Jenny E. Zablah

Background: The presence of an atrial level right to left shunt may be desirable in patients with severe pulmonary hypertension (PH) or failing Fontan circulation. The Occlutech Atrial Flow Regulator (AFR) was originally designed to create an atrial shunt for left heart failure and is currently being used off‐label in patients with PH or failing Fontan circulation. There is limited evidence supporting AFR use for these indications. Aims and Methods: We performed a retrospective review of consecutive patients with Fontan circulation or severe irreversible PH who underwent AFR implantation. Comprehensive data were collected and analyzed. Results: Sixteen Fontan and eight PH patients underwent AFR implantation. Median age and weight at implantation were 7.5 years (range 2–34) and 22.3 kg (range 11.3–80), respectively. Twenty‐eight devices were implanted in 24 patients during 27 procedures. Successful deployment was achieved in all. The device proved versatile and durable across diverse anatomic substrates, even after multiple repositioning attempts. There were no deaths or urgent surgical interventions. Transseptal puncture or Fontan baffle perforation using a Brockenbrough needle or radiofrequency before AFR implantation was required in 10 patients (42%). The most serious complication was a hemorrhagic stroke related to anticoagulation therapy. Thrombotic events occurred in three Fontan patients (11% of all implantations). Conclusions: AFR appears to be a promising adjunctive option for PH and failing Fontan patients, with acceptable safety and clinically effective results. Device thrombosis remains a risk, particularly with smaller devices in Fontan circulation, likely related to the Fontan patients' underlying hypercoagulable state.

Background: Transcatheter pulmonary valve replacement (TPVR) requires selecting the optimal device type, size, and position. Variability in anatomical shape may affect procedural planning. Aim: This study aimed to evaluate interobserver agreement (IOA) in TPVR device selection using 3D patient‐specific anatomies and explore a framework for determining agreement. Methods: Six experienced observers from three regions of the Americas independently assessed valve type (self‐expanding [S‐E], balloon‐expandable [B‐E], surgical approach [SA]), size, and position for 60 3D reconstructed anatomies (pediatric and adult) derived from cardiac magnetic resonance images. Agreement was quantified using Cohen's and Fleiss' Kappa coefficients. Results and Discussion: Overall, IOA was fair to moderate in the adult group and slight to fair in the pediatric group. Perfect agreement occurred in only eight cases, seven involving S‐E valves and one SA. S‐E valves were generally selected for anatomies with regular geometry but variable curvature, while SA valves were mainly chosen for markedly large or small anatomies. B‐E selections showed no consistent pattern. One consideration of this study is that not all transcatheter therapies were available across the regions, which may have influenced decision‐making. Additionally, interventionists typically rely on 2D imaging for procedural planning, and the use of 3D reconstructions without clinical data may also have influenced the results. Coronary anatomy was not included in the assessment. Conclusion: Agreement in selecting TPVR devices is limited for the pediatric group but moderate for adults. Variation in preferences among observers highlights the need for equitable access to diverse valve solutions across different RVOT‐PA anatomies and demographic contexts.

Background: After transcatheter pulmonary valve replacement (TPVR), changes in left ventricular loading conditions can result in increased pulmonary capillary wedge pressure (PCWP). Recognizing this effect may allow better understanding of the physiologic response of the left ventricle (LV) as well as early identification and treatment of procedural complications. Aims: Our aim was to describe the hemodynamic changes in LV filling pressures after TPVR measured by a PCWP before and after valve deployment. Methods: We present a single center, retrospective cohort of patients that underwent TPVR at the University of Colorado. Outcomes considered were need for ventilatory support, prolonged length of stay and ventricular arrhythmias. Abnormal wedge physiology was defined as an elevated pre‐PCWP (>15 mmHg) or an increase (delta‐PCWP) of at least 5 mmHg immediately after TPVR. Results: A total of 104 patients were included with a median age at procedure of 22.5 years of age (IQR 14.3−36.8, and range 6−67). Twenty‐two (21.2%) patients were determined to have abnormal wedge physiology. Patients in this group were older (median 37, IQR 22.8−51 vs. 18.5, IQR 13−32.3, p < 0.001), with higher pre‐ and post‐procedure right ventricular systolic and end diastolic pressures, higher mean pulmonary artery pressures and lower pre‐procedure cardiac index ( p < 0.05). Conclusions: An alteration in the loading conditions of the LV is among several hemodynamic changes that occur after TPVR and can manifest as an elevated PCWP. An awareness of this phenomenon and monitoring of PCWP before and after TPVR may promote the initiation of early interventions in this patient population. In the setting of medical interventions, abnormal wedge physiology was not associated with longer length of stay, ventilatory support, or early ventricular arrhythmias.

