Shunt Closure Research Articles

Cupping of the left atrial disc: a new echocardiographic pointer towards atrial septal defect-device mismatch

We report a case of percutaneous atrial septal defect closure (ASD) in which, despite careful device selection and successful shunt closure, a number of adverse echocardiographic features developed, necessitating surgical extraction of the device and patch closure of the defect. Lessons regarding case selection, device choice, appropriate follow-up and recognition of adverse echocardiographic features can be learned from this experience.

The persistent primitive marginal sinus—observations in children with Vein of Galen malformation

Knowledge of venous anatomy and drainage in children with neurovascular diseases is crucial. The primitive marginal sinuses (PMS) are embryonic sinuses forming the later superior sagittal sinus. Their angiographic persistence has not been reported before. The purpose of this study is to demonstrate the angiographic characteristics in children with Vein of Galen malformation and to discuss their embryology and clinical significance. We retrospectively reviewed digital subtraction angiography and magnetic resonance venography of 102 Vein of Galen malformations (VGM) from the database of two high-load centres for paediatric neurovascular diseases. We found 10 persistent PMS in 102 children indicating a frequency of 9.8%. Illustrative cases are shown to demonstrate the vast spectrum of venous variability. The PMS becomes visualised in situations of high-flow arteriovenous shunt in children and can even disappear or remodel after successful shunt reduction or closure. Knowledge and recognition of the PMS are important for neurointerventionalists in endovascular treatment planning using the transvenous route and can help neurosurgeons in avoiding severe surgical complications.

Surgical treatment for portosystemic encephalopathy in patients with liver cirrhosis: Occlusion of portosystemic shunt in combination with splenectomy

Operative ligation of the portosystemic shunt may control hepatic encephalopathy effectively, but the subsequent increase in portal vein pressure (PVP) leads to high mortality. Splenectomy can decrease inflow into the portal system, resulting in decreased portal pressure. We retrospectively examined the effect of splenectomy in combination with shunt closure on portosystemic encephalopathy. Clinical symptoms of encephalopathy disappeared in all six patients who underwent splenectomy in combination with portosystemic shunt ligation, with the exception of one patient who had relapsing encephalopathy after 6 months. Follow-up computed tomography showed complete obliteration of the portosystemic shunts, except in the one patient with relapsing encephalopathy who underwent balloon-occluded retrograde transvenous obliteration for the remaining splenorenal shunt 8 months after surgery. PVP significantly decreased after splenectomy. PVP did not increase to the baseline PVP value after ligation of the shunts, except in two patients who had elevated PVP after surgery: PVP increased from 18 to 19 mmHg after ligation in one patient and from 18 to 23 mmHg in one patient. Splenectomy followed by surgical ligation of the portosystemic shunt may be feasible and safe for cirrhotic patients with portosystemic shunts.

Percutaneous ASD Closure in a Large Australian Series: Short- and Long-Term Outcomes

To assess the clinical and echocardiographic outcomes in patients referred for device closure of atrial septal defects in a tertiary referral hospital in Australia. A prospective follow-up study was performed on all patients who had device closure of a secundum atrial septal defect (ASD) from June 1999 to December 2007. Clinical and echocardiographic data at the time of implantation and follow-up is presented. 176 patients were referred for shunt closure of ASD. All patients had a significant shunt defined as a shunt with right heart dilatation and/or a shunt ratio of at least 1.5:1. The majority were female (67%) and the average age was 36.5 ± 22.7 years; age range 3-84. The average hospital admission time was 2.5 ± 1.7 days. The average follow-up occurred at 3.7 ± 3.6 months for the first follow-up and 26.3 ± 18.2 months (range 3 months-7.8 years) for the long-term follow-up. Baseline echocardiogram findings showed the majority had a normal left ventricular ejection fraction (99%); average LVEF=63.2 ± 7.2% while the right ventricle was dilated in 61% of patients. Procedure information: The average procedure time was 94.8 ± 36.4 min. Procedural imaging was performed using Transoesophageal echocardiography (TOE) in 107 cases (61%); Intracardiac Echocardiography (ICE) in 69 (39%). Device use was as follows: Amplatzer=156 cases, Helex=18, and Starflex=2. Postprocedure shunt assessment by transthoracic echocardiography showed successful closure (no shunt or trivial shunt) in 99% cases. Two patients were referred for inpatient surgery due to a significant residual shunt in one case and an unstable device in another. One patient who had an unstable device had their device repositioned successfully. Atrial arrhythmia was the most common complication occurring in the peri-implantation period in 12 cases (6%) with four further cases at final up. The high prevalence of right ventricular dilatation in 65% patients at baseline had improved significantly at the first and long term follow-up to 2% (p=0.0001). Device closure of secundum atrial septal defects in this large Australian cohort demonstrates a high procedural success rate with a low incidence of complications in the short and long term.

