Emergent Placement of an Occlutech AFR Device in Critically Ill Pediatric Patients
Christopher Iskander, MD, MPH, Children's Hospital Colorado, Denver, CO
Christopher Iskander, MD, MPH1, Mehmet Kucuk, MD2, Anne C Taylor, MD3, Jenny E. Zablah, M.D., FSCAI4 and Gareth J. Morgan, M.B.B.S., FSCAI4, (1)Children's Hospital Colorado, Denver, CO, (2)Children's Hospital Colorado, Aurora, CO, (3)University of Colorado School of Medicine, Denver, CO, (4)University of Colorado Anschutz Medical Campus, Aurora, CO
Keywords: Congenital Heart Disease (CHD) and Fontan
Title
Emergent Placement of an Occlutech AFR Device in Critically Ill Pediatric Patients
Introduction
This case series highlights the use of the Occlutech Atrial Flow Regulator (AFR) in pediatric patients who underwent emergent catheterization due to complex congenital heart defects or post-surgical complications. Clinical Case
Case 1: 2yo male HLHS (MS/AA) s/p 16 mm extracardiac fenestrated Fontan s/p fenestration balloon angioplasty admitted for desaturations to the 50s found to have reduced RV function and worsening TR on echo. Underwent repeat catheterization showing elevated RVEDP (25 mmHg) and Fontan pressure (20 mmHg). He was treated with milrinone gtt before repeat catheterization during which a 4 mm x 5 mm Occlutech AFR was placed with no change in saturations, so a second 4 mm x 5 mm Occlutech AFR was placed within the first device. Saturations improved and Fontan pressures remained at baseline (15 mmHg). Patient has remained stable and is awaiting transplant. Case 2: 15 yo female with pulmonary arterial hypertension (PAH) associated with ILD, pulmonary vein changes, and prematurity (25-week twin gestation). She required ECMO with her first catheterization in early childhood, was maintained on dual oral PAH therapy and was doing well, however developed progressively worsening evidence of severe PH with multiple episodes of syncope with evidence of moderate-severely depressed RV function. A Versacross RF wire was used for RF perforation of the atrial septum. A 10 mm x 2 mm Occlutech AFR was then delivered into the atrial communication. Repeat echo 2 months later demonstrated normal RV function. Case 3: 2yo male HLHS (MS/AA) s/p 16 mm extracardiac Fontan with 4 mm fenestration was referred for surveillance catheterization to evaluate of his Fontan circuit in the setting of persistent high output chylothorax. Noted to have extensive thrombus in the Fontan and occlusion of his fenestration. He had successful thrombectomy performed with removal of extensive thrombus. His fenestration was dilated with an 18 mm x 4 cm Atlas balloon, but acutely occluded within the case, so a 6 mm x 5 mm Occlutech AFR was placed in the fenestration. Echocardiogram the following day revealed repeat occlusion, so patient was brought back for repeat thrombectomy. Patient was able to discharge and is doing well outpatient. Case 4: 2mo male HLHS (MS/AA) with a severely restrictive atrial septum initially underwent a static dilation and BAS emergently following birth before septectomy with Norwood Sano. Developed worsening pulmonary edema and respiratory distress in setting of restrictive atrial septum. Referred for catheterization during which LA pressure was 24/10/9 with an 10 mmHg across the septum. With balloon angioplasty there was a small waist on deflation suggesting compliant tissue that would not be amenable for atrial stent placement. A 6 mm x 5 mm Occlutech AFR device was placed with no residual gradient across the septum (RA=LA 5 mmHg) and improvement in the RA and LA A-waves. He is currently admitted awaiting 2nd stage palliation Discussion
The Occlutech AFR device demonstrated promising results in managing complex shunts and controlling hemodynamics in these critically ill patients.