Spring 2010

Less Invasive Treatments Improve Risk Profiles

Phillip Moore, M.D.Advances in interventional catheterization are averting or mitigating the risks of cardiac surgery for fetuses, neonates and children with a variety of congenital heart conditions. "These procedures generally require quite a team effort," says Phillip Moore, M.D., director of the Pediatric Cardiac Catheterization Laboratory at UCSF Benioff Children's Hospital. Cardiologists, cardiac surgeons, radiologists and, at times, high-risk obstetricians and obstetrician-radiologists might all be required. Below, we describe some of the procedures expanding the treatment options for severe fetal and pediatric heart conditions.

Fetal Intervention

"In a fetus with critical aortic stenosis developing hypoplastic left heart syndrome (HLHS), if we can get in and improve blood flow and pressure by around 20 weeks, we can mitigate the effect on left ventricle development," says Moore.

Such interventions are considered only after a multidisciplinary team assesses risk and benefit. "The key is to reliably predict which babies won't form an adequate ventricle," says Moore. "We have good data on aortic stenosis and the left ventricle, and have developed protocols for critical pulmonary stenosis and restrictive atrial septum."

If, after counseling, a family decides upon a fetal procedure, the interventional cardiologist opens a path through the mother's uterus and then through the fetal chest wall and heart. A small wire is threaded through the abnormal valve, and angioplasty opens the valve.

Hybrid Procedures

In most cases, cardiologists and cardiac surgeons address HLHS after birth. Historically, this has meant three stages of open heart surgery, with all of the attendant risks of cardiac and neurological complications from bypass. To avoid those risks, the UCSF Pediatric Heart Center is offering a new, hybrid stage 1 (Norwood) procedure that involves stenting and banding blood vessels through a tiny opening in the chest.

Similarly, the team has developed a hybrid procedure for high-risk pulmonary valves. "For smaller patients in whom heart stoppage and cooling are life-threatening, we use a catheter and a stented valve that we place directly into the ventricle while the heart is actively beating," says Moore. For those with a small area of blockage or stenosis, this procedure requires only a very small incision exposing the lower half of the heart.

Transcatheter Pulmonary Valve Implantation

The UCSF Pediatric Cardiac Catheterization Laboratory is one of nine centers nationwide performing clinical trials with the Melody valve for transcatheter pulmonary valve implantation. The procedure is for school-age through adult patients who have had multiple bypass operations, whose valves are functioning poorly, and in whom it is too dangerous to stop and cool their hearts again.

Coarctation of the Aorta

coarctationThough interventional cardiologists have been treating coarctation of the aorta with catheterization, until now, they have been limited to stents designed for other problems. "We've been trialing a smaller, uncovered stent, and we have one with a Gore-Tex covering that will be available later this year, which can help avoid puncturing," says Moore.

Patent Ductus Arteriosus

"We've been closing patent ductus arteriosus in the cath lab for last 20 years, but we are now actively enrolling in a stage 2 clinical trial with a nitinol patch, which is better suited to working with small children — and possibly premature infants, in whom this condition often appears," says Moore.

"Any invasive procedure with fetuses, infants and children contains risks, but these techniques and technologies can reduce the risks when compared with surgical procedures," says Moore.

For more information, contact Dr. Moore at (415) 353–4140.

 

Spring 2010 Table of Contents

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