The correct arterial cannula size for percutaneous femoral venoarterial extracorporeal membrane oxygenation (VA-ECMO) cannulation is imperative for adequate circulatory support. We aimed to describe the relationship between cannula size, predicted arterial size, and vascular complications. Here, we present a single-center cohort of patients who underwent percutaneous femoral VA-ECMO cannulation. A formula using height and body mass index was used to predict the estimated common femoral artery (CFA) diameter and compared it to the cannula size used. The primary endpoint was major vascular complications. Receiver Operating Characteristic (ROC) curve was used to determine the cutoff point for significant cannula size discrepancy (≥2.7 Fr greater than predicted). Twenty-five patients were included, with a median predicted CFA diameter of 5.4mm (16.2 Fr), 1.9 Fr lower than the chosen cannula. Eight patients (32%) had a significant cannula discrepancy with more vascular complications ( p = 0.039). ROC analysis confirmed a moderate correlation between cannula discrepancy and major vascular complications (area under the curve [AUC] 0.640, sensitivity of 67%; specificity of 84%) and overall vascular complications (AUC 0.662, sensitivity of 63%; specificity of 88%). Thus, the use of arterial cannulas for percutaneous VA-ECMO that are ≥2.7 Fr larger than the estimated CFA appears to be related to a higher risk of overall vascular complications. The estimated arterial diameter should be considered when selecting the arterial cannula size. https://links.lww.com/ASAIO/B590

Pulmonary vein stenosis (PVS) is a complex disease that requires repeated percutaneous interventions. Electrical impedance tomography (EIT) is a functional imaging technique that provides real-time images of pulmonary perfusion and ventilation. We aimed to determine the feasibility of EIT to evaluate ventilation/perfusion in PVS before and after catheter-based interventions. EIT was conducted in patients with PVS using the ACT5 EIT system. Lung regions were segmented from the perfusion images, and time-dependent blood volume curves were computed voxel-wise and by lung region. The distribution of pulmonary blood flow (PBF) was computed from EIT images and compared pre and post intervention. Finally, a blinded interventional cardiologist reviewed the results to evaluate three findings: (1) side and extent of PVS, (2) perfusion, and (3) ventilation. During the study period, twelve patients were included. Of these, seven were female (58.3%) with a median age of 3.5 years. Six patients had history of prematurity, and four had history of previous surgical PVS intervention. Three patients (25%) had an episode of pulmonary hemorrhage during the current intervention. In general, ventilation/perfusion data were successfully obtained in all cases. EIT correctly depicted all 12 cases of PVS correlating with angiography performed on the same day. EIT is a non-invasive, radiation-free technique that estimates lung perfusion/ventilation and percent distribution of PBF. The subject-based evaluation of EIT correlates to the severity and sidedness of the veins involved. This technology has the potential of providing perfusion/ventilation information in-PVS patients without the need of contrast or radiation.

