Cardiac Catheterization for Congenital Heart Disease: From Fetal Life to Adulthood, 2nd

The second edition of this handbook is an up-to-date guide to the application of catheter-based interventions across the entire age range of congenital heart disease patients, from fetal life through to adulthood. It considers the changes and improvements that have occurred during the last few years in terms of new procedures, new tools and devices (in particular in the field of valves), new imaging and pre-procedural strategies, such as 3D-printing, 3D- rotational angiography and fusion imaging. It provides readers with clear instructions on techniques for vascular access, valve dilatation, angioplasty, stent implantation, defect closure, defect creation, pulmonary valve implantation and on the hybrid approach, as well as on various other procedures. As in the first edition, topics are approached using a step-by-step format, ensuring that readers can immediately access the information relevant to their daily practice. Numerous explanatory figures and drawings are included in each chapter in order to further clarify how to plan, perform and evaluate diagnostic and interventional procedures in the field of congenital heart disease. It also highlights important tips and tricks that will assist health operators in achieving optimal outcomes, and includes an appendix with additional general equations and BSA, and oxygen consumption charts. This practical guide will be a valuable resource for surgeons and cardiologists in their daily clinical practice. Foreword: “Nothing Endures But Change” Preface Contents Part I: General 1: Patient Information and Informed Consent 1.1 Introduction 1.2 Background 1.3 Information and Consent in Clinical Practice 1.4 Conclusion References 2: Anaesthesiological Management of the Paediatric Patient in the Catheterisation Laboratory 2.1 Introduction 2.2 Anaesthesia 2.2.1 Preoperative Consideration 2.2.2 Premedication 2.2.3 Sedation and Anaesthesia 2.3 Monitoring and Anaesthetic Equipment in the Cardiac Catheterisation Laboratory 2.3.1 Electrocardiogram 2.3.2 Blood Pressure 2.3.3 Pulse Oximetry 2.3.4 Capnometry 2.3.5 Temperature Monitoring 2.3.6 ScvO2 (Continuous Mixed Venous Oxygen Saturation) Monitoring 2.3.7 NIRS (Near-Infrared Spectroscopy) Monitoring 2.3.8 Anaesthetic Equipment 2.4 Ventilation Strategies During Cardiac Catheterisation Procedures 2.5 Fluid Management 2.6 Complications of Cardiac Catheterisation Suggested Reading 3: Antibiotics and Anticoagulation 3.1 Antibiotic Prophylaxis 3.2 Anticoagulation in Catheterization Laboratory Further Reading 4: Angiography: Basics and Contrast Media 4.1 Cardiac Catheterization Laboratory Equipment Overview and Basic Roentgenology 4.2 Tactics for Radiation Dose Reduction and Image Quality Improvement 4.2.1 Diagnostic Information Should be Obtained Primarily Noninvasively 4.2.2 Position Patients Properly (Isocentered and Straight on the Table) 4.2.3 Use the Lowest Acceptable Frame Rate During Pulsed Fluoroscopy and Cine Angiography 4.2.4 Do Not Use Fluoroscopy to Make Changes to the Patient/Table Position or Collimator/Shields 4.2.5 Remove Unnecessary Body Part (or Instruments) from the Field 4.2.6 Always Perform a Test Injection of a Small Amount of Contrast Material Using Fluoroscopy Prior to Acquiring an Angiogram 4.2.7 Use the Lowest Acceptable Magnification Mode 4.2.8 Use Collimators and Partial-Thickness Shields 4.2.9 Center the Region of Interest Correctly in the Field 4.2.10 Keep the Image Intensifier as Close to the Patient as Possible (and the X-Ray Tube as Far Away as Possible) 4.2.11 Use the Angiographic Projection That Reduces Operator Exposure Whenever Possible 4.2.12 Decrease Beam-On Time 4.2.13 Remove Anti-Scatter Grids When Catheterizing Small Children 4.2.14 Use X-Ray Stand Position Memory 4.2.15 Use Biplane