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\begin{document}

\title{Outcome of cardiac catheterization performed in the early postoperative
period after congenital heart surgery: single center experience}



\author[1]{Saud Bahaidarah}%
\author[2]{Jameel Al-Ata}%
\author[1]{Naif  Alkhushi}%
\author[1]{Mohammed Sameer Mujahed}%
\author[3]{Mohamed Ibrahim}%
\author[1]{Osman Al Radi}%
\author[4]{Ahmed Elassal}%
\author[1]{Zaher Zaher}%
\author[1]{Ahmed Azhar}%
\author[5]{Ahmed   Dohain}%
\author[5]{Gaser  Abdelmohsen}%
\affil[1]{King Abdulaziz University Faculty of Medicine}%
\affil[2]{King Faisal Specialist Hospital and Research Centre - Jeddah}%
\affil[3]{Banha University}%
\affil[4]{King Abduziz university Hospital}%
\affil[5]{Cairo University Kasr Alainy  Faculty of Medicine}%


\vspace{-1em}



  
  \date{May 24, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Objective: The Main objective of the study was to evaluate the outcome
of cardiac catheterization performed in the early postoperative period
after congenital heart surgery. Background: Cardiac catheterization
after congenital heart surgery may play an important role in the
diagnosis and management of patients with complicated or unusual
unexplained post-operative course. Methods: All patients underwent
cardiac catheterization \textless{} 5 weeks after congenital heart
surgery from November 2015 to May 2018 in pediatric cardiac center of
King Abdul-Aziz University Hospital (KAUH) were included in the study.
Results: Thirty procedures were performed for 27 patients (20
interventional and 10 diagnostic). The median age of the patients was 15
months (15 days to 20 years), weight 8.2 kg (3.4 to 53 kg), and time
from surgery was 3 days (0-32 days). Eleven procedures performed for 11
patients on extracorporeal membrane oxygenation (ECMO). The main
indications for catheterization were inability to wean from ECMO (10
procedures) and cyanosis (10 procedures). Interventional procedures
were: Angioplasty using stents (10 procedures, success 90\%),
angioplasty using only balloons (2 procedures, success 50\%), and
occlusion for residual shunts (8 procedures, success 100\%). No
mortality was recorded during procedure. Procedural complications were
recorded in 3 procedures. Survival among patients was 51.8\%. There was
no significant difference between interventional and diagnostic group
regarding procedural complications. Patient on ECMO support had higher
mortality than other patients. Conclusion: Cardiac catheterization could
be performed safely in the early postoperative period; it could affect
the outcome that is mostly dependent on complexity of cardiac lesions.%
\end{abstract}%



\sloppy


\textbf{INTRODUCTION}

Over the past several decades cardiac catheterization considered one of
the most important tools that used in the management of congenital heart
diseases. There is minimal risk of adverse events in most cardiac
catheterization procedures in the current era\textsuperscript{1--5}. In
certain conditions however, cardiac catheterization may carry a
relatively important risk of major adverse events especially in
critically ill patients especially after congenital heart surgery.
Despite this risk, the role of catheterization is considered essential
in critically ill patients after congenital heart surgery in which there
is a residual lesion or unexpected progress. Data and experience in this
field is growing \textsuperscript{6,7}.

\textbf{AIM OF THE STUDY}

The aim of this study was to evaluate the outcome of cardiac
catheterization performed in the early postoperative period after
congenital heart surgery in pediatric cardiac center of excellence
(PCCC) at King Abdulaziz University Hospital (KAUH) from November 2015
to May 2018.

