Publications by authors named "Elchanan Bruckheimer"

44 Publications

Clinical Features and Comparison of Kingella and Non-Kingella Endocarditis in Children, Israel.

Emerg Infect Dis 2021 Mar;27(3):703-709

Kingella spp. have emerged as an important cause of invasive pediatric diseases. Data on Kingella infective endocarditis (KIE) in children are scarce. We compared the clinical features of pediatric KIE cases with those of Streptococcus species IE (StIE) and Staphylococcus aureus IE (SaIE). A total of 60 patients were included in the study. Throughout the study period, a rise in incidence of KIE was noted. KIE patients were significantly younger than those with StIE and SaIE, were predominately boys, and had higher temperature at admission, history of oral aphthae before IE diagnosis, and higher lymphocyte count (p<0.05). Pediatric KIE exhibits unique features compared with StIE and SaIE. Therefore, in young healthy children <36 months of age, especially boys, with or without a congenital heart defect, with a recent history of oral aphthae, and experiencing signs and symptoms compatible with endocarditis, Kingella should be suspected as the causative pathogen.
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http://dx.doi.org/10.3201/eid2703.203022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7920667PMC
March 2021

Extracorporeal Membrane Oxygenation as a Rescue Therapy for Postoperative Diastolic Dysfunction and Refractory Chylothorax.

ASAIO J 2021 05;67(5):e99-e101

Pediatric Cardiac Intensive Care Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.

This is the first published case, as far as we know, of a term neonate with refractory chylothorax secondary to diastolic dysfunction in the cardiac postoperative period, where extracorporeal membrane oxygenation (ECMO) was used to improve the physiologic derangements, thus allowing resolution of the chylous effusion. The infant was prenatally diagnosed with d-transposition of the great arteries. He was started on prostaglandin infusion and underwent balloon atrial septostomy followed by arterial switch operation. After surgery, he developed anasarca and high-volume chylothorax that did not respond to medical management and fasting. Cardiac catheterization demonstrated severe diastolic dysfunction and pulmonary hypertension. On postoperative day 19, he was placed on veno-arterial (VA) ECMO and had gradual regression of the chylothorax and edema. After 13 days on ECMO support, he was decannulated with small, self-limiting, reaccumulation of chylous effusion. He was discharged home on postoperative day 57, and has since been thriving with no evidence of reaccumulation of the chylous effusion. In summary, VA ECMO support could be considered as a rescue modality for patients with uncontrollable refractory high-volume chylous effusion, after other treatment options have been pursued.
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http://dx.doi.org/10.1097/MAT.0000000000001279DOI Listing
May 2021

Fetal-TAPSE for Surveillance of Cardiac Function in Growth-restricted Fetuses With a Portosystemic Shunt.

J Ultrasound Med 2021 Jan 11. Epub 2021 Jan 11.

Ultrasound Unit, The Helen Schneider Women's Hospital, Rabin Medical Center, Petach Tikva, Israel.

Objectives: Congenital portosystemic shunt (CPSS) in a growth-restricted fetus may lead to cardiac overload and ultimately hemodynamic imbalance. The aim of the study was to describe the application of tricuspid annular plane systolic excursion (TAPSE) for surveillance of cardiac function in growth-restricted fetuses diagnosed with CPSS.

Methods: The study group consisted of 7 fetuses with growth restriction diagnosed with CPSS between 2018 and 2020. Patients were followed longitudinally every 2 weeks. Sonographic fetal-TAPSE (f-TAPSE) was performed every 2 weeks. At each visit, the following parameters were recorded: estimated fetal weight, biophysical profile, nonstress test, Doppler flow indices, and fetal cardiothoracic index. Postnatal laboratory and imaging tests were retrieved from the medical files.

Results: Mean gestational age at diagnosis of CPSS was 32 + 1 weeks. Cardiomegaly was observed in all cases. All portosystemic shunts were classified as intrahepatic. Values of f-TAPSE were above the 95th percentile in 6/7 fetuses at presentation and throughout follow-up. Gestational age at delivery ranged between 36 + 5 and 38 + 5 weeks. Postnatally, spontaneous closure of the shunt was noted in 2 infants. Transient hyperammonemia was diagnosed in 2 neonates, with no signs of the characteristic complication.

Conclusions: In growth-restricted fetuses diagnosed concomitantly with CPSS, f-TAPSE offers a practical sonographic tool for assessment of cardiac function and may serve as an additional clinical marker for follow-up. The appearance of cardiomegaly in growth-restricted fetuses should prompt a dedicated sonographic evaluation of the fetal portal system.
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http://dx.doi.org/10.1002/jum.15629DOI Listing
January 2021

Topical Propranolol Improves Epistaxis Control in Hereditary Hemorrhagic Telangiectasia (HHT): A Randomized Double-Blind Placebo-Controlled Trial.

J Clin Med 2020 Sep 28;9(10). Epub 2020 Sep 28.

Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel.

Epistaxis is a common debilitating manifestation in hereditary hemorrhagic telangiectasia (HHT), due to mucocutaneous telangiectases. The epistaxis can be difficult to control despite available treatments. Dysregulated angiogenesis has been shown to be associated with telangiectases formation. Topical propranolol has demonstrated antiangiogenic properties. We performed a two-phase study, i.e., a double-blind placebo-controlled phase, followed by an open-label phase. The aim of the study was assessment of safety and efficacy of nasal propranolol gel in HHT-related epistaxis. Twenty participants with moderate-severe HHT-related epistaxis were randomized to eight weeks of propranolol gel 1.5%, or placebo 0.5 cc, applied to each nostril twice daily; and continued propranolol for eight weeks in an open-label study. For the propranolol group, the epistaxis severity score (ESS) improved significantly (-2.03 ± 1.7 as compared with -0.35 ± 0.68 for the placebo group, = 0.009); hemoglobin levels improved significantly (10.5 ± 2.6 to 11.4 ± 2.02 g/dL, = 0.009); and intravenous iron and blood transfusion requirement decreased. The change in nasal endoscopy findings was not significant. During the open-label period, the ESS score improved significantly in the former placebo group (-1.99 ± 1.41, = 0.005). The most common adverse event was nasal mucosa burning sensation. No cardiovascular events were reported. Our results suggest that topical propranolol gel is safe and effective in HHT-related epistaxis.
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http://dx.doi.org/10.3390/jcm9103130DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7601781PMC
September 2020

Catheter ablation of left-sided accessory pathways in small children.

