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Open heart surgery is absolutely essential for the treatment of many types of
congenital heart defects. However, there are an increasing number of defects
that can be treated with special catheters or tiny devices that can be folded
into catheters. If a defect can be treated effectively with a catheter
technique, the procedure is much easier on the patient.
Most catheter treatment procedures are done with the patient sedated or under
mild anesthesia. The only incision is a 1/8-inch insertion point over the blood
vessels (usually in the legs). These do not even require a stitch. In most
cases, patients are able to leave the hospital the same day as the procedure or
sometimes, after an overnight observation period. Patients can return to school
or to work within 1 to 2 days after a catheter treatment procedure in most
cases. Because of the greatly shortened hospital stay and reduced need for
complicated equipment in the operating room and intensive care unit, the costs
of catheter procedures are usually significantly less than the cost of treatment
of the same defect by surgical techniques.
Common catheterization procedures
The most common types of interventional catheterization procedures
are those performed to:
- Create septal defects
- Open stenotic valves
- Open stenotic vessels
- Close abnormal vessels
- Close certain septal defects
Creating septal defects
Certain types of congenital heart defects require that there be a
large communication between the two atria (upper chambers of the heart). These
heart conditions include transposition of the great vessels and some patients
with mitral or aortic stenosis or atresia. The communication can be created by
either rapidly pulling a round balloon through the defect to tear the septum or
by placing a long valvuloplasty balloon in the septum and inflating it to a
large size. These procedures are usually temporary procedures to allow the
patient to recover or survive until the time of surgery.
Opening stenotic valves
Both the aortic and pulmonary valves can be treated in many patients
with aortic or pulmonic stenosis. The basic technique is to advance a special
catheter through the small opening in the valve. A long balloon on the catheter
is then rapidly inflated and deflated. The procedure works by pulling apart the
fused leaflets of the stenotic valve.
Pulmonary balloon valvuloplasty is almost universally considered the
treatment of choice for isolated pulmonary stenosis. Balloon aortic
valvuloplasty is a technically more difficult procedure to perform and carries a
higher risk than pulmonary valvuloplasty so that only experienced centers
utilize this technique.
The results with balloon valvuloplasty at The Cleveland Clinic Foundation
have been excellent and this is usually the first procedure done on patients who
do not have significant leakage of the aortic valve.
Opening stenotic vessels
Children with congenital heart disease frequently have narrowed
vessels in the pulmonary arteries or may have coarctation of the aorta which is
a narrowing or stenosis of the aorta.
Balloon angioplasty is the procedure wherein a special balloon catheter is
advanced to the stenotic area. The balloon is rapidly inflated and deflated.
The procedure works by stretching the stenotic area enough that small tears
are created in the inner two layers of the vessel wall. If the vessel is not
dilated enough, then the stenotic area will simply stretch and return to it's
original size. If the area is dilated too far, there is the possibility of
rupture or creating a thin enough area in the vessel that an aneurysm forms
later.
In older patients, stents can be used to overcome the elastic recoil of the
vessel and usually provide a better result. Angioplasty procedures may need to
be repeated and if stents are placed in growing children, they will need to be
further dilated as the child grows larger.
Closing abnormal vessels
The most common abnormal vessel that need to be closed is the patent
ductus arteriosus (PDA). If this vessel is large, then the patient may have
signs of heart failure and will have a significantly shortened life.
If the PDA is small, the patient may have no symptoms, but may be at risk for
an infection called endocarditis which is fatal if not treated with high doses
of intravenous antibiotics for 4 to 6 weeks. Closing the PDA eliminates both of
these problems. PDAs are most often closed with a device called a coil. This is
a long, slinky-like device with long cloth fibers imbedded in it. Coils can be
straightened and pushed through a small catheter. When they come out of the
catheter, they form loops of a predetermined size. If these loops are very
carefully placed in the PDA, then they will cause clumping of blood cells in the
material and will form a plug to close the vessel. In over 90 percent of
patients, PDAs can be closed with the catheter treatment. Surgery or a specially
designed PDA closure device can be used to close larger PDAs.
Closing septal defects
Several devices have been devised to fold up into catheters and open
like umbrellas to close atrial septal defects and certain types of other septal
defects. These devices have proven to be effective in most ASD patients. We use
the one device that has received FDA approval (Amplatzer ASD device) and also
use some newer devices that may have some advantages but are still
investigational. The ASD devices are usually placed with the aide of
transesophageal echocardiography or intracardiac enchocardiography. Most
patients can leave the hospital later on the day of their procedure.
Investigational devices to close a hole between the ventricles (VSD) may be used
in some patients who are at high risk for surgery.
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