Challenging Case Presentation For Structural Heart Disease Program

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Presentation transcript:

Challenging Case Presentation For Structural Heart Disease Program SCAI Structural Heart Disease December 7, 2012 Jonathan Tobis, MD Professor of Medicine Director of Interventional Cardiology UCLA

Orthodeoxia Platypnea post Op 67-year old male anesthesiologist referred for endovascular repair of thoracic aneurysm. 1990- while at work in OR: ascending aortic dissection, hemopericardium, cardiac arrest, with emergent repair complicated with perioperative CVA 1997- Aortic valve insufficiency: aortic valve replacement (29 mm St. Jude valve) and Bentall procedure. 2012-Thoracic aorta distal to the graft enlarged to 5.9 cm. The patient was referred for staged endovascular repair.

CT of Residual Aortic Dissection

Orthodeoxia Platypnea post op 1st Stage: R carotid to L carotid shunt 8mm dacron graft. Connect L subclavian to L carotid. Post-op hypoxemia. O2 Sat=86% Pulmonary w/u shows L hemi-diaphragm paralysis (presumed trauma to phrenic nerve). R to L shunt on TTE bubble study at atrial level. Referred for PFO closure. Hx visual aura w/o headache since 20’s. Hx of low O2 Sat =92% “for years”

Presence of clubbing indicates a chronic condition of RLS with exacerbation due to diaphragm paralysis and opening up PFO TCD = 4 at rest 5 Valsalva

With balloon inflated across PFO, the O2 Sat inc to 98% off O2

Baseline angiogram shows large R-L shunt 14mm by balloon sizing so 30mm Helex chosen

Final bubble study 30mm Helex disk in place

pre post O2 Sat = 95% on room air

3-month post PFO closure 2 weeks post implant, pt strained while using a wrench and felt “something in his heart.” Hypoxemia worsened. TEE showed significant residual right to left shunt with Helex 30 mm device in correct position. 3-month post PFO closure

Clinical Options Remove previous Helex device Place a second Helex device Place an Amplatzer ASD device Surgical closure of PFO

2nd attempt at PFO closure RA gram Agitated saline injection shows significant residual shunt

2nd attempt at PFO closure GW crossing Helex device GW across Helex device

Balloon sizing of the residual shunt SaO2 = 100% with sizing balloon across the septum next to Helex device. The PFO looks larger?

Delivery and release of a 15mm Amplatzer ASO

Agitated saline injection after Amplatzer ASO placement Final RA gram Agitated saline injection after Amplatzer ASO placement Post-procedure Sa O2 was 93%

Discussion Chronic orthodeoxia through a PFO produced digital clubbing, exacerbated by phrenic nerve damage This case demonstrates the ability to cross a Helex device that is not completely endothelialized. 30mm Helex device, although appropriately sized for this PFO (14 mm diameter), did not have sufficient closure force Should 30 mm Helex devices be used for PFO closure?

UCLA experience with Helex devices Percent of patients with shunting on TCD Months since closure procedure Larger Helex device size associated with greater frequency of residual shunting 106 patients with Helex device 95 patients had TCD every 3months after PFO closure Average time of the PFO closure occurred at month 5.2±3.5 Helex 30mm device demonstrated the lowest closure rate = 60%