J Arrhythm 2019 Oct 2;35(5):742-747. Epub 2019 Aug 2.

Kaplan Medical Center, The Hebrew University Rehovot Jerusalem Israel.

Background: Accessory pathways (APs) are a common reason for supraventricular tachycardia in small children. Trans-septal puncture (TSP) approach is commonly used for the ablation of left-sided APs, however it may be challenging in small children. The aim of this study was to assess the efficacy and safety of trans-septal approach radiofrequency (RF) ablation of left-sided APs in children weighing up to 30 kg.

Methods: Of the 658 children who underwent catheter ablation of APs since 06/2002, 86 children had left-sided AP and weighed less than 30 kg. TSP approach guided with TEE and fluoroscopy was used for left atrium access.

Results: The mean age, height, and body weight were 7.6 ± 1.9 years, 122.4 ± 9.3 cm and 24.0 ± 4.2 kg, respectively. Forty-three children (50%) were male, 46 of 86 (53%) had manifest AP, 17 of 86 (20%) weighed less than 20 kg and in 24 of 86 children (28%) a three-dimensional system (3DS) was used to reduce fluoroscopy time. The acute success rate was 98.8% (85/86), with a recurrence rate of 2.4% (2/85) in a mean follow-up of 66.2 ± 42.7 (9.1-184.2) months. The mean procedure time and fluoroscopy time were significantly lower for the 3DS group compared to the standard fluoroscopy group 131 ± 41 (55-262) and 2.4 ± 1.5 (1-6) minutes vs 164 ± 51 (62-249) and 27 ± 13 (8-77) minutes,  < 0.01 and  < 0.0001, respectively. There were no ablation-related complications.

Conclusions: RF ablation of left-sided APs using TSP approach in small children had an excellent efficacy and safety profile. The use of 3DS significantly reduces the procedure and fluoroscopy time.
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http://dx.doi.org/10.1002/joa3.12219DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6787155PMC
October 2019

Urgent Surgical Treatment of Aortic Endocarditis in Infants and Children.

Pediatr Cardiol 2019 Mar 2;40(3):580-584. Epub 2019 Jan 2.

Department of Pediatric Cardiology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.

Infective endocarditis (IE) in the pediatric population can present as a life-threatening condition. Optimal timing for surgical intervention should consider surgical risks versus the risk of neurologic complications. We herein report our experience with this group of critically ill children. Retrospective analysis of patient charts of all patients who underwent urgent surgical treatment of aortic IE from 1994 to 2014 was performed. Nine patients with acute storming IE of the aortic valve or the ascending aorta were urgently operated (eight normal heart, one congenital aortic stenosis), age ranged from 8 weeks to 4.2 years. Causative organisms were Staphylococcus aureus (2), Staphylococcus coagulase negative (1), Kingella kingae (2), Streptococcus pneumoniae (2), or culture negative (2). Presenting symptoms other than hemodynamic instability were neurologic decompensation (5) coronary embolization (1) and cardiogenic shock due to scalded skin syndrome (1). CT and MRI demonstrated significant brain infarcts in four patients. Operations performed were the Ross operation (7) and ascending aortic reconstruction (2). There were no operative deaths. At a median follow-up of 6 years (range 2-196 months), all patients are alive and well. Re-intervention included homograft replacement (2) and transcatheter Melody valve implantation (1). At their last follow-up, the neo-aortic valve was functional in all patients with minimal regurgitation and all had full resolution of the neurological deficits. Urgent surgical treatment for aortic valve IE in infants is challenging. Although surgery is complex and pre-disposing conditions such as sepsis, neurologic and cardiac decompensations are prevalent, operative results are excellent and gradual and significant neurologic improvement was noted over time.
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http://dx.doi.org/10.1007/s00246-018-2030-5DOI Listing
March 2019

Doxorubicin-Eluting Intra-Arterial Therapy for Pediatric Extra-Abdominal Desmoid Fibromatoses: A Promising Approach for a Perplexing Disease.

J Vasc Interv Radiol 2018 10 31;29(10):1376-1382. Epub 2018 Jul 31.

The Rina Zaizov Hematology-Oncology Division, Schneider Children's Medical Center of Israel, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Systemic doxorubicin is effective for desmoid fibromatosis (DF), but its use is limited by dose-dependent cardiotoxicity. A protocol of selective intra-arterial doxorubicin drug-eluting embolization (DEE) was designed to maximize target tissue efficacy of doxorubicin, while minimizing systemic exposure. Four children with recurrent or refractory DF were treated between 2014 and 2017. Tumor volumes were reduced by 54%-97% over a follow-up interval of 6-32 months. A single patient experienced transient lower extremity paresthesia (Common Terminology Criteria for Adverse Events grade I). Further investigation is needed to better establish these promising results for doxorubicin DEE in DF treatment.
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http://dx.doi.org/10.1016/j.jvir.2018.04.009DOI Listing
October 2018

Topical propranolol improves epistaxis in patients with hereditary hemorrhagic telangiectasia - a preliminary report.

