1. 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

2. 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.

3. 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

4. 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.

5. 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.

6. 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.

7. 06/19/13

8. 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 mmHg throughout

9. 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 mmHg throughout

10. Respirophasic variation and injection of saline into baffle further demonstrate patency

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

12. 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

13. 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 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 Feb 1;95(3):424-7.