[Show abstract][Hide abstract] ABSTRACT: Background: The use of three-dimensional rotational angiography (3D-RA) to assess patients with congenital heart diseases appears to be a promising technique despite the scarce literature available. Objectives: The objective of this study was to describe our initial experience with 3D-RA and to compare its radiation dose to that of standard two-dimensional angiography (2D-SA). Methods: Between September 2011 and April 2012, 18 patients underwent simultaneous 3D-RA and 2D-SA during diagnostic cardiac catheterization. Radiation dose was assessed using the dose-area-product (DAP). Results: The median patient age and weight were 12.5 years and 47.5 Kg, respectively. The median DAP of each 3D-RA acquisition was 1093µGy.m2 and 190µGy.m2 for each 2D-SA acquisition (p<0.01). In patients weighing more than 45Kg (n=7), this difference was attenuated but still significant (1525 µGy.m2 vs.413µGy.m2, p=0.01). No difference was found between one 3D-RA and three 2D-SA (1525µGy.m2 vs.1238 µGy.m2, p = 0.575) in this population. This difference was significantly higher in patients weighing less than 45Kg (n=9) (713µGy.m2 vs.81µGy.m2, P = 0.008), even when comparing one 3D-RA with three 2D-SA (242µGy.m2, respectively, p<0.008). 3D-RA was extremely useful for the assessment of conduits of univentricular hearts, tortuous branches of the pulmonary artery, and aorta relative to 2D-SA acquisitions. Conclusions: The radiation dose of 3D-RA used in our institution was higher than those previously reported in the literature and this difference was more evident in children. This type of assessment is of paramount importance when starting to perform 3D-RA.
Arquivos Brasileiros de Cardiologia 08/2014; 103(2):131-137. · 1.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Early diagnosis and treatment of congenital heart defects have a well-known impact on patient´s quality of life. This study aimed to describe the population of patients with congenital heart disease submitted to percutaneous diagnostic or therapeutic procedures at a tertiary referral center. METHODS: Retrospective analysis of 1,002 patients submitted to cardiac catheterization between 2003 and 2009 at Instituto de Cardiologia do Rio Grande do Sul. Clinical, demographic and procedure variables were obtained from an institutional database and patient charts. RESULTS: Median age was 33 (0-73) years and median weight was 23 (9.6-52.6) kg. Patients were predominantly females (52%), with acyanotic heart disease (63.2%) and postnatal diagnosis (94.8%). Pulmonary stenosis (22.9%), atrial septal defect (22.5%) and patent ductus ateriosus (21.6%) were the most common acyanotic heart defects, whereas tetralogy of Fallot was the most frequent cyanotic heart disease (15,2%). Most of the procedures (58,6%) were therapeutic, including pulmonary balloon valvuloplasty (32.9%), atrial septal defect closure (20.9%) and ductus arteriosus closure (15%). Complications were observed in 19.2% of patients, and inguinal hematomas (7.8%) and fever (7.6%) were the most frequent findings. There were 3 procedure-related deaths (0.3%). CONCLUSIONS: The study results demonstrated the prevalence of therapeutic procedures in patients with acyanotic heart disease, performed with a low complication rate at a tertiary referral center.
Revista Brasileira de Cardiologia Invasiva. 12/2012; 20(4):408-412.
[Show abstract][Hide abstract] ABSTRACT: The difficult performance of certain percutaneous interventions in the field of congenital heart disease is well known. Crossing pulmonary arteries in patients who have previously undergone surgical repair or stenotic pulmonary veins in infants can be typical examples of these technical challenges in the catheterization laboratory. The Venture wire 6 Fr control catheter (St Jude Medical) is compatible with a steerable tapered radiopaque tip that can be manually angulated (up to 90°) by clockwise rotation of a knob located in the proximal handle. This mechanism directs any 0.014″ guidewire and provides back-up support. This catheter has been successfully used in coronary artery intervention for crossing severely tortuous vessels, extreme angulations of side-branch ostia, jailed stents, saphenous vein graft anastomoses, and chronic total occlusions. We report the first use of the Venture wire control catheter (St Jude Medical) in the field of congenital heart disease. Patient #1 was diagnosed with pulmonary atresia and ventricular septal defect and had a proximally migrated stent in the pulmonary trunk and severe left pulmonary artery stenosis. We have used this catheter in order to cross this stent and perform left pulmonary artery stent placement. Patient #2 had postoperative vein restenosis after surgery. The Venture catheter was used to reach the obstructed insertion of the right medium lobe pulmonary vein from a transseptal approach. Techniques from coronary interventional colleagues can help interventional cardiologists in the field of congenital heart disease to treat complex situations.