J Otolaryngol Head Neck Surg 2017 Oct 4;46(1):58. Epub 2017 Oct 4.

Department of Hematology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.

Background: Severe epistaxis is often difficult to control in patients with hereditary hemorrhagic telangiectasia (HHT). Propranolol has been shown to have antiangiogenic properties in vitro and in vivo and is commonly used to treat hemangiomas. We present our experience with topical nasal propranolol for the treatment of moderate to severe epistaxis in patients with HHT.

Methods: Retrospective case series. Six patients with HHT were treated with 0.5 cm of 1.5% propranolol gel, applied to each nostril twice daily for at least 12 weeks. Outcome measures were epistaxis severity score (ESS), hemoglobin level, and number of blood transfusions prior to and while on treatment. Local and systemic side effects were recorded.

Results: The mean duration of treatment was 30 ± 5.6 weeks. A significant improvement in the ESS was found in all patients, with a mean decrease from 6.4 ± 2.1 at treatment onset to 3.5 ± 1.7 at 12 weeks (p = 0.028). Hemoglobin level increased significantly from 8.4 ± 3.1 to 11.0 ± 1.8 g/dL at 12 weeks (p = 0.043). The mean number of blood transfusions decreased from 4.5 ± 4.9 before treatment to 2.5 ± 2.9 at 12 weeks and 0.3 ± 0.8 at 24 weeks, but the difference did not reach statistical significance (p = 0.109 for both). No significant side effects of treatment were recorded.

Conclusions: These preliminary results suggest that topical propranolol may be effective for the treatment of epistaxis in patients with HHT. A prospective controlled trial is required to confirm our findings.
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http://dx.doi.org/10.1186/s40463-017-0235-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5628419PMC
October 2017

Neonatal Cardiac Surgery in the New Era: Lessons learned from 1000 Consecutive Cases.

Isr Med Assoc J 2016 Nov;18(11):645-648

Division of Pediatric Heart Institute, Schneider Children's Medical Center of Israel, Petah Tikva, Israel.

Background: neonatal cardiac surgery has evolved over the last 50 years with a large percentage of the patients achieving complete physiological repair in the neonatal period. The remaining patients achieve staged palliation with an increasing amount of success.

Objectives: To report our experience with 1000 neonatal cardiac surgical procedures performed in the last 10 years.

Methods: We conducted a retrospective analysis of surgical outcome in all neonatal patients who underwent cardiac surgery between January 2007 and July 2016 at Schneider Children's Medical Center of Israel.

Results: A total of 1003 neonates aged < 30 days underwent surgery for congenital heart defects at our center. Neonatal surgery accounted for 22.5% of all cardiac surgeries. Neonatal operative mortality was 7.3%, Operative mortality for individual lesions were: simple aortic coarctation (CoA) (198 patients, 2.5%), CoA with hypoplastic arch (24, 4%), CoA with ventricular septal defect (VSD) (84, 2.3%), transposition of the great arteries (TGA, simple and complex, 185, 6.3%), TGA with VSD (37, 0%), truncus arteriosus (26, 3.8%), interrupted aortic arch (25, 4%), Norwood Sano (71, 19.7%), neonatal tetralogy of Fallot (41, 0%), and shunt (131 patients, 12%).

Conclusions: Neonatal surgical capabilities have improved substantially over the last decades. Excellent results can be expected for lesions that can be repaired to create biventricular circulation. Improved results can be attributed in part to the evolution of surgical strategies and assistive technologies, but essential is the collaborative effort of surgeons, cardiologists, anesthesiologists, and intensive care specialists acting as a cohesive team whose performance far exceeds the sum of its individual members' contributions.
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November 2016

Limited fluoroscopy catheter ablation of accessory pathways in children.

J Cardiol 2017 Oct 6;70(4):382-386. Epub 2017 Mar 6.

The Schneider Children's Medical Center of Israel, Cardiology Institute, Petach Tiqva, Sackler School of Medicine, Tel Aviv University, Israel.

Background: Limited fluoroscopy ablation using 3D electro-anatomical system (3DS) has been used for arrhythmias in children, however it is not a common practice. We aimed to facilitate a fluoroscopy limited approach for ablation of accessory pathways (AP) in children.

Methods: Following electrophysiologic (EP) catheter placement a single dual-plane fluoroscopic image (right anterior oblique-30° and left anterior oblique-60° views) was acquired and the 3DS views were rotated to be a perfect match to the fluoroscopy. Ninety-four consecutive pediatric patients [mean age 11.8±4.1 (4.2-18) years, 61.7% males] with Wolf-Parkinson-White syndrome underwent ablation of an AP. Fifty-seven had manifest AP, 54 had left-sided AP (LSAP) and 40 had right-sided AP (RSAP).

Results: The acute success rate was 95.7% (90/94), with a recurrence rate of 1.1% (1/90) at a mean follow-up of 13±5.5 (4.4-22.9) months. Mean procedure and fluoroscopy times were 144±45 (55-262)min and 1.8±1.4 (0.1-5.6)min, respectively. Comparison of the first 20 procedures to the next 74 procedures demonstrated an extended procedure time (171±53min vs 135±38min, p<0.005), however the fluoroscopy time, the number of long applications, the time to effect, and the acute success rate were similar. There were no permanent ablation-related complications.

Conclusions: A limited fluoroscopy approach for ablation of AP in children using 3DS is easily acquired, adapted, reduces the fluoroscopy time, and has an excellent efficacy and safety profile.
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http://dx.doi.org/10.1016/j.jjcc.2016.12.018DOI Listing
October 2017

Radiofrequency catheter ablation of atrioventricular node reentrant tachycardia in children with limited fluoroscopy.

