Left Atrial Shunt Research Articles

Postoperative Left Atrial Shunt in a Child with Ventricular Septal Defect Repair

Postoperative Left Atrial Shunt in a Child with Ventricular Septal Defect Repair

PO-04-028 INTERATRIAL SHUNT LEADING TO SEVERE HYPOXEMIA: A RARE COMPLICATION OF PACEMAKER-ASSOCIATED INFECTIVE ENDOCARDITIS

Pacemaker-lead-associated infective endocarditis is a serious complication with high morbidity and mortality. We present a case of persistent hypoxemia from significant right to left atrial shunting across the patent foramen ovale (PFO) as a result of pacemaker-lead-associated infective endocarditis with large vegetations. N/A A 56-year-old female with stroke, sleep apnea, diabetes mellitus, hypertension, and sick sinus syndrome with dual chamber pacemaker implantation, was admitted with acute hypoxic respiratory failure requiring high flow nasal cannula. A chest x-ray did not show any obvious etiology of hypoxemic respiratory failure. Arterial blood gas showed no hypercapnia ruling out hypoventilation as the cause of hypoxemia. A very high A-a gradient was noted, raising suspicion for shunting. Blood cultures were positive for staphylococcus capitis bacteremia. A transesophageal echocardiogram (TEE) showed several large vegetations (Image A) attached to the atrial and ventricular lead, tricuspid valve with associated severe tricuspid regurgitation, and a PFO (Image B) with a large right to left shunt as a result of large right-sided vegetations (Image C). A pacemaker extraction procedure was planned; however, there was a concern for paradoxical septic embolism across the PFO. As such, an ASD occluder device was temporarily placed across the PFO during the procedure to prevent right-to-left embolization. PFO occlusion dramatically improved hypoxemia during the procedure. The infected pacemaker system was then successfully extracted. The PFO occluder device was subsequently removed at the end of the case, given ongoing bacteremia and the risk of device seeding. The patient recovered well with the resolution of hypoxemia and was discharged however presented again one month later with a stroke. TEE exam showed a large echo-dense lesion straddling the atrial septum through the PFO, likely vegetation that embolized to the left circulation causing the stroke (Image D). The patient is currently awaiting cardiac surgery for definitive treatment once medically stable. Pacemaker-associated infective endocarditis can lead to mechanical complications, including tricuspid regurgitation and rarely shunting across the atria, causing severe hypoxemia as in our patient. There are no clear guidelines regarding the management of such atrial defects with shunting peri-device extraction to prevent systemic embolization of vegetations.

One-Year Results of Occlutech’s Atrial Flow Regulator for Left Atrial Shunting in Symptomatic Heart Failure: The Prelieve Study

One-Year Results of Occlutech’s Atrial Flow Regulator for Left Atrial Shunting in Symptomatic Heart Failure: The Prelieve Study

CRT-600.05 One-Year Results of Occlutech’s Atrial Flow Regulator for Left Atrial Shunting in Symptomatic Heart Failure: The Prelieve Study

CRT-600.05 One-Year Results of Occlutech’s Atrial Flow Regulator for Left Atrial Shunting in Symptomatic Heart Failure: The Prelieve Study

