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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3737_Библиотеки_им_академика_М_И_Перельмана
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https://t.me/med1917
T. Safder et al.
ab
Fig. 7 ICE Bi-caval view visualizing the IAS. Right
atrium (RA), Left atrium (LA), Arrow-points towards
catheter tip in RA (Panel a) and shows tenting of IAS
Heart Team Approach
andDiscussion
Once a determination is made as to the potential
benet of an IASD for the patient, procedural
feasibility should be assessed. While there are a
few absolute contraindications to the Corvia
IASD (Table4), special precaution must be taken
with the presence of intracardiac leads as the
device could impinge or trap the leads causing
lead malfunction, difculty with future lead
exchange or worsening of tricuspid regurgitation
due to increased tension on the lead.
Heart Team Decision
Since our patient was conrmed to have type I
HFpEF with hemodynamic exercise testing, it
was likely he would benet from an IASD based
therapy option. Additionally, our patient did not
meet any absolute contraindications and did not
have any intracardiac leads and so likelihood of
procedural success was deemed to be high.
Decision was made to move forward with IASD
implantation.
(Panel b) into LA at the optimal location of transeptal
puncture, near the center of foramen ovalis
Absolute contraindication for Corvia IASD
Table 4
Absolute contraindications
HCM, constrictive pericarditis, inltrative
cardiomyopathies (i.e. amyloid, sarcoid)
Unable to tolerate procedural or post-procedural
anti-coagulation/anti-platelet regimen
Signicant RV dysfunction
Intraprocedural Imaging Modalities
andMeasurements
Below are the key steps and imaging highlights
of an IASD, more specically the Corvia device,
deployment using ICE.Alternatively, a TEE can
also be used for device deployment.
Key
procedural
steps Key imaging highlights
Transeptal
puncture
– Conrm presence
of adequate space
for placement of
IASD without
impinging on
other structures
(20mm diameter
when fully
deployed)
– Optimal position
of transeptal
puncture is center
of fossa ovalis
Correlated
video/gure
– Figure 7
– Video 1
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Key
procedural
steps Key imaging highlights
Delivery
system
guidance
Device
positioning
Device
deployment
– Aid in guidewire
positioning in to
the LA and
pulmonary vein
followed by
advancing of
delivery system
over the wire and
into the left atrium
– The catheter tip
should be
positioned in the
mid-LA cavity
– The LA legs and
barrel of the
device are
deployed rst
– Next, the delivery
system is
retracted until the
LA legs make
contact with the
interatrial septum.
A slight amount
of tension is held
on the septum
with the LA legs
while
echocardiographic
visualization
conrms good
positioning of the
device and good
LA legs-septal
contact
– While
maintaining that
slight tension on
the septum, the
RA legs are
deployed
– Deployment of
the RA legs
releases the
device from the
delivery system
– It is important to
note presence and
positioning of any
intra-cardiac leads
as to avoid
entrapment of the
leads within the
device
Correlated
video/gure
– Figure 8
– Figures
9, 10, 11
and 12
– Videos
2, 3 and
4
Key
procedural
steps Key imaging highlights
Delivery
system
withdrawal
Evaluation
post
deployment
– Under
uoroscopic and
echocardiographic
guidance, conrm
slow withdrawal
and position of
the delivery
system into the
RA
– Once in the RA,
the closed
delivery system
can be fully
removed but the
guidewire is kept
in place until post
deployment
evaluation can
conrm good
device
deployment and
function
– Proper positioning
and function of
the device is
conrmed with
echocardiographic
and uoroscopic
imaging
– Direction of shunt
ow should be
conrmed by
echocardiography
– After conrmation
of proper
placement and
function of
device, guidewire
can be carefully
removed as not to
get it entangled
within the device
Correlated
video/gure
– Figure
13
– Video 5
Post procedural Assessment
Possible adverse events associated with IASD
implantation include the same risks associated
with other cardiac catheterization procedure with
instrument manipulation within the cardiovascular system. They range from access site complications, arrhythmias, to cardiac perforation,
256
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T. Safder et al.
tamponade and cardiac arrest to name a few notable ones. Complications related more specically
to the IASD device include embolization of the
device, device thrombus formation, and intracardiac lead malfunction due to entrapment within
the device.
