RESULTS
Patients’ characteristics: 27 patients underwent 30 cardiac
catheterization procedures (10 diagnostic and 20 interventional). The
median age at the time of cardiac catheterization was 15 months ranging
from 15 days to 20 years. The median time from cardiac surgery was 3
days ranging from 0 day (same day of surgery) to 32 days. Out of 30
procedures, six procedures were performed for 6 patients immediately
after surgery (3 interventional and 3 diagnostic), 18 procedures
(including the 6 procedures done immediately after surgery) were
performed in the 1st week post-surgery (8 diagnostic,
10 interventions) and 20 procedures were performed in the
1st 2 weeks post-surgery (9 diagnostic, 11
interventions). The median weight at time of cardiac catheterization was
8.2 kg, (3.4 – 53 kg). Fourteen (14) procedures were performed in
patients with single ventricle physiology and 10 procedures in
conotruncal anomalies. Two genetic syndromes were identified in this
cohort one was DiGeorge and the other was William syndrome. Twenty-three
(23) procedures were performed while patients were on mechanical
ventilation and inotropic support; the median time for mechanical
ventilation was 23 days (2-89 days). Eleven procedures were done for 11
patients on ECMO support, the median duration for ECMO were 5 days,
range (2-7 days), Table (1). There was no significant difference between
patients underwent diagnostic cardiac catheterization and those
underwent interventional procedure regarding age, weight, diagnosis,
time from surgery, mechanical ventilation, vasoactive inotropic score or
ECMO support (table 1).
Indication for cardiac catheterization: Inability to wean from
ECMO /cardiopulmonary support (CPS) and cyanosis were the most frequent
indications. There was no significant difference between diagnostic
group and interventional group regarding the indication for cardiac
catheterization (Table 2).
Catheterization procedures: For the intervention group
angioplasty through stenting was performed in 10 procedures, 6 of them
were for pulmonary artery branches (Fig. 1), 2 for right ventricular
outflow tract (RVOT), one for coronary artery and one for pulmonary
venous baffle. The success rate in stenting group was 90% (one patient
with pulmonary atresia –VSD that underwent surgical repair developed
embolized left pulmonary artery stent in the conduit that required redo
surgery for retrieval of the stent and fenestration of the VSD patch).
Angioplasty through ballooning was performed in 2 procedures; one for
stenosis of pulmonary venous confluence -left atrial connection after
repair of total anomalous pulmonary venous connection (TAPVC) that
failed to decrease the pressure gradient or heart failure symptoms and
required a redo surgery, the other was for a kink in a modified Blalock
Thomas Taussig (BTT) shunt that was successful with improvement of
oxygen saturation after the procedure. In all angioplasty procedures the
median balloon size to stenosis diameter ratio was 2.5 (1.8-3).
Occlusion was performed in 8 procedures (2 for MAPCAS, 2 for Fontan
fenestrations, 1 for pulmonary arteriovenous malformation, 1 for
modified Blalock Taussig (BT) shunt (Fig. 1), 1for aorta to right
ventricular outflow tract (AO to RVOT) fistula (Fig. 2) and 1 for missed
antegrade pulmonary flow in Fontan patient) (Table 4), the success rate
in occlusion procedures was 100%.
Outcome: Out of total 30 procedures there were no
complications during transportation of patients from operating room or
PICU to the cardiac catheterization laboratory. Three procedures had
complications during cardiac catheterization namely; cardiac arrest that
required cardiopulmonary resuscitation, embolization of stent in the
RV-PA conduit during stenting of stenotic branch pulmonary artery and
post procedural arterial thrombosis of the femoral artery that improved
on Heparin infusion. All complications were reported in the
interventional group. No reported mortality during procedures.
Seven (7) patients required redo surgery in the form of arch repair (1
patient), pulmonary venous baffle augmentation (2 patients), VSD
fenestration (3 patients), and Fontan fenestration (1 patient). The
median duration of hospital stay was 20 days (2-330 days) and for
pediatric intensive care unit (PICU) stay was 16 days (1-99 days). There
was no significant difference between the diagnostic group and
interventional group regarding PICU stay, hospital stay, need for redo
surgery, and occurrence of complications during procedure (table 3). No
mortality was reported in catheterization laboratory.
Regarding survival, the overall survival till the time of the study was
51.8% (14 out of 27 patients). Survival to discharge was 55.5% (15 out
of 27 patients, 1 patient died one year after the procedure from
infective endocarditis).
Procedures performed on ECMO support: 11 procedures were
performed for 11 patients on ECMO support (4 diagnostic and 7
interventions), 8 patients (72.7%) successfully disconnected from ECMO
support, 5 (45.4%) survived to discharge and 4 (36.3%) thereafter (1
died 1 year after procedure with infective endocarditis). Kaplan Meier
univariate analysis demonstrated that patients performed cardiac
catheterization on ECMO support had less survival than others (Fig. 3).