Transcatheter Interventions in Patients With Adult Congenital Heart Disease

Figure 1. Transcatheter occlusion of an ostium secundum atrial septal defect (ASD) using the Amplatzer septal occluder. (A) The top panel shows fluoroscopic images of a sizing balloon across the ASD to measure the waist of the defect, whereas the bottom panel shows the simultaneous transesophageal echocardiographic (TEE) images. (B) The device is now deployed across the ASD, as observed using fluoroscopy (top panel), and is seen to be in a stable position, as detected using TEE imaging (bottom panel). (C) After release of the device from the delivery cable, the septal occluder has aligned with the atrial septum in a more natural way (top panel) and is seen to be still in a stable position across the ASD while straddling the retroaortic rim using TEE imaging (bottom panel).

Figure 2. Transcatheter stenting of a superior sinus venosus defect with associated partial anomalous pulmonary venous connection. (A) Three-dimensional rendering from a computed tomography angiogram demonstrating a superior sinus venosus defect with the associated partial anomalous pulmonary venous connection. (B) Deployment of a covered stent within the superior vena cava to exclude the sinus venosus defect, which allows systemic venous blood from the superior vena cava to drain into the right atrium while pulmonary venous blood can drain into the left atrium from the partial anomalous pulmonary venous connection. (C) Angiogram of the partial anomalous pulmonary venous connection demonstrating unobstructed blood flow back to the left atrium from behind the covered stent and through the sinus venosus defect. Ao, aorta; CS, covered stent; IV, innominate vein; LA, left atrium; PA, pulmonary artery; PAPVC, partial anomalous pulmonary venous connection; RA, right atrium; RV, right ventricle; SVC, superior vena cava.

Figure 3. Transesophageal echocardiography during stenting of a superior sinus venosus defect. (A) Traditional bicaval view of the superior sinus venosus defect, with superior vena cava blood draining into both the left and right atriums. (B) Color Doppler imaging demonstrating blood flow with mainly left-to-right shunting across the superior sinus venosus defect. (C) Traditional bicaval view of the superior sinus venosus defect after deployment of a covered stent to direct superior vena cava blood to the right atrium while excluding the superior sinus venosus defect to prevent shunting of left atrial blood to the right atrium. (D) Color Doppler imaging demonstrating only a trace residual left-to-right shunt around the covered stent at the end of the case. CS, covered stent; LA, left atrium; RA, right atrium; SVC, superior vena cava. The asterisk indicates the superior sinus venosus defect.

Central Illustration. Timeline of the evolution of the transcatheter pulmonary valve technologies. CE, European Commission; FDA, Food and Drug Administration; HDE, humanitarian device exemption; TPV, transcatheter pulmonary valve; US, United States.

Figure 4. Harmony valve implantation. (A) Using a preprocedural computed tomography angiogram of the chest, the operator receives an analysis of the patient’s pulmonary artery and right ventricular outflow tract, which can help predict the appropriate location for deployment of the valve. (B) Medtronic uses the computed tomography angiogram data to create a perimeter plot, which helps predicts the potential fit of a Harmony transcatheter pulmonary valve within the pulmonary artery. (C) Three-dimensional rendering of how the valve would fit within the pulmonary artery. (D) Fluoroscopic image of the Harmony valve after deployment. Angiography with a pigtail catheter demonstrates no residual pulmonary valve regurgitation. The arrow indicates the Harmony valve. LPA, left pulmonary artery; LZ, landing zone; MPA, main pulmonary artery; PA, pulmonary artery; RPA, right pulmonary artery; RV, right ventricle; TPV, transcatheter pulmonary valve.

Figure 5. Alterra prestent and Sapien valve deployment. (A) A lateral projection of a right ventriculogram demonstrating a dilated pulmonary artery that is suitable for an Alterra prestent. (B) Three-dimensional rendering using computed tomography angiogram data simulating placement of the Alterra prestent within the dilated pulmonary artery. (C) A lateral projection of the deployed Alterra prestent in a stable position as well as the Edwards Sapien S3 valve within the Alterra prestent. (D) A computed tomography angiogram of the pulmonary artery in a simulated lateral projection after the prestent and valve have been deployed demonstrating stable position of both the valve within the prestent and the prestent within the pulmonary artery. MPA, main pulmonary artery; RV, right ventricle; S3, Edwards Sapien S3 valve.

Figure 6. Stenting of a coarctation of the aorta. (A) 3-dimensional rendering using a preprocedural computed tomography angiogram of the chest. There is a tight coarctation of the aorta that appears to be remote from the left subclavian artery. (B) Lateral fluoroscopic projection of an aortogram demonstrating a tortuous, discrete coarctation. (C) Placement of a covered stent across the coarctation with resolution of the waist. (D) Aortogram after stent deployment demonstrating no residual coarctation and no evidence of dissection, hematoma, or rupture of the aorta.