Most patients, barring any procedural complications, recover well and are able to go home the
next day. Our patient did well post-procedure and
was discharged home the next day. Follow up
plan can vary depending on institution protocols
but follow up in clinic is typically in 1 month
with a TTE follow up in 4–6months. Decision on
Fig. 8 ICE Bi-caval view conrming successful septal
puncture and positing of guidewire in LA.Right atrium
(RA), left atrium (LA)
anti-platelet and anti-coagulation therapy varies
with patient characteristics (i.e. atrial brilla-
ab
Fig. 9 ICE Bi-caval view. Arrow shows deployment of device legs on the LA side with septal contact (Panel a). Arrow
(Panel b) shows deployment of device legs on the RA side
Fig. 10 TEE 3D image showing LA legs deployed in LA but prior to retraction of device towards the septum (Panel a),
while panel b showing a fully deployed IASD device from LA
ab
ab
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Fig. 11 RAO cranial uoroscopic view shows (arrow) position of partially deployed device with legs in the LA (Panel
a). RAO caudal uoroscopic view showing (arrow) fully deployed device (Panel b)
257
Fig. 12 Stable position of the device (arrow) immediately after deployment (Panel a) and color Doppler through the
device where Left to right shunt ow (arrow) can be appreciated (Panel b). Right atrium (RA), left atrium (LA)
tion). But generally, dual anti-platelet therapy is
administered for 6months and then can typically
be discontinued. If a patient is on oral anticoagulant for a different indication prior to device
implantation, the OAC can continued post procedure. Our patient was on OAC due to his atrial
brillation and he was instructed to continue his
OAC at discharge.
At subsequent follow ups, our patient reported
signicant improvement in his dyspneic symp-
toms. At 4months, patient reported he was able
to walk a mile without signicant symptoms.
Patient was designated to have NYHA I–II
symptoms (improved from NYHA III). His
6month follow up TTE noted stable position of
IASD and continued left to right shunt (Fig.13).
Patients with HFpEF remain a challenging
group of patients to manage but IASD therapy
appears to be a promising therapeutic option in
appropriately selected patients.
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T. Safder et al.
Fig. 13 ICE Bi-caval view with continuous wave Doppler
through the device which shows predominantly continuous left to right shunt ow (Panel a). Six month follow up
Key Points
– HFpEF is a complex disease process with a
multifactorial etiology and thus treatment
options for these patients must be individualized to their specic risk factors.
– Categorizing HFpEF patients by specic phe-
notypic classes (type I, II or III) may help
guide device based therapy.
– Symptomatic HFpEF patients with elevated
LA pressures but without signicant PH or RV
dysfunction, may benet from LA decompression therapy with an ISAD.
TTE (subcostal view) showing patent left to right ow
from IASD (Panel b)
C. Peak exercise PCWP 26mmHg, Exercise
PVR 1.4 WU, TAPSE 20 mm, RV FAC
45%
D. Peak exercise PCWP 26mmHg, Exercise
PVR 1.4 WU, TAPSE 8 mm, RV FAC
20%
Answers
A. Incorrect. These are essentially normal
values and would not benet from a IASD
B. Incorrect. While this patient does have
elevated left sided cardiac pressures, as
evidenced by an elevated exercise PCWP,
the signicant PVD (PVR 3 WU) likely
makes this patient a poor candidate for
Chapter Review Questions
IASD therapy
C. Correct answer. This patient might benet
1. In the context of ndings from REDUCE
LAP-HF II trial, a patient with which of the
following hemodynamic prole might benet
from a IASD therapy?