The Journal of invasive cardiology 07/2012; 24(7):E148-52. · 1.57 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Aortic coarctation comprises approximately 7% of all known congenital heart defects. Surgery and balloon angioplasty have been performed for many years but are associated with a significant incidence of recoarctation and aneurysm formation. Although bare-stent implantation decreases the incidence of recoarctation, the risk of aortic dissection or aneurysm formation is not eliminated. Described initially to treat patients with coexistent aneurysm of the aortic wall, we currently believe that covered-stent implantation for aortic coarctation should play a more important role. Our increasing experience from expanding their indication to deal with complications from previous interventions, associated defects or particular anatomical situations has led us to conclude that most of cases of aortic coarctation in adolescents and adults should be treated by the implantation of covered stents.
Expert Review of Medical Devices 03/2012; 9(2):123-30. · 2.43 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To test the hypothesis that the aortic isthmus flow index (IFI) is lower in fetuses of diabetic mothers than in fetuses of nondiabetic mothers.
We performed a cross-sectional observational study to assess the IFI in fetuses, with (n = 13) and without (n = 37) myocardial hypertrophy, of mothers with diabetes mellitus and in fetuses of nondiabetic mothers (n = 23). Analysis of variance and Tukey test were used to assess differences among the groups.
There were no differences in maternal or gestational age among the groups. In fetuses of diabetic mothers, the mean IFI in fetuses with myocardial hypertrophy was 1.19 ± 0.06, and in fetuses without it was 1.18 ± 0.09. The mean IFI in fetuses of nondiabetic mothers was 1.32 ± 0.07 (P < 0.001).
The IFI in fetuses of diabetic mothers is lower than in fetuses of nondiabetic mothers, possibly as a result of a decreased left ventricular compliance.
[Show abstract][Hide abstract] ABSTRACT: INTRODUÇÃO: A abordagem percutânea é opção de escolha em neonatos portadores de estenose pulmonar crítica (EP) e atresia pulmonar com septo interventricular íntegro (APSI). Neste trabalho são descritos casos tratados consecutivamente em centro de referência e seu seguimento a médio prazo. MÉTODOS: A maioria dos pacientes recebeu infusão endovenosa de prostaglandina pré-procedimento, independentemente da necessidade hemodinâmica. Na abordagem da APSI, foi utilizada guia de ponta rígida e, mais recentemente, valvotomia com cateter de radiofrequência. Na maioria dos casos, foi realizada dilatação sequencial com balão até atingir 110% a 120% do diâmetro do anel valvar pulmonar. RESULTADOS: Entre 1998 e 2011, 17 neonatos com APSI (idade mediana de 5 dias, peso de 3,1 + 0,6 kg) e 30 neonatos com EP (idade mediana de 12 dias, peso médio de 3 + 1,4 kg) foram tratados em um serviço terciário. Na APSI, 14 pacientes foram abordados com guia rígida, com sucesso de 71,4%, e 3 com radiofrequência, com sucesso de 100%. Na EP, o sucesso foi alcançado em todos os casos. O óbito hospitalar foi de 23,5% no grupo com APSI e de 3,3% no grupo com EP, nenhum relacionado ao procedimento percutâneo. Na evolução a médio prazo, a taxa de reintervenção por reestenose foi de 21,4% no grupo com APSI e de 10% no grupo com EP. CONCLUSÕES: A valvoplastia pulmonar na EP e na APSI apresenta resultados clínicos e hemodinâmicos aceitáveis, desde que se observem características anatômicas favoráveis e se mantenha a patência do fluxo pulmonar até o procedimento. A morbidade e a mortalidade dos portadores de EP crítica são mais baixas que as de portadores de APSI.