\textbf{MATERIALS AND METHODS}

A retrospective cohort study performed including all patients who
underwent cardiac catheterization in the first 5 weeks after congenital
heart surgery. It included diagnostic and interventional procedures from
November 2015 to May 2018 in PCCC at King KAUH. Patients who had cardiac
catheterization \textgreater{} 5 weeks after cardiac surgery were
excluded from the study. The study was approved by the ethical committee
of KAUH. Data collected include: Age, weight, diagnosis, type of
surgery, indication of cardiac catheterization, type of cardiac
catheterization, time from surgery, the need for redo surgery, the type
of redo surgery, duration of mechanical ventilation, Inotropic Score
(IS) \&Vasoactive Inotropic Score (VIS), duration of ECMO support,
duration of hospital and Pediatric Intensive Care Unit (PICU) admission,
procedure complications and outcome (survival /death). IS is calculated
as dopamine dose (\selectlanguage{greek}μ\selectlanguage{english}g/kg/min) + dobutamine dose (\selectlanguage{greek}μ\selectlanguage{english}g/kg/min) + 100 \selectlanguage{ngerman}×
epinephrine dose (\selectlanguage{greek}μ\selectlanguage{english}g/kg/min). VIS is calculated as IS + 10 \selectlanguage{ngerman}× milrinone
dose (\selectlanguage{greek}μ\selectlanguage{english}g/kg/min) + 10,000 \selectlanguage{ngerman}× vasopressin dose (Units/kg/min) + 100 ×
norepinephrine dose (\selectlanguage{greek}μ\selectlanguage{english}g/kg/min){]}\textsuperscript{8}.

The success of the interventional procedures was also reported and
defined for angioplasty (ballooning or stenting) as the increase in the
vessel diameter to more than 75 \% of adjacent normal vessel or at least
50\% increase from the pre-procedural diameter. For occlusion procedures
success was defined as absence of significant residual shunting seen by
angiography \textsuperscript{7,9}. All procedures were performed during
the same admission for cardiac surgery.

\textbf{STATISTICAL ANALYSIS}

Statistical analysis was performed using SPSS Version 16 software (IBM,
Armonk, New York). Data were expressed as median and range
(minimum-maximum) for numerical data, number and percentage for
categorical data. Comparisons between groups were calculated using
nonparametric Mann--Whitney test for numerical data and \selectlanguage{greek}χ\selectlanguage{english}2 test for
categorical data. Survival analysis was done using Kaplan-Meier log-rank
univariate analysis.

\textbf{RESULTS}

\emph{Patients' characteristics:} 27 patients underwent 30 cardiac
catheterization procedures (10 diagnostic and 20 interventional). The
median age at the time of cardiac catheterization was 15 months ranging
from 15 days to 20 years. The median time from cardiac surgery was 3
days ranging from 0 day (same day of surgery) to 32 days. Out of 30
procedures, six procedures were performed for 6 patients immediately
after surgery (3 interventional and 3 diagnostic), 18 procedures
(including the 6 procedures done immediately after surgery) were
performed in the 1\textsuperscript{st} week post-surgery (8 diagnostic,
10 interventions) and 20 procedures were performed in the
1\textsuperscript{st} 2 weeks post-surgery (9 diagnostic, 11
interventions). The median weight at time of cardiac catheterization was
8.2 kg, (3.4 -- 53 kg). Fourteen (14) procedures were performed in
patients with single ventricle physiology and 10 procedures in
conotruncal anomalies. Two genetic syndromes were identified in this
cohort one was DiGeorge and the other was William syndrome. Twenty-three
(23) procedures were performed while patients were on mechanical
ventilation and inotropic support; the median time for mechanical
ventilation was 23 days (2-89 days). Eleven procedures were done for 11
patients on ECMO support, the median duration for ECMO were 5 days,
range (2-7 days), Table (1). There was no significant difference between
patients underwent diagnostic cardiac catheterization and those
underwent interventional procedure regarding age, weight, diagnosis,
time from surgery, mechanical ventilation, vasoactive inotropic score or
ECMO support (table 1).

\emph{Indication for cardiac catheterization:} Inability to wean from
ECMO /cardiopulmonary support (CPS) and cyanosis were the most frequent
indications. There was no significant difference between diagnostic
group and interventional group regarding the indication for cardiac
catheterization (Table 2).