A. Peak exercise PCWP 14mmHg, Exercise
PVR 1 WU, TAPSE 20 mm, RV FAC
45%
B. Peak exercise PCWP 26mmHg, Exercise
PVR 3 WU, TAPSE 20mm, RV FAC 45%
from IASD therapy. In a sub-group analysis of REDUE LAP-HF II, a positive signal was found in patients with elevated
left sided pressures but without signicant
PVD(peak exercise PVR<1.74 WU).
D. Incorrect. The signicant RV dysfunction
in this patient makes them a poor candidate for IASD therapy as these patients
were excluded from IASD trials.
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2. Which of the following is not an absolute contraindication for the Corvia IASD?
A. Intracardiac leads
B. Severe RV dysfunction
C. Inltrative cardiomyopathy
D. Recent history of life threatening bleeding
episode
Answer
Correct answer A.Presence of intracardiac
leads should be noted pre-procedurally and
caution should be taken during procedure as
not to entangle device with leads but it does
not preclude placement of an IASD as a possible treatment option. The other choices are
all absolute contraindications.
3. What is the optimal position for a transeptal
puncture for the Corvia IASD?
A. Center of fossa ovalis
B. Midpoint of IAS
C. Anywhere in the top 1/3 of IAS
D. Anywhere in the bottom 1/3 of IAS
Answer
Correct Answer A.Center of fossa ovalis is
the most optimal position for transeptal
puncture.
4. Which of the following classes of medications
have shown mortality benet in patients with
HFpEF?
A. Beta blockers
B. ACEi/ARBs
C. ARNI
D. SGLT2 inhibitors
E. None of the above
Correct answer D.So far, only SGLT2 inhibitors have shown mortality benet in a robust
RCT in patients with HFpEF. EMPERORPRESERVED showed that SGLT2 use
reduced the combined risk of CVD death or
HF hospitalization in HFpEF patients.
References
1. Emani S, Burkhoff D, Lilly SM. Interatrial shunt
devices for the treatment of heart failure. Trends
Cardiovasc Med. 2021;31(7):427–32. https://doi.
org/10.1016/J.TCM.2020.09.004.
2. Maggioni AP, Dahlström U, Filippatos G, et al.
EURObservational research Programme: regional
differences and 1-year follow-up results of the heart
failure pilot survey (ESC-HF pilot). Eur J Heart
Fail. 2013;15(7):808–17. https://doi.org/10.1093/
EURJHF/HFT050.
3. Tsao CW, Lyass A, Enserro D, etal. Temporal trends
in the incidence of and mortality associated with heart
failure with preserved and reduced ejection fraction. JACC Hear Fail. 2018;6(8):678–85. https://doi.
org/10.1016/J.JCHF.2018.03.006.
4. Roger VL. Epidemiology of heart failure. Circ
Res. 2021;128:1421–34. https://doi.org/10.1161/
CIRCRESAHA.121.318172.
5. Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022
AHA/ACC/HFSA guideline for the management
of heart failure: a report of the American College of
Cardiology/American Heart Association joint committee on clinical practice guidelines. Circulation.
2022;145(18):e895–e1032. https://doi.org/10.1161/
CIR.0000000000001063.
6. Borlaug BA, Redeld MM.Diastolic and systolic heart
failure are distinct phenotypes within the heart failure
spectrum. Circulation. 2011;123(18):2006–13. https://
doi.org/10.1161/CIRCULATIONAHA.110.954388.
7. Shah SJ, Borlaug BA, Kitzman DW, etal. Research
priorities for heart failure with preserved ejection fraction: National Heart, Lung, and Blood
Institute working group summary. Circulation.
2020;141:1001–26. https://doi.org/10.1161/
CIRCULATIONAHA.119.041886.
8. Grifn JM, Borlaug BA, Komtebedde J, etal. Impact
of interatrial shunts on invasive hemodynamics and
exercise tolerance in patients with heart failure. J
Am Heart Assoc. 2020;9(17):16760. https://doi.
org/10.1161/JAHA.120.016760.
