Assessing for Baffle Stenosis using Intravascular Ultrasound 06/19/13 Assessing for Baffle Stenosis using Intravascular Ultrasound CRT Interesting Case 2017 Benes LB, Rosenberg JR, Tharian TS, Shah AP Assessing for Baffle Stenosis using Intravascular Ultrasound

06/19/13 Patient Information 34 year-old-male with episodes of presyncope, chest pain, fatigue and dyspnea Known history of d-transposition of the great arteries status post Mustard procedure at age 18 months Followed in clinic for recurrent atrial arrhythmias, sinus node dysfunction and reduced systemic ventricular ejection fraction (EF) of 30% Dual chamber ICD indicated given his symptomatic bradycardia and elevated risk of sudden cardiac death1 His episodes of presyncope, CP and dyspnea have been increasing in frequency.

Mustard Procedure Great arteries Baffle To pulmonic ventricle 06/19/13 Mustard Procedure Great arteries Baffle To pulmonic ventricle Pulmonic veins lead to right atrium Originally from Mullins CE, Mayer DC: Congenital Heart Disease: A Diagrammatic Atlas. New York, Wiley-Liss, 1988. Exact picture from Bruanwald’s Heart Disease: A Textbook of Cardiovascular Medicine 7th edition. 2005 Atrial switch: Mustard Procedure

Hospital Course and Management 06/19/13 Hospital Course and Management Cardiac MRI was performed to assess anatomy, showing significant narrowing of the SVC and IVC baffle to 5-6 mm at the narrowest dimension Cardiac MRI was performed to assess anatomy, showing significant narrowing of the SVC and IVC baffle to 5-6 mm at the narrowest dimension.

Hospital Course and Management 06/19/13 Hospital Course and Management Cardiac MRI was performed to assess anatomy, showing significant narrowing of the SVC and IVC baffle to 5-6 mm at the narrowest dimension Cardiac MRI was performed to assess anatomy, showing significant narrowing of the SVC and IVC baffle to 5-6 mm at the narrowest dimension.

Hospital Course and Management 06/19/13 Hospital Course and Management Cardiac MRI was performed to assess anatomy, showing significant narrowing of the SVC and IVC baffle to 5-6 mm at the narrowest dimension Cardiac MRI was performed to assess anatomy, showing significant narrowing of the SVC and IVC baffle to 5-6 mm at the narrowest dimension.

06/19/13

Hospital Course and Management 06/19/13 Hospital Course and Management Referred for invasive baffle assessment using intravascular ultrasound (IVUS) 0.035” Volcano Eagle Eye catheter revealed a patent baffle with no significant stenosis With injection of saline, baffle cross-sectional diameter measured at 21 mm Baffle pressure normal at 8 mmHg throughout

Hospital Course and Management 06/19/13 Hospital Course and Management Referred for invasive baffle assessment using intravascular ultrasound (IVUS) 0.035” Volcano Eagle Eye catheter revealed a patent baffle with no significant stenosis With injection of saline, baffle cross-sectional diameter measured at 21 mm Baffle pressure normal at 8 mmHg throughout

Respirophasic variation and injection of saline into baffle further demonstrate patency

Treatment and Outcome Given baffle patency, successfully underwent device implantation At 1 month follow-up, reported significant symptom improvement

Case Implications IVUS has been described to better visualize baffle anatomy in patients who have previously undergone stent placement to relieve stenosis and to accommodate pacemaker leads2 This case demonstrates its additional usefulness in patients for whom the concern for baffle stenosis on imaging prior to lead implantation requires more definitive evaluation

References Dos L, Teruel L, Ferreira IJ, et al. Late outcome of Senning and Mustard procedures for correction of transposition of the great arteries. Heart. 2005 May;91(5):652-6. Chintala K, Forbes TJ, Karpawich PP. Effectiveness of transvenous pacemaker leads placed through intravascular stents in patients with congenital heart disease. Am J Cardiol. 2005 Feb 1;95(3):424-7.