1、先心病外科殘留病變的介入治療,周啟東 醫生 翁德璋 醫生 香港大学葛量洪医院小儿心脏科Division of Paediatric Cardiology, Grantham Hospital Department of Paediatrics and Adolescent Medicine, The University of Hong KongThe 10th South China International Congress of Cardiology 第十屆中國南方國際心血管病學術會議,Complexity of congenital heart operation varies wi
2、dely,Simple Ducts arteriosus ligation Atrial septal defect closure Ventricular septal defect closure Moderate to Highly complex Shunt operations Repair of coarctation of aorta Tetralogy of Fallot repair Rastelli operation Fontan-like operation Arterial switch Konno operation Ross procedure Norwood o
3、peration,Residual Lesions after Cardiac Surgery for Congenital Heart Disease,Residual shunting Ventricular outflow tract obstruction Residual blood vessel stenosis Residual valvar lesions Ventricular dysfunction Cardiac arrhythmias,Treatment of Residual Lesions after Cardiac Surgery,Medical therapy
4、Surgical treatment Device implantation for rhythm disturbance Interventional cardiac catheterization (IVC),Residual Structural Lesions,Medical therapy Not curative, temporary Surgical treatment Conventional Interventional cardiac catheterization (IVC) Widely accepted for treatment of native lesionse
5、.g. PDA, ASD occlusion, valve and vessel dilatations Applicable also to treat residual structural lesions,Advantages of Interventional cardiac catheterization (IVC) over surgical treatment for residual structural lesions:IVC: less invasive, less morbidity than surgery IVC: more simple than surgery e
6、.g. correction of stenotic vessels Some lesions are more accessible by catheter e.g. peripheral branch pulmonary artery stenosis Some lesions are more difficult to define clearly during surgery because of complex anatomy, or anatomy distorted by pervious procedures,Interventional cardiac catheteriza
7、tion (IVC) and Surgical treatment are complimentary:IVC cannot replace surgery IVC is not suitable to correct certain lesions e.g. valve regurgitations Experience and skill of operator is key or limiting factor to success of IVC Availability of apparatus, device and equipment also limits IVC applica
8、tion,IVC or Surgery?Which one is the best option? Patient characteritics: age , body size, clinical status Each residual lesion is unique Residual lesions may be multiple Risk and complexity of the intervention Experience of both cardiologists and surgeonsIn many cases joint decision is the best app
9、roach !,Residual Ventricular Septal Defect : Transcatheter Occlusion,Case: M/4 multiple muscular VSDs, residual lesions after 2 attempted surgical closure,LV angiogram before surgical closure,RV angiogram after surgical closure,LV angiogram after surgical closure,Trabeculation in RV,septum,4 chamber
10、 view,4 chamber view,AP view,4 chamber views,4 chamber view with second device implanted,4 chamber view shunting much reduced,Re-coarctation after Surgical Repair : Balloon Angioplasty and Stenting,Re-coarctation after Surgical Repair,Pre-balloon angioplasty,Re-coarctation after Surgical Repair,Ball
11、oon angioplasty,Re-coarctation after Surgical Repair,Post-balloon angioplasty,IVC for Re-coarctation,IVC is more simple than surgery Highly Effectiveness 90%,Re-coarctation after Surgical Repair,Stent Implantation (MLP) Pre-implantation,Re-coarctation after Surgical Repair,Stent Implantation (MLP) B
12、alloon expansion,Re-coarctation after Surgical Repair,Stent Implantation (MLP) Post-implantation,Reduce recoarctation by providing support to prevent recoil after balloon dilation Reduce risk of aneurysm formation and aortic rupture LimitationsNot suitable for small child Large sheath relative to th
13、e vessel Restenosis can still occur,Stent Implantation in Coarctation of Aorta Advantages,Management of Shunt Stenosis - Balloon dilatation - Stenting,Balloon dilatation of Shunt Stenosis,Management of Shunt Stenosis,Stent Implantation in Shunt,Management of Shunt Stenosis,Balloon dilation of stent
