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Invited Commentary

Department of Cardiothoracic Surgery 1 Department of Pediatric Cardiology The Edith Wolfson Medical Center P.O. Box 5 Holon 58100, Israel

As in the treatment of adults with cardiac disease, invasive cardiology is playing an increasing role in the treatment of children with congenital heart disease. Balloon dilation of stenosed pulmonary arteries, recoarctation, and aortic stenosis, as well as coil occlusion of patent ductus arteriosus (PDA) are accepted as first-line treatments in many centers. The use of these invasive cardiology techniques as the primary treatment to close atrial septal defects, dilate primary coarctation, and close muscular ventricular septal defects is currently the subject of investigation and debate.

Treatment of these lesions by invasive cardiology has several advantages: cosmetic benefits, reduced pain, potential reduction in hospital stay, and avoidance of the social stigma associated with patients who undergo heart surgery. However, the decision of whether to treat patients by established surgical techniques or the newer invasive cardiology procedures is frequently influenced by superfluous nonscientific considerations. These include the enthusiasm of the cardiologist for these new procedures, with a propensity for self-referral of most debatable cases, and a defensive posture from surgeons who feel their domain threatened. These emotional considerations have resulted in a paucity of data concerning the appropriate management of patients in whom both modalities can be used. The reporting has been retrospective, skewed, and purposeful. Consequently, for PDA coil closure, one can find data showing surgical closure to be more medically effective and cost-effective, and data showing coil occlusion to be equally effective and more cost-effective.^1,2 Similarly, for atrial septal defect closure by occlusion devices, one can find series with an 8% serious complication rate, and other series with almost 100% success and no complications.^3,4 The small amount of retrospective data comparing balloon dilation with surgical valvotomy for infants and neonates shows no clear benefit of either modality.

This dilemma is compounded by the fact that invasive cardiologic procedures are currently evolving, and there are constant improvements in techniques and equipment. For example, closure of PDA has progressed from the problematic Rashkind occluder to the highly effective Gianturco coil with a success rate of over 90%.⁵ Amplatzer devices have now been introduced to close bigger PDAs and broaden the indication for PDA closure by cardiologic techniques. Further confusion is introduced by the fact that the procedures are also being performed by cardiologists with great variability in their experience and capabilities. Even more striking is the lack of data concerning treatment of complications after device placement in centers where invasive cardiology procedures are common. Doctors are forced to manage complications of these procedures with little data to guide decisions. Common problems faced continually in acting centers have not been addressed. For example, does evidence of limited wall dissection of the aorta after dilation of primary coarctation require exploration? In the asymptomatic patient with significant aortic insufficiency after balloon dilation for aortic stenosis, what are the indications for surgery? How should residual shunt be handled after PDA occlusion?

In the above paper by Aydoan and colleagues, the best and worst features of this dilemma are demonstrated. The authors continued to follow a child with a large left-to-right shunt and failure to thrive for months because they were intent on using invasive cardiology as a mode of treatment rather than a low-risk effective surgical procedure. At 8.5 months, they used a coil that was too big for the child and the result was obstruction of the descending aorta. With this complication, these authors could find very little in the literature to guide their management, because of the paucity of reports of such a complication. The authors should be congratulated for recognizing the need to report their complication and starting a database to guide others in similar circumstances.

Invasive cardiology in pediatric patients is here to stay. To help establish its place, surgeons and cardiologists need to cooperate for the good of their young patients. Cardiologists should proceed slowly, collecting data, and using the modality of invasive cardiology where its efficacy is established. Surgeons should welcome the modality as another effective, valid method of treatment to complement their established techniques. Finally, cardiologists and surgeons should cooperate in prospective randomized studies to establish the efficacy of both modalities in the treatment of lesions such as atrial septal defect, native coarctation, PDA, and aortic stenosis. We are at the point where professional cooperation and scientific investigation should establish the best modality of treatment for our patients.

	REFERENCES

TOP REFERENCES

 

1. Gray DT, Fyler DC, Walker AM, Weinstein MC, Chalmers TC. Clinical outcomes and costs of transcatheter as compared with surgical closure of patent ductus arteriosus. The Patent Ductus Arteriosus Closure Comparative Study Group. N Engl J Med 1993;329:1517–23.[Abstract/Free Full Text]

2. Prieto LR, DeCamillo DM, Konrad DJ, Scalet-Longworth L, Latson LA. Comparison of cost and clinical outcome between transcatheter coil occlusion and surgical closure of isolated patent ductus arteriosus. Pediatrics 1998; 101:1020–4.[Abstract/Free Full Text]

3. Berdat PA, Chatterjee T, Pfammatter J-P, Windecker S, Meier B, Carrel T. Surgical management of complications after transcatheter closure of an atrial septal defect or patent foramen ovale. J Thorac Cardiovasc Surg 2000; 120:1034–9.[Abstract/Free Full Text]

4. Matitiau A, Birk E, Kachko L, Blieden LC, Bruckheimer E. Transcatheter closure of secundum atrial septal defects with the Amplatzer septal occluder: early experience. Isr Med Assoc J 2001;3:32–5.[Medline]

5. Janorkar S, Goh T, Wilkinson J. Transcatheter closure of patent ductus arteriosus with the use of Rashkind occluders and/or Gianturco coils: long-term follow-up in 123 patients and special reference to comparison, residual shunts, complications, and technique. Am Heart J 1999;138: 1176–83.[Medline]

This Article Extract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Amram J Cohen Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Cohen, A. J Articles by Tamir, A. Search for Related Content PubMed Articles by Cohen, A. J Articles by Tamir, A.