Fluoroscopy, Roadmap, and Overlay Features 4.2.16 Catheter Selection 4.2.17 Contrast Delivery 4.3 Contrast Media 4.4 Contrast Reactions 4.4.1 Anaphylactoid Reactions 4.4.2 Nonanaphylactoid Reactions 4.4.2.1 Chemotoxic, Organ Specific Nephrotoxicity Cardiovascular Toxicity Neurotoxicity Thyroid Dysfunction 4.4.2.2 Vasovagal Reactions References 5: Angiography: Radiation Exposure and Standard Projections 5.1 Radiation Exposure Today 5.2 Potential Hazards of Radiation Exposure [1] 5.2.1 Deterministic Risks 5.2.2 Stochastic Risks 5.3 Special Problems of Medical Radiation in Children [2] 5.4 Terminology [1] 5.5 How to Manage Radiation Doses for Invasive Cardiac Procedures [1] 5.5.1 Preprocedure 5.5.2 Procedure 5.5.3 Postprocedure 5.6 Angiographic Projections 5.7 Specific Lesions (In Situs Solitus with Left Aortic Arch) [3] (Fig. 5.5) 5.7.1 Secundum Atrial Septal Defect and Fenestrated Fontan 5.7.2 Ventricular Septal Defect 5.7.3 Patent Ductus Arteriosus 5.7.4 Surgical Fistula Between Supraortic Arch and Branch Pulmonary Artery 5.7.5 Aortic Valve 5.7.6 Coarctation of the Aorta 5.7.7 Mustard Baffle 5.7.8 Bidirectional Cavopulmonary Connection 5.7.9 Fontan Operation 5.7.10 Pulmonary Valve Stenosis, Tetralogy of Fallot, and Pulmonary Valve Atresia with Intact Ventricular Septum 5.7.11 Branch Pulmonary Artery Stenosis 5.7.12 Total Anomalous Pulmonary Venous Connection References 6: Catheters and Wires 6.1 Diagnostic Catheters 6.1.1 Anatomy of the Catheter 6.1.2 Types of the Catheters 6.1.2.1 Angiographic Catheters 6.1.2.2 Pulmonary Balloon Wedge Catheters 6.1.2.3 Curved Catheters 6.1.2.4 Special Catheter Types 6.1.3 Selection of the Catheter and Catheter Manipulation 6.1.3.1 Floating Catheters 6.1.3.2 Torque-Controlled Catheters 6.2 Guidewires 6.3 Introducer Sheaths Suggested Reading 7: Balloons 7.1 Introduction 7.2 Direct Dilation of Valves and Vessels 7.2.1 Characteristics of Balloons 7.2.2 Low-Pressure, Medium-Pressure, High-Pressure, and Ultrahigh-Pressure Balloons 7.2.3 Cutting Balloons 7.2.4 Coronary Balloons 7.2.5 Other Special Balloon Dilation Catheters 7.3 Septostomy Balloons 7.4 Sizing Balloons 7.5 How to Use Balloons 7.5.1 Preparation, Introduction and Inflation 7.5.2 Deflation and Withdrawal 7.6 Double-Balloon Technique 7.7 Complications 7.8 Basic Requirements References 8: Stents 8.1 Introduction 8.2 Indications 8.3 Stent Features 8.4 Stent Implantation 8.5 Complications References 9: Transcatheter Valve Devices in Congenital Heart Disease 9.1 Balloon-Expandable Valves 9.1.1 Medtronic Melody Valve 9.1.2 Edwards Sapien XT and Sapien 3 Valves 9.2 Self-Expanding Valve Replacement Devices 9.2.1 Medtronic Harmony Valve 9.2.2 Edwards Alterra Adaptive Prestent 9.2.3 Venus P Valve 9.2.4 Taewong Pulsta Valve 9.2.5 Med-Zenith PT-Valve References 10: “Adult” Tools Relevant for Congenital Heart Disease 10.1 Equipment 10.1.1 Cardiac Catheters 10.1.2 Coronary Wires 10.1.2.1 Types of Coronary Guidewires 10.1.3 Coronary Balloons 10.1.3.1 Types of Coronary Balloons 10.1.4 Coronary Stents 10.1.4.1 Types of Coronary Stents Most Frequently Used in Congenital Heart Disease 10.1.5 Delivery Sheaths 10.2 Transcatheter Imaging Tools 10.2.1 Fractional Flow Reserve 10.2.2 Intracardiac Echocardiography Further Reading 11: Hemodynamic Assessment: Pressures, Flow, Resistances and Vasoreactive Testing 11.1 Hemodynamic Assessment 11.2 Pressure Evaluation and Waveforms (Table 11.1) 11.3 The Pressures 11.3.1 The Right Atrium 11.3.2 The Right Ventricle 11.3.3 The Pulmonary Artery 11.3.4 Pulmonary Capillary Wedge Pressure 11.3.5 The Left Atrium 11.3.6 The Left Ventricle 11.3.7 The Aorta 11.4 Assessment of Cardiac Output 11.4.1 The Fick Method 11.4.2 Indicator-Dilution Method 11.4.3 Thermodilution Method 11.4.4 Angiographic Method 11.5 Assessment of Flows and the Qp:Qs Ratio 11.6 Resistance 11.7 Pulmonary Vascular Reactivity Testing