759 Platypnoea orthodeoxia syndrome following middle-lower bilobectomy: a case report

Abstract Aims PlatypneaOrthodeoxiasyndrome (POS) is a rare clinical condition characterized by dyspnoea and arterial desaturation, typically occurring in orthostatism and vanishing in a supine position. The real pathophysiologic triggers are still not completely understood. Methods and results In January 2021, a 76-year-old female patient was admitted to our department for the management of a large mass in the right lung (69 × 54 × 76 cm). Pre-operative Computed Tomography (CT)-scan showed a lesion of the right lower lobe, with suspected infiltration of posterior costal pleura and bronchoscopy revealed distal occlusion of intermedious bronchus. Surgical treatment was planned: extrapleural lower bilobectomy with the removal of the VI rib to reduce intracavity space was performed, using postero-lateral thoracotomy approach. On the third post-operative day, an acute neurologic deficit with left-sided paralysis, associated with desaturation and hypotension, occurred during a new attempt to mobilize the patient. Nonetheless the patient showed complete resolution of symptoms in supine position. A new similar episode of severe desaturation (SO2 80%) was observed in the 7th post-operative day. Arterial blood gas test showed PO2 37 mmHg; PCO2 27 mmHg; SO2 80.3%, pH 7.61, tHb 12.4 g/dl; O2Hb 78.4%. CT pulmonary angiography excluded a suspicious of pulmonary embolism. A right to left atrial shunt was suspected. Contrast-enhanced transcranial Doppler ultrasound showed microembolic signals in the basal cerebral arteries. Transoesophageal echocardiography was performed, confirming an interatrial septum with an exuberant hyperdynamic movement and showing an abundant passage of contrast from the right atrium to the left, even without the Valsalva manoeuvre, compatible with an important patent foramen ovale (PFO). Patient was referred to the cardiac Catheterization Laboratory for percutaneous closure of PFO. The device was successfully placed via right femoral venous catheter access and on transesophageal echocardiogram guidance. The procedure was performed without any complications. The implanted device was noted to be in a stable position with trivial residual inter-atrial shunting immediately after the procedure. The day after implantation, positional discomfort improved remarkably and the patient was able to stand-up with no symptoms, maintaining normal saturation (SaO2 100%). The patient was discharged and sent home on the third post-implantation day. The 4 month follow-up examination showed a good andstable condition. Conclusions Platypnoea Orthodeoxia Syndrome after lobectomy is a rare cause of postoperative dyspnoea/hypoxia.It is the result of right-to-left shunt via interatrial communication. Mediastinal relocation, stretching of the atrial septum are among the functional elements necessary for the clinical manifestations. It is essential to have a high index of suspicion to detect POS in patient with dyspnoea given the subtle and positional nature of the symptoms. Physicians should always consider POS in patients with unexplained dyspnoea; hence the treatment modalities could alleviate symptoms and be potentially curative.

One-year results of the first-in-man study investigating the Atrial Flow Regulator for left atrial shunting in symptomatic heart failure patients: the PRELIEVE study.

Attenuating exercise-induced elevated left atrial pressure with an atrial shunt device is under clinical investigation for treatment of symptomatic heart failure (HF). PRELIEVE was a prospective, non-randomised, multicentre, first-in-man study in symptomatic HF patients with reduced (HFrEF) or preserved (HFpEF) ejection fraction and pulmonary capillary wedge pressure (PCWP) ≥15 mmHg at rest or ≥25 mmHg during exercise. Here, we provide follow-up data up to 1 year after implantation of the Atrial Flow Regulator (AFR) device. The AFR was successfully implanted in 53 patients (HFrEF n=24 and HFpEF n=29). Two patients were not enrolled due to an unsuccessful transseptal puncture. There was one device embolisation into the left atrium, which required surgical removal. One patient experienced a serious procedure-related adverse event (post-procedural bleeding and syncope). All patients with sufficient echocardiography readout confirmed device patency with left-right shunt both at 3 (n=47/51, 92%) and 12 (n=45/49, 92%) months. At 3 months, rest PCWP decreased by 5 (-12, 0) mmHg (P=0.0003, median Q1, Q3). No patient developed a stroke, worsening of right heart function or significant increase of pulmonary artery pressure. Six (6/53, 11%) patients were hospitalised for worsening of HF and three (3/53, 6%) patients died. We observed improvements in New York Heart Association functional class, 6-min walking distance and quality of life (Kansas City Cardiomyopathy Questionnaire) in certain patients. Implantation of the AFR device in HF patients was feasible. No shunt occlusion, stroke or new right HF was observed during the 1-year follow-up, with clinical improvements in certain patients.