\emph{Catheterization procedures:} For the intervention group
angioplasty through stenting was performed in 10 procedures, 6 of them
were for pulmonary artery branches (Fig. 1), 2 for right ventricular
outflow tract (RVOT), one for coronary artery and one for pulmonary
venous baffle. The success rate in stenting group was 90\% (one patient
with pulmonary atresia --VSD that underwent surgical repair developed
embolized left pulmonary artery stent in the conduit that required redo
surgery for retrieval of the stent and fenestration of the VSD patch).
Angioplasty through ballooning was performed in 2 procedures; one for
stenosis of pulmonary venous confluence -left atrial connection after
repair of total anomalous pulmonary venous connection (TAPVC) that
failed to decrease the pressure gradient or heart failure symptoms and
required a redo surgery, the other was for a kink in a modified Blalock
Thomas Taussig (BTT) shunt that was successful with improvement of
oxygen saturation after the procedure. In all angioplasty procedures the
median balloon size to stenosis diameter ratio was 2.5 (1.8-3).
Occlusion was performed in 8 procedures (2 for MAPCAS, 2 for Fontan
fenestrations, 1 for pulmonary arteriovenous malformation, 1 for
modified Blalock Taussig (BT) shunt (Fig. 1), 1for aorta to right
ventricular outflow tract (AO to RVOT) fistula (Fig. 2) and 1 for missed
antegrade pulmonary flow in Fontan patient) (Table 4), the success rate
in occlusion procedures was 100\%.

\emph{Outcome\textbf{:}} Out of total 30 procedures there were no
complications during transportation of patients from operating room or
PICU to the cardiac catheterization laboratory. Three procedures had
complications during cardiac catheterization namely; cardiac arrest that
required cardiopulmonary resuscitation, embolization of stent in the
RV-PA conduit during stenting of stenotic branch pulmonary artery and
post procedural arterial thrombosis of the femoral artery that improved
on Heparin infusion. All complications were reported in the
interventional group. No reported mortality during procedures.

Seven (7) patients required redo surgery in the form of arch repair (1
patient), pulmonary venous baffle augmentation (2 patients), VSD
fenestration (3 patients), and Fontan fenestration (1 patient). The
median duration of hospital stay was 20 days (2-330 days) and for
pediatric intensive care unit (PICU) stay was 16 days (1-99 days). There
was no significant difference between the diagnostic group and
interventional group regarding PICU stay, hospital stay, need for redo
surgery, and occurrence of complications during procedure (table 3). No
mortality was reported in catheterization laboratory.

Regarding survival, the overall survival till the time of the study was
51.8\% (14 out of 27 patients). Survival to discharge was 55.5\% (15 out
of 27 patients, 1 patient died one year after the procedure from
infective endocarditis).

\emph{Procedures performed on ECMO support:} 11 procedures were
performed for 11 patients on ECMO support (4 diagnostic and 7
interventions), 8 patients (72.7\%) successfully disconnected from ECMO
support, 5 (45.4\%) survived to discharge and 4 (36.3\%) thereafter (1
died 1 year after procedure with infective endocarditis). Kaplan Meier
univariate analysis demonstrated that patients performed cardiac
catheterization on ECMO support had less survival than others (Fig. 3).

\textbf{DISCUSSION}

After congenital heart surgery in the early postoperative periods some
children become critically ill either due to residual lesions, severe
myocardial dysfunction, low cardiac output or inability to wean from
CPS/ECMO support. Cardiac catheterization may play a role not only in
the diagnosis but also in management of such patients. Cardiac
catheterization is an invasive procedure that may carry a high risk in
patients that their transfer from the operating room or the PICU to the
catheterization laboratory itself is risky. Despite the advance in the
field of pediatric cardiac catheterization that makes it possible to be
performed in small weight and critically ill babies, cardiac
catheterization in the early period post-operative period is thought to
carry a prohibitive high risk\textsuperscript{6,10}. It is believed that
at least 6 weeks should pass post cardiac surgery before any attempt for
interventional cardiac catheterization to allow a scar tissue to be
formed around the suture lines and anastomotic sites despite no studies
to support such thoughts \textsuperscript{7}. In this cohort we aimed to
study the safety, success and outcome of cardiac catheterization
performed \textless{} 5weeks post congenital heart surgery.