9. Shah SJ, Borlaug BA, Chung ES, et al. Atrial shunt
device for heart failure with preserved and mildly
reduced ejection fraction (REDUCE LAP-HF II): a
randomised, multicentre, blinded, sham- controlled
trial. Lancet. 2022;399:1130–40. https://doi.
org/10.1016/S0140- 6736(22)00016- 2.
10. Eisman AS, Shah RV, Dhakal BP, etal. Pulmonary
capillary wedge pressure patterns during exercise
predict exercise capacity and incident heart failure.
Circ Heart Fail. 2018;11(5):e004750. https://doi.
org/10.1161/CIRCHEARTFAILURE.117.004750.
Part IV
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Percutaneous Therapeutic Intervention in
Adult Congenital Heart Diseases
Patent Foramen Ovale andAtrial
https://t.me/med1917
Septal Defect
AkenDesai, EdwardGill, andJohnCarroll
Abstract
Patent Foramen Ovale (PFO) is the most common congenital cardiac abnormality and
found in ~25% of all adults. PFO results from
the failed closure of the foramen ovale and is
associated with an increased risk of stroke in
symptomatic patients and recent trials have
demonstrated the utility of PFO closure for the
prevention of recurrent stroke in patients with
cryptogenic stroke and PFO.Imaging plays an
important role in determining both the presence of a PFO as well as its suitability for closure in a patient with cryptogenic stroke.
Atrial septal defects are the third most common congenital defect (after PFOs and bicuspid aortic valve) but are often asymptomatic
until adulthood. Complications of undetected
ASDs include arrythmia, paradoxical embolization, cerebral abscess, right ventricular (RV)
volume overload with late RV failure, and
potentially irreversible pulmonary hypertension. This chapter explores the indications and
important imaging features in diagnosis, preprocedural planning and interventional closure of PFOs and ASDs. The heart team
discussion highlights the multifactorial
approach regarding surgical vs. percutaneous
closure and device choice.
Keywords
Atrial septal defect · Patent foramen ovale ·
Inter-atrial shunting · Percutaneous closure
devices
Supplementary Information The online version contains supplementary material available at https://doi.
org/10.1007/978- 3- 031- 50740- 3_10.
A. Desai (*) · E. Gill · J. Carroll
Division of Cardiology, University of Colorado
School of Medicine, Aurora, CO, USA
e-mail: aken.desai@cuanschutz.edu;
edward.gill@cuanschutz.edu;
john.carroll@cuanschutz.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
A. M. Kelsey et al. (eds.), Cardiac Imaging in Structural Heart Disease Interventions,
https://doi.org/10.1007/978-3-031-50740-3_10
263
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Test your learning and check your under-
standing of this book’s contents: use the
“Springer Nature Flashcards” app to
access questions using ▶ https://sn.pub/
ambACS.
To use the app, please follow the instruc-
tions in the chapter “Transcatheter
Aortic Valve Replacement.”
Learning Objectives
1. Identify the indication for closure of interatrial shunts
2. Understand the differences in the evaluation
of patent foramen ovale and atrial septal
defects
3. Understand the role of multimodality imaging
in atrial septal defects
4. Understand sizing of devices for patent foramen ovale and atrial septal defects
5. Understand the intra-procedural imaging
needs for patent foramen ovale and atrial septal defects
Case Study
A 34-year old woman with no major medical history presents with acute left sided
weakness and aphasia approximately
90 min prior to arrival. A CT angiogram
reveals an acute right middle cerebral
artery territory ischemic stroke of the M3
segment. She undergoes acute thrombectomy with retrieval of a small thrombus
from the M3 segment. Her symptoms
resolve and she is admitted to the neurology service for post-stroke care.
Background andDenitions
PFO: Inter-atrial shunts encompass a broad variety of defects, most of which are discovered in
childhood given increased awareness in the pediatric community. Of those which make it into
A. Desai et al.
adulthood without treatment, the vast majority
are patent foramen ovale with a smaller number
of patients presenting with true atrial septal
defects, most commonly ostium secundum
defects. PFOs are not considered atrial septal
defects by many as they are not a true deciency
of tissue but a remnant of fetal circulation [1].
