Minimalistic Approach of Intervention In Common Congenital Heart Lesions

Prerequisite of a successful transcatheter cardiac intervention for congenital heart disease

• A good Echocardiography machine for proper diagnosis & evaluation
• A good Cath Lab   machine with bi-plane   facilities

• A good team of Cath Lab technician trained in pediatric intervention.
• Good P. Card ICU with all kinds of support including ventilator, defibrillator, temporary pacing, central venous line insertion.
• A team of trained ICU nurse & assistant.

A skilled interventional cardiologist with all-round capabilities to manage any situation and to bail out from critical complications.

Transcatheter Intervention in CHD

• There are some rules & regulation which should be followed for each different intervention.
• If any pediatric cardiologist follows this rules & regulation there will be very minimal chance of complication.
• All the new learners & beginners should follow these rules, regulation & guidelines set up by many school/ institutes/ academies.

• But sometimes experienced cardiologist bypass some of the steps as they gain confidence by doing a large number of cases.
• The minimalistic approach is one such simplification of procedure which is practiced in pediatric Cath lab of LABAID cardiac hospital & CMH Dhaka.

Steps of normal cardiac intervention for CHD

1. Selection: by Echocardiography
2. Sedation: by General anesthesia/ local anesthesia/ sedatives.
3. Intervention:

a)Thorough diagnostic cath

b)Identification of lesion

c)Measurement of size

d)Selection of device/ balloon/ stents

e)Deployment/ inflation of the target implant to a destination.

  4. Perioperative  guidance: fluoroscopy/ TEE/ TTE

5. Recovery from general anesthesia & hemostasis.

All these steps need longer time to complete especially recovery from general anesthesia.

But in a minimalistic approach, we can reduce the procedure time by avoiding many steps thus reducing sedation time & also reducing the radiation of the patient, operators & cath lab stuff. We will show you a few procedures now how minimalistic approach has been done.

Minimalistic approach

Echocardiography

• Thorough echocardiography did on the day before the procedure to asses size of the lesion and the range of implants required for treating the condition.
• Cath lab, P cardiac ICU & supplier of implants are informed about the nature of procedure & support which will be required from them.

Sedation

*We use cocktail sedation instead of GA.

*Advantages :

> Reduce induction time of sleep

> The procedure can be started within 5 minutes of sedation

> Recovery time after procedure also very minimum.

Transthoracic Echocardiography (TTE)

TTE doesn’t need any GA to introduce probe through the esophagus. In our series, we found no difference in the assessment of size with TEE. As TTE is non-invasive it can be done instantly and can be stopped immediately. So a significant amount of time can be saved by taking the TTE guide.

Procedure

ASD closure

*ASD device closure:

Catheter is placed in the left upper pulmonary vein to start the procedure of ASD device closure. Then balloon sizing done under fluoroscopy & TTE guide and device size is selected.  It has been observed that success rate of ASD device closure is more if balloon sizing is done. So we do balloon sizing  in minimalistic approach.

Measurement of ASD

Device deployment

Statistic of ASD device  closure

(LABAID cardiac hospital & CMH Dhaka)

PDA Closure

Aortogram

PDA measurement

Deployment of device

Statistic of PDA device closure (LABAID cardiac hospital & CMH Dhaka)

VSD Device Closure

LV angiogram

VSD measurement

Device deployment

Statistic of VSD device closure (LABAID cardiac hospital & CMH Dhaka)

PDA stenting

RV Angiogram

Aortogram

Statistic of PDA stenting (Lab Aid cardiac hospital & CMH Dhaka)

Pulmonary Balloon Valvoplasty

Balloon Dilatation

Statistic of Pulmonary Balloon Valvoplasty (BVP) (Lab Aid cardiac hospital & CMH Dhaka)

Balloon Coarctoplasty

Aortogram

Ballooning of COA

Statistic of Balloon Coartoplasty (LABAID cardiac hospital & CMH Dhaka)

Conclusion

Experienced & skilled Pediatric cardiologist innovate many new ideas & steps during procedure just to simplify procedure or to bail out from an unwanted situation. Later they use this as their routine steps. This is what results in minimalistic approach in intervention in cath lab of LABAID cardiac center & CMH Dhaka.