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 醫醫生生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Complexity of congenital 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 switchlKonno 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 after Cardiac SurgerylMedical therapylSurgical treatmentlDevice implantation for rhythm disturbancelInterventional cardiac catheterization (IVC)Residual Structural Lesions lMedical therapylNot curative, temporarylSurgical treatmentlConventionallInterventional cardiac catheterization (IVC)lWidely accepted for treatment of native lesionse.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:lIVC: less invasive, less morbidity than surgerylIVC: more simple than surgerye.g. correction of stenotic vesselslSome lesions are more accessible by cathetere.g. peripheral branch pulmonary artery stenosislSome lesions are more difficult to define clearly during surgery because of complex anatomy, or anatomy distorted by pervious proceduresInterventional cardiac catheterization (IVC) and Surgical treatment are complimentary:lIVC cannot replace surgerylIVC is not suitable to correct certain lesionse.g. valve regurgitationslExperience and skill of operator is key or limiting factor to success of IVClAvailability of apparatus, device and equipment also limits IVC applicationIVC or Surgery?lWhich one is the best option?lPatient characteritics: age , body size, clinical statuslEach residual lesion is uniquelResidual lesions may be multiplelRisk and complexity of the interventionlExperience of both cardiologists and surgeonsIn many cases joint decision 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 RVseptum4 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 RepairBalloon 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 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 Limitations lNot suitable for small childlLarge sheath relative to the vessellRestenosis 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 Occlusion 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 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, pulmonary 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 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)lImprove 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 OperationlSpontaneous closure usually does not occurlRight to left shunting cyanosis, impaired exercise capacity, paradoxical embolisation,Fenestration - Disadvantages:lDevice : Amplatzer Septal OccluderlTest 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 FenestrationContrast Injection after Release of OccluderStenting of Superior vena cava Obstruction F/5yrlRight isomerism, univentricular heart, severe pulmonary stenosislmodified LBT shunt (2 mth), right cavopulmonary shunt (3 yr), progressive upper body edemaltaking down of cavopulmonary connection, aorto-RPA shunt and reconstruction of SVC lSVC obstructionBalloon Dilation of SVCFirst Stent Implanted in SVCSecond Stent Implantation 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 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 operationDilated right atrial venous channels, with connection to left atrium Occlusion of collateral by Amplatzer deviceLau 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 yearsLeft cavopulmonary connection at 4 yearsPersistent cyanosis due to venous connections from IVC to hepatic veins( occluded at 9 years old), low PA pressure (11 mmHg)ConclusionslSurgical reoperation of residual lesions after repair of congenital heart disease may be technically difficult, carry a high risk.lInterventional catheterization (IVC) can often effectively treat these residual lesions and have become the treatment of choice in many instances