Vishal R. Kaley, MBBS, MD; Chad B. Hopkins, BS; Harikrishnan K. N. Kurup, MBBS, MD; Bennett P. Samuel, MHA, BSN, RN; Yasser Al-Khatib, MD, FAAP, FACC, FSCAI; E. Oliver Aregullin, MD, FAAP; Joseph J. Vettukattil, MBBS, MD, DNB, CCST, FRCPCH, FRSM, FRCP
Keywords: Complications, Pediatric Catheterization/Intervention; Catheterization – Diagnostic; Congenital Heart Disease, Pediatrics; Hemodynamics
Introduction
Neonates and infants with Complex Congenital Heart Disease (CCHD) often require palliation followed by multiple surgeries for complete repair. Optimal outcomes following cardiac surgery is dependent on patient-specific anatomy, pulmonary artery (PA) pressures, ventricular pressures, and hemodynamic status. Prior to each surgical procedure these patients frequently require cardiac catheterizations for complete hemodynamic assessment.[1]. Using end-hole catheters can lead to unreliable measurements due to occlusion of the lumen against the vessel wall. A catheter obstructing the blood flow through the shunt or entrapment while crossing a prosthetic valve may lead to inaccurate measurements and cause acute hemodynamic compromise. We describe our experience of using a micromanometer pressure wire for hemodynamic assessment in nine children with CCHD. The median age at the time of catheterization was five months (two months to 16 years) with weight of 6.15 kg (3.5 to 100 kg). Accurate measurements were feasible without any procedure-related complications. The case series suggests the micromanometer pressure wire can be a safer alternative to end-hole catheters for hemodynamic assessment in children with CCHD.
Case Series
From March 2015 to September 2017, a total of 12 cardiac catheterizations were performed in nine children (females n=5) with CCHD using a micromanometer pressure wire for pre-surgical evaluation of PA pressures or post-surgical hemodynamic assessment. Five patients had diagnosis of Hypoplastic Left Heart Syndrome (HLHS), two had tricuspid atresia, one had pulmonary atresia with coarctation of the aorta (CoA), and one had Shone’s Complex characterized by mitral and aortic stenosis. The median age at the time of catheterization was five months with a range of two months to 16 years with median weight of 6.1 kg and range of 3.5 to 100 kg. Four patients with HLHS were palliated with the Norwood procedure and 3.5 mm modified Blalock Taussig (BT) shunt, and one patient with a 4 mm BT shunt. Both patients with tricuspid atresia had a 3.5 mm BT shunt. The patient with pulmonary atresia and CoA had a 3.5 mm central shunt from the aorta to the left PA. The patient with Shone’s Complex had mitral and aortic valve replacement followed by modified Konno procedure (Table 1).
FIGURE 1A Anteroposterior view showing the micromanometer pressure wire (red arrows) passed across the Blalock-Taussig shunt into the left pulmonary artery.
FIGURE 1B Lateral view angiograms showing the micromanometer pressure wire (red arrows) passed across the Blalock-Taussig shunt into the left pulmonary artery.
All catheterizations were performed under general anesthesia and aseptic precautions. Percutaneous access was achieved by standard methods with 80-100 units/kg of intravenous heparin as per established protocols. A 0.035 inch Terumo glidewire and 4F pigtail angiographic catheters were used to obtain an ascending aortogram and to define the exact location of the BT shunt. Ascending and descending aortic pressures were recorded. A 2.5 Judkins right (JR) coronary catheter was then advanced into the ascending aorta over a 0.035 inch standard glidewire and positioned at the arterial end of the BT shunt. Using the JR catheter and fluoroscopic guidance, the 0.014 inch micromanometer pressure wire was advanced into the shunt and the right and left PAs (Figure 1). The micromanometer pressure wire was calibrated and zeroed according to the instructions for use. Pressures were recorded in the PAs, femoral artery, ascending and descending aorta. The pressures obtained in the ascending and descending aorta using the pressure wire were compared with those obtained using conventional end-hole catheters.
To read the full article, please go to the May 2019 Issue of CCT.