Interventional catheterization performed in the early post-operative period following congenital heart surgery in children

Director, Pediatric Cardiology, Miami Children's Hospital,
Miami, Florida, USA
Evan M. Zahn

Over the last several decades transcatheter interventions have become a mainstay in the treatment of children with congenital heart disease. The risk of performing these procedures is generally low although certain interventions performed in selected patient populations are associated with an increased risk of complications and death. There is little published data regarding catheterization and transcatheter intervention performed on patients early in the postoperative period, especially the critically ill infant. It is commonly perceived that the risk of the procedure outweighs the potential benefits especially when an intervention is required. Particular concerns include the risk of transporting critically ill patients, exacerbating hemodynamic instability during the procedure and catastrophic bleeding resulting from perforation, coagulopathy or suture disruption.
In 1995 we hypothesized that any child could safely undergo cardiac catheterization, regardless of the time elapsed from cardiac surgery or degree of illness and that a variety of transcatheter interventions could be safely and effectively performed in this high risk population.
Objectives: The purpose of this lecture is to examine the safety and efficacy of interventional catheterization performed early after congenital heart surgery.
Background: Transcatheter interventions performed in the early postoperative period are viewed as high risk, and often avoided.
Methods: All catheterizations performed within 6 weeks following congenital heart surgery between August 1995 and January 2001 were retrospectively reviewed. An interventional cardiologist and cardiac anesthesiologist performed all procedures. A cardiac intensivist, cardiac surgeon, and operating room team were available for all cases. Interventional procedures were performed based on clinical indications; regardless from the time elapsed from surgery. Previously published criteria were used to assess the success of interventional procedural outcomes.
Results: Sixty-two patients, median age 4 months（2 days - 11 yrs）, weight 4.7 kg（2.3 - 45 kg）underwent 66 catheterizations on median post-operative day 9（0 - 42 days）. Thirty-five cases involved 50 interventional procedures. Nine patients required extracorporeal cardiopulmonary support at the time of the procedure. Success rates by procedure were: angioplasty 100%, stent implantation 87%, vascular/septal occlusion 100% and palliative pulmonary valvotomy 75%. Major complications were limited to: stent migration（1）, cerebral vascular injury（1）and left pulmonary artery stenosis（1）. Thirty procedures involved angioplasty or stent implantation, including 26 in which a recently created suture line was involved. Suture disruption or trans-mural vascular tears were not observed. There was no procedural mortality and thirty-day survival for patients undergoing intervention was 83%.
Conclusion: Transcatheter interventions can be successfully performed in the early post-operative period. These procedures can have a positive impact on patient outcome, however, they should only be performed by an experienced pediatric interventional cardiologist supported by a multidisciplinary team.