References 12: Congenital Heart Disease: An Integrated Care Approach 12.1 Introduction 12.2 The Importance of Communication in the Relationship Between the Cardiologist and the Patients in the Prenatal and Neonatal Phase 12.3 Congenital Heart Disease: Impact on Quality of Life and Psychosocial Aspects for Children and Adolescents 12.4 Psychological Functioning in Adults with Congenital Heart Disease 12.5 How to Help Families and Patients: Clinical Psychology Service, Patient Associations and Peer-to-Peer Programs 12.6 Conclusions References Part II: Vascular Access 13: The Usual Vascular Access 13.1 Femoral Venous and Arterial Access 13.1.1 Positioning and Anatomic Landmark Guidance 13.1.2 Ultrasound-Guided Puncture 13.2 Internal Jugular Vein Access 13.2.1 Positioning and Anatomic Landmark Guidance 13.2.2 Ultrasound-Guided Puncture 13.3 Subclavian Vein Access 13.4 Umbilical Venous Access 13.4.1 Problems 13.5 Radial Artery Access 13.5.1 Positioning and Landmarks 13.5.2 Technique 13.6 Axillary Artery Access 13.6.1 Positioning and Landmarks 13.6.2 Technique References 14: Unusual Access 14.1 Introduction 14.2 Ultrasound-Guided Puncture 14.3 Transhepatic Vascular Access 14.4 Paravertebral Access 14.5 Iliac Venous Access References 15: Hemostasis 15.1 Hemostasis 15.1.1 Manual Compression (MC) 15.1.2 Vascular Closure Devices (VCD) 15.1.2.1 Passive Vascular Closure Devices Hemostasis Pads Compression Devices: FemoStop (St. Jude Medical, USA) and ClampEase (Pressure Products Inc., USA) 15.1.2.2 Active Vascular Closure Devices Cardiva Catalyst (Cardiva Medical Inc., USA) Collagen Plug Device: Angio-Seal (St. Jude Medical, USA) Collagen Plug Device: Mynx (Access Closure, USA) Polyglycolic Acid (PGA) Plug Device: ExoSeal (Cordis Corporation, USA) FISH (Morris Innovative, USA) Clip Device: StarClose (Abbott Vascular, USA) Suture Devices: Perclose (Abbott Vascular, USA) 15.1.3 Hemostasis in Non-femoral Access Sites 15.1.3.1 Jugular Access 15.1.3.2 Umbilical Access 15.1.3.3 The Transhepatic Access 15.1.3.4 Surgical Vascular Access 15.1.3.5 Hybrid Procedures 15.1.3.6 Fetal Interventions References 16: Access Complications and Management 16.1 Access Complications and Management 16.1.1 Preventive Measures 16.1.2 Complications Linked to the VAS and Techniques 16.1.2.1 Femoral Access Hematoma Acute Arterial Occlusion Chronic Arterial Occlusion Retroperitoneal Hemorrhage Pseudoaneurysm Arteriovenous Fistula 16.1.2.2 The Internal Jugular Vein 16.1.2.3 Transhepatic Access 16.1.2.4 Umbilical Access 16.1.2.5 Vascular Closure Devices (VCD) References 17: Transseptal Access 17.1 Introduction 17.2 Procedures Requiring TS 17.3 Understanding Transseptal Anatomy 17.4 Transseptal Technique 17.4.1 Site-Specific TSP 17.4.1.1 Mitral Valve Interventions 17.4.1.2 LAA Occlusion Procedure 17.4.1.3 EP Ablations 17.5 Knowledge of Imaging 17.5.1 Fluoroscopy 17.5.2 Echocardiography 17.6 Advanced Imaging 17.7 High-Risk Transseptal Anatomy 17.8 Alternative Approaches and Advanced Techniques 17.9 Knowing the Contraindications 17.10 Complications 17.11 Conclusion References 18: Hybrid Access 18.1 Hybrid Carotid Access 18.2 Hybrid Axillary Access 18.3 Perventricular Access 18.3.1 Subxiphoid Incision Technique 18.3.2 Anterior Thoracotomy 18.3.3 Full Median Sternotomy 18.4 Transapical Left Ventricular Access 18.4.1 Left Anterior Thoracotomy 18.5 Main Pulmonary Artery Hybrid Access for Delivery of Ductal Stent or Branch Pulmonary Artery Stent 18.6 Right Mini-Axillary Thoracotomy 18.7 Left Thoracotomy 18.8 Open Heart Access or Intraoperative Procedures 18.8.1 Intraoperative Diagnostic Angiograms (Completion or “Exit” Angiography) 18.8.2 Aortic Arch Obstruction: Hybrid Balloon Stent Implantation After Norwood Procedure During Stage II Palliation or Fontan Procedure 18.8.3 Pulmonary Valve: Intraoperative Balloon Valvotomy 18.8.4 Pulmonary