Taggart, Nathaniel W

Objectives To determine event‐free survival after transcatheter closure of ventricular septal defect (VSD), and to identify predictors of adverse events (AE) in post myocardial infarction VSD (post‐MI VSD) subgroup. Background There are limited data on mid‐term follow‐up after transcatheter VSD closure. Methods Retrospective review of 27 cases of transcatheter VSD closure (post‐MI = 18 and non‐ischemic = 9) performed from 1999 to 2013. We defined AE as death, device embolization, hemolysis requiring blood transfusion, heart block and reintervention. Results In the post‐MI VSD subgroup, mean age and follow‐up was 69 ± 11 and 7.3 ± 7 years, respectively. AE occurred in 8 (44%) patients (death‐3, device embolization‐1, hemolysis‐1, surgical VSD closure‐2, reintervention‐1). Event‐free survival was 56% at 1 month and 5 years, and all AE occurred in the periprocedural period. Cardiogenic shock (HR: 3.21, CI: 1.82–5.41, P = 0.002), and VSD closure in acute phase (HR: 2.14, CI: 1.12–4.31, P = 0.004) were independent predictors of AE. In the non‐ischemic VSD subgroup, mean age and follow‐up was 49 ± 15 and 8.7 ± 8 years, respectively. AE occurred in 3 (33%) patients (late death‐1, surgical VSD closure‐2). For the entire cohort, freedom from death was 89% and 85% at 1 month and 5 years, and event‐free survival was 70% and 61% at 1 month and 5 years. Conclusions Transcatheter closure of post‐MI VSD carries a moderate risk of periprocedural complications but low event rates afterwards. By comparison, device closure of non‐ischemic VSD has lower periprocedural morbidity but some patients continued to experience AE during follow‐up. © 2015 Wiley Periodicals, Inc.

ObjectiveTo describe the effects of percutaneously implanted valve‐in‐valve in the tricuspid position for patients with pre‐existing transvalvular device leads.MethodsIn this case series, we describe implantation of the Melody valve and SAPIEN XT valve within dysfunctional bioprosthetic tricuspid valves in three patients with transvalvular device leads.ResultsIn all cases, the valve was successfully deployed and device lead function remained unchanged. In 1/3 cases with 6‐month follow‐up, device lead parameters remain unchanged and transcatheter valve‐in‐valve function remains satisfactory.ConclusionsTranscatheter tricuspid valve‐in‐valve is feasible in patients with pre‐existing transvalvular devices leads. Further study is required to determine the long‐term clinical implications of this treatment approach. © 2015 Wiley Periodicals, Inc.

BackgroundPatent foramen ovale (PFO) is common and may predispose to paradoxical embolism. Transcatheter device closure of PFO can be challenging in certain cases of “long‐tunnel” PFO morphology. We report our experience with device closure of long‐tunnel PFO using transseptal puncture.MethodsWe retrospectively reviewed all cases of PFO device closure using transseptal puncture at the Mayo Clinic from January 1, 2010 to September 30, 2013. We arbitrarily defined a PFO tunnel configuration as a tunnel length ≥ 12 mm as observed in intracardiac echocardiography (ICE) at the time of device closure.ResultsTwelve patients (mean age 40.8 [range 15–67] years; 7 males [58%]) underwent PFO device closure with transseptal puncture. The most common indication for PFO closure was previous stroke (n = 7, 58%). Median tunnel length measured by ICE was 15 mm (12–20 mm). GORE® HELEX® Septal Occluder was used for closure in all but one patient. The only significant procedural complication was a minor perforation of the left atrial wall during attempted septal puncture, which resulted in a trivial pericardial effusion that resolved without intervention. At latest follow‐up (mean 543 days, [range 170–1162]) one patient had a residual shunt and subsequently died due to complications during surgical PFO closure. No recurrent strokes or TIAs were reported.ConclusionThough not without risk, transseptal puncture can be a valuable tool for facilitating device closure of long‐tunnel type PFOs. GORE® HELEX® Septal Occluder may be an effective option for facilitating device closure for patients with long‐tunnel type PFO. © 2014 Wiley Periodicals, Inc.