Int J Cardiol 2017 Jun 31;236:198-202. Epub 2017 Jan 31.

Schneider Children's Medical Center Israel, Petach Tikva, and Sackler School of Medicine, Tel Aviv University, Israel.

Background: Limited fluoroscopy cryo-ablation using a 3D electro-anatomical system (3DS) has been used for AVNRT in children. We aimed to facilitate a fluoroscopy limited approach of RF ablation of AVNRT in children.

Methods: A retrospective study was performed of procedure parameters in children undergoing RF ablation of AVNRT in 75 consecutive children (June 2011 to November 2013 - Group A) using standard fluoroscopy techniques compared to those of 64 consecutive children (December 2013 to May 2015 - Group B), using a fluoroscopy limited approach with 3DS.

Results: The acute success rate was 98.7% (74/75) and 98.4% (63/64) for groups A and B, respectively. The recurrence rate was 2.7% (2/74) and 0% (0/63) with a mean follow-up period of 45.5±12.1 and 14.3±6.1months for group A and group B, respectively. The mean procedure and fluoroscopy times were significantly lower for group B compared to group A (119±37 (43-203) and 0.83±1.04 (0.05-3.83) minutes versus 146±53 (72-250) and 16.1±8.9 (4.39-55) minutes, p<0.003 and p<0.0001, respectively). There were no ablation-related complications.

Conclusions: A fluoroscopy limited approach for RF ablation of AVNRT in children using a 3DS is easily acquired and adapted, and significantly reduces the fluoroscopy and procedure time with excellent efficacy, safety and low recurrence rate.

Condensed Abstract: This study confirmed that a 3D mapping system (3DS) to guide ablations of AVNRT in children reduces radiation exposure. Combined, limited fluoroscopy and 3DS in a methodology that resembles the familiar conventional fluoroscopy approach for RF ablation of AVNRT in children is proposed. Combined limited fluoroscopy and RF-energy in children with AVNRT are associated with a shorter procedure time, minimal fluoroscopy time, a high success rate and a low recurrence rate.
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http://dx.doi.org/10.1016/j.ijcard.2017.01.128DOI Listing
June 2017

Reply to Letter Regarding "Amplatzer Vascular Plugs Versus Coils for Embolization of Pulmonary Arteriovenous Malformations in Patients with Hereditary Hemorrhagic Telangiectasia".

Cardiovasc Intervent Radiol 2016 10 9;39(10):1520. Epub 2016 Aug 9.

Sackler Faculty of Medicine, Institute of Pediatric Cardiology, Tel Aviv University, Tel Aviv, Israel.

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http://dx.doi.org/10.1007/s00270-016-1448-5DOI Listing
October 2016

Pulmonary hypertension specific treatment in infants with bronchopulmonary dysplasia.

Pediatr Pulmonol 2017 01 22;52(1):77-83. Epub 2016 Jun 22.

Pulmonary Outpatient Clinic, Schneider Children's Medical Center of Israel, Petach Tikva, Affiliated With Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Objective: When bronchopulmonary dysplasia (BPD) is complicated by pulmonary hypertension (PH), morbidity and mortality are significantly increased. BPD-associated PH is not included in the current indications for PH medications. However, limited data demonstrate hemodynamic improvement and decreased mortality with PH-specific treatment. This report describes our 6-year experience treating BPD-associated PH with PH medications, mainly sildenafil.

Study Design: The medical records of 20 infants diagnosed with BPD-associated PH at a tertiary pediatric pulmonary hypertension clinic in 2008-2014 were reviewed. Clinical improvement was defined as a decrease in Ross functional class by at least one degree. PH severity was classified by echocardiography as mild, moderate, or severe. Hemodynamic improvement was defined as a decrease in PH severity by at least one level.

Results: Eighteen out of 20 patients were treated with PH medications: 12 sildenafil, 5 sildenafil and bosentan, and 1 bosentan. Median follow-up time was 2 years. Mean functional class significantly decreased from 3.2 ± 0.9 at diagnosis to 1.7 ± 0.9 at the last follow-up. Improvement in functional class was observed in 15/16 children (94%). Moderate or severe PH was found in 13/18 children (72%) at diagnosis, and in three (17%, all moderate PH) at the last follow-up. Improvement in PH class by echocardiography was demonstrated in 14/18 children (78%). The survival rate was 95%.

Conclusion: Treatment of BPD complicated by PH with PH-specific medications, mainly sildenafil, is associated with improvement in both clinical and hemodynamic parameters and a low mortality rate. Pediatr Pulmonol. 2017;52:77-83. © 2016 Wiley Periodicals, Inc.
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http://dx.doi.org/10.1002/ppul.23508DOI Listing
January 2017

Computer-generated real-time digital holography: first time use in clinical medical imaging.

Eur Heart J Cardiovasc Imaging 2016 Aug 9;17(8):845-9. Epub 2016 Jun 9.

Section of Pediatric Cardiology, Schneider Children's Medical Center Israel, Petach Tikva, Israel.

Aims: Assessment of the feasibility of creating real-time interactive 3D digital holograms in a standard catheterization laboratory. 3D medical images are typically displayed and interacted with on 2D screens limiting their usefulness. A digital computer-generated real-time holographic display of patient's 3D data could provide a spatially accurate image with all the depth cues and afford interaction within the image.

Methods And Results: We performed a feasibility study of creating real-time interactive 3D digital holograms with a purpose-built prototype using intraprocedural data from 3D rotational angiography and live 3D transesophageal echocardiography. The primary objective was to demonstrate that all the anatomical landmarks identified on standard imaging can be similarly identified using dynamic and static holographic images. The secondary objective was to demonstrate the usability of interactions with the image. Parameters were assessed by a rating scale. Eight patients were enrolled of whom five underwent transcatheter ASD closure using 3DTEE and three patients were evaluated by 3D rotational angiography. In all cases dynamic real-time and static 3D holograms were created in standard cath lab conditions. Four individual observers identified all anatomical landmarks on the holographic display independently from the 2D display. Interactions with the hologram including marking, cropping and rotation were performed. There were no adverse events.

