先心病外科残留病变的介入治疗英文课件

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 Kong Complexity of congenital heart operation varies widely lSimple lDucts arteriosus ligation lAtrial septal defect closure lVentricular septal defect closure lModerate to Highly complex lShunt operations lRepair of coarctation of aorta lTetralogy of Fallot repair lRastelli operation lFontan-like operation lArterial switch lKonno operation lRoss procedure lNorwood operation Residual Lesions after Cardiac Surgery for Congenital Heart Disease lResidual shunting lVentricular outflow tract obstruction lResidual blood vessel stenosis lResidual valvar lesions lVentricular dysfunction lCardiac arrhythmias Treatment of Residual Lesions after Cardiac Surgery lMedical therapy lSurgical treatment lDevice implantation for rhythm disturbance lInterventional cardiac catheterization (IVC) Residual Structural Lesions lMedical therapy lNot curative, temporary lSurgical treatment lConventional lInterventional cardiac catheterization (IVC) lWidely accepted for treatment of native lesions e.g. PDA, ASD occlusion, valve and vessel dilatations lApplicable also to treat residual structural lesions Advantages of Interventional cardiac catheterization (IVC) over surgical treatment for residual structural lesions: lIVC: less invasive, less morbidity than surgery lIVC: more simple than surgery e.g. correction of stenotic vessels lSome lesions are more accessible by catheter e.g. peripheral branch pulmonary artery stenosis lSome lesions are more difficult to define clearly during surgery because of complex anatomy, or anatomy distorted by pervious procedures Interventional cardiac catheterization (IVC) and Surgical treatment are complimentary: lIVC cannot replace surgery lIVC is not suitable to correct certain lesions e.g. valve regurgitations lExperience and skill of operator is key or limiting factor to success of IVC lAvailability of apparatus, device and equipment also limits IVC application IVC or Surgery? lWhich one is the best option? lPatient characteritics: age , body size, clinical status lEach residual lesion is unique lResidual lesions may be multiple lRisk and complexity of the intervention lExperience of both cardiologists and surgeons In many cases joint decision is the best approach ! 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 RVseptum 4 chamber view4 chamber viewAP 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 Balloon angioplasty Re-coarctation after Surgical Repair Post-balloon angioplasty IVC for Re-coarctation lIVC is more simple than surgery lHighly Effectiveness 90% Re-coarctation after Surgical Repair Stent Implantation (MLP) Pre-implantation Re-coarctation after Surgical Repair Stent Implantation (MLP) Balloon expansion Re-coarctation after Surgical Repair Stent Implantation (MLP) Post-implantation lReduce recoarctation by providing support to prevent recoil after balloon dilation lReduce risk of aneurysm formation and aortic rupture Limitations lNot suitable for small child lLarge sheath relative to the vessel lRestenosis 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 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 Results% Overall Success Rate67% Restenosis Rate25% Reintervention Rate25% Period : 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 Right 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 connectionL cavopulmonary connection PA stenosis after Fontan operation Balloon dilation of PA stenosis Fenestration after Fontan Operation : Transcatheter Occlusion Transcatheter Occlusion of Fenestrations after Fontan Operation lDecrease systemic-venous pressure in high risk patients (e.g. high pre-operative mean PA pressure) lImprove cardiac output lDecrease pleural effusion lDecrease 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 lSpontaneous closure usually does not occur lRight to left shunting cyanosis, impaired exercise capacity, paradoxical embolisation, Fenestration - Disadvantages: lDevice : Amplatzer Septal Occluder lTest balloon occlusion of the fenestration to ensure maintenance of systemic blood pressure and cardiac output and absence of significant elevation 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 lRight isomerism, univentricular heart, severe pulmonary stenosis lmodified LBT shunt (2 mth), right cavopulmonary shunt (3 yr), progressive upper body edema ltaking down of cavopulmonary connection, aorto-RPA shunt and reconstruction of SVC lSVC obstruction Balloon Dilation of SVC First Stent Implanted in SVC Second Stent Implantation in SVC Post Stent Implantation in 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 , 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