Revista Brasileira de Cardiologia Invasiva. 12/2011; 19(4):423-429.
[Show abstract][Hide abstract] ABSTRACT: To test the hypothesis that maternal restriction of polyphenol-rich foods (PRF), which, like non-steroidal anti-inflammatory drugs (NSAID), inhibit prostaglandin synthesis in the third trimester, reverse fetal ductal constriction (DC).
An open clinical trial of 51 third trimester fetuses with DC with no history of NSAID intake was designed. All mothers were submitted to a food frequency questionnaire and were oriented to withdrawl PRF, being reassessed after 3 weeks. Doppler parameters were assessed before and after discontinuation of these substances. A control group of 26 third trimester normal fetuses, with no ductus arteriosus (DA) constriction, in which no dietary intervention was offered, was reviewed after 3 weeks. Student's t-test and Wilcoxon's test were used.
Mean gestational age was 32±3 weeks (28 to 37 weeks). After discontinuation of PRF (≥3 weeks), 48/51 fetuses (96%) showed complete reversal of DC, with decrease in mean ductal systolic velocity (1.74±0.20 m s(-1) to 1.31±0.34 m s(-1), P<0.001), mean diastolic velocity (0.33±0.09 m s(-1) to 0.21±0.07 m s(-1), P<0.001) and mean right to left ventricular dimension ratio (1.37±0.26 to 1.12±0.17, P<0.001) and increase in mean ductal pulsatility index (PI) (1.98±0.36 to 2.46±0.23, P<0.001). Median daily maternal consumption of PRF was 286 mg per day and decreased after orientation to 0 mg per day, P<0.001. In the control group, with GA of 32±4 w (29-37 w), there was no significant differences in median daily maternal consumption of PRF, mean ductal systolic velocitiy, diastolic velocity, PI and right ventricular to left ventricular diameter ratio (RV/LV) ratio.
Reduction of maternal PRF intake during pregnancy, especially in the third trimester, is followed by complete reversal of DC (wide open DA), which may influence maternal dietary habits in late pregnancy.
Journal of perinatology: official journal of the California Perinatal Association 11/2011; 32(8):574-9. · 1.59 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The aim of this article is to report a 16-year experience with percutaneous balloon aortic valvuloplasty (BAVP) in newborns and young infants up to 3 months of age in a tertiary care cardiac reference center in a developing country and to determine its value in postponing open heart surgery.
Congenital aortic stenosis (AS) is a potentially life threatening disorder. BAVP and surgical procedures have similar short and medium-term efficacy.
Thirty-one consecutive newborns and young infants with critical AS underwent BAVP in our department from 1991 to 2007. Mean patient age at time of the procedure was 22 days (range 2-92 days) and mean weight was 3,310 g (1,840-4,400 g).
There was a significant reduction in mean Doppler-derived peak gradient across the aortic valve immediately after the procedure (75.1 ± 22 versus 32.2 ± 13.02, P < 0.001), and this finding was maintained throughout follow-up. Since 2003, when the carotid approach became routine practice, no major vascular complications were observed. Mean time of follow-up was 81 months (5 days-196 months) with only two deaths (7.4%). Only 24% patients required surgical reintervention on the aortic valve during follow-up. Survival free from aortic valve surgery was 80% at 24 months, 66% at 63 months, and 50% at 80 months.
Percutaneous intervention for relief of critical aortic stenosis in newborns in a tertiary center of a developing country is safe and has excellent short and long-term results comparable to other centers throughout the world.