In this cohort, a multidisciplinary team including the surgeon, the
intensivist, cardiac anesthesiologist, cardiac interventionist, ECMO
team and respiratory therapist was ready to intervene at any time during
catheterization procedures or patients' transportation to the
catheterization lab. No complications were reported during patients'
transportation to the catheterization laboratory ,and this was
concordant with previous published data\textsuperscript{7,11}\emph{.}

\emph{Diagnostic cardiac catheterization:} Diagnostic cardiac
catheterization in the early post-operative period can play a great role
in evaluation of the adequacy of surgical repair and detection of
significant residual lesions that may affect the hemodynamics and
postoperative course and hence can help for taking a proper decision
either for conservative management, redo surgery or further catheter
intervention. There was no significant difference between patients
underwent diagnostic catheterization and those underwent interventional
procedures regarding hospital stay, PICU stay, complications and
survival, Nicholson et al reported similar results in their
cohort\textsuperscript{6}.

\emph{Angioplasty and vascular stenting:} Theoretically angioplasty
(ballooning/ stenting) in the early post-operative period, when less
time is allowed for a scare tissue to be formed around vascular suture
lines may cause catastrophic disruption of the freshly formed sutures.
In this cohort angioplasty was performed in 12 procedures, 9 of them
done on fresh suture lines with no reported vascular tear or suture
disruption and this was concordant with report by Zahn et al who
attributed that to the distensibility of Prolene filaments that can
afford elongation up to 34\% before disruption and enlargement of the
circumference of the suture line (increased distance between parallel
throws) in response to balloon inflation. They thought that continuous
Prolene suture lines can be expanded safely without disruption when
using balloon stenosis ratio [?]2.5/1\textsuperscript{7}. Rosales et al.
Reported a 20\% mortality due to vascular disruption after balloon
angioplasty of the branch pulmonary arteries in the early postoperative
period\textsuperscript{9}. In majority of cases stent placement is
better than balloon dilatation because it prevents the recoil giving
better results for a considerable period of time\textsuperscript{7}.

\emph{Cardiac catheterization for patient on ECMO support:} Several
reports studied the safety of catheter intervention for patients on ECMO
support\textsuperscript{12--15}. Still the results are less promising in
our cohort as despite 72\% successfully disconnected from ECMO support,
survival to discharge was 45.4\% and overall survival was 36\%. This is
likely as a result of their complex anatomy, associated comorbidities or
unsuccessful surgical intervention. It is not clear if the early cardiac
catheterization contributed to the 72 \% successful ECMO discontinuation
or its natural progress. This needs to be explored separately and with a
larger sample. Similar results were reported by Kojima et al (overall
survival rate was 29\%) while DesJardins et al reported lower survival
rate ( overall survival was 14\%) . Booth et al , Zahan et al , Panda et
al and Callahan et al reported higher over all survival rate in their
series ( 43\%, 56\%, 64\% , and 69\%
respectively).\textsuperscript{10,13--16}

\textbf{LIMITATIONS OF THE STUDY}

This study is only presenting a small number of patients with different
disease severities for short time period. It is also limited by its
retrospective design and lack of control group comparison.

\textbf{CONCLUSION}

Cardiac catheterization after congenital heart surgery may play an
important role in the diagnosis and management of patients with
complicated or unusual unexplained post-operative course, it could
affect the outcome that is mostly dependent on complexity of cardiac
lesions and associated comorbidities. Further studies on larger scale
are recommended.

\textbf{FUNDING}

This project was funded by the Deanship of Scientific Research (DSR),
King Abdulaziz University, Jeddah, under grant No. (D1441-94-140). The
authors, therefore, gratefully acknowledge DSR technical and financial
support.

\textbf{CONFLICT OF INTEREST}

Authors declare that there is no conflict of interest.

