Catheter Interventions in Congenital Heart Disease – Hot Topics 2013

Due to its less invasiveness, its widespread availability, and its favorable outcome results, transcatheter interventions have established as a serious alternative to surgery and thereby as a cornerstone in the treatment of congenital heart disease (CHD). The hot topics in this field having been discussed at specific meetings or having been published in 2012/2013 reflect their diversity; they range from new imaging modalities during the procedure to modified indications and approaches for established procedures, and to early results from novel implants. This is an individual selection of newsworthy actual issues:

• Three-dimensional rotational angiography (3DRA) is an emerging technology which has been introduced in the field of CHD. Early experiences show that it can be performed safely and effectively in this specific patient group. It may even be more sensitive in morphological diagnosis than 2D angiography.

• Transcatheter pulmonary valve replacement (PPVI) nowadays is an established procedure with excellent early and mid-term results. Still, the official indications for this intervention are restrictive – among others circular conduit ≥ 16 mm – and thereby exclude multiple patients with a significant dysfunction of their (native) right ventricular outflow tract (RVOT). An increasing number of physicians/centers have gained so far limited experience with the off-label use of percutaneous pulmonary valves in very small or native RVOTs. Creating an adequate “landing zone” by presenting is crucial in these patients. It makes the procedure safe and predictable. Facing these promising results, the question arises whether updating the indications for PPVI should be considered.

• To implant any kind of foreign material (occlusion devices or stents) in a growing organism, which fulfill their task for a certain time period and then “go away,” has long been a desirable attribute for any kind of heart implants in children. New biodegradable devices for ASD closure, VSD closure, and stent implantation, primarily consisting of poly lactic-co-glycolic acid, have been tested in animal models and showed excellent results with regard to endothelialization and progressive degradation without risk of embolizing device parts.

• Catheterization in hypoplastic left heart syndrome does not only cover any possible hybrid procedures during neonatal period but also various transcatheter interventions before and after Fontan procedure. Long-term follow-up of this specific group of univentricular hearts now is available. It clearly demonstrates that interventions are an integral part in the peri- and postoperative management. Over one-third of patients undergoing staged palliation require catheter intervention during childhood and adolescent FU.

• Whether closure of a patent foramen ovale is effective in the prevention of recurrent ischemic stroke in patients who have had a cryptogenic stroke remains unknown. Actual studies still did not show a clear superiority of device therapy, but it seems to turn out that especially in young patients without any additional cardiovascular risk factors, it has a significant benefit.

Bibliography:

[1] Berman DP, Khan DM, Gutierrez Y, Zahn EM. The use of three-dimensional rotational angiography to assess the pulmonary circulation following cavo-pulmonary connection in patients with single ventricle. Catheter Cardiovasc Interv 2012;80(6):922–930

[2] Boshoff DE, Cools BL, Heying R, et al. Off-label use of percutaneous pulmonary valved stents in the right ventricular outflow tract: time to rewrite the label? Catheter Cardiovasc Interv 2013;81(6):987–995

[3] Söderberg B et al.: Septal defect closure using a device with biodegradable framework: chronic results in a swine model. Presented at EuroPCR 21–24 May, 2013 in Paris. EuroIntervention Abstracts; 2013.

[4] Reinhardt Z, De Giovanni J, Stickley J, et al. Catheter interventions in the staged management of hypoplastic left heart syndrome. Cardiol Young 2013;8:1–8

[5] Carroll JD, Saver JL, Thaler DE, et al; RESPECT Investigators. Closure of patent foramen ovale versus medical therapy after cryptogenic stroke. N Engl J Med 2013;368(12):1092–1100