Conclusions: This study demonstrates, for the first time, the feasibility of generating high quality, clinically relevant, 3D real-time colour dynamic holograms in a standard clinical setting with real patient volumetric data. The impact of computer-generated holography needs to be evaluated in controlled clinical trials.
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http://dx.doi.org/10.1093/ehjci/jew087DOI Listing
August 2016

Holography for imaging in structural heart disease.

EuroIntervention 2016 May;12 Suppl X:X81-X84

Section of Pediatric Cardiology, Schneider Children's Medical Center Israel, Petach Tikva, Israel.

Three-dimensional imaging modalities for structural heart disease interventions have become a common feature in the procedural workflow. The images acquired are usually presented on 2D displays, thereby restricting their usefulness and the ability to interact with them. Holographic images created in real time from the volumetric data which float in the air during the procedure, in front of the operator and above the patient, could provide an intuitive and interactive display for the interventionalist and improve procedure outcomes.
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http://dx.doi.org/10.4244/EIJV12SXA15DOI Listing
May 2016

Amplatzer Vascular Plugs Versus Coils for Embolization of Pulmonary Arteriovenous Malformations in Patients with Hereditary Hemorrhagic Telangiectasia.

Cardiovasc Intervent Radiol 2016 Aug 5;39(8):1110-4. Epub 2016 May 5.

Institute of Pediatric Cardiology, Schneider Children's Medical Center of Israel, 14 Kaplan Street, Petach Tikva, Israel.

Purpose: Coil embolization of pulmonary arteriovenous malformations (PAVMs) has a high re-canalization/re-perfusion rate. Embolization with Amplatzer plugs has been previously described, but the long-term efficacy is not established. This study reports the experience of a referral medical center with the use of coils and Amplatzer plugs for treating PAVMs in patients with hereditary hemorrhagic telangiectasia.

Methods: The study was approved by the Institutional Review Board with waiver of informed consent. The cohort included all patients who underwent PAVM embolization in 2004-2014 for whom follow-up imaging scans were available. The medical files were retrospectively reviewed for background data, embolization method (coils, Amplatzer plugs, both), and complications. Re-canalization of treated PAVMs was assessed from intrapulmonary angiograms (following percutaneous procedures) or computed tomography angiograms. Fisher's exact test and Pearson Chi-squared test or t test were used for statistical analysis, with significance at p < 0.05.

Results: 16 patients met the study criteria. Imaging scans were available for 63 of the total 110 PAVMs treated in 41 procedures. Coils were used for embolization in 37 PAVMs, Amplatzer plugs in 21, and both in five. Median follow-up time was 7.7 years (range 1.4-18.9). Re-canalization was detected in seven vessels, all treated with coils; there were no cases of re-canalization in plug-occluded vessels (p = 0.0413).

Conclusion: The use of Amplatzer plugs for the embolization of PAVMs in patients with hemorrhagic telangiectasia is associated with a significantly lower rate of re-canalization of feeding vessels than coils. Long-term prospective studies are required to confirm these findings.
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http://dx.doi.org/10.1007/s00270-016-1357-7DOI Listing
August 2016

Congenital Malformations Leading to Paradoxical Embolism.

Cardiol Clin 2016 May 10;34(2):247-54. Epub 2016 Mar 10.

Cardiac Catheterization, Section of Pediatric Cardiology, Schneider Children's Medical Center Israel, Kaplan 14, Petach Tikva 42902, Israel. Electronic address:

The absolute separation of the right and left circulations and the filtration of blood by the pulmonary circulation are essential to prevent the passage of thrombotic material from the venous system into the systemic arterial circulation. Any breach of the intracardiac septae or circumvention of the pulmonary capillary network may cause a paradoxical embolus. The most common causes are atrial septal defects and pulmonary arteriovenous malformations. This article discusses unusual connections and pathways related to congenital malformations. Although anticoagulation is necessary to prevent paradoxical emboli, the hematologic disturbances and the most appropriate therapy in these patients warrant further investigation.
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http://dx.doi.org/10.1016/j.ccl.2015.12.005DOI Listing
May 2016

Cryotherapy ablation of parahisian accessory pathways in children.

Heart Rhythm 2015 May 29;12(5):917-25. Epub 2015 Jan 29.

Schneider Children's Hospital in Israel, Petach Tikva, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.

Background: Because of its safety profile, cryoablation has become an alternative therapy for septal arrhythmias, including parahisian accessory pathways (APs). Data regarding its efficacy, safety, and late outcome for parahisian APs in children are limited.

Objective: The purpose of this study was to evaluate the safety and efficacy of cryoablation of parahisian APs in children.

Methods: Fifty-nine cryoablations of parahisian APs were performed in 50 patients [76% males; median age 16.5 years (range 5.3-20 years)]. Thirty-three had manifest APs and 17 had concealed APs. The time to effect was defined as the duration of time from reaching -30°C to the disappearance of AP during the cryomapping phase. The acute success rate for the first ablation was 94% (47/50).

Results: Mean fluoroscopy time and number of cryoablations were 28.5 ± 23.3 minutes and 2.6 ± 1.2 seconds, respectively. The time to effect was 8.5 ± 7.1 seconds. The overall recurrence rate was 14.9%, decreasing from 40% in the first 10 cases to 8.1% in the next 37 (P <.02). Multivariate analysis showed that the only independent predictor for recurrence rate was time to effect <10 seconds (P <.001). A high recurrence rate was also associated with concealed APs and ablation during supraventricular tachycardia (P <.03 and P <.05, respectively). The patients who had recurrence underwent a second successful cryoablation. During median follow-up of 59.7 months (range 6-102 months), a long-term success rate of 94% was achieved. No permanent ablation-related complications occurred.

