# Presentation: 475246

## PEDIATRIC INTERVENTIONAL CARDIAC CATHETERIZATION

- Phillip Moore M.D.
- Department of Pediatrics
- University of California at San Francisco

## Slide 2

## Surgery

- Interventional
- Cardiology

## Slide 4

## CHD - INCIDENCE

- VSD				45%
- PDA				10%
- Sec ASD			7%
- PS					7%
- COARCTATION		6%
- AS				5%
- TOF				5%
- TGA				5%
- Single Ventricle		5%
- AV Canal			4%

## UCSF Congenital Cath  Lab

## INTERVENTIONAL  IMPACT

- 0.8 % of all live births have CHD
- 32,000 infants / year in U.S.; 15 mil worldwide
- 60% require treatment
- 19,200 in U.S. / 9 million worldwide
- Primary treatment for up to 1/3rd
- 6,500 in U.S. / 3 million worldwide
- Potential for up to 2/3rds of patients
- 13,000 in US / 6 million worldwide

## APPROVED  PROCEDURES

- Balloon Dilation : stenotic valves / vessels
- Stent Implantation : stenotic vessels
- Coil closure : PDA, cor fistula, collaterals
- Device closure : PDA, ASD, PFO, VSD
- RF Perforation : Pulm Atresia, restrictive atrial septum in HLH

## INVESTIGATIONAL PROCEDURES

- Valved Stent Implantation : PI, AI
- Covered Stent Implantation : Fontan completion, Shunt palliation
- Internal Vessel Band : HLH palliation
- Intravascular Suturing : PFO, ASD

## PATIENT POPULATION

- Premature infants and newborns
- 600 gms to 4 kg
- to
- Adolescents and young adults
- 70 to 100+ kg

## CURRENT IMAGING MODALITIES / DRUGS

- Radiography / flouroscopy (95+%)
- iohexol or iodixanol (max 5 cc / kg / procedure)
- Echocardiography (surface, TEE, ICE)
- Agitated saline
- Optison (rarely)

## Post Op RVOT Obstruction

## ASD Device Repair 

## ICE ASD Device Closure

## CATH COMPLICATIONS

- 1-2 % major
- 7-9 % minor
- Risk factors
- Age < 2 years
- Interventional procedure
- Contrast (amount or type) not risk factor
- Transient renal failure (dose dependant)
- Allergic reaction (non dose dependent)

## ADJUNCT IMAGING MODALTIES / DRUGS

- MRI / MRA
- Gadolinium
- Coarctation : Pre and post anatomy and collateral flow
- post op TOF / Truncus : RV size and PI

## MRA:VR

**MRA:****VR**

**Oblique Sag SE**

**MRA:****MIP**

## COARCTATION STENT REPAIR

## P308 Coarc Stent Repair

## ADJUNCT IMAGING MODALTIES / DRUGS

- Nuclear Medicine Lung Perfusion Scan
- Technesium 99
- Branch PA stenosis flow evaluation - TOF

## PA / VSD PRE - POST REPAIR

## Slide 22

## Pulmonary Artery Stenosis Dilation

## RADIOGRAPHY LIMITATIONS

- Anatomic soft tissue detail poor
- Radiation exposure prolonged and repetitive
- Expensive non portable equipment

## FUTURE CATH IMAGINGMODALITIES / DRUGS

- MRI / MRA
- Gadolinium, ?
- CT - ?
- Iomeprol, ?
- 3 D Echocardiography - ?
- ?

## BACKGROUND

- MRI - excellent diagnostic / imaging tool
- Short bore magnets - access to patients
- Shortened sequence / processing times allows for “real time imaging” of the heart

## MRI Cath Lab

## UCSF MRI / CATH LAB

- Phillips Medical Systems
- 1.5 T Intera MR Scanner
- Integris V5000 Digital X ray

## Slide 29

## Slide 30

## MRI Cardiac Catheterization

## MRI Compatable ASD Device Prototype

- Bucker et al, Proc. Int. Soc. Mag. Reson. Med., 2002

## MRI Guided Device Delivery

## MRI - STENT COMPATABILITY

- Platinum

- Nitinol

- Stainless Steel

**Fast segmented cine MR**
**(TR/TE 8/3, flip angle=20********, slice thickness=10mm)**

## MRI STENT DELIVERY

## CONCLUSIONS

- Current radiography techniques and agents are safe / useful for peds interventional cath
- Advances will require real time 3-D imaging which will come in the form of MRI , CT , or 3-D echo
- SAFE and EFFECTIVE contrast agents will be needed in these modalities to allow interventional advances

## CHALLENGES

- MRI / CT / Echo Compatible Equipment
- Faster Acquisition times
- Will need 30 frames/sec
- Image Resolution
- New contrast agents - allow tissue definition to < 2mm (3 mm slices to thick for thin structures)

## THE FUTURE

**Improved Accuracy for**
**Repair of Complex CHD**

**Real time 3-D imaging**

**Interventional cath**

**IMPROVED CONTRAST AGENTS**

## Slide 39