The Effect of Patent Foramen Ovale Closure on Visual Aura Without Headache or Typical Aura With Migraine Headache

The aim of this study was to assess the prevalence of right-to-left (R to L) shunt in patients with visual aura and evaluate the effect of shunt closure on resolution of aura. Right-to-left shunting is associated with migraine headache (MH) with aura. Some patients present with visual aura without headaches. It is unclear whether visual aura without headache is a form of migraine or a transient neurologic dysfunction. Of patients referred to the University of California, Los Angeles for suspected patent foramen ovale (PFO), 225 had visual aura with or without MH. Patients were assessed for a shunt and evaluated for MH and/or visual aura. They were divided into 3 groups: 1) visual aura associated with MH; 2) visual aura unrelated in time to MH; and 3) visual aura without MH. The frequency of R to L shunt was compared with a control group of 200 patients. Eighty patients underwent PFO closure. Residual shunts, MH, and visual aura were reassessed after 3 and 12 months. The prevalence of R to L shunt in Groups A, B, and C was 96%, 72%, and 67%, respectively, versus 18% in the control group (p < 0.0001). The frequency of shunting was similar in Group B versus Group C, but much higher in all 3 groups compared with control subjects. Twelve months after PFO closure, symptoms of aura were resolved in 52%, 75%, and 80% of patients in Groups A, B, and C, respectively (p = NS). The similar distribution of R to L shunting in all 3 patient groups and the correlation between PFO closure and improvement of aura suggests a similar pathophysiology between the presence of PFO and the visual aura phenomenon, whether or not headache is present in the symptom complex.

Percutaneous closure of atrial right-to-left shunt in patients with Ebstein’s anomaly of the tricuspid valve

Patients with Ebstein's anomaly of the tricuspid valve may have right-to-left shunt at atrial level resulting in hypoxaemia, high haematocrit and hyperviscosity syndrome. The purpose of this study was to assess the results of percutaneous closure of atrial right-to-left shunt in patients with Ebstein's anomaly. Records of patients treated between January 2002 and June 2010 were reviewed. Their condition before and after shunt closure (clinical data, oxygen saturation and haematocrit) were studied. During this period nine selected patients with Ebstein's anomaly and right-to-left shunt at atrial level were treated. Ages ranged from six to 67 years; seven were male. Mean pulmonary artery pressures were under 25 mmHg in all. Three patients had previous episodes of stroke and three had very high haematocrit, two of whom required therapeutic phlebotomies. Test occlusion of the shunt was performed in all patients with a balloon catheter, revealing an increase in systemic oxygen saturation, with right atrial pressures remaining <18 mmHg in all. Percutaneous closure of atrial shunt was achieved in all. There were no major complications. Arterial oxygen saturations increased in all patients from 85.0 ± 4.5% to 96.7 ± 1.5% (mean ± standard deviation). Medium follow-up was five years. The three patients with very high haematocrit levels had a decrease in its values from 62.9 ± 2.8% to 45.5 ± 3.9% after device occlusion. Both therapeutic phlebotomy programs were discontinued. All patients reported a marked improvement in effort tolerance. Percutaneous closure of atrial right-to-left shunt in selected patients with Ebstein's anomaly offers significant improvement, abolishing hypoxaemia and hyperviscosity and preventing paradoxical embolisation.