Arteries and Pulmonary Veins: Intraoperative Stent Implantation 18.8.5 Intraoperative Transcatheter Closure of Blalock–Taussig Shunts or Major Aorto-pulmonary Collateral Artery 18.8.6 Intraoperative Delivery of Aortic Valve Prosthesis References Part III: Fetal Procedures 19: Fetal Interventions 19.1 Introduction and Clinical Scenarios 19.2 Anatomy, Physiopathology, Indications for Interventions, and Patient Selection 19.3 Pre-procedural Imaging and Planning 19.4 Technique (Step-by-Step), Materials, and Tips and Tricks 19.5 Pitfalls and Complications 19.6 How to Manage Complications 19.7 Post-procedural Care and Follow-Up 19.8 Expected Immediate Results and Postnatal Outcomes References Part IV: Step-By-Step Procedures: Valve Dilatation 20: Aortic Valvular Stenosis 20.1 Anatomic Description and Physiopathologic Factors 20.2 Clinical Scenarios 20.2.1 Critical Aortic Stenosis in Newborn 20.2.2 Aortic Stenosis in Older Children and Adolescents 20.3 Indications and Patient Selection 20.4 Treatment Options 20.5 Preprocedure Imaging 20.6 Step-by-Step Technique 20.7 Materials 20.8 Expected Results 20.9 Suggestions for Procedural Success 20.10 Pitfalls 20.11 Complications 20.12 Management of Complications 20.13 Postprocedure Care 20.14 Follow-Up References 21: Pulmonary Valve Stenosis 21.1 Anatomic Description and Physiopathology 21.2 Clinical Scenarios 21.3 Indication for Treatment and Treatment Options 21.4 Pre-procedural Imaging 21.5 Technique (Step-by-Step) 21.6 Materials (Balloon Angioplasty Catheters) 21.7 Expected Results 21.8 Tips and Tricks 21.9 Pitfalls 21.10 Complications 21.11 Post-procedural Care 21.12 Follow-Up References 22: Pulmonary Atresia and Intact Ventricular Septum 22.1 Introduction 22.2 Anatomic Description 22.2.1 Major Anatomic Subtypes 22.3 Pathophysiology and Clinical Presentation 22.4 Treatment Options, Indications and Patient Selection 22.5 Pre-procedure Imaging 22.6 Technique, Materials, Tips and Tricks 22.7 Expected Results 22.8 Pitfalls, Complications and Their Management 22.9 Post procedure 22.10 Follow-up References 23: Percutaneous Transcatheter Balloon Mitral Commissurotomy 23.1 Introduction 23.2 Anatomic Description and Physiopathology 23.3 Indications and Patient Selection 23.4 Pre-procedural Evaluation 23.5 Balloon Catheters for PTMC 23.6 PTMC Procedure 23.7 Alternate Methods and Newer Techniques of PTMC 23.8 PTMC in Special Situations 23.9 Tips and Tricks for Successful PTMC 23.10 Expected Results 23.11 Complications and Management 23.12 Summary of Critical Points for Safe and Successful PTMC References Part V: Step-By-Step Procedures: Vessel Treatment 24: Stent Implantation in Patients with Pulmonary Arterial Stenosis 24.1 Introduction 24.2 Anatomic Description and Pathophysiology 24.3 Indication for Stent Treatment in Pulmonary Arterial Vessel Stenosis 24.4 Pre-procedural Imaging 24.5 Stent Implantation 24.6 Stents 24.7 Expected Results 24.8 Tips and Tricks 24.8.1 Challenging Anatomies 24.8.2 Choosing the Right Balloon Diameter 24.9 Pitfalls 24.10 Complications and Their Management 24.10.1 Dissection 24.10.2 Vessel Rupture 24.10.3 Stent Embolization 24.11 Post-procedural Care 24.12 Follow-Up References 25: Aortic Coarctation 25.1 Anatomic Description and Physiopathology 25.2 Clinical Scenarios 25.3 Indications for Treatment of Aortic Coarctation 25.4 Pre-procedural Imaging 25.5 Surgical Treatment 25.6 Balloon Angioplasty 25.6.1 Indications 25.6.2 Technique 25.6.3 Expected Results 25.6.4 Hints 25.6.5 Pitfalls 25.6.6 Limitations 25.6.7 Main Complications 25.6.8 After the Procedure 25.7 Stent Implantation 25.7.1 Indications 25.7.2 Technique 25.7.3 Tips and Tricks 25.7.4 Limitations 25.7.5 Complications 25.7.5.1 Aortic Wall Complications 25.7.5.2 Technical Complications 25.7.5.3 Access-Related Complication 25.8 Restenosis 25.9 Stent Fracture 25.10 Post-procedural Care