Conclusion: Cryoablation of parahisian APs has excellent short- and long-term efficacy and safety profile. Increased physician experience is associated with a reduced recurrence rate.
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http://dx.doi.org/10.1016/j.hrthm.2015.01.042DOI Listing
May 2015

The Amplatzer Duct Occluder II Additional Sizes device for transcatheter PDA closure: initial experience.

Catheter Cardiovasc Interv 2014 Jun 4;83(7):1097-101. Epub 2014 Mar 4.

Section of Pediatric Cardiology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.

Objectives: To present our initial experience with the Amplatzer Duct Occluder II Additional Sizes (ADOIIAS) device.

Background: The ADOIIAS is a modified PDA closure device of various lengths and widths with small disks to avoid flow disturbance in the pulmonary arteries and descending aorta.

Methods:

Patient Population: All patients who underwent attempted closure with an ADOIIAS device at our institution CATHETERIZATION: Following aortography the PDA was closed using a 4-5Fr delivery system from the pulmonary or aortic side with an ADOIIAS. Aortography to confirm position and leak was performed before and after device release. Echocardiography was performed before discharge the following day.

Results: Between June 2011 and December 2012, 60 patients [33 female], median age 3.3 yrs [0.6-15.8 years], and weight 14.5 kg [4-79] underwent attempted PDA closure with an ADOIIAS device. 56/60 [93.3%] ADOIIAS devices were successfully deployed [52 aortic side]. In 55/56 [98.2%], the PDA was closed on follow up echocardiogram usually on the next day. In one case, there was a small residual PDA of no hemodynamic significance on follow up. In four cases, the ADOIIAS was unstable, including one device embolization which was retrieved with no sequelae, and the PDA was closed in all cases with an alternative device in the same procedure. The mean ratio of ADOIIAS height:PDA pulmonary diameter was 2.4 ± 0.5:1.

Conclusions: We report a large single-center experience with the new ADOIIAS device which proved to be versatile, safe, effective, and easy to use in the appropriate ductal anatomy.
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http://dx.doi.org/10.1002/ccd.25445DOI Listing
June 2014

Efficacy of bronchoscopic closure of a bronchopleural fistula with amplatzer devices: long-term follow-up.

Respiration 2014 14;87(3):227-33. Epub 2014 Jan 14.

Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.

Background: The development of a bronchopleural fistula (BPF) is associated with high rates of morbidity and mortality. We have developed a minimally invasive method of bronchoscopic BPF closure using Amplatzer devices (AD) and Amplatzer vascular plugs (AVP), with excellent short-term results.

Objectives: The aim of the present report was to explore the long-term outcome of patients treated by Amplatzer occluders and the durability of this novel modality of BPF treatment.

Methods: A total of 31 central BPF in 31 patients (mean age 66.8 years, range 19-91) were sealed under moderate sedation bronchoscopically by either AD (n = 19) or AVP (n = 12). The average follow-up period was 17.6 months (range 1-68 months).

Results: The main etiology for BPF was surgery (n = 24), pneumonectomy (n = 14) or lobectomy/segmentectomy (n = 10). The underlying disease was either primary (n = 19) or metastatic (n = 2) lung cancer. The immediate success rate was 96% as symptoms related to BPF disappeared in 30 of the 31 patients. Short-term (<30 days) mortality was 13% (4 patients). At follow-up, 14 patients (45%) are still alive. Out of 12 patients with late mortality, in 5 patients (41%) the death was directly related to cancer relapse, and no patient died due to BPF recurrence.

Conclusion: Endobronchial closure of BPF using both types of Amplatzer occluders (AD and AVP) is a minimally invasive effective modality of treatment with high safety profile and satisfactory long-term outcome considering the poor prognosis in this particular group of patients.
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http://dx.doi.org/10.1159/000357074DOI Listing
October 2014

Preliminary experience using the transcatheter mitral valve leaflet repair procedure.

Isr Med Assoc J 2013 Oct;15(10):608-12

Department of Cardiology, Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel.

Background: Mitral regurgitation (MR) causes increased morbidity and mortality in heart failure patients and is often associated with augmented surgical risk.

Objectives: To assess the preliminary results oftranscatheter mitral valve leaflet repair (TMLR) in a single academic center.

Methods: Data were collected prospectively in the cardiology department of Rabin Medical Center in 2012. Ten consecutive patients (age 69.3 +/- 15.9 years, ejection fraction 36.5 +/- 9.4) who were poor surgical candidates with severe functional MR underwent general anesthesia, followed by trans-septal puncture and a TMLR procedure using the MitraClip device.

Results: All 10 patients were considered to have severe functional MR prior to TMLR treatment and were all symptomatic; the mean New York Heart Association (NYHA) class was 3.4 +/- 0.5. The MR severity was 4 +/- 0. There were no immediate complications or failures of the procedure. One patient died on day 5 due to massive gastrointestinal bleeding. Immediately following TMLR all 10 patients showed a profound MR reduction to a mean severity grade of 1.6 +/- 0.6. At one month after the procedure, NYHA had decreased to an average of 1.7 +/- 1.0 and was at least grade 2 in all but one patient. After 6 months the MR remained < or = 2 in six of eight patients, with a NYHA average of 1.4 +/- 0.5.

Conclusions: The MitraClip procedure was shown to be relatively safe, providing significant clinical benefit to a relatively sick population with severe MR. It is therefore an important alternative to surgery in these high risk patients.
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October 2013

Percutaneous coronary intervention of the left main artery before MitraClip implantation.

