Pediatric Cardiology Associates  
Practice of Congenital Heart Disease  
Pediatric Cardiology - congenital heart disease - cardiovascular disease

Cardiac Catheterization

Cardiac catheterization has long been an important tool for diagnosing congenital heart disease and helping to direct appropriate surgical intervention. Today, much of that work can be done non-invasively with echocardiography and magnetic resonance imaging. Cardiac catheterization has now moved into the therapeutic realm with catheter-based intervention becoming increasingly utilized as a curative therapy for simpler, more common forms of congenital heart disease.

Congenital lesions such as atrial septal defects and patent ductus arteriosus can be closed with specialized devices that are delivered through catheters that are smaller than a drinking straw. Similarly, congenitally obstructed blood vessels, such as coarctation of the aorta, or pulmonary artery stenosis can be completely opened with current stent technology. "It is exciting to be able to completely fix a patient's heart defect with no surgical incisions and essentially no recovery time," says Jon Donnelly M.D., Director of the Pediatric Cardiac Catheterization Laboratory. "Our efforts continue to be in collaboration with our surgical colleagues as many of the emerging catheter interventions take place in the operating room to augment a complex surgical repair".

The Pediatric Catheterization laboratory at Maine Medical Center offers all FDA-approved procedures and devices used to treat children and adults with congenital heart disease. Because this is the only Pediatric Cardiac Catheterization laboratory in the state volume and variety of cases is high. This translates into experienced operators and quality care for the patient. A recent review of the last 1000 cases reveals a mortality rate of 0.2% and a major complication rate of 0.8%, both of which are well below the national average.

Catheter-based services provided include:



What to Expect:




Diagnostic Catheterization

Occasionally non-invasive imaging cannot adequately image structures such as pulmonary arteries or veins and angiography is necessary for accurate diagnosis. Other times, hemodynamic information gained by measuring pressures and saturations within the heart provides important insight into the function of the heart. This information, along with the clinical information obtained in the office setting, allows us to determine the most appropriate timing and strategy for your child's surgery or catheter-based intervention.

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Balloon Valvuloplasty

Balloon valvuloplasty is the first-line therapy for severely obstructive heart valves from newborns to young adults. Heart valves become obstructed when the normal leaflet maturation fails during development of the heart. The result is often fused leaflets that provide very little opening for blood flow. The obstructed valve is measured carefully by echocardiography and angiography and is then traversed with a wire and balloon angioplasty catheter in the catheterization suite. The balloon is then inflated to a prescribed pressure and the fused leaflets of the obstructive valve are torn. The objective is to relieve the obstruction by improving the mobility of the valve leaflets without causing significant valve leakage. Balloon valvuloplasty is curative for some valves, while providing palliative relief for others until surgical valve replacement is necessary.

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Angioplasty/Stent

Obstructed blood vessels in and around the heart can be detrimental to the cardiac function and dangerous to the health of the patient since flow in and out of the heart is impaired. Unlike obstructed coronary arteries in adults, congenitally obstructed vessels are due to abnormal vessel formation in fetal life. Similarly, mildly obstructed vessels at birth can become more obstructive with abnormal growth and development in childhood. Balloon angioplasty with or without stent placement can open these vessels with no surgical incisions and essentially no recovery time.

As with balloon valvuloplasty, careful measurements are made of the obstructed vessel prior to the procedure by echocardiography and/or MRI. Additional angiographic imaging is performed in the catheterization suite prior to traversing the obstruction with a wire and balloon angioplasty catheter. If the lesion is thought likely to recoil with balloon angioplasty alone, a stent is loaded onto the balloon with the intention of inflating this within the lesion and "stenting open" the obstruction. Care is taken to select the appropriate balloon size to minimize the risk of damage to the surrounding vessel. Procedural success is based on the pressure relief across the previously obstructed area and the angiographic appearance of the stented vessel.

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Device Closure of ASD, PFO, PDA

Transcatheter device closure has revolutionized the treatment of simple cardiac shunt lesions such as ASD, PFO, and PDA. What used to require chest incisions, cardiopulmonary bypass, and incisions in the heart, now can be accomplished through suture-less puncture wounds in the groin and device closure of the lesion on a normally beating heart. Recovery time has been reduced from 6-8 weeks to 6-8 hours, and durable, permanent cure rates are realized.

