Therapeutic perioperative cardiac catheterization: A cardiosurgical cooperative approach

Director, Pediatric Cardiology and Cardiac Catherization,
Arnold Palmer Hospital for Women and Children, Orlando,
Congenital Heart Institute at APH and MCH,
Miami and Orlando, Florida, USA
David G. Nykanen

This lecture will focus on specific aspects of the role of intervention in the perioperative management of congenital heart problems with a specific focus on cooperation between surgeon and interventional cardiologist in perioperative strategy.
There is increasing evidence that transcatheter intervention is feasible and effective in the immediate post operative period. Further, transcatheter interventions can compliment, expedite and facilitate open surgical procedures. Clearly the boundary between the operating room and the therapeutic transcatheter procedures becomes less distinct as one considers the application of hybrid procedures. Only with a cooperative approach can innovative applications be attempted with confidence. To illustrate this lecture will draw for experience with intraoperative interventions and the utility of transcatheter intervention in the immediate postoperative period, particularly with respect to management of residual stenosis. An ability to consider alternative routes of vascular access increases the interventional cardiologist's ability to successfully address significant anatomic and hemodynamic challenges. Finally the role of cardiac catheterization in the management of patients who require mechanical cardiopulmonary support will be discussed.
Mechanical cardiopulmonary support represents an increasingly utilized therapeutic modality in the post operative management of refractory cyanosis and low cardiac output syndromes. Recent manuscripts in series of greater than 50 patients report survival to discharge for this population that ranges from 33-55%. This is consistent with the ECMO registry (1986-2002) figure of 39%, suggesting minimal improvement over time despite advances in cardiac intensive care. Most reports of cardiac catheterization on mechanical cardiopulmonary support are limited to case report and small case series. Most reports of intervention on mechanical support have been limited to technical problems such as the need for left atrial decompression with few reports of therapeutic intervention. It has been our experience that there is a more favorable outcome for patients that undergo cardiac catheterization that results in an intervention (data to be presented) whether this be transcatheter in nature, in the operating room, or with a hybrid approach.
Naturally there are many technical issues associated with undertaking cardiac catheterization on mechanical cardiopulmonary support. Despite these issues there are few reports of death or complications associated with cardiac catheterization in this setting. Cardiac Catheterization on mechanical cardiopulmonary support is technically feasible and by all reports can be achieved safely when a multidisciplinary approach is utilized. Early reports suggest that catheterization can disclose unexpected diagnostic information that may result in a change in management strategy or therapeutic intervention which impacts favorably on survival in this select population of patients.