Transcatheter Treatment of Congenital Heart Disease

D URING THE 1980s the pediatric cardiac catheterization laboratory has undergone a transition from a diagnostic laboratory to a therapeutic suite where congenital cardiac abnormalities are not only evaluated but often can be treated. Therapeutic transcatheter procedures have been developed that can provide palliative or definitive therapy to children with a variety of congenital cardiovascular disorders. Nonsurgical transcatheter treatment is now available for obstructive lesions including pulmonary valve stenosis, pulmonary artery stenosis, aortic valve stenosis, coarctation of the aorta, and mitral stenosis. Some left-to-right shunt lesions can also be treated in the catheterization laboratory. Embolization techniques are available to deal with aortopulmonary collateral vessels or surgical shunts. Further, new approaches are being developed which promise effective transcatheter treatment of a secundum atria1 septal defect or patent ductus arteriosus. Clearly, a pediatric cardiac catheterization is no longer complete once a hemodynamic and angiographic evaluation is performed. The pediatric cardiologist must go further, and ask whether the lesion at hand can be effectively treated in the catheterization laboratory without resorting to a more invasive surgical approach. At C.S. Mott Children’s Hospital, transcatheter treatment of congenital heart disease has been performed since 198 1, and has steadily increased in importance. Figure 1 demonstrates the increasing number of therapeutic transcatheter procedures performed at this institution during the period from 1981 through 1987. In 1987 therapeutic catheterizations accounted for approximately 15% of all our pediatric cardiac catheterizations. These procedures provided palliative or definitive treatment for children with a variety of structural cardiac abnormalities. The figures underestimate the current significance of catheter therapy as they do not include other interventional procedures such as balloon atria1 septostomy, blade septostomy, foreign body retrieval, endomyocardial biopsy, or transcatheter ablation of an accessory pathway. Further, these figures do not include transcatheter patent ductus arteriosus (PDA) occlusions, which are planned, but have not yet been performed at this institution. The data presented in Fig 1 clearly demonstrate the current importance of transcatheter treatment of congenital heart disease. Further, from the increasing trend one can infer that therapeutic catheterization will account for an even larger percentage of total pediatric cardiac catheterizations in the near future. In this article we discuss therapeutic transcatheter approaches to a variety of congenital cardiovascular abnormalities. Some procedures have become the treatment of choice (eg, valvuloplasty for pulmonary stenosis) while others remain investigational (eg, angioplasty for native coarctation). Formal cost-benefit analyses of these procedures including a comparison to accepted surgical alternatives have not yet been performed, and long-term follow-up data are generally lacking. Nevertheless, we will discuss the current role played at our institution by therapeu-