Succesfull management of a giant pulmonary artery aneurysm associated with severe congenital pulmonary valve stenosis in an adult patient

Pulmonary artery aneurysms are rare entities usually associated with congenital anomalies that increase blood flow/pressure in the pulmonary circulation, like left to right shunts and/or severe pulmonary valve pathologies. Clear re-commendations about their management are lacking. We report on a case of severe congenital pulmonary valve stenosis associated with a giant pulmonary artery aneurysm, secondary right ventricular outflow tract obstruction and right to left atrial shunt. We discuss the diagnostic pathway, therapeutic approach and patient evolution. The case report proves that a complete imaging of the heart and blood vessels is mandatory with severe pulmonary valve stenosis, in order to better describe its repercussions on the right ventricle and pulmonary circulation. They might be under detected by simple tran-sthoracic echocardiography but their presence has important therapeutic implications.

Gerbode Defekt, Sol Ventrikül-Sağ Atrium Şantı Önemi

Gerbode Defekt, Sol Ventrikül-Sağ Atrium Şantı Önemi

A postoperative left ventricular-right atrial shunt due to infectious endocarditis after aortic repair with aortic valve replacement detected by transesophageal echocardiography

Infectious endocarditis (IE) with acute heart failure is a medical emergency. In particular, postoperative IE after aortic repair with an artificial vascular graft is a life-threatening matter. We present a case in which a mobile abscess appeared on the aortic valve annulus with an intra-cardiac shunt in the left ventricle (LV) to the right atrium (RA) after ascending aortic repair with aortic valve replacement (AVR) for acute type A aortic dissection. It was diagnosed with transesophageal echocardiography (TEE), which prompted further exploration.

Surgical repair of inferior sinus venosus defects: a novel approach with unsnared inferior vena cava.

BackgroundInferior sinus venosus defects (SVD) are very rare and difficult to image from transthoracic echocardiography. Surgical errors were occasionally reported in the repair of inferior SVDs.ResultsThe authors have operated on 12 inferior SVD patients using bicaval cannulation with unsnared inferior vena cava (IVC) and proved successful.ConclusionThis technique guaranteed a better exposure of surgical field and facilitate identifying the anatomical relationship between lower part of the SVD and IVC orifice, thus avoiding postoperative IVC - left atrial shunt and other surgical mistakes.

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Introduction: 28 y/o African American female, G5P2A3, no significant PMH, presented to ED3 with Right Lower Extremity (RLE) and Right Upper Extremity(RUE) pain, attributed to a motor vehicle crash 12 days prior, from which patient had no significant injury. 14 days prior to admission, home pregnancy test was positive. At time of MVC, ED1 observed fetal heart tones, beta-HCG of 79000. 6 days prior to admission, pain in RUE, fevers, chills and vaginal bleeding. ED2 visit revealed fetal demise, and discharged home with OB/Gyn follow-up. Pt then developed foul smelling clots, dyspnea on exertion, headache, chills, and presented to the ED3. Admitted to ICU with severe sepsis. Treated with IV drugs vancomycin, pip/tazo, clindamycin, and gentamicin. OB/GYN exam revealed no retained products, some cervical motion tenderness, negative vaginal u/s, beta-HCG of 1616. Right shoulder CT revealed inflammatory/infectious process, confirmed with MRI. Contrast CT right hip also concerning for metastatic septic process. CT chest confirmed septic pulmonary emboli. Blood cultures positive in 12 hours, with GPC's in clusters, found to be MRSA. Vaginal and urine cultures were also positive for MRSA. Transthoracic Echocardiogram (TTE) and Transthoracic Echocardiogram (TEE) were negative for endocarditis. TTE with Bubble study however revealed a small right to left atrial shunt, suggestive of patent foramen ovale. Pt continued to spike temperatures on therapeutic antibiotics. CT abd/pelvis with contrast revealed right internal iliac vein thrombus. Pt was started on full dose anticoagulation with enoxaparin for presumed septic pelvic thrombophlebitis. I&D of right shoulder and hip performed on day 7 after admission, with MRSA growth from right shoulder. Pt defervesced and was sent home in good condition, on antibiotics and anticoagulation, with scheduled repeat scans of pelvis to assess the internal iliac vein thrombus. Discussion: This case represents a very rare case of post-spontaneous abortion MRSA septicemia with septic pelvic thrombophlebitis (SPT), septic pulmonary emboli, and pyomyositis. Our theory for this case is possible MVC/trauma/stress induced miscarriage, leading to infected products of conception. Our suspicion is that deep pelvic vein septic thrombophlebitis developed, leading to septic pulmonary emboli. Although the frank bacteremia with MRSA on its own could lead to disseminated abscesses, the presence of a PFO seen on TTE may also have contributed. Our conclusion of SPT arose from persistent febrile episodes, with negative TEE for endocarditis, in a patient with an obvious endovascular source. SPT can present as either ovarian vein thrombophlebitis (OVT) or deep septic pelvic thrombophlebitis. Although OVT presents with abdominal pain, deep SPT generally does not. Much of the literature surrounding SPT stems from papers in the 1970's and earlier. Post-partum persistent fever 4-5 days after initiation of therapeutic antibiotics for infected individuals, elicits the consideration of SPT. Early on, the treatment was surgical ligation of the involved pelvic vessels, be it the ovarian vein, or deep pelvic veins. Studies found that patients with SPT could be treated with anticoagulation, preventing surgical intervention, and defervescence could be obtained. A more recent study in 1999 has questioned whether anticoagulation is necessary as anticoagulation had no impact on defervescence, however, this study included only 15 patients. Our review of the literature showed other studies in which patients were safely treated with anticoagulation, achieving defervescence, which led us to choose enoxaparin for treatment in this case. Deep SPT historically has been a diagnosis of exclusion due to poor imaging modalities. With improving imaging modalities, it is becoming easier to diagnose SPT, however this does not preclude the high degree of suspicion for SPT required on clinicians behalf in post-partum patients with persistent fever.