and Follow-Up References 26: The Role of Transcatheter Interventions in Middle Aortic Syndrome 26.1 Introduction 26.2 Factors to Consider in the Invasive Management of MAS 26.2.1 Associated Diagnoses 26.2.2 End-Organ Function 26.2.3 Anatomic Characteristics 26.3 Invasive Management of MAS 26.4 Role of Transcatheter Interventions in the Management of MAS 26.5 Complications of Transcatheter Therapies in MAS References 27: Reopening of Peripheral and Central Arteries and Veins 27.1 Anatomic Description and Physiopathology 27.2 Clinical Scenarios 27.3 Indications and Patients Selection 27.4 Treatment Options 27.5 Preprocedural Imaging 27.6 Technique (Step by Step) 27.6.1 Choosing the Optimal Vascular Access Site 27.6.2 Obtaining Vascular Access 27.6.3 Crossing the Total Occlusion 27.6.4 Establishing a Wire Loop, If Necessary 27.6.5 Thrombectomy, If Necessary 27.6.6 Balloon Angioplasty 27.6.7 Stent Implantation, If Necessary 27.7 Materials 27.8 Expected Results 27.9 Tips and Tricks 27.10 Pitfalls 27.11 Complications 27.12 How to Manage Complications 27.13 Postprocedural Care 27.14 Follow-Up References 28: PDA Stenting in Duct-Dependent Pulmonary Circulation 28.1 Ductal Stenting for Pulmonary Circulation 28.2 Anatomic Description and Physiopathology 28.2.1 Anatomy of Ductus Arteriosus 28.2.2 Pathophysiology 28.2.3 Different Anatomical Lesions 28.2.3.1 Group A: Pulmonary Atresia in Biventricular Hearts 28.2.3.2 Group B: Pulmonary Atresia in Univentricular Circulation 28.2.3.3 Group C: Transient Inadequacy of Pulmonary Circulation 28.3 Clinical Scenarios 28.4 Indications and Patients Selection 28.4.1 Group A: Pulmonary Atresia with Biventricular Physiology 28.4.2 Group B: Univentricular Hearts with Pulmonary Atresia 28.4.3 Group C: Transient Need for Ductal Patency 28.5 Treatment Options 28.5.1 Group A: Tetralogy of Fallot with Pulmonary Atresia Suited for Biventricular Conduit Repair 28.5.2 Group B: Pulmonary Atresia in Univentricular Hearts 28.5.3 Group C: Transient Neonatal Dependence on Duct 28.6 Preprocedural Imaging 28.7 Advanced Three-Dimensional Imaging 28.8 Technique (Step-by-Step) 28.9 Materials 28.10 Expected Results 28.11 Tips and Tricks 28.12 Pitfalls 28.13 Complications 28.13.1 How to Manage Complications 28.14 Postprocedural Care and Follow-Up References 29: PDA Stenting in Duct-Dependent Systemic Circulation 29.1 Anatomic Description and Physiopathology 29.2 Clinical Scenarios 29.3 Indications and Patient Selection 29.4 Treatment Options (See Also Chap. 39) 29.5 Pre-procedural Considerations/Imaging 29.6 Technique (Step-by-Step) 29.7 Materials 29.7.1 Currently Used Materials 29.8 Expected Results 29.9 Tips 29.9.1 Tip 1: Preparation 29.9.2 Tip 2: Avoidance of Hemodynamic Instability 29.9.3 Stent Placement 29.10 Pitfalls (See Sect. 29.11) 29.11 Complications 29.12 How to Manage Complications 29.13 Post-procedural Care 29.14 Follow-Up References Part VI: Step-By-Step Procedures: Closing Or Creating A Defect 30: Step-by-Step Closure of Atrial Septal Defects (ASDs) 30.1 Introduction 30.2 Anatomic Description 30.3 Physiology 30.4 Clinical Scenarios: Natural History 30.5 Indications for ASD Closure 30.6 Treatment Options 30.7 Device Options 30.8 Pre-procedural Imaging 30.9 Techniques: Step by Step 30.10 Materials 30.10.1 Essential Equipment for ASD Closure 30.11 Tips and Tricks 30.11.1 Using Non-self-Centring Devices 30.12 Pitfalls 30.12.1 Patient Selection 30.12.2 Younger Children 30.13 Complications 30.13.1 Managing Complications 30.14 Post-procedural Care 30.15 Follow-Up 30.15.1 Then..... Further Reading 31: Step-by-Step Device Closure of Persistent Foramen Ovale (PFO) 31.1 Introduction 31.2 Anatomic Description 31.3 Physiology 31.4 Clinical Implications of a PFO and Indications for Closure 31.4.1 PFO-Associated Stroke and Systemic Arterial Embolisation 31.4.2 Decompression Sickness 