14、in shunt,Occlusion of unneccessary surgical implanted shunt,Post-operative Branch Pulmonary Artery Stenosis : Balloon Angioplasty and Endovascular Stenting,Branch Pulmonary Artery Stenosis Balloon Angioplasty,Experience of Balloon Angioplasty for Branch Pulmonary Artery Stenosis at Grantham,Period :
15、 1989 1997 N = 30,Branch Pulmonary Artery Stenosis,Branch Pulmonary Artery Stenosis,Stent Implantation,Branch Pulmonary Artery Stenosis,Post-implantation of Endovascular Stent,Li YC M/15 years right atrial isomerism, atrioventricular septal defect, pulmonary atresia, left pulmonary artery stenosis R
16、ight modified BT shunt in neonatal period left modified BT shunt at 3 year old Extracardiac conduit Fontan operation at 8 year of age,Balloon Angioplasty for Branch Pulmonary Artery Stenosis after Fontan operation,R cavopulmonary connection,L cavopulmonary connection,PA stenosis after Fontan operati
17、on,Balloon dilation of PA stenosis,Fenestration after Fontan Operation : Transcatheter Occlusion,Transcatheter Occlusion of Fenestrations after Fontan Operation,Decrease systemic-venous pressure in high risk patients (e.g. high pre-operative mean PA pressure) Improve cardiac output Decrease pleural
18、effusion Decrease Fontan failure rate,Fenestration - Short-term post-operative benefits :,F/7 , Post fenestrated extracardiac Fontan at 5 years old,Contrast Injection in the Extracardiac Conduit,Transcatheter Occlusion of Fenestrations after Fontan Operation,Spontaneous closure usually does not occu
19、r Right to left shunting cyanosis, impaired exercise capacity, paradoxical embolisation,Fenestration - Disadvantages:,Device : Amplatzer Septal Occluder Test balloon occlusion of the fenestration to ensure maintenance of systemic blood pressure and cardiac output and absence of significant elevation
20、 of systemic-venous pressure,Transcatheter Occlusion of Fontan Fenestrations :,Deployment of the Amplatzer Septal Occluder at Fenestration,Contrast Injection after Release of Occluder,Stenting of Superior vena cava Obstruction,F/5yr Right isomerism, univentricular heart, severe pulmonary stenosis mo
21、dified LBT shunt (2 mth), right cavopulmonary shunt (3 yr), progressive upper body edema taking down of cavopulmonary connection, aorto-RPA shunt and reconstruction of SVC SVC obstruction,Balloon Dilation of SVC,First Stent Implanted in SVC,Second Stent Implantation in SVC,Post Stent Implantation in
22、 SVC,Residual Ascending Vein in Post-operative Total Anomalous Pulmonary Venous Connection (TAPVD): Transcatheter Occlusion,Patent Residual Ascending Vein after surgical correction of supracardiac TAPVD,Placement of Occluder,Post of Occlusion of ascending vein,Lau KY F/14 year double inlet ventricle
23、 , severe pulmonary stenosis Modified Fontan operation at age 7 years ( SVC- MPA, RPA anastomosis, RA partitioned) post-operation developed dilated venous channels causing desaturation occlusion of venous channel at 14 years old.,Occlusion of abnormal venous channel after Fontan operation,Dilated ri
24、ght atrial venous channels, with connection to left atrium,Occlusion of collateral by Amplatzer device,Lau PY F/ 11 years Left atrial isomerism, double inlet right ventricle, pulmonary stenosis, IVC connected to LSVC via azygous vein, hepatic veins drain to common atrium Left modified BTshunt at 2 y
25、ears Left cavopulmonary connection at 4 years Persistent cyanosis due to venous connections from IVC to hepatic veins( occluded at 9 years old), low PA pressure (11 mmHg),Conclusions,Surgical reoperation of residual lesions after repair of congenital heart disease may be technically difficult, carry a high risk. Interventional catheterization (IVC) can often effectively treat these residual lesions and have become the treatment of choice in many instances,