Chemoembolic Hepatopulmonary Shunt Reduction to Allow Safe Yttrium-90 Radioembolization Lobectomy of Hepatocellular Carcinoma

Yttrium-90 ((90)Y) radioembolization represents an emerging transcatheter treatment option for the management of hepatocellular carcinoma (HCC). Elevation of the hepatopulmonary shunt fraction risks nontarget radiation to the lungs and may limit the use of (90)Y therapy in patients with locally advanced disease with vascular invasion, who often demonstrate increased shunting. We present two cases in which patients with HCC and portal vein invasion resulting in elevated hepatopulmonary shunt fractions underwent chemoembolic shunt closure to allow safe (90)Y radioembolization. Both patients demonstrated excellent tumor response and patient survival. On this basis, we propose a role for chemoembolic reduction of the lung shunt fraction before (90)Y radioembolization in patients with extensive tumor-related hepatopulmonary shunting.

AS-194: Percutaneous Device Closure of Latrogenic Gerbode Shunt in 3 Months Old Patient

AS-194: Percutaneous Device Closure of Latrogenic Gerbode Shunt in 3 Months Old Patient

Surgical outcomes for patients with pulmonary atresia/major aortopulmonary collaterals and Alagille syndrome

Pulmonary atresia with major aortopulmonary collateral arteries (PA/MAPCAs) is a complex congenital heart defect that has undergone significant advances in treatment over the past 15 years. A small subset of patients with PA/MAPCAs have associated Alagille syndrome, which can have an adverse impact on many other organ systems. The purpose of this study was to review our institutional outcomes for the surgical patients with PA/MAPCAs and Alagille syndrome. This was a retrospective review of patients with PA/MAPCA's and Alagille who underwent surgical reconstruction from November 2001 to August 2011. Fifteen patients were identified in our data base. Thirteen had pulmonary atresia with ventricular septal defect (PA/VSD) and two had pulmonary atresia with intact ventricular septum (PA-IVS). There has been no early or late mortality in this cohort of 15 patients with PA/MAPCA' and Alagille syndrome. The patients have undergone a total of 38 cardiac surgical procedures. Ten of the 13 patients with PA/VSD have achieved complete repair, including unifocalization, a right ventricle to pulmonary artery conduit and closure of all intra-cardiac shunts. The three unrepaired patients with PA/VSD remain potential candidates for eventual complete repair, while the two patients with PA-IVS remain viable candidates for a single ventricle pathway. The patients in this series have also undergone 12 major non-cardiac procedures. The data demonstrate that surgical reconstruction of PA/MAPCAs can be successfully achieved in patients with Alagille syndrome. The longer-term prognosis remains guarded on the basis of the multi-organ system involvement of Alagille syndrome.

Uncommon acquired Gerbodedefect following extensive bicuspid aortic valve endocarditis

Gerbode defect is a rare type of left ventricle to right atrium shunt. It is usually congenital in origin, but acquired cases are also described, mainly following infective endocarditis, valve replacement, trauma or acute myocardial infarction. We report a case of a 50-year-old man who suffered an extensive and complex infective endocarditis involving a bicuspid aortic valve, the mitral-aortic intervalvular fibrosa and the anterior leaflet of the mitral valve. After dual valve replacement and annular reconstruction, a shunt between the left ventricle and the right atrium - Gerbode defect, and a severe leak of the mitral prosthesis were detected. Reintervention was performed with successful shunt closure with an autologous pericardial patch and paravalvular leak correction. No major complications occurred denying the immediate post-surgery period and the follow-up at the first year was uneventful.

Interventional cardiology in Switzerland during the year 2010

Summary Background: Since 1987, a nationwide annual survey of percutaneous cardiac interventions has been performed in Switzerland to assess trends in endovascular cardiac procedures. Methods: The volume and type of endovascular cardiac procedures performed during the year 2010 were collected by means of a standardised questionnaire from all adult cardiac intervention centres in Switzerland. Results: The number of coronary angiographies (2010: n = 42 648; +2.5% compared to 2009) and percutaneous coronary interventions (n = 19 925; +4.7%) continued to increase with a slight increase in the PCI/CA ratio (46.7%; 2009: 45.7%). After a decrease from 2006 to 2007 and a plateau from 2007 to 2009, the proportion of drug-eluting stents (DES) raised again to 79% in 2010 (2009: 72%). Apart from shunt closures which remained stable (closure of patent foramen ovale [n = 733; 2009: n = 728] and atrial septal defects [n = 142; 2009: n = 152]), the number of procedures for structural heart disease increased in 2010 mainly due to an increasing number of transcatheter aortic valve implantations (n = 382 performed in 11 centres; 2009: n = 277 performed in 8 centres) although the number of procedures for transcatheter mitral valve repair rose as well (n = 67; 2009: n = 33). Conclusions: The number of both CA and PCI procedures increased in Switzerland in 2010 compared with the previous year. However, the most expanding segment of percutaneous cardiac intervention involved those for structural heart disease, namely TAVI.