31.4.2.1 Migraine with Aura 31.4.3 Platypnea-Orthodeoxia 31.5 Treatment and Device Options 31.6 Pre-Procedural Imaging and Diagnosis of a PFO 31.7 Technique Step-by-Step 31.8 Materials Required 31.9 Tips and Tricks 31.10 Pitfalls 31.11 Post-Procedural Care 31.12 Follow-Up 31.13 Further Reading and Future Developments References 32: Fontan Fenestration Closure 32.1 Introduction 32.2 Timing of Closure 32.3 Patient Selection 32.4 Evaluation Before Catheterization 32.5 Catheterization Procedure 32.6 Haemodynamic Assessment and Test Occlusion of Fenestration 32.7 Choice of Device 32.8 Crossing and Outlining the Fenestration/Baffle Leak 32.9 Alternatives to Device Closure 32.10 Closing the Stented Fenestration 32.11 Devices for Partial Occlusion 32.12 Follow-Up After Fenestration Closure References 33: Ventricular Septal Defects 33.1 Clinical Indications 33.2 Patient Selection 33.2.1 Technical and Equipment Issues 33.2.1.1 Device for MVSD 33.2.1.2 Device for PMVSD Procedure Access Site Catheterization and Haemodynamic Evaluation for MVSD Closure 33.2.2 Alternative Techniques 33.2.2.1 Retrograde Approach Hybrid Approach [7, 8] Catheterization and Haemodynamic Evaluation for PMVSD Closure Specific Technical Aspects for Post-Surgical Residual VSD [9] 33.3 Complications [10–12] References 34: Patent Ductus Arteriosus Closure 34.1 Patent Ductus Arteriosus Morphology 34.2 Indications of Closure and Patient Selection 34.3 Devices 34.3.1 Coil 34.3.2 Devices 34.4 Step-by-Step Procedure 34.5 Coil Occlusion of Patent Ductus Arteriosus 34.6 Device Occlusion of Patent Ductus Arteriosus 34.7 Hints and Pitfalls in Coil Implantation 34.8 Hints and Pitfalls in Amplatzer Device Implantation 34.9 Possible Complications Further Reading 35: Percutaneous Closure of PDA in Premature Babies 35.1 Background 35.2 Patient Selection and Organisation of the Procedure 35.3 Available Devices 35.4 Description of the Procedure 35.5 Complications 35.6 Conclusion References 36: Catheter Closure of Coronary Artery Fistula 36.1 Anatomic Description and Physiopathology 36.2 Pathophysiology 36.3 Clinical Scenarios 36.4 Indications 36.5 Patient Selection 36.6 Treatment Options 36.7 Preprocedural Imaging 36.8 Technique (Step by Step) 36.9 Materials 36.10 Tips and Tricks 36.11 Pitfalls and Complications 36.12 How to Prevent and Manage Complications 36.13 Post-procedural Care 36.14 Follow-Up Further Reading 37: Vessel Embolization: Transcatheter Embolization of Pulmonary Arteriovenous Malformations and Aortopulmonary Collateral Arteries 37.1 Transcatheter Embolization of Pulmonary Arteriovenous Malformations 37.1.1 Anatomic Description and Physiopathology 37.1.2 Clinical Manifestation 37.1.3 Indications and Patient Selection 37.1.4 Treatment Options 37.1.5 Pre-procedural Imaging 37.1.5.1 Contrast-Enhanced Echocardiography 37.1.5.2 Chest Computed Tomography 37.1.5.3 Contrast-Enhanced Magnetic Resonance Angiography (MRA) 37.1.6 Technique (Step-by-Step) 37.1.6.1 Diagnostic Pulmonary Angiography 37.1.6.2 Occluding Materials Coils ADO AVP 37.1.6.3 Techniques for Closing PAVM with Coils 37.1.6.4 Techniques for Closing PAVM with Amplatzer Devices 37.1.6.5 Techniques for Closing PAVM Using Venous Sac Embolization (VSE) in Combination with Feeding Vessel Embolization (FVE) 37.1.7 Expected Results 37.1.8 Complications and Its Management 37.1.8.1 Device Embolization 37.1.8.2 Pulmonary Infarction 37.1.8.3 Air Embolization 37.1.8.4 Pleurisy 37.1.8.5 PAVM Recurrence 37.1.9 Post-procedural Care and Follow-Up 37.2 Transcatheter Embolization of Aortopulmonary Collateral Arteries 37.2.1 Anatomic Description and Physiopathology 37.2.2 Clinical Manifestation 37.2.3 Indications and Patient Selection 37.2.3.1 Indications 37.2.3.2 Relative Indications 37.2.3.3 Contraindications 37.2.4 Treatment Options 37.2.5 Pre-procedural Imaging 37.2.6 Technique (Step by Step) 