Catheterization and Cardiovascular Interventions 07/2011; 78(1):84-90. · 2.51 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Atrial septal defect (ASD) is one of the most frequent congenital malformations, representing 5% to 10% of all congenital heart defects. The most common type is the ostium secundum ASD (OS ASD), and represents 75% of these malformations. When diagnosed late or left untreated, in addition to abnormalities in the clinical examination, there may be heart failure, cardiac arrhythmias, mitral insufficiency, right ventricular overload and pulmonary hypertension. In advanced cases with severe pulmonary hypertension and interatrial shunt reversal (right to left), there is cyanosis, which indicates severe cardiopulmonary disease and increased mortality. In the last decades, with the improvement of percutaneous techniques and devices, the possibility of percutaneous treatment of congenital defects has increased dramatically. Several studies have shown excellent early and long-term results of percutaneous atrial septoplasty. In addition to providing greater comfort for patients, lower complication rates, less in-hospital and extra-hospital recovery time and efficacy similar to that of surgical atrial septoplasty in developed countries, it is definitely the most economic option. There is no doubt that in the near future, the cost-effectiveness ratio of this procedure will also be observed in developing countries such as Brazil, where the cost of the prosthesis is, to this day, the major obstacle for the standardization of this procedure and the amounts paid for surgical procedures are outdated.
Revista Brasileira de Cardiologia Invasiva. 06/2010; 18(2):212-222.
[Show abstract][Hide abstract] ABSTRACT: Fetal ductus arteriosus constriction is a clinical disorder that occurs as a result of inhibition of the prostaglandin synthesis pathway, and has long been associated to maternal intake of nonsteroidal antiinflammatory drugs in late pregnancy. As a consequence of an increased right ventricular pressure, with tricuspid regurgitation and heart failure, there is a risk for the development of neonatal pulmonary artery hypertension. This article reviews the basic knowledge of the mechanisms involved in this important disorder. Clinical and experimental evidence that maternal consumption of polyphenol-rich substances, such as herbal teas, orange and grape juice, chocolate, and others, may interfere with fetal ductus arteriosus dynamics are discussed. Preventive measures to avoid fetal ductal constriction in the third trimester of pregnancy are discussed, including the possible need to change maternal dietary orientation, aiming to limit ingestion of foods with high concentrations of polyphenol-rich substances.
Expert Review of Cardiovascular Therapy 02/2010; 8(2):291-8.
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: The introduction of total cavopulmonary anastomosis (TCPA) or Fontan procedure significantly changed the natural history of patients with complex heart diseases inadequate for biventricular repair. However, the development of silent stenosis is well known. In addition, fenestrated conduits are frequently used. The present study reports the experience of a tertiary center with percutaneous devices implanted in the conduits of patients with univentricular circulation. METHOD: From July 2000 to July 2010, 12 patients received percutaneous devices in conduits after Fontan procedure. Patients were divided into two groups, according to the indication for the procedure: 5 patients received septal occluders to close surgical fenestrations (group 1), 6 patients received stents for the relief of conduit obstructions (group 2) and 1 patient received both devices simultaneously. Mean age of group 1 patients at the time of the procedure was 174 ± 53.5 months and mean weight was 30.7 ± 6.8 kg. Mean age of group 2 patients was 148.5 ± 84.6 months and mean weight was 28.9 ± 19.8 kg. RESULTS: In group 1, oxygen saturation rose from 82.6 ± 7.5% to 90.4 ± 7.5% immediately after the procedure (P = 0.001). In group 2, oxygen saturation rose from 81.8 ± 8.9% to 91.3 ± 8.7% (P = 0.01). The minimal conduit diameter changed from 6.9 + 4,8 mm to 16.6 ± 3.5 mm after the procedure (P = 0.02). The patient who was submitted to both procedures simultaneously had an increase of the minimal conduit diameter from 11.7 mm to 16 mm and an improvement in systemic saturation from 60% to 90%. CONCLUSION: Treatment of conduit obstructions with non-covered stents and the occlusion of surgical fenestrations with covered stents or AmplatzerTM devices are safe procedures, with high immediate success rates which are maintained in the mid-term follow-up.