Intrahepatic Portosystemic Venous Shunt: Successful Embolization Using the Amplatzer Vascular Plug II

A 67-year-old woman presented with memory impairment and behavioral changes. Brain MRI indicated hepatic encephalopathy. Abdominal CT scans revealed an intrahepatic portosystemic venous shunt that consisted of two shunt tracts to the aneurysmal sac that communicated directly with the right hepatic vein. The large tract was successfully occluded by embolization using the newly available AMPLATZERTM Vascular Plug II and the small tract was occluded by using coils. The patient's symptoms disappeared after shunt closure and she remained free of recurrence at the 3-month follow-up evaluation.

巨大門脈大循環シャントによる猪瀬型肝性脳症に対し外科的シャント閉鎖を行った1例

巨大門脈大循環シャントによる猪瀬型肝性脳症に対し外科的シャント閉鎖を行った1例

Double BioDisk: a new bioprosthetic device for transcatheter closure of atrial septal defects - a feasibility study in adult sheep

BackgroundTo evaluate the long-term effectiveness and safety of a new Double BioDisk (DBD) device for closure of atrial septal defect (ASD).Materials and methods.ASD was created with transeptal needle (TS) followed by balloon dilatation in 12 sheep weighing 40.1 to 64 kg (mean 55.2 ± 7.1). The ASD diameters were measured after creation and two weeks later before DBD implantation. The DBDs consists of two nitinol rings 18 to 28 mm in diameter connected with small cannulas and covered with a porcine small intestinal submucosa (SIS). They were implanted via a 10 Fr sheath. DBD effectiveness was evaluated by angiocardiography and by intra-cardiac echogram (ICE) with Doppler studies. Two animals were acute, two were followed for 6 weeks, three for 3 months, three for 6 months and two for 12 months.ResultsTS punctures were successful in 10 sheep. In two sheep ASD was created by existing PFO dilation. The ASD size ranged from 13–15 mm (mean 14.1± 0.73 mm) after initial balloon dilation and from 9–13 mm (mean 10.06 ± 1.37 mm) after two weeks. In all animals none of the successfully implanted DBDs spontaneously embolized on release or on follow up. ICE demonstrated no shunting around the DBDs during follows ups. Macroscopic and histologic evaluation of the 6, 12, 24 and 52 weeks animals showed that DBDs were well incorporated in the atrial septum with complete shunt closure. The SIS showed progressive remodeling with the host cells, including endothelization of the DBD devices.ConclusionsASD closure with the Double BioDisk is safe and effective in adult sheep.

Transcatheter closure of an iatrogenic aorto-right ventricular fistula

Aortocardiac fistulas are rare, especially if they develop after an aortic valve replacement surgery. We report the case of a 54-year-old male submitted to aortic valve replacement and implantation of an ascending aortic prosthetic graft, complaining of exertional dyspnea, who was found to have significant shunt between the aortic root and right ventricle (RV), and de novo moderate pulmonary hypertension. At the catheterization laboratory, the left-to-right shunt was confirmed (Qp:Qs = 1.9:1). Contrast angiography of the ascending aorta showed a significant flow into the right ventricular cavity, and the fistulous tract was then measured, inflating a Tyshak II balloon of 10 × 20 mm (NuMED, Hopkinton, New York), until achieving a complete interruption of flow. Minimal diameter of the defect was 4.9 mm. Percutaneous closure of the aorto-RV shunt was performed under general anesthesia and transesophageal echocardiogram and fluoroscopic guidance. Using a venous and an arterial femoral access, a 0.035″ hydrophilic guide-wire crossed the defect between the aorta and RV, creating an arteriovenous loop. Then, using a 7F Delivery System 45° (AGA medical corporation, Golden Valley, MN) an Amplatzer Duct Occluder(®) (AGA Medical Corporation) 8/6 mm was advanced and released within the defect, achieving an almost complete closure of the fistulous tract.