37.2.6.1 Aortography and Pulmonary Angiography 37.2.6.2 Occlusion Techniques and Devices 37.2.7 Expected Results 37.2.8 Complications and Its Management 37.2.8.1 Device Embolization 37.2.8.2 Pulmonary Infarction 37.2.8.3 Hemolysis 37.2.9 Post-procedural Care and Follow-Up References 38: Closure of Residual Postsurgical Defects 38.1 Anatomic Description and Physiopathology 38.2 Clinical Scenario 38.3 Indications and Patient Selection for Defect Closure 38.4 Treatment Options 38.5 Pre-procedural Imaging 38.6 Technique (Step-by-Step) and Materials 38.7 Expected Results 38.8 Complications and How to Manage 38.9 Post-procedural Care and Follow-Up References 39: ASD Closure in Special Situations: Elderly, PA-IVS 39.1 ASD Closure in Elderly 39.2 ASD Closure in Pulmonary Atresia with Intact Ventricular Septum 40: Creating an Interatrial Communication 40.1 Anatomy of the Oval Fossa and Surrounding Structures 40.2 Catheterization Procedure: General Principles 40.3 Imaging Techniques 40.3.1 Fluoroscopy 40.3.2 Echocardiography 40.4 Balloon Atrial Septostomy 40.4.1 Balloon Catheters 40.4.2 Procedure 40.4.3 Tips for Crossing the “Difficult” Septum 40.4.4 Intact Interatrial Septum 40.5 Blade Atrial Septostomy 40.6 Cutting Balloon Septostomy 40.7 Static Balloon Septostomy 40.8 Stent Implantation in Congenital Heart Defects: Nonrestrictive Technique 40.8.1 Procedure 40.9 Stenting of the Interatrial Septum: Restrictive Technique 40.9.1 Pulmonary Arterial Hypertension 40.9.1.1 Stent Preparation 40.9.1.2 Stent Deployment 40.9.2 Fontan Circulation 40.10 Atrial Flow Reducer 40.11 Complications 40.12 Conclusions References 41: Transcatheter Correction of the Superior Sinus Venosus ASD 41.1 Anatomic Description and Pathophysiology 41.2 Clinical Effects 41.3 Indications for Treatment 41.4 Treatment Options 41.5 Pre-procedural Imaging 41.6 Patient Selection 41.7 Technique (Step-by-Step) 41.8 Materials 41.9 Tips and Tricks 41.9.1 Balloon Testing 41.10 Monitoring and Protection of Pulmonary Venous Return 41.11 Choice of Stents, Positioning and Fixation 41.12 Complications 41.13 Post-procedural Care 41.14 The Authors’ Current Experience 41.15 Future Directions References Part VII: Step-By-Step Procedures: Valve Implantation 42: Melody Valve Implantation in Pulmonary Position 42.1 Clinical Indications 42.2 Patient Selection 42.3 The Valve and the Delivery System 42.3.1 Device 42.3.2 The Delivery System 42.4 Procedure 42.4.1 Preparation 42.5 Access Site 42.6 Catheterization and Haemodynamic Evaluation 42.7 Pre-Stenting 42.8 Stent Choice 42.9 Stent Implantation 42.10 Melody Valve Implantation 42.10.1 Complications References 43: SAPIEN XT Valve Implantation in the Pulmonary Position 43.1 Introduction 43.2 Anatomic Description and Pathophysiology 43.3 Clinical Scenarios 43.4 Indications and Patient Selection 43.5 Treatment Options 43.6 Pre-procedural Imaging 43.7 Technique (Step by Step) 43.8 Expected Results 43.9 Tips and Tricks 43.10 Complications 43.10.1 Vascular Complications 43.10.2 Coronary Artery Compression 43.10.3 Conduit Rupture 43.10.4 Valve Embolization 43.10.5 Pulmonary Artery Obstruction 43.10.6 Pulmonary Artery Hemorrhage 43.10.7 Stent Fracture 43.10.8 Endocarditis 43.11 How to Manage Complications 43.12 Post-procedural Care 43.13 Follow-Up References 44: Percutaneous Tricuspid Valve Implantation (PTVI) 44.1 Introduction 44.2 Patient Selection and Pathophysiology 44.3 Procedure 44.4 Post- procedural Care 44.5 Outcome References 45: Novel Self-Expanding Pulmonary Valves and Devices 45.1 Introduction 45.2 Venus P-Valve 45.2.1 Device and Delivery Systems 45.2.2 Efficacy Outcomes 45.2.3 Complications and Mortality 45.2.4 Summary 45.3 Pulsta Valve 45.3.1 Device and Delivery System 45.3.2 Efficacy Outcomes 45.3.3 Complications and Mortality 45.3.4 Summary 45.4 Harmony Transcatheter Pulmonary Valve (hTPV) 45.4.1 Efficacy