Few specialties in medicine have witnessed as rapid a rate of progress over the past few decades than the discipline of pediatric and congenital cardiac catheterization. The initial description of the balloon atrial septostomy procedure by Rashkind and Miller in 1966, a procedure still performed today, not only drastically improved survival for children with transposition of the great arteries, but also paved the way for innovations over the years in both pediatric/congenital interventional cardiology and adult interventional cardiology.
In this chapter, we begin with a brief overview of diagnostic cardiac catheterization. The rest of this chapter is dedicated primarily to interventional catheterization procedures that are commonly performed in children. Many more complex interventional cardiac procedures and their applications to other organ systems are beyond the scope of this text.
DIAGNOSTIC CARDIAC CATHETERIZATION
The types of purely diagnostic cardiac catheterization procedures performed in children have evolved over the years. Advances in noninvasive imaging, including echocardiography, computed tomography (CT) scans, and magnetic resonance imaging (MRI) scans, have rendered obsolete a great number of diagnostic catheterizations that were previously considered standard for many congenital lesions. Currently, the majority of procedures performed in the cardiac catheterization laboratory in children are interventional.
However, diagnostic cardiac catheterizations with hemodynamic and/or anatomic assessment still play a crucial role in the management of some conditions. Cardiac catheterizations can be essential for some medical diagnostic dilemmas (eg, distinguishing between constrictive vs restrictive pericarditis). For imaging of small vessels (eg, distal coronary arteries in children), angiography is still superior to noninvasive imaging. Additional imaging modalities possible only in the catheterization laboratory, such as intravascular ultrasound and optical coherence tomography, as well as functional assessment of fractional flow reserve, can aid in the management of children with coronary stenoses. It is routine in most centers to perform diagnostic cardiac catheterizations in children after heart transplantation and to perform endomyocardial biopsies for surveillance of rejection. Children with myocarditis or other forms of heart failure may also benefit from a cardiac catheterization and endomyocardial biopsy to aid in their diagnosis. In addition, most children with significant pulmonary hypertension undergo diagnostic cardiac catheterizations to determine their pulmonary vascular resistance at baseline and in follow-up to assess the response to pulmonary vasodilator therapy.
Diagnostic cardiac catheterizations may be important for the preoperative assessment of some patients to assess suitability for surgical repair (eg, calculation of pulmonary vascular resistance in patients undergoing staged single-ventricle palliation prior to cavopulmonary anastomosis and Fontan operations). Moreover, they can be helpful in the postoperative period for obtaining information useful in the management of critically ill patients, when the decision-making process is not clear based on noninvasive imaging alone.
ANESTHETIC CONSIDERATIONS, VASCULAR ACCESS, AND RADIATION SAFETY
Most cardiac catheterizations in infants and young children in the United States are performed under general anesthesia with endotracheal mechanical ventilation; ...