Cyanosis due to tricuspid regurgitation

MOTS CLES Echographie We report the case of a 59-year-old woman followed in our institution for an Ebstein anomaly; she had tricuspid valvuloplasty at the age of 56 years, associated with a cavopulmonary anastomosis. The patient presented in our unit with recent exertional dyspnea. Examination revealed no symptom of congestive heart failure at rest. Oxygen saturation was 97% at rest but fell to 85% after a 3-minute walk. Transthoracic echocardiography showed an interatrial bidirectional flow. Contrast echocardiography was markedly positive at rest, confirming the right-to-left shunt. There was no pulmonary hypertension. The cavopulmonary shunt was difficult to visualize. Right ventricular function was good. Moderate tricuspid regurgitation was also present (grade II). Transoesophageal echocardiography (TEE) and percutaneous shunt closure were

Abstract 17001: Safety and Efficacy of Balloon Atrial Septostomy for Advanced Pulmonary Hypertension in Patients Failing Prostanoid Therapy

Background: Prostanoid therapy improves quality of life and may increase survival in patients with advanced pulmonary hypertension (PH). Balloon atrial septostomy (BAS) can palliate or a serve as a bridge to transplantation for patients resistant to medical therapy. The safety and efficacy of BAS in the era of prostanoid therapy has not previously been reported. Methods: All patients had progressive symptoms despite prostanoid therapy at the time of their first BAS. Eleven patients who underwent a total of 16 septostomies between 2004-11 were included in this retrospective analysis. Results: Baseline demographics are shown in Table 1. Survival at a mean of 739 days was 73%. No patient died within 24 hours post-procedure. Thirty-day and 1-year survival were both 82%. 4 subjects required repeat BAS due to shunt closure; 3 subjects were successfully bridged to transplant. 9 of 11 patients had improvement by one functional class. Hemodynamic and echocardiographic measurements are presented in Table 2. All non-survivors were male and had higher baseline serum creatinine, mean right atrial pressure, right ventricular (RV) end diastolic pressure and left ventricular filling pressures, and lower RV ejection fraction. Mortality was associated with unchanged post-septostomy cardiac output despite an increase in LVEDP. Tricuspid annular plane systolic excursion (TAPSE) and serum BNP were not different between the two groups. Conclusions: BAS appears to be a promising therapy for select PH patients who have symptomatic progression despite prostanoid therapy. Survival is comparable to prior reports of patients undergoing BAS in the pre-prostanoid era.

Successful shunt closure and improvement of hemodynamics in an ASD patient with severe pulmonary arterial hypertension and small shunt following a long-term use of bosentan

Successful shunt closure and improvement of hemodynamics in an ASD patient with severe pulmonary arterial hypertension and small shunt following a long-term use of bosentan

Ocular pulse amplitude measured by PASCAL dynamic contour tonometry in patients with a cavernous sinus dural arteriovenous fistula

Ocular pulse amplitude measured by PASCAL dynamic contour tonometry in patients with a cavernous sinus dural arteriovenous fistula

Intraoperative contrast echocardiography to verify the surgical occlusion of a single extrahepatic portosystemic shunt in a dog

This report details a bubble echocardiographic study carried out during the surgical treatment of a congenital single extrahepatic portosystemic shunt (PSS) in a Labrador Retriever. After celiotomy, agitated saline was injected through a jejunal vein and microbubbles appeared rapidly in the right cardiac chambers. The test confirmed the presence of a PSS, helping the surgeon to identify the vessel concerned and to rule out a second shunt. Successively, portography confirmed what the exploratory celiotomy had revealed before with the aid of the bubble study: a single shunt was located between the portal vein and the right renal vein. It was completely ligated, as all the criteria for this solution were met. Intraoperative contrast echocardiography (ICE) was easy to perform, helpful and undemanding. It is proposed here as an intraoperative ancillary test to diagnose all PSS and to confirm successful treatment when complete shunt closure is possible.