先心病外科残留病变的介入治疗ppt课件

1、先心病外科殘留病變的介入治療周啟東周啟東 醫生醫生翁德璋翁德璋 醫生醫生香港大学葛量洪医院小儿心脏科香港大学葛量洪医院小儿心脏科Division of Paediatric Cardiology, Grantham HospitalDepartment 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第十屆中國南方國際心血管病學術會議Complexity of c

2、ongenital heart operation varies widelylSimplelDucts arteriosus ligationlAtrial septal defect closurelVentricular septal defect closure lModerate to Highly complexlShunt operationslRepair of coarctation of aorta lTetralogy of Fallot repairlRastelli operationlFontan-like operationlArterial switchlKon

3、no operationlRoss procedurelNorwood operationResidual Lesions after Cardiac Surgery for Congenital Heart DiseaselResidual shuntinglVentricular outflow tract obstructionlResidual blood vessel stenosis lResidual valvar lesionslVentricular dysfunctionlCardiac arrhythmiasTreatment of Residual Lesions af

4、ter Cardiac SurgerylMedical therapylSurgical treatmentlDevice implantation for rhythm disturbancelInterventional cardiac catheterization (IVC)Residual Structural Lesions lMedical therapylNot curative, temporarylSurgical treatmentlConventionallInterventional cardiac catheterization (IVC)lWidely accep

5、ted for treatment of native lesionsle.g. PDA, ASD occlusion, valve and vessel dilatationslApplicable also to treat residual structural lesionsAdvantages of Interventional cardiac catheterization (IVC)over surgical treatment for residual structural lesions:IVC: less invasive, less morbidity than surg

6、eryIVC: more simple than surgerye.g. correction of stenotic vesselsSome lesions are more accessible by cathetere.g. peripheral branch pulmonary artery stenosisSome lesions are more difficult to define clearly during surgery because of complex anatomy, or anatomy distorted by pervious proceduresInter

7、ventional cardiac catheterization (IVC) and Surgical treatment are complimentary:IVC cannot replace surgeryIVC is not suitable to correct certain lesionse.g. valve regurgitationsExperience and skill of operator is key or limiting factor to success of IVCAvailability of apparatus, device and equipmen

8、t also limits IVC applicationIVC or Surgery?Which one is the best option?Patient characteritics: age , body size, clinical statusEach residual lesion is uniqueResidual lesions may be multipleRisk and complexity of the interventionExperience of both cardiologists and surgeonsIn many cases joint decis

9、ion is the best approach ! Residual Ventricular Septal Defect :Transcatheter OcclusionCase: M/4multiple muscular VSDs, residual lesions after 2 attempted surgical closureLV angiogram before surgical closureRV angiogram after surgical closureLV angiogram after surgical closureTrabeculation in RVseptu

10、m4 chamber view4 chamber viewAP view4 chamber views4 chamber view with second device implanted4 chamber view shunting much reducedRe-coarctation after Surgical Repair :Balloon Angioplasty and StentingRe-coarctation after Surgical RepairPre-balloon angioplastyRe-coarctation after Surgical RepairBallo

11、on angioplastyRe-coarctation after Surgical RepairPost-balloon angioplastyIVC for Re-coarctation lIVC is more simple than surgerylHighly Effectiveness 90%Re-coarctation after Surgical RepairStent Implantation (MLP) Pre-implantationRe-coarctation after Surgical RepairStent Implantation (MLP) Balloon

12、expansionRe-coarctation after Surgical RepairStent Implantation (MLP) Post-implantationlReduce recoarctation by providing support to prevent recoil after balloon dilation lReduce risk of aneurysm formation and aortic rupture lLimitationsl lNot suitable for small childlLarge sheath relative to the ve

13、ssellRestenosis can still occur Stent Implantation in Coarctation of AortaAdvantagesManagement of Shunt Stenosis - Balloon dilatation- StentingBalloon dilatation of Shunt Stenosis Management of Shunt StenosisStent Implantation in Shunt Management of Shunt StenosisBalloon dilation of stent in shunt O

14、cclusion of unneccessary surgical implanted shuntPost-operativeBranch Pulmonary Artery Stenosis :Balloon Angioplasty and Endovascular StentingBranch Pulmonary Artery Stenosis Balloon AngioplastyExperience of Balloon Angioplasty for Branch Pulmonary Artery Stenosis at GranthamResults%Overall Success

15、Rate67%Restenosis Rate25%Reintervention Rate25%Period : 1989 1997 N = 30Branch Pulmonary Artery StenosisBranch Pulmonary Artery Stenosis Stent ImplantationBranch Pulmonary Artery StenosisPost-implantation of Endovascular StentLi YC M/15 yearsright atrial isomerism, atrioventricular septal defect, pu

16、lmonary atresia, left pulmonary artery stenosisRight modified BT shunt in neonatal periodleft modified BT shunt at 3 year oldExtracardiac conduit Fontan operation at 8 year of age Balloon Angioplasty for Branch Pulmonary Artery Stenosis after Fontan operationR cavopulmonary connectionL cavopulmonary

17、 connectionPA stenosis after Fontan operationBalloon dilation of PA stenosisFenestration after Fontan Operation :Transcatheter Occlusion Transcatheter Occlusion of Fenestrations after Fontan OperationlDecrease systemic-venous pressure in high risk patients (e.g. high pre-operative mean PA pressure)l

18、Improve cardiac outputlDecrease pleural effusion lDecrease Fontan failure rateFenestration - Short-term post-operative benefits :F/7 , Post fenestrated extracardiac Fontan at 5 years oldContrast Injection in the Extracardiac ConduitTranscatheter Occlusion of Fenestrations after Fontan OperationlSpon

19、taneous closure usually does not occurlRight to left shunting l cyanosis, l impaired exercise capacity, l paradoxical embolisation,Fenestration - Disadvantages:lDevice : Amplatzer Septal OccluderlTest balloon occlusion of the fenestration to ensure maintenance of systemic blood pressure and cardiac

20、output and absence of significant elevation of systemic-venous pressure Transcatheter Occlusion of Fontan Fenestrations :Deployment of the Amplatzer Septal Occluder at FenestrationContrast Injection after Release of OccluderStenting of Superior vena cava Obstruction F/5yrRight isomerism, univentricu

21、lar heart, severe pulmonary stenosismodified LBT shunt (2 mth), right cavopulmonary shunt (3 yr), progressive upper body edemataking down of cavopulmonary connection, aorto-RPA shunt and reconstruction of SVC SVC obstructionBalloon Dilation of SVCFirst Stent Implanted in SVCSecond Stent Implantation

22、 in SVCPost Stent Implantation in SVCResidual Ascending Vein in Post-operative Total Anomalous Pulmonary Venous Connection (TAPVD):Transcatheter Occlusion Patent Residual Ascending Vein after surgical correction of supracardiac TAPVDPlacement of OccluderPost of Occlusion of ascending veinLau KY F/14

23、 yeardouble inlet ventricle , severe pulmonary stenosisModified Fontan operation at age 7 years ( SVC- MPA, RPA anastomosis, RA partitioned)post-operation developed dilated venous channels causing desaturationocclusion of venous channel at 14 years old.Occlusion of abnormal venous channel after Fontan operati