術後感染性心内膜炎による左室右房シャントで再手術を施行した両大血管右室起始症の1治験例

症例は9カ月, 女児. 両大血管右室起始症(Fallot型)に対して根治術を施行し術直後の経過は良好であった. 術後6日に発熱し血液培養でメチシリン耐性黄色ブドウ球菌(MRSA)が検出された. 抗菌薬により解熱したが, 術後15日に心エコーで心室中隔欠損(VSD)パッチに疣腫を認め感染性心内膜炎(infective endocarditis : IE)と診断した. VSDの遺残短絡を認めなかったため抗菌薬による治療を継続したが, 術後20日に右心不全と肝不全が急激に進行し心エコーで左室右房(LV-RA)シャントが確認された. 凝固系が破綻した状態での手術は出血のリスクが高いため, 持続的血液透析濾過と血漿交換を行い凝固能の改善後に再手術を施行した. 再手術はVSDパッチと右室流出路パッチを交換し三尖弁の形成を行った. 再手術後も感染の再燃がみられたが軽快し, 再手術後75日に退院した. 術後IEによって生じたLV-RAシャントが急性肝不全を来した症例の治験例として報告する.

Mechanical Support for Pulmonary Veno-occlusive Disease: Combined Atrial Septostomy and Venovenous Extracorporeal Membrane Oxygenation

The use of atrial septostomy for refractory pulmonary hypertension and right ventricular failure results in an adequate left ventricular preload and improved cardiac output at the expense of a profound hypoxic shunt. Combined dual-lumen venovenous extracorporeal membrane oxygenation and atrial septostomy provides extracorporeal gas exchange of venous return before the directional right atrial to left atrial shunt, can be deployed percutaneously, and results in an ambulatory patient with stable hemodynamics.