Outcomes 45.4.2 Complications and Mortality 45.4.3 Summary 45.5 Summary of Novel Self-Expanding Pulmonary Valves 45.6 Others 45.6.1 Med-Zenith PT-Valve 45.6.2 Alterra Adaptive Prestent 45.7 Conclusions References 46: Approaches to Large or Complex Right Ventricular Outflow Tract 46.1 Introduction 46.2 Patient Selection 46.3 Technical Modifications for Challenging RVOT 46.3.1 Folded Technique (Fig. 46.1) [3, 4] 46.3.2 One-Step Procedure (Fig. 46.2) [5] 46.3.3 Extending the Indications up to 26 Mm 46.3.4 Russian Doll Technique and/or Branch Pulmonary Artery Jailing for Anchor in Large Patched RVOTs (Fig. 46.3) [7, 8] 46.4 Step by Step. What Technique to Use in Patients? 46.5 Conclusion References Part VIII: Step-By-Step Procedures: Principles of Hybrid Approach 47: Hybrid Approach in Hypoplastic Left Heart Syndrome (HLHS) 47.1 Anatomic Description and Pathophysiology 47.2 Clinical Scenarios 47.3 Indications and Patient Selection 47.4 Pre-procedural Imaging 47.5 Giessen Hybrid Features 47.5.1 Bilateral Pulmonary Banding 47.5.2 Atrial Septum Manipulation 47.5.3 Elective Percutaneous Duct Stenting (See Chap. 25) 47.6 Follow-Up Care 47.7 Tips and Tricks 47.8 Pitfalls (See also Chap. 25) 47.9 How to Manage Complications 47.10 Postprocedural Care 47.11 Follow-Up 47.12 Summary References 48: Hybrid Approach: Defect Closure 48.1 Anatomical Considerations 48.2 Indications and Patient Selection 48.3 Indications 48.4 Typical Clinical Scenario 48.5 Treatment Options 48.6 Pre-procedural Imaging 48.7 Technique (Step-by-Step) 48.8 Tips and Tricks 48.9 Expected Results 48.10 Pitfalls 48.11 Complications 48.12 How to Manage Complications 48.13 Post-procedural Care and Follow-Up References 49: Hybrid Approach: Stent Implantation 49.1 Introduction 49.2 Hybrid Stent Delivery Using Direct Visualization 49.3 Hybrid Stent Delivery Using Angiographic Guidance 49.4 Hybrid Stent Delivery Using Combined Approaches 49.5 Other Hybrid Stent Deliveries 49.6 Exit Angiography References Part IX: Step-By-Step Procedures: Miscellanea 50: Retrieval Techniques 50.1 Introduction and Clinical Scenarios 50.2 Embolized Materials Requiring Retrieval 50.3 Indications and Patient Selection: Should It Be Retrieved? 50.4 X-Ray Equipment 50.5 Planning the Procedure 50.6 Available Retrieving Systems and Devices 50.6.1 Snares 50.6.1.1 Single-Loop Snares 50.6.1.2 Multiple-Loop Snares 50.6.1.3 Snares for Retrieval of Closed-End Catheters and Wires 50.7 Graspers and Forceps 50.8 Baskets 50.9 Step-by-Step Approach 50.9.1 Retrieval of a Fragment of Catheter (or a Coil) Embolized 50.9.2 Retrieval of an Embolized Occluder Device 50.9.3 Retrieval of an Embolized Stent 50.9.4 Retrieval of a Fractured Balloon 50.10 Complications of Retrieval References 51: Pericardiocentesis 51.1 Introduction 51.2 Diagnosis of Cardiac Tamponade 51.3 Indication for Pericardiocentesis 51.4 Complications 51.5 Contraindications for Pericardiocentesis 51.6 Preparation 51.7 Access and Drainage 51.8 Monitoring After Drainage Suggested Reading 52: Endomyocardial Biopsies 52.1 Indications 52.2 Clinical Scenarios 52.3 Preparation of the Exam and Vascular Access 52.4 Materials 52.5 Technique 52.6 Tips and Tricks 52.7 Limits and Potential Complications 52.8 How to Manage Complications 52.9 Postprocedural Care References 53: Evaluations Before Partial and Total Cavopulmonary Connections 53.1 Anatomic Description and Physiopathology 53.2 Clinical Scenarios 53.3 Indications and Patient Selection 53.4 Imaging 53.5 Pre-PCPC Catheterization 53.6 Pre-TCPC Catheterization 53.7 Materials 53.8 Expected Results 53.9 Tips and Tricks 53.10 Pitfalls 53.11 Complications 53.12 Post-procedural Care and Follow-Up References 54: Hemodynamics in Pericardial and Myocardial Diseases 54.1 Pericardial Disease 54.1.1 Anatomy and Function 54.1.2 Physiology and Physiopathology 54.2 Clinical Scenarios 54.