of balloon dilatation for coarctation of the aorta are not yet established, the short-term results are encouraging. In light of the high risk of surgical resection of coarctation of the aorta in neonates and small infants (especially when other intracardiac anomalies are present), a high incidence of recurrence (10-30%), and difficulties encountered during reoperation, balloon dilatation of coarctation of the aorta offers a safer and effective alternative.13 With balloon dilatation, surgery may be avoided or at least postponed until the baby is larger and the risk of death and recoarctation are less. Recurrence of stenosis or the development of aneurysm at the site of dilatation can be treated by surgical resection when the acute illness has passed. Published reports14,15 indicate that balloon dilatation for restenosed coarctation is consistently effective without any complications. In older children with native coarctation, however, balloon dilatation should not be performed routinely until the risk of aneurysm has been assessed in long-term studies.13,16 The role of balloon dilatation in aortic stenosis is not clearly established.A relatively new application of this technique, not yet published, is dilatation of pulmonic valve stenosis in patients with complex cyanotic heart defect. We have had good success with the technique in infants who are not candidates for total corrections either because of their size or because of complexity of their cardiac problem.This has eliminated the need for immediate palliative shunt surgery by augmenting pulmonary blood flow and hopefully will make the patients better-risk candidates for subsequent surgery.In summary, there are a large number of transcatheter techniques and procedures to correct or palliate cardiac problems in infants and children. Miniaturization of the currently bulky catheter systems and refinement of the techniques are necessary to further enhance the transcatheter approach as an option to surgical intervention.ARTICLE REFERENCES:1. Rubio V, Limon-Lason R. Treatment of pulmonary valvular stenosis and of tricuspid stenosis using a modified catheter [abstract] . Second World Congress of Cardiology, Program Abstracts II. washington, DC,, 1954:205. Google Scholar2. Dotter CT, Judkins MP. Transluminal treatment of arteriosclerotic obstruction. Description of a new technique and a preliminary report of its application . Circulation. 1964; 30:654–70. Google Scholar3. Rashkind WJ, Miller WW. Creation of an atrial septal defect without thoracotomy. A palliative approach to complete transposition of the great arteries . JAMA. 1966; 196:991–2. Google Scholar4. Gruntzig AR, Senning A, Siegenthaler WE. Nonoperative dilatation of coronary artery stenosis: percutaneous transluminal coronary angioplasty . New Engl J Med. 1979; 301:61–8. Google Scholar5. Park SC, Neches WH, Zuberbuhler JR, et al.. Clinical use of blade atrial septostomy . Circulation. 1978; 58(4):600–6. Google Scholar6. Rao PS. Transcatheter blade atrial septostomy . Cathet Cardiovasc Diagn. 1984; 10(4):335–42. Google Scholar7. Park SC, Neches WH, Mullins CE, et al.. Blade atrial septostomy: colaborative study . Circulation. 1982; 66(2):258–66. Google Scholar8. Porstmann W, Wierny L, Warnke H, et al.. Catheter closure of patent ductus arteriosus: 62 cases treated without thoracotomy . Radiol Clin North Amer. 1971; 9(2):203–18. Google Scholar9. King TD, Thompson SL, Steiner C, et al.. Secundum atrial septal defects. Nonoperative closure during cardiac catheterization . JAMA. 1976; 235(23):2506–9. Google Scholar10. Rashkind WJ, Causo CC. Transcatheter closure of patent ductus arteriosus: successful use in a 3.5 kilogram infant . Pediatr Cardiol. 1979; 1(1):3–7. Google Scholar11. Semb BKH, Tjonneland S, Stake G, Aabyholm . ‘Balloon valvulotomy’ of congenital pulmonary valve stenosis with tricuspid valve insufficiency . Cardiovasc Radiol. 1979; 2(4):239–41. Google Scholar12. Kan JS, White RI, Mitchell SE, Gardner TJ. Percutaneous balloon valvuloplasty: a new method for treating congenital pulmonary valve stenosis . New Engl J Med. 1982; 370(9):540–2. Google Scholar13. Rao PS. Transcatheter treatment of pulmonary stenosis and coarctation of the aorta: experience with percutaneous balloon dilatation . Br Heart J. 1986; 56:250–8. Google Scholar14. Lock JE, Bass JL, Amplatz K, et al.. Balloon dilatation angioplasty of aortic coarctation in infants and children . Circulation. 1983; 68(1):109–16. Google Scholar15. Kan JS, White RJ, Mitchell SE, et al.. Treatment of restenosis of coarctation by percutaneous transluminal angioplasty . Circulation. 1983; 68(5):1087–94. Google Scholar16. Cooper R, Ritter S, Golinko R. Balloon coarctation angioplasty: long-term hemodynamic and angiographic results [abstract] . Am Heart J. 1985; 110(3):706. Google Scholar Next article FiguresReferencesRelatedDetails Volume 7, Issue 2April 1987 Metrics History Published online1 April 1987 InformationCopyright © 1987, Annals of Saudi MedicinePDF download" @default.
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