Objective: To compare the safety and effectiveness of video-assisted thoracic surgery (VATS) versus conventional median sternotomy (open) in the repair of secundum atrial septal defect (ASD) or patent foramen ovale (PFO). Design: Among 415 consecutive patients undergoing open or VATS ASD/PFO closure between 1993 and October 2012, 153 patients were compared using 2:1 frequency matching (n = 102 open vs 51 VATS). Matching variables include age, gender, body surface area, past medical history of neurologic events, and need of patch closure. Median age was 43 years (3-71 years), and 67% were female. Results: There were no early deaths in either group. There were no conversions to open sternotomy. Although mean cross-clamp time (14.5 ± 7.6 vs 26.3 ± 13.2 minutes, P < .001) and bypass time (31.7 ± 13.8 vs 60.9 ± 20.9 minutes, P < .001) were longer in the VATS group, patients who underwent VATS had shorter postoperative ventilation time (7.5 ± 6.4 vs 4.4 ± 2.8 hours, P = .03) with 62.7% extubated in the operating room, along with shorter intensive care unit stay (26.7 ± 10.8 vs 19.1 ± 9.9 hours, P < .001) and hospital stay (5.2 ± 1.9 vs 3.5 ± 0.9 days, P < .001). At early follow-up (mean 1.5 years, maximum 4.2 years), there was no difference in need for reintervention. Of the 27 patients who underwent VATS ASD/PFO closure for a neurologic event, none had a recurrence. Conclusion: The use of VATS provides a safe, equally effective alternative to conventional sternotomy for ASD/PFO closure, using a less invasive approach.

ObjectivesOur objective was to determine if technical changes combined with radiation safety initiatives reduced the radiation dose delivered to patients during congenital catheterization.BackgroundUse of ionizing radiation is necessary during cardiac catheterization. Minimizing radiation dose, while maintaining clinically useful image quality, is an important safety issue. In our congenital heart center intentional practice changes, including technical changes and provider awareness initiatives, were implemented to decrease radiation dose.MethodsData were retrospectively collected for all procedures involving children and adults with congenital heart disease (CHD) undergoing catheterization over 45 months. Cases were divided into three categories including: noninterventional (NI), simple intervention (SI), and complex intervention (CI). The change in dose was modeled as log of cumulative air kerma (Ka,r). The change in Ka,r was evaluated for each procedural category as well as changes occurring as a function of age and weight.ResultsConsidering all procedures (n = 1,082), Ka,r decreased by 61%. In the NI group (n = 481), Ka,r decreased by 71%. In the SI group (n = 424), Ka,r decreased by 74%. The Ka,r for the 10–17 year old group (n = 125) and those ≥18 years (n = 709) decreased 74 and 67%, respectively. The Ka,r decreased 72 and 66% for those 20–60 kg and ≥60 kg, respectively. Groups not showing significant change in Ka,r included CI, age ≤9 years, and weight ≤20 kg.ConclusionsThrough technical changes and provider awareness initiatives, our institution dramatically reduced the radiation dose in the majority of pediatric and adult CHD patients undergoing cardiac catheterization. © 2014 Wiley Periodicals, Inc.