Revista Brasileira de Cardiologia Invasiva. 12/2009; 18(4):435-442.
[Show abstract][Hide abstract] ABSTRACT: Sinus venous atrial septal defects are commonly associated with abnormal pulmonary venous connection. Numerous surgical techniques have been proposed with excellent short- and long-term outcomes. Pulmonary and superior vena cava obstructions, as well as rhythm disturbances, are the most common problems seen during follow up. However, acute postoperative superior vena cava obstruction with successful percutaneous covered-stent implantation has not been reported in the literature. The objective of this study is to report a unique case of acute obstruction of the superior vena cava on the first postoperative day after sinus venous atrial septal defect repair in an infant who was successfully relieved by a percutaneous angioplasty with covered-stent implantation, and the midterm follow up after this intervention.
Catheterization and Cardiovascular Interventions 07/2009; 74(7):1085-8. · 2.51 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Myocardial tissue Doppler (MTD) is a technique for the measurement of myocardial velocities in systole and diastole. This study evaluates the use of MTD in the assessment of cardiac diastolic function in fetuses with intrauterine growth restriction (IUGR) with placental insufficiency and in appropriate-for-gestational age (AGA) fetuses with hypertensive mothers.
This study included 14 IUGR fetuses with placental insufficiency (Group 1), 13 AGA fetuses with hypertensive mothers (Group 2), and 29 AGA fetuses with healthy mothers (Group 3). Patients with other diseases were excluded. All fetuses had a gestational age of at least 25 weeks. MTD assessment was performed with the sample volume placed at the basal segment of the left ventricular side wall (LV), the interventricular septum (IVS) and the right ventricular free wall (RV). E'/A' ratios were calculated for each location. Mitral and tricuspid flows were assessed by conventional spectral pulsed Doppler.
Significant differences were found between groups for E'/A' at the IVS (P < 0.001) and LV (P = 0.009), with a higher mean (+/- SD) value in Group 1 (IVS: 0.92 +/- 0.28; LV: 0.85 +/- 0.19) than in Groups 2 (IVS: 0.62 +/- 0.09; LV: 0.68 +/- 0.14) and 3 (IVS: 0.71 +/- 0.14; LV: 0.69 +/- 0.15). In the RV, there was no statistically significant difference in the E'/A' ratio (P = 0.2). No differences were observed for mitral and tricuspid flow velocities and ratios.
Using MTD, the ratios between early and late diastolic myocardial velocities are higher in IUGR fetuses than in AGA fetuses at the IVS and the LV, regardless of the presence of maternal hypertension. MTD may be more sensitive than atrioventricular spectral Doppler for the detection of ventricular diastolic dysfunction in IUGR fetuses.
Ultrasound in Obstetrics and Gynecology 07/2009; 34(1):68-73. · 3.56 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To test the hypothesis that maternal consumption of polyphenol-rich foods during third trimester interferes with fetal ductal dynamics by inhibition of prostaglandin synthesis.
In a prospective analysis, Doppler ductal velocities and right-to-left ventricular dimensions ratio of 102 fetuses exposed to polyphenol-rich foods (daily estimated maternal consumption >75th percentile, or 1089 mg) were compared with 41 unexposed fetuses (flavonoid ingestion <25th percentile, or 127 mg).
In the exposed fetuses, ductal velocities were higher (systolic: 0.96+/-0.23 m/s; diastolic: 0.17+/-0.05 m/s) and right-to-left ventricular ratio was higher (1.23+/-0.23) than in unexposed fetuses (systolic: 0.61+/-0.18 m/s, P<0.001; diastolic: 0.11+/-0.04 m/s, P=0.011; right-to-left ventricular ratio: 0.94+/-0.14, P<0.001).
As maternal polyphenol-rich foods intake in late gestation may trigger alterations in fetal ductal dynamics, changes in perinatal dietary orientation are warranted.
Journal of perinatology: official journal of the California Perinatal Association 07/2009; 30(1):17-21. · 1.59 Impact Factor