Cardiovasc Revasc Med 2014 Jan 5;15(1):51-3. Epub 2013 Jul 5.

Cardiology Department, Rabin Medical Center, Petach Tikva 49100, Israel.

Functional mitral regurgitation (MR) is common in patients with ischemic cardiomyopathy. We present a case of an 83-year-old patient with ischemic heart disease and ischemic cardiomyopathy, who was repeatedly admitted for pulmonary edema and underwent a percutaneous trans-septal MitraClip procedure. During coronary angiography, a severe left main stenosis was demonstrated. Treatment included both percutaneous coronary intervention and the implantation of two MitraClip devices, with very good results. We believe that this case illustrates the need for comprehensive assessment of ischemia in patients with functional MR.
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http://dx.doi.org/10.1016/j.carrev.2013.05.006DOI Listing
January 2014

Percutaneous intraperitoneal catheters in neonates following open heart surgery.

J Intensive Care Med 2014 May-Jun;29(3):160-4. Epub 2013 Mar 25.

Division of Pediatric Cardiothoracic Surgery, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.

Objective: Ascitic fluid in the peritoneal cavity may severely impair respiratory and renal function following neonatal heart surgery. It has been our practice to liberally insert percutaneous peritoneal catheters (PPCs) in order to manage fluid balance and thereby improve ventilatory function. We herein report our experience with PPC.

Methods: Retrospective analysis of charts of all surviving neonates that underwent PPC insertion from January 2007 through March 2010. Charts were reviewed for demographic and clinical variables from the preoperative, operative, and postoperative periods.

Results: A total of 1268 patients underwent surgery, 292 (23%) were neonates. 17 (5.8%) patients required PPC. Mean age and weight were 16 days and 3.1 kg, respectively. Mean amount drained upon insertion was 55 ± 46 ml. Catheters were maintained for a mean of 5 days and drained an average of 201 ml on the first postinsertion day. Ventilatory settings did not change significantly prior to and postcatheter insertion (respiratory rate [29 ± 3.8 vs 28.7 ± 3.9; P = .93], inspiratory pressures [26.3 ± 3.6 vs 26.1 ± 3.3 cm H2O; P = .34], and fraction of inspired oxygen [0.66 ± 0.21 vs 0.63 ± 0.18; P = .53]). Carbon dioxide values decreased significantly (43.2 ± 9.7 vs 37 ± 4.9 mm Hg; P = .01), and PO2 values increased (78 ± 69 vs 104 ± 57 mm Hg; P = .05).

Conclusions: The PPC insertion can be easily performed at the bedside with minimal complications. Fluid balance management is facilitated, and ventilation is improved. The PPC insertion is a valuable addition to the armamentarium of the physician treating neonates in the intensive care unit after complex congenital heart surgery.
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http://dx.doi.org/10.1177/0885066613482086DOI Listing
January 2015

Staged transcatheter treatment of portal hypoplasia and congenital portosystemic shunts in children.

Cardiovasc Intervent Radiol 2013 Dec 22;36(6):1580-1585. Epub 2013 Feb 22.

Section of Pediatric Cardiology, Schneider Children's Medical Center Israel, Kaplan 14, Petach Tikva, Israel.

Purpose: Congenital portosystemic shunts (CPSS) with portal venous hypoplasia cause hyperammonemia. Acute shunt closure results in portal hypertension. A transcatheter method of staged shunt reduction to afford growth of portal vessels followed by shunt closure is reported.

Methods: Pressure measurements and angiography in the CPSS or superior mesenteric artery (SMA) during temporary occlusion of the shunt were performed. If vessels were diminutive and the pressure was above 18 mmHg, a staged approach was performed, which included implantation of a tailored reducing stent to reduce shunt diameter by ~50 %. Recatheterization was performed approximately 3 months later. If the portal pressure was below 18 mmHg and vessels had developed, the shunt was closed with a device.

Results: Six patients (5 boys, 1 girl) with a median age of 3.3 (range 0.5-13) years had CPSS portal venous hypoplasia and hyperammonemia. Five patients underwent staged closure. One patient tolerated acute closure. One patient required surgical shunt banding because a reducing stent could not be positioned. At median follow-up of 3.8 (range 2.2-8.4) years, a total of 21 procedures (20 transcatheter, 1 surgical) were performed. In all patients, the shunt was closed with a significant reduction in portal pressure (27.7 ± 11.3 to 10.8 ± 1.8 mmHg; p = 0.016), significant growth of the portal vessels (0.8 ± 0.5 to 4.0 ± 2.4 mm; p = 0.037), and normalization of ammonia levels (202.1 ± 53.6 to 65.7 ± 9.6 μmol/L; p = 0.002) with no complications.

Conclusion: Staged CPSS closure is effective in causing portal vessel growth and treating hyperammonemia.
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http://dx.doi.org/10.1007/s00270-013-0581-7DOI Listing
December 2013

Stenting Options for Coarctation of the Aorta.

Interv Cardiol Clin 2013 Jan 3;2(1):115-129. Epub 2012 Dec 3.

Catheterization Laboratory for Congenital Heart Disease, Instituto Dante Pazzanese de Cardiologia, Avenida Doutor Dante Pazzanese, 500 CEP 04012-180, Sao Paulo, Brazil; Catheterization Laboratory for Congenital Heart Disease, Hospital do Coração, Sao Paulo, Brazil.