Acute pressure overload of the right ventricle. Comparison of two models of right-left shunt. Pulmonary artery to left atrium and right atrium to left atrium: experimental study

AbtractBackgroundIn right ventricular failure (RVF), an interatrial shunt can relieve symptoms of severe pulmonary hypertension by reducing right ventricular preload and increasing systemic flow. Using a pig model to determine if a pulmonary artery - left atrium shunt (PA-LA) is better than a right atrial - left atrial shunt (RA-LA), we compared the hemodynamic effects and blood gases between the two shunts.MethodsThirty, male Large White pigs weighting in average 21.3 kg ± 0.7 (SEM) were divided into two groups (15 pigs per group): In group 1, banding of the pulmonary artery and a pulmonary artery to left atrium shunt with an 8 mm graft (PA-LA) was performed and in group 2 banding of the pulmonary artery and right atrial to left atrial shunt (RA-LA) with a similar graft was performed. Hemodynamic parameters and blood gases were measured from all cardiac chambers in 10 and 20 minutes, half and one hour interval from the baseline (30 min from the banding). Cardiac output and flow of at the left anterior descending artery was also monitored.ResultsIn both groups, a stable RVF was generated. The PA-LA shunt compared to the RA-LA shunt has better hemodynamic performance concerning the decreased right ventricle afterload, the 4 fold higher mean pressure of the shunt, the better flow in left anterior descending artery and the decreased systemic vascular resistance. Favorable to the PA-LA shunt is also the tendency - although not statistically significant - in relation to central venous pressure, left atrial filling and cardiac output.ConclusionThe PA-LA shunt can effectively reverse the catastrophic effects of acute RVF offering better hemodynamic characteristics than an interatrial shunt.

Novel treatment concept for acute severe pulmonary hypertension with right to left atrial shunting and veno-venous extracorporeal membrane oxygenation

Purpose: A considerable number of patients suffering from pulmonary hypertension die of right ventricular (RV) failure. One option is an atrial septostomy (AS), but this causes perilous hypoxemia. AS combined with veno-venous extracorporeal membrane oxygenation (VV ECMO) could be a novel therapy option.

Use of Venovenous Extracorporeal Membrane Oxygenation and an Atrial Septostomy for Pulmonary and Right Ventricular Failure

Right ventricular failure is a major contributor to morbidity and mortality on the lung transplant waiting list. This study was designed to evaluate the effectiveness of an atrial septostomy with venovenous extracorporeal membrane oxygenation (VV-ECMO) as a novel potential bridge to transplantation. Adult sheep (58±3 kg; n=12) underwent a clamshell thoracotomy and instrumentation to measure all relevant pressures and cardiac output (CO). Sheep with tricuspid insufficiency (TI [n=5]) and without tricuspid insufficiency (ØTI [n=7]) were examined. After creation of a 1-cm atrial septal defect and initiating VV-ECMO, the pulmonary artery (PA) was banded to allow progressive reduction of pulmonary blood flow, and data were collected. The CO in both groups remained unchanged from baseline at all pulmonary blood flow conditions. With TI, the CO was 5.1±1.2 L/min at baseline versus 5.1±1.2 L/min with a fully occluded PA (p=0.99). For ØTI, the CO was 4.5±1.4 L/min at baseline versus 4.5±1.2 L/min with no pulmonary blood flow (p=0.99). Furthermore, CO was not affected by the presence of TI (p=0.76). Mean right ventricular pressures were significantly lower in the TI group (TI=20.2±11 mm Hg versus ØTI=29.9±8.9 mm Hg; p<0.00001). Right and left atrial mean arterial pressures were not different between both groups (p>0.5). Lastly, VV-ECMO maintained normal blood gases, with mean O2 saturations of 99% ± 4.1% in both groups. Right to left atrial shunting of oxygenated blood with VV-ECMO is capable of maintaining normal systemic hemodynamics and normal arterial blood gases during high right ventricular afterload dysfunction.

Reduction of a previous atrial septostomy in a patient with end-stage pulmonary hypertension by a manually fenestrated device

A case of profound systemic oxygen desaturation after atrial septostomy in a patient with primitive pulmonary hypertension is reported. A new method to correct such severe complication of atrial septostomy is described, consisting in a graded reduction of the right to left atrial shunt by deployment of a manually perforated atrial septal closure device.