Device closure of ASD, PFO & PDA.

The family of closure devices is designed specifically for the above cardiac lesions. As with all interventional procedures, careful imaging with detailed measurements of the lesions is made non-invasively prior to taking the patient to the catheterization suite. Catheters are percutaneously placed in the femoral vessels in the groin through a needle without incisions or stitches. The lesion is once again traversed with a wire followed by a long sheath. The device is then carefully placed in the lesion. Extensive imaging ensues while the device is still connected to the delivery cable. If the device proves stable within the lesion, and imaging shows successful closure, the device is released. Patients spend one night in the hospital, have an echocardiogram and EKG in the morning, and then are discharged home with follow-up in the office.

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Vessel Embolization and Foreign Body Retrieval

Certain congenital heart lesions have persistence of fetal vessels that can be detrimental to the function of the postnatal heart. Other patients have palliative surgical shunts placed that have served their role and are now detrimental to the changing cardiac physiology. Surgically placed patches or valves can develop leaks that make the patient struggle postoperatively. These problems can all be remedied without a re-operation through transcatheter embolization techniques. Various embolization devices are used depending on the size, shape and location of the unwanted vessel or leak.

Catheter retrieval of indwelling catheters, clots, or other foreign bodies can also be accomplished in the catheterization suite without having to surgical enter the heart or vasculature. Specialized snares, baskets, and forceps enable the interventionalist to "grab" the foreign body and pull it out through catheters placed in the groin.

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Cardiac Catheterization
Catheterization Lab Team

Pre-Procedural Work-up

The need for a cardiac catheterization will be determined by your cardiologist and communicated with you during an office visit. Your cardiologist will then create a "clinical summary sheet" which includes you or your child's history, exam, diagnostic testing and proposed transcatheter intervention. This is discussed in great detail at a Monday morning conference with the Congenital Heart Team so that all of the clinical services that may participate in the care of your child are knowledgeable about the clinical condition.

An appointment will be scheduled in the office with Dr. Donnelly to answer any questions about the procedure, obtain pre-procedural labwork, and sign informed consent. This is usually a brief meeting, but should be attended by all those who may have questions regarding the procedure.

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Day of Procedure

On the day of the procedure, you will need to be in admitting at 6am (if you are the first case) or 7:30am (second case). They will take demographic information and you will have a blue, hospital card made. If you have been admitted to MMC previously, please submit your blue medical card upon arrival. Within 10-20 minutes you will arrive at your room in Barbara Bush Children's Hospital (< 16yo) or ACCU (> 16yo). If you are the first case of the morning, you will get weighed and have your vital signs taken before being brought to the holding room in the catheterization suite. The anesthesiologist will meet with you there, discuss any anesthetic concerns, and have you sign the anesthesia consent form. Your child may receive an oral sedative in the holding room depending on their age. You and your child will then be brought into the catheterization lab where further anesthetic medication
will be given, usually with an inhalation agent. Parents typically are allowed to be with their child until they drift off to sleep. Once the child is asleep, a peripheral IV is placed and the anesthetic is delivered through the vein for the remainder of the case. After leaving your child in the cathlab, we suggest that you return to your child's room so that we can contact you during the case if necessary. For those patients > 16yo, a peripheral IV will be placed in ACCU and IV sedation will commence in the cathlab.

At the conclusion of the procedure, the catheters are withdrawn and bleeding is stopped by holding pressure on the groin. Dr. Donnelly will usually be able to discuss the results immediately after the case while pressure is being held in the lab. If the case is lengthy, or the child is young, recovery will take place in PACU (level B in MMC). Parents may be with their child in PACU for the 1-2 hours prior to transfer back to your room at BBCH. For older patients, recovery from anesthesia is conducted in the holding room adjacent to the cathlab for ~1hr prior to returning to your room in PACU. If the procedure is diagnostic only, your child can be discharged 6 hours after withdrawal of the catheters. If there is any post-procedural bleeding from the groin or persistent nausea/vomiting from anesthesia, we may observe you or your child in the hospital overnight. For most interventional procedures, the patient will be observed in the hospital overnight.