AHA Statement Recommends Cardiac Cath Options for Pediatric Conditions
A broad spectrum of procedures ranging from basic diagnostic cardiac catheterization to transcatheter closure of atrial septal defects (ASDs) has progressed to the point where such techniques are viable treatment options for pediatric patients with congenital defects, according to an American Heart Association (AHA) statement updating the field for the first time in 13 years. The new recommendations are published online May 2, 2011, ahead of print in Circulation, and also were endorsed by the Society for Cardiovascular Angiography and Interventions and the American Academy of Pediatrics.
Because studies testing transcatheter methods are rare for pediatric congenital heart defects, the AHA writing committee, led by Timothy F. Feltes, MD, of the Ohio State University College of Medicine (Columbus, OH), performed a literature review and formulated recommendations to guide clinicians in utilizing the extensive catalog of interventional therapies that have developed since 1998, the last time an AHA statement was published on this topic.
Accumulating the Data
“Quite frankly, in the world of pediatric cardiology, there are many procedures that are available in the cath lab, but in terms of the volume of the literature, it’s not like what you see in adults simply because the number of kids with congenital heart disease is so much smaller,” Dr. Feltes told TCTMD in a telephone interview. “It does take time to accumulate a critical mass of data.”
According to the guidelines, diagnostic cardiac catheterization is now recommended for numerous situations in pediatric patients, including:
- To assess pulmonary resistance and reversibility of pulmonary hypertension to make surgical and medical decisions
- To characterize lung segmental pulmonary vascular supply in patients with complex pulmonary atresia
- To determine coronary circulation in pulmonary atresia with intact sputum
- For surveillance of graft vasculopathy after cardiac transplantation
- To determine pulmonary pressure/resistance and transpulmonary gradient in palliated single-ventricle patients before a staged Fontan procedure
- To obtain a complete diagnosis in any congenital heart disease patient in whom noninvasive testing is insufficient
- To assess cardiomyopathy or myocarditis
ASD accounts for 7% of all congenital heart defects, according to the AHA statement. Over the past 30 years, innovative device development has progressed to the point where transcatheter ASD closure has been shown by several studies to be comparable to surgical closure in selected patients. Transcatheter ASD closure is now recommended in patients:
- With hemodynamically significant ASD with suitable anatomic features
- With transient right to left atrial shunting who have experienced stroke or TIA
- With a small ASD who are believed to be at risk of thromboembolic events
When Not to Proceed
“Just as important in the spirit of patient safety and quality, we highlight procedures that should not be attempted, and that was certainly not addressed in the first guidelines,” Dr. Feltes said.
In the case of ASD closure, the AHA statement recommends not performing such procedures in patients with:
- A small ASD of no hemodynamic significance and no other risk factors
- An ASD other than of the secundum variety
- An ASD and advanced pulmonary vascular obstructive disease
Ventricular septal defects (VSDs), meanwhile, account for about 20% of all forms of congenital heart disease, spurring the development of numerous occlusion devices. Percutaneous device closure of muscular VSDs is recommended for infants weighing at least 5 kg (11 lbs) as well as children and adolescents with hemodynamically significant VSD.
A Hybrid Approach
“One of the most prominent things we did is to highlight the innovative spirit that exists between interventionalists and surgeons where they do combined procedures called hybrid procedures,” Dr. Feltes said. “There’s a component of surgical as well as interventional. That’s one of the things that is highly unique about congenital heart disease, whereas in the adult world it’s often a very contentious relationship.”
In the case of VSDs, a hybrid procedure is recommended in neonates, infants weighting less than 5 kg, and children with significant VSD and associated cardiac defects requiring cardiopulmonary bypass.
Procedures for transcatheter VSD closure are not recommended for pediatric patients with inlet defects with inadequate space between the VSD and the atrioventricular or semilunar valves, and those with a small- to moderate-sized VSD in whom there is a reasonable expectation that the defect will decrease over time.
Multiple studies have proven the effectiveness and safety of transcatheter balloon valvuloplasty in children. The AHA statement recommends when the procedure should and should not be performed in cases involving the pulmonary, aortic and mitral valve. No recommendations are made for tricuspid valvuloplasty due to the rarity of tricuspid valve stenosis and the lack of literature on interventions for the condition in the pediatric age group.
Statement Serves Multiple Goals
According to Dr. Feltes, the statement will serve an important purpose for both practicing cardiologists as well as trainees.
“This will help the practicing pediatric cardiologist determine what some of the criteria are and techniques used for a procedure. That will help them in educating their patients as well as gaining an individual appreciation,” he said. “This also gives the practicing cardiologist who does cardiac catheterization an understanding of what the expectations are in the field, so that if they’re not meeting those, they have to consider what they need to do to get to that point.”
Since the field requires specialization among a relatively small pool of clinicians who perform these procedures, Dr. Feltes does not see this as a problem. “I don’t think there’s a lot of abuse of interventional procedures in congenital heart disease, so I don’t think this will lead to labs shutting down or anything like that,” he said.
The new recommendations also should serve as a model for training programs. “The person who is training in interventional cardiology should be adept in all of these various procedures, so it will help as a guideline,” Dr. Feltes said.
Another clinical area the statement addresses is transcatheter pulmonary valve replacement, which has been performed with good results in hundreds of patients. Currently, the only device cleared for marketing in the United States for this indication is the Melody valve (Medtronic, Minneapolis, MN), approved under a humanitarian device exemption. The guidelines state that valve implantation is reasonable in patients with a right ventricle-to-pulmonary artery conduit with associated moderate to severe pulmonary regurgitation or stenosis, and provided the patients meet inclusion/exclusion criteria for the valve.
Other areas touched on in the new guidelines include angioplasty and/or stenting of obstructive lesions and transcatheter vascular occlusion.
Source:
Feltes TF, Bacha E, Beekman RH III, et al. Indications for cardiac catheterization and intervention in pediatric cardiac disease: A scientific statement from the American Heart Association. Circulation. 2011;Epub ahead of print.
Disclosures:
- Dr. Feltes reports no relevant conflicts of interest.
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