ObjectivesTo compare procedural outcomes of transcatheter balloon pulmonary valvuloplasty (BPV) in adults to a concurrent pediatric cohort and to identify whether BPV leads to improvement in symptoms among adults.BackgroundBPV has long been utilized to relieve right ventricular outflow tract (RVOT) obstruction in neonates and young children. More recently, BPV has been performed in adults, but outcome data are limited in this population.MethodsWe reviewed all cases of BPV performed at Mayo Clinic's Congenital Cardiac Cath Lab from December 1993 to July 2012. Patients were excluded if they had additional congenital heart defects, other than simple left‐to‐right shunt lesions.Results89 children and 40 adults underwent 132 BPV procedures. Among the adults, 78% were symptomatic at the time of BPV. The most common symptoms were dyspnea and fatigue. RVOT systolic gradient was 42 ± 19 mmHg (children) and 54 ± 26 mmHg (adults) prior to BPV (P = 0.002). Adults experienced a greater reduction in gradient following BPV (32 ± 21 mmHg vs. 23 ± 19 mmHg; P = 0.007). No patients exhibited “suicide right ventricle” physiology after BPV. Among adults, mean follow‐up was 1.9 years (30 days–11 years). Symptoms improved in 20 of the 24 previously symptomatic adults for whom follow‐up data were available. Mean NYHA score improved from 2.2 to 1.4 following BPV. At last follow‐up, 52% of adults were free of any symptoms, a significant improvement from pre‐BPV (P = 0.0003). Only one patient described worsening of symptoms after BPV.ConclusionsBPV is an effective procedure for symptomatic adults with pulmonary valve stenosis. In addition to immediate relief of RVOT gradient, adult patients may experience symptomatic improvement following BPV.© 2013 Wiley Periodicals, Inc.

BackgroundIn recent years, percutaneous device closure has become commonplace for treatment of atrial septal defect (ASD) and patent foramen ovale (PFO). However, the effect of device closure on aortic valve regurgitation (AR) has been questioned.ObjectiveThe purpose of this study was to define changes in AR using echocardiography, before and after device closure of ASD or PFO.MethodsWe retrospectively reviewed all patients who had percutaneous device closure of ASD or PFO at our institution between 2005 and 2009. We compared the preprocedure echocardiogram to the most recent follow‐up study. All investigators were blinded to referral diagnosis, patient demographics, and size and type of the device placed. Aortic regurgitation was graded as none/trivial, mild, moderate, or severe.ResultsOverall, 322 patients qualified for inclusion; 204 with PFO and 118 with ASD. Mean age at time of closure was 48 ± 20 years (range 3–85 years). Mean duration of follow‐up was 1.2 years (range 2 months to 5 years). Only two patients (0.6%) demonstrated any appreciable increase in AR severity. However, both of these patients manifested a clinically insignificant change from a trivial to mild grade of aortic regurgitation.ConclusionsPercutaneous device closure of PFO or ASD does not increase the incidence or severity of AR over medium‐term follow‐up. © 2012 Wiley Periodicals, Inc.

OBJECTIVE: Long-QT syndrome (LQTS) is both underdiagnosed and overdiagnosed. Many patients are incorrectly diagnosed as having LQTS after presenting to an emergency department (ED) with presyncope/syncope and demonstrating “borderline” QT-interval prolongation (QTc ≥ 440 milliseconds) in a sentinel ED-obtained electrocardiogram (ECG). We sought to evaluate the distribution and clinical significance of QT intervals in the ED. METHODS: We retrospectively reviewed data for all patients 22 years of age or younger (N = 626; 369 females; age, mean ± SD: 17 ± 5 years) who had ECGs obtained in our ED between July 1, 2007, and June 30, 2008. A total of 223 patients were excluded because of known structural heart disease, arrhythmias, electrolyte abnormalities, or exposure to QT-interval–prolonging medications. RESULTS: The average QTc was 428 ± 28 milliseconds (range: 344–566 milliseconds), and approximately one-third of patients had QTc values of ≥440 milliseconds (females: 41%; males: 21%). Overall, 104 patients presented with presyncope/syncope, of whom 14 (13%) had follow-up ECGs. On follow-up, these patients demonstrated significant decreases in QTc values of 33 ± 43 milliseconds (P &lt; .04). Only 8 (31%) of 26 patients with presyncope/syncope with borderline QT values had follow-up ECGs performed, in 5 of which the QTc values were decreased significantly. No patients ultimately received LQTS diagnoses. CONCLUSIONS: In the ED setting, approximately one-third of pediatric patients exhibited QTc values of ≥440 milliseconds and had significant normalization of QTc values in follow-up evaluations. First-time ECGs obtained after a syncopal episode must be interpreted with caution, particularly in the context of so-called borderline QT intervals.