For the purposes of this chapter, we will focus on
patent foramen ovale given it is the predominant
lesion that seen in adults while addressing issues
important to the management of true atrial septal
defects. At least in a small series of adults presenting with paradoxical embolism, PFO was
seen in 57% of patients vs ASD in 43% of
patients [2].
The patent foramen ovale is a remnant of the
fetal circulation that is a ap like defect. The
PFO begins in the fossa ovalis on the right atrial
side and ends with the ostium secundum on the
left atrial side. In fetal circulation, this structure
is open due to the right atrial pressure being
higher than left atrial pressure. With the rst
breath after birth, the left atrial pressure
becomes higher than the right atrial pressure
and the septum primum on the left side compresses onto the secundum on the right side.
These two layers then fuse and create the
largely impermeable inter-atrial septum.
However, incomplete fusion results in a the patent foramen ovale [1]. Autopsy studies have
shown this incomplete fusion to be present in
about 25% of the population but there is a wide
spectrum of patency ranging from only probe
patent to widely patent and shunting signicantly without provocative maneuvers [3].
Other types of atrial septal defects can be
found in the evaluation of patients with cryptogenic stroke as all defects are associated with
some degree of right to left shunting.
ASD: ASDs represent the third most common
congenital defect (after PFO and bicuspid aortic
valve). The most common type of atrial septal
defect in adults is a septum secundum defect and
this represents 60–80% of atrial septal defects.
These are typically caused by incomplete formation of the fossa ovalis and surrounded by infolded atrial wall that forms the rims of the
defects. Septum primum defects are likely better
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265
referred to as atrio-ventricular septal defects as
they are commonly associated with abnormalities
of the atrio-ventricular valves, atrio-ventricular
conduction and left ventricular outow tract.
These are most seen in patients with Downs’ syndrome. Sinus venosus ASDs are due to either
vena cava (most commonly the superior vena
cava) over-riding the inter-atrial septum and are
associated with anomalous pulmonary venous
return. Lastly, coronary sinus ASDs are due to
deciency of the coronary sinus—atrial wall with
drainage directly into the left atrium and are associated with persistent left SVCs [4].
Diagnosis andPre-procedural
Assessment
Given the patient’s MCA stroke, an evaluation
for embolic source is warranted. As the initial
evaluation for potential cardiac sources of emboli,
the patient underwent transthoracic echocardiography with microbubble injection revealing an
intermittent right to left shunt at rest (thus no
Valsalva was performed) (Fig.1 and Video 1).
Additionally, further testing for potential
causes of stroke was undertaken. A thorough
evaluation for hypercoagulable disorders was
unrevealing. Guideline directed malignancy
screening should be considered in appropriate
patients and was negative in this case. She is not
found to have atrial brillation on telemetry
while admitted and a post-discharge 14-day event
monitor shows no signicant arrhythmias. No
deep venous thrombosis is found on venous
duplex imaging. She is discharged 3days after
presentation with no residual neurologic decits
on aspirin and clopidogrel.
In patients with cryptogenic stroke, there are
ve primary goals to pre-procedure imaging:
understanding the mechanism of stroke, the presence of intra-cardiac shunts, the anatomy of the
shunt, the physiologic signicance of the shunt
(degree of shunting) and lastly identication of
anatomies which may prove challenging for
device closure.
PFO: Anatomically, patent foramen ovales are
evaluated based on degree of right to left shunting and features that correlate with increased
likelihood of paradoxical embolization. Although
several different methods of quantifying the
degree of shunt exist, for the purposes of determining eligibility for the trials that demonstrated
efcacy of PFO closure for reducing recurrent
stroke, large shunts are typically dened as
greater than 20–25 microbubbles seen within 4
beats after arrival on the right sided chambers.
“Massive” shunts are typically called when there
Fig. 1 Transthoracic 4
chamber view of
microbubble injection
revealing right to left
shunt at rest
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