Purpose of Review Our goal of this review is to describe the current evidence and future applications of virtual reality (VR) from echocardiographic acquired images to enhance diagnostic accuracy and improve the visualization of cardiac structures by providing immersive 3-dimensional (3D) environments for better interpretation, communication between healthcare providers, families and trainees. Recent Findings Virtual reality is a powerful tool for education, procedural planning and simulation. Using readily available echocardiographic images for this purpose is feasible, effective and safe. Summary This document highlights the increasing role of VR in procedural planning, education, and intraprocedural guidance using three-dimensional echocardiography (3DE). Key advancements include the development of smaller 3D transthoracic and pediatric transesophageal probes with better temporal resolution, which enable enhanced imaging for preoperative planning. VR allows surgeons to visualize dynamic 3D cardiac models created from echocardiographic or Computed Tomography (CT) data, enabling better pre-surgical rehearsal, device selection, and landing zone visualization. It also provides immersive training tools for echocardiographers and offers potential for intraprocedural guidance in interventions such as atrial septal defect closures. These developments underscore the growing synergy between VR and 3DE for refining diagnosis and procedural strategies.

Despite advancements in imaging technologies, including CT scans and MRI, these modalities may still fail to capture intricate details of congenital heart defects accurately. Virtual 3D models have revolutionized the field of pediatric interventional cardiology by providing clinicians with tangible representations of complex anatomical structures. We examined the feasibility and accuracy of utilizing an automated, Artificial Intelligence (AI) driven, cloud-based platform for virtual 3D visualization of complex congenital heart disease obtained from 3D rotational angiography DICOM images. Five patients selected at random with 3DRA performed in the pediatric cardiac catheterization suite were selected. 3DRA’s were performed following published institutional protocols and segmentations performed by primary operators. The 3DRA DICOM images were anonymized as per protocol and exported. Images when then processed by Axial3D Artificial Intelligence (AI) driven cloud-based platform for virtual segmentation. Two separate expert operators were selected to subjectively analyze the segmentations and compare them to the operator reconstructions for anatomic accuracy. Comparing results with local reconstructions by expert operators, five different patient anatomies were analyzed, showcasing Axial3D’s ability to produce highly detailed reconstructions with improved visual appeal, including color-coded segments for implanted materials like stents. The reconstructions exhibited superior segmentation of different intrathoracic structures when compared to local models, offering valuable insights for medical professionals and patients. The use of the AI driven, cloud-based platform for 3D visualization of complex congenital heart lesions presents a promising advancement in pediatric interventional cardiology, facilitating enhanced patient care, procedural planning, and educational opportunities for trainees and patients alike.

Though major complications during transcutaneous pulmonary valve replacement (TPVR) are rare, clinically-significant ventricular arrythmia (CSVA) has been reported following self-expanding valve placement. We assess whether alterations in valve frame dimensions and geometry within the right ventricular outflow tract (RVOT) post-implantation in patients who underwent TPVR with Harmony TPV25 or Alterra contribute to CSVA risk. A single center review was performed of patients who underwent TPVR with either Harmony TPV25 or Alterra Pre-stent between August 2019 and April 2023. Using post-procedural 3D rotational acquisitions, minimum and maximum diameters were measured at 5 locations along the valve frame and perimeter and cross-sectional area (CSA) were measured closest to the pulmonary artery bifurcation and right ventricular (RV) cavity. To assess the relationship between the RVOT and valve frame, a RVOT-to-valve frame ratio together with percentage expansion, circularity and expansion ratios, and eccentricity indices were calculated. Twenty-eight patients were included (14 Harmony TPV25, 14 Alterra pre-stent). CSVA was seen more often in patients with congenital pulmonary stenosis (p = 0.02). CSVA was associated with a larger mean valve frame perimeter (118.3 vs 108.6 mm, p = 0.03) and CSA (1124.5 vs 926.2mm², p = 0.03) closest to the RV cavity. No associations between difference in diameters, RVOT-to-valve frame ratio, parameters evaluating valve frame geometry, and level of implant and CSVA were demonstrated. No single mechanism was identified that contributed to CSVA in patients following self-expanding valve implantation. Future studies implementing these mathematical constructs and measurements to a larger cohort of self-expanding valve patients may yield more instructive results.