The narrowing of the lumen in coarctation of the aorta can be relieved with a high degree of immediate success by transcatheter methods. All methods are associated with immediate and longer-term complications, including dissection, aneurysm formation, and recoarctation. The introduction of the use of covered stents in aortic coarctation is encouraging because the material cover provides additional protection to the acutely disrupted aortic wall and can provide long-term protection of the dilated segment and the downstream area of poststenotic dilation. This review discusses the currently available options for stenting aortic coarctation.
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http://dx.doi.org/10.1016/j.iccl.2012.08.002DOI Listing
January 2013

Direct innominate artery cannulation for antegrade cerebral perfusion in neonates undergoing arch reconstruction.

Ann Thorac Surg 2013 Mar 20;95(3):956-61. Epub 2012 Dec 20.

Division of Pediatric Cardiothoracic Surgery, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.

Background: Antegrade cerebral perfusion (ACP) is performed in neonates either by direct cannulation (DC) or indirect cannulation (IC) of the innominate artery. IC is achieved by a graft sutured to the innominate artery or advancement of a cannula through the ascending aorta into the innominate artery, whereas DC is performed by directly cannulating the innominate artery. These techniques may be limited by technical problems that can compromise perfusion. The purpose of the present study was to evaluate the flow measurements and safety of DC when compared with IC.

Methods: This was a retrospective chart review of consecutive neonates who underwent ACP from January 2007 to December 2010. Patient characteristics, surgical and hemodynamic measurements, and postoperative neurologic findings were recorded.

Results: Seventy neonates underwent ACP during the study period (46 using DC and 24 using IC). The groups were similar in age and weight. Operative variables were similar regarding cardiopulmonary bypass (CPB), cross-clamp times, maximal flow at full CPB, minimal temperature, ACP time, flow and flow index, and upper extremity blood pressure and proximal cannula pressure during ACP. There was a significantly higher flow index at full CPB in the DC group (217 ± 40 mL/kg/min versus 190 ± 46 mL/kg/min; p = 0.013), which correlated with higher proximal cannula pressures at full CPB (172 ± 27 mm Hg versus 158 ± 26 mm Hg; p = 0.04). Sixty-two of the 65 survivors (95%) had normal neurologic evaluations on discharge.

Conclusions: ACP using DC is comparable to that using IC, with appropriate pressures in the proximal aortic line at full CPB and adequate upper extremity pressures during ACP, reflecting suitable flows in the cerebral circulation.
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http://dx.doi.org/10.1016/j.athoracsur.2012.10.029DOI Listing
March 2013

Endobronchial closure of bronchopleural fistulas with Amplatzer vascular plug.

Eur J Cardiothorac Surg 2012 Jan;41(1):46-9

The Pulmonary Institute, Department of Cardiothoracic Surgery, Rabin Medical Center, Petah Tiqwa, Israel.

Objective: Bronchopulmonary fistula (BPF) is a severe complication following lobectomy or pneumonectomy and is associated with a high rate of morbidity and mortality. We have developed a novel minimally invasive method of central BPF closure using Amplatzer vascular plug (AVP) device that was originally designed for the transcatheter closure of vascular structures in patients with small BPF.

Methods: Patients with BPFs were treated under conscious sedation by bronchoscopic closure of BPFs using AVP. After locating the fistula using bronchography, the self-expanding nitinol made AVP occluder to be delivered under direct bronchoscopic guidance over a loader wire into the fistula followed by bronchography to assure correct device positioning and sealing of the BPF.

Results: Six AVPs were placed in five patients, four males and one female, with a mean age of 62.3 years (range: 51-82 years). The underlying disorders and etiologies for BPF development were lobectomy (two patients), pneumonectomy for lung cancer (one patient), lobectomy due to necrotizing pneumonia (one patient), and post-tracheostomy tracheo-pleural fistula (one patient). In all the patients, the bronchoscopic procedure was successful and symptoms related to BPF disappeared following closure by the AVP. The results were maintained over a median follow-up of 9 months (range: 5-34 months).

Conclusions: Endobronchial closure using the AVP is a safe and effective method for treatment of small postoperative BPF. The ease of their implantation by bronchoscopy under conscious sedation adds this novel technique to the armatorium of minimally invasive modalities for the treatment of small BPF.
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http://dx.doi.org/10.1016/j.ejcts.2011.02.080DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3241098PMC
January 2012

Endobronchial closure of bronchopleural fistulae using amplatzer devices: our experience and literature review.

Chest 2011 Mar;139(3):682-687

Department of Pediatric Cardiology, Schneider Children's Medical Center of Israel, Petah Tiqwa; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.

Bronchopulmonary fistulae (BPFs) are a severe complication of lobectomy and pneumonectomy and are associated with high rates of morbidity and mortality. We have developed a novel, minimally invasive method of central BPF closure using Amplatzer devices (ADs) that were originally designed for the transcatheter closure of cardiac defects. Ten patients with 11 BPFs (eight men and two women, aged 66.3±10.1 years [mean±SD]) were treated under conscious sedation with bronchoscopic closure of the BPFs using ADs. A nitinol double-disk occluder device was delivered under direct bronchoscopic guidance over a guidewire into the fistula. By extruding a disk on either side of the BPF, the fistula was occluded. Bronchography was performed by injecting contrast medium through the delivery sheath following the procedure to ensure correct device positioning. In nine patients, the procedure was successful and symptoms related to the BPF disappeared following closure by the AD. The results were maintained over a median follow-up period of 9 months. Therefore, we state that endobronchial closure using an AD is a safe and effective method for treatment of a postoperative BPF.
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http://dx.doi.org/10.1378/chest.10-1528DOI Listing
March 2011

Diagnosis and percutaneous closure of a large coronary fistula.

Echocardiography 2011 Feb;28(2):248-52

Department of Cardiology, Assaf Harofeh Medical Center, Zerifin, Israel.

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http://dx.doi.org/10.1111/j.1540-8175.2010.01283.xDOI Listing
February 2011