1. PROF. DR. ALPAY ÇELIKER

5. Complication is destiny of the every pediatric cardiologist who is working at interventional area.

6.  Patient related  Intervention related  Operator related  Catheter & device related  Miscellaneous

7.  Age and BW  Severity of underlying heart disease  Previous intervention and operation  General status of the patient Heart Failure Hypoxia Acidosis Electrolyte imbalance Bleeding diathesis Neurologic status Other conditions related with syndromic patients

8. Type of Intervention Duration of intervention Difficulty of procedure Supply of Needed Devices Enough number and type Appropriate alternatives Beware of “reuse” catheters and devices

9. First and second operator Experince level Competence at alternative methods Anesthesia Intervention familiar Echocardiographist Competent associated personal: Nurse, technician Surgical back-up when needed

10.  Not appropriate  “Reuse”  Not indicated  Very stiff or floopy; short-long, small internal diameter  Newer catheter and devices

11.  Relatively safe; but carries risk at small ages/body weight; and bad hemodynamic condition  May occur any phase from the beginning to a few weeks

12.  Small age and body weight  Complex procedures  Severe underlying heart disease Large VSD in an infant Hybrid procedures Patients at CICU

13.  Beginners may have more complications  Personal first interventions  Beginning of a new method More experience may lead less complications.

14.  High degree difficulty regarding the  Manipulation  Imaging  Alternative routes  Unique complications  Rhythm problems  Semilunar (aortic valve) regurgitation  Av valve (Tricuspid>mitral)  LV perforations

15.  Preoperative planning  Previous operations & interventions  Latest clinical&echocardiographic evaluation (>1 week)  Indivudialized planning for each patient  Continuous monitoring for the complications  Do not lean any body (including nurses and anesthesia team)  Intervene before the final phase of the complication  Prepare to solve for the possible complications at the cath lab.

17.  Brachial plexsus injury  Usually temporary  Treatment: Time and physical rehabilitation  May occur direct puncture, local anesthesic infiltration

18.  Specifically in small kids  Stiff and large catheters and sheaths  Vigorous and uncontrolled manipulation  Close follow-up during manipulation  Correct equipment/technique and meticulous work

19.  Inadvertent catheterization of coronary arteries  Emboli (air, clot) at coronary circulation

20.  Sinus bradicardia : May occur secondary to catheter manipulation, anesthesia >>> controlled respiration, atropine IV  Bundle branch blocks: Catheter or wire travma to the conduction system  Tachycardia (VT>SVT) Stop the catheter movement or pull back Pullback or reposition the catheter Kardiyoversiyon 0.5 joule/kg

21. Complete AV block  Catheter/wire/ sheath/ device trauma to the conduction system  It is very important since it may be related with the early or late permanent AV block Pull-back or reposition the catheter. If it recurs with unforced and appropriate catheter manipulation consider to abandone the procedure

22.  Blood loss, anemia, shock  Hemolysis  Hypotermia  Hypoxia, acidosis  Allergic reactions  Malign hypertermia  Infection

23. The most common reasons are incorrect device size/type selection and imaging problems May cause hemodynamic problems LV, RV, ascending aorta Percutaneous extraction tolls should be on the shelf Surgical backup may be needed

28. General Measures: Hemodynamic status Cardiac rhythm Blood and blood products Surgical backup Another cardiologist (if needed) Equipment Sheaths Snares Bioptome Various catheters

29. Gooseneck Snare Endomyocardial Biopsy Forceps

30. Embolization site is very important Echocardiographic imaging is very important ıf embolizations would occur to the ventricles. Generally, there is no rhythm problems, and hemodynamic deterioriation at aortic and pulmonary embolization Planning of device capture and extraction route Always monitor the arterial pressure 30

31. > 2F form the delivery sheath Braided sheaths should be used 31

32. Must have appropriate inner lumen diameter/lenght for the capture device/snare High torque capability. Longer than the sheath Usually Judkins right coronary artery catheter 32

33. Capture of the device Devices embolized to the ventricles should be expelled to the great vessels to prevent AV valve chordae or semilunar valve damage. Device should be catched from the delivery hub One may try to capture the delivery hub as proximal as possible to facilitate to extraction Pullback of the device inside the sheath Do not move the device before the pullback of the device inside the sheath If there would be a diffculty for pulbback one can move the catheter very cautiously. 33

34.  Detailed history, clinical, laboratory, ECHO,, catheter and surgical data of the patient  Anticipate the possible complications  Usage of appropriate equipment  Do not force the catheter, test injections  Continuous monitoring for the complications  Working careful and patience  Knowing how do you solve the complication.

35. Every effort should be instituted to prevent complications This measures may be paramount importance in sick/small children  Prepare for unexpected complications in every patients.  Appropriate equipment and surgical back-up is very important to manage the complications.