Developing and Optimizing a Chronic Cyanotic Swine Model

Pulmonary artery (PA)-left atrial (LA) shunt models in piglets have been described, but technical details critical to limit morbidity/mortality and promote study of chronic cyanosis are lacking. Accordingly, we describe our experience with an optimized technique. In 25 6- to 8-wk-old Yorkshire piglets, a beveled, 8 mm, polytetrafluoroethylene tube graft was anastomosed to the PA and LA. Systemic pressure was maintained at >60 mmHg. Saturation targets were met by adjusting a Teflon band on the graft and distal PA. The target oxygen saturation (SO(2)) was 85% on a 50% fraction of inspired oxygen (FiO(2)). If the SO(2) was <75% on a 50% FiO(2), the graft was constricted to achieve a SO(2) ≥ 90% on a 100% FiO(2) and 75%-80% on a 21% FiO(2). Complications affecting mortality were neutralized with a stepwise strategy to minimize risk. Thrombosis, blood loss, and arrhythmia were determinants of survival. Protocol optimization over time increased survival while assuring chronic cyanosis. Survival approached 90%, with a SO(2) of 80% to 90%, 3 to 5 wk postoperatively. Complications included bleeding, excessive hypoxemia, uncontrolled shunt flow, arrhythmias, and thrombosis. Refinement of surgical technique, shunt adjustment via graft banding, and thrombotic and arrhythmia prophylaxis are the keys to success with this model.

Transcatheter Diagnosis and Intervention for Iatrogenic Right-to-Left Shunts Decades After Surgical Repair of Partial Anomalous Pulmonary Veins and an Atrial Septal Defect

A 57-year-old man presented with symptomatic right-to-left shunts decades after surgical closure of an atrial septal defect and partial anomalous pulmonary veins. Two sources of shunting were identified: a baffle leak from the right superior vena cava (RSVC) to the left atrium secondary to complete occlusion of the RSVC-to-right atrium connection and an acquired previously unpublished coronary sinus to the left atrial shunt secondary to inadvertent closure of the coronary sinus. The diagnosis and transcatheter management of these unusual right-to-left shunts are reported.

Acute right to left shunt through patent foramen ovale presenting as hypoxemia after myocardial infarction: a case report

IntroductionThis is a report of a 56-year-old man who became hypoxic due to an acute right to left shunt after sustaining a myocardial infarction involving the right ventricle. This case provides the opportunity to review several key pathophysiologic concepts in the setting of acute right ventricular infarction. Although the development of an acute right to left shunt is a rare complication of myocardial infarction, it is important to recognize the diagnosis early in order to prevent life threatening or debilitating clinical sequelae that may result from tissue hypoxia and embolic events. Transesophageal echocardiography is the noninvasive study of choice to confirm the diagnosis. Treatment involves optimization of right ventricular function to minimize shunting. However, medical therapy may provide only temporary relief, and closure of the atrial septal defect should be considered if a clinically significant shunt persists.Case presentationA 56-year-old Caucasian man with severe aortic insufficiency presented to the emergency department for evaluation of substernal chest pain. An inferior myocardial infarction was diagnosed by the electrocardiogram and serologic markers. Cardiac catheterization revealed complete occlusion of the right coronary artery as well as a 50-75% stenosis of the left anterior descending artery. Angioplasty of the right coronary artery was performed, but immediate re-occlusion occurred. Subsequently, hypotension and severe hypoxemia developed and persisted despite intubation and mechanical ventilation with 100% oxygen. A significant right-to-left shunt through a patent foramen ovale was diagnosed by contrast transesophageal echocardiogram. Surgical intervention was required and included coronary artery bypass grafting, aortic valve replacement as well as closure of his atrial septal defect.ConclusionA right to left atrial shunt is a rare complication of inferior myocardial infarction with right ventricular infarction. The diagnosis should be considered in the presence of inferior myocardial infarction when hypoxemia persists despite administration of 100% oxygen. Early diagnosis and treatment are critical in order to reduce the risk of embolization and to prevent end-organ damage due to hypoxemia.