\textbf{LEGENDS}

\textbf{Fig. 1. A:} Selective angiography for residual MBT shunt (white
asterisk) in a patient after Fallot tetralogy repair, patient developed
heart failure symptoms due to significant left to right
shunt.\textbf{B:} The same patient after occlusion of the MBT shunt with
vascular plug (yellow arrow) with no residual flow is seen after aortic
angiography. \textbf{C:} Significant LPA stenosis (yellow arrow) with
decreased left lung vascularity in another patient after Glenn surgery,
patient developed significant desaturation (68-73\%) after
surgery.\textbf{D:} The same patient after LPA stenting (yellow arrow)
with improvement of left lung vascularity and patient saturation
increased to 85\%.MBT shunt: Modified Blalock-Taussig shunt, LPA left
pulmonary artery.

\textbf{Fig. 2.} Cardiac catheterization performed for a six months old
baby presented late with DORV, subpulmonic VSD, Intramural left coronary
artery and hypoplastic aortic arch after arterial switch operation on
ECMO support. Patient developed an iatrogenic AO to RV fistula that led
to severe coronary steal, severe cardiac dysfunction and inability to
wean from ECMO support. \textbf{A} : Contrast injection in the neo-aorta
revealed a large AO-RV fistula (white asterisk) with coronary steal
(coronary arteries are not seen with neo-aortic injection). \textbf{B} :
Selective injection of the AO-RV fistula (white
asterisk).\textbf{C-D:}Neo-aortic injection after fistula is occluded
with vascular plugs showed no residual fistula and no more coronary
steal as coronary arteries are seen well after neo-aortic injection (
yellow arrows). Three days later patient was successfully disconnected
from ECMO and contractility progressively improved and patient
discharged home. DORV: double outlet right ventricle, VSD: ventricular
septal defect, VC: venous cannula, AC: arterial cannula, AO aorta, RV:
right ventricle, ECMO: extracorporeal membrane oxygenation.

\textbf{Fig. 3. Kaplan Meier survival curve} : Demonstrating less
survival among patients performed cardiac catheterization on ECMO
support. ECMO: Extracorporeal membrane oxygenation.

\textbf{SUPPLEMENTARY MATERIAL}

Vid.1. A: Selective angiography for residual MBT shunt in a patient with
Fallot tetralogy after repair, patient developed heart failure symptoms
due to significant left to right shunt. As noted, the MBT arises from
LSCA to LPA. MBT: Modified Blalock Taussig shunt. LPA: left pulmonary
artery, LSCA: left subclavian artery.

Vid.1. B: The same patient after occlusion of the MBT shunt with
vascular plug, there is no residual flow seen after aortic angiography
and as noted patient has right aortic arch. MBT: Modified Blalock
Taussig shunt.

Vid.2. A: Neo-aortic angiography done for a six months old baby with
DORV, sub-pulmonic VSD after arterial switch operation on ECMO support.
During neo-aortic injection, the contrast fills the ventricular cavity
and coronary arteries are not seen with poor contractility due to
significant coronary steal secondary to large fistula between the
neo-aorta and RV. RV: right ventricle, VSD: ventricular septal defect,
DORV: double outlet right ventricle\textbf{,} ECMO: extracorporeal
membrane oxygenation.

Vid.2. B: Selective injection of the AO-RV fistula showing a large
fistula stealing blood from neo-aorta to ventricular cavity. Ao: aorta,
RV: right ventricle.

Vid.2.C: Neo-aortic injection after the fistula is occluded with
vascular plugs showing no residual fistula and no more coronary steal as
the left coronary artery is well seen.

Vid.2. D: Neo-aortic injection after the fistula is occluded with
vascular plugs showing no residual fistula and no more coronary steal as
the right coronary artery is well seen.

\textbf{AUTHOR CONTRIBUTIONS:}

Saud Abdulaziz Bahaidarah: Data analysis ,Gaser Abdelmohsen Abdelmohsen:
statistical analysis, Jameel Abdulaziz Al Ata : Concept and design, Naif
Owedah Alkhushi: Drafting article Mohamed Hassan Abdelsalam: Data
collection , Mohammed Sameer Mujahed : Data Collection, Osman Osama Al-
Radi: Approval of the article , Ahmed Abdelrahman Elassal: Approval of
article , Zaher Faisal Zaher : Funding ,Ahmad Saeed Azhar : Funding ,
Ahmed Mohamed Dohain : Revision of the article.

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