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Pediatric Interventional Catheterization

Cutting Edge Technologies for Congenital and Structural Heart Disease

New York, NY (Sep 25, 2009)

Stents

Pediatric interventional cardiac catheterization is advancing techniques and technologies for congenital and structural heart disease. In 2007, NewYork-Presbyterian Morgan Stanley Children's Hospital was one of only three hospitals in the United States to participate in a feasibility study involving a pulmonary valve created from bovine venous jugular tissue that could be implanted percutaneously. Presently, more than 100 of these valves have been implanted in the country by five institutions – one-third of this number has been placed at Morgan Stanley Children's Hospital.

"All of these patients would have otherwise required open heart surgery for valve replacement," notes William E. Hellenbrand, MD, Chief of Pediatric Cardiology at Morgan Stanley Children's Hospital. "Under the current protocol, these patients are admitted on the day of the procedure and are ready for discharge home the following day. Furthermore, there are no sutures required for this procedure, no chest tubes or ICU admission. This is just one of the newly developed technologies that has and will continue to make a great impact on the overall morbidity and mortality of patients with congenital heart disease, as well as in decreasing hospital length of stay and overall medical costs."

Earlier this year the Hospital's interventional cath team enrolled their first patients into the Coarctation of the Aorta Stent Trial (COAST), a multicenter trial involving the use of both bare metal Cheatham Platinum (CP) stents and covered CP stents for relief of native and recurrent coarctations of the aorta. Though a variety of bare metal stents have been used for treatment of aortic coarctation in the recent past, the safety and efficacy of stents for this indication has not yet been established. The covered stent has been developed to treat severe vascular injury such as aneurysm formation that can develop following surgery or balloon angioplasty for coarctation of the aorta. Furthermore, covered stents may help reduce acute complication from transcatheter balloon or stent dilation of the aorta when used primarily.

Coarctation of the aorta is a congenital defect consisting of a discrete or occasionally tubular narrowing within the lumen of the aorta. These narrowings most often occur just beyond the origin of the artery to the left arm or left subclavian artery. In the U.S., this defect is usually diagnosed in infancy or early childhood. Late diagnoses also occur in older children and even in adulthood.

"In neonates and infants, surgical repair is most common," says Julie A. Vincent, MD, Medical Director of the Pediatric Interventional Catheterization Laboratory. "The majority of patients requiring treatment for aortic coarctation as older children or adults is usually because of recurrent obstruction following prior intervention, either surgical or balloon dilation. While surgical relief of these lesions is usually successful at all ages and fatalities are rare, the overall complication rate remains high – 25 to 36 percent in some studies. Furthermore, these complication rates do not take into account the incidence of rebound systemic hypertension requiring medical management in the early postoperative period that can occur, or the pain and disability the patients experience in association with the thoracotomy incision required for surgical repair."

Later this year, the Hospital's Interventional Cardiology Service will begin evaluating a new patent ductus arteriosus (PDA) occlusion device as part of another multicenter trial here in the U.S. The device is designed to close more complex PDAs via transcatheter approach. Currently, though PDAs are frequently closed in the interventional cath lab sparing the patient from a surgical incision on the side of the chest and a more invasive procedure, this new device (Amplatzer Duct Occluder IITM) has two retention discs (one at each end) that articulate enabling the device to be better positioned in more complex PDAs of multiple sizes and shapes. Furthermore, this device may be better suited for smaller patients and those who have some amount of pulmonary hypertension at the time of PDA closure and may decrease the risk of aortic arch obstruction following placement in small infants and the risk of embolization.

Contributing faculty for this article:

William E. Hellenbrand, MD, Chief of Pediatric Cardiology at NewYork-Presbyterian Morgan Stanley Children's Hospital, and Professor of Clinical Cardiology at Columbia University College of Physicians and Surgeons.

Julie A. Vincent, MD, Medical Director of the Pediatric Interventional Catheterization Laboratory at NewYork-Presbyterian Morgan Stanley Children's Hospital, and Assistant Professor of Clinical Cardiology at Columbia University College of Physicians and Surgeons.

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