Cath Conf
Transcript of Cath Conf
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Adult Congenital Heart
Disease. Part 2
2012Individual Lesions in a Nutshell
Guideline Recommendations
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The Atrial Septum Formation
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Question 1
Which of the following statements is true regarding shunts
that occur before the tricuspid valve?
1. If left unrepaired, they invariably lead to
pulmonary hypertension.
2. There are now clear data that percutaneous closure of a
PFO in a patient
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PFO and TIA or Stroke
Association of PFO and Stroke-controversial
Mandkem M et al NEJM 2007;357:2268
Risk of recurrent stroke
Cryptogenic and otherwise
PFO in Cryptogenic Stroke Study
Homma S et al Circ 2002;105:2625.
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PFO and TIA or Stroke
Kent DM et al Stroke 2010;41:52
Issues:
? Whether PFO related to event-
20-25% of population have PFO
? Hypercoagulable state
? Advantage of PFO closure to prevent recurrences
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Results of CLOSURE 1 Trial
Furlan HJ et al NEJM 2012;366:991
Primary endpoint:Composite of CVA or TIA at 2 years,
30 day mortality or 2 year neuro mortality
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PFO and TIA or Stroke
No advantage yet established for PFO closure incryptogenic stroke
CLOSURE 1* trial (mostly Starflex device) safe but
no difference between closure and medical therapy
Ongoing Trials include: RESPECT- Amplatzer PFO device
PC-TRIAL- Amplatzer PFO device
REDUCE- Helex PFO device
CLOSE- Any device
AHA/ACC advisory position: Await completion of
trials**
*Furlan A, et al. NEJM 2012;366:991. **OGara P et al. Circulation 2009;119:2743
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Types of ASDs
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Question 2
Which of the following is true regarding the affectedstructural enlargement one expects in a patient with a
shunt due to an secundum atrial septal defect?
1. The RA, RV are the only structures enlarged.2. The RA, RV and PA are the structures enlarged.
3. The RA, RV, PA and LA are structures enlarged.
4. The RA, RV, PA, LA and LV are enlarged.
5. The RA, RV, PA, LA and Aorta are enlarged.
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Expected Chamber Enlargement
in Cardiac Shunting
RA RV PA LA LV Aorta
+ + + - - -
- + + + + -
- - + + + +
ASD
VSD
PDA
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Secundum ASD
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Secundum Atrial Septal Defect
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Secundum Atrial Septal Defect Clinical Pearls
About 30% have an associated malformation. 60% are female. Enlarged RA, RV, PA not LA
ECG with RIVCD. Crochetage in inferior leads.
Fixed splitting of A2and P2
Direction of shunt dependent on RA/LA compliance
Small shunts increase with age as LA compliance worsens
If right heart failure, JVP may not go up but pt may turn cyanotic
Only 10-15% develop pulmonary hypertension
Atrial arrhythmias common
Echo diagnostic. MRI for localization. Multiple fenestrations at times. Redundant septal tissue can
rarely be an issue for percutaneous closure
Intervene whenever RA and RV are enlarged regardless of
symptoms. Percutaneous closure if feasible.
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Secundum Atrial Septal Defect
Percutaneous closure preferred option iffeasible. Surgical results excellent if required.
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Percutaneous ASD Closure
BEFORE CLOSURE AFTER CLOSURE
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Secundum ASD Follow-up
Atrial arrhythmias remain common after
closure
Pregnancy well tolerated
Rare patients develop pulmonary
hypertension independent of ASD closure
(but generally in those closed late)
Chest pain after percutaneous closure
may imply device erosion
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Sinus Venosus ASD
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Sinus Venosus ASD
Bubble Study TEE
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Sinus Venosus ASD
Clinical Pearls About 10% of all atrial shunts
Defect in vena cava/LA junction
Association with SVC >>>IVC Anomalous RUPVC almost universal
SA node dysfunction with ectopic atrial rhythm
common on ECG
May be missed by chest wall echo. TEE or MRIbetter.
Operate when RA and RV enlarged. Surgical closure
only.
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Traditional Sinus Venosus Repair
Yale Website
RULPVs
Russel JL et al. Asian CV Thorac Ann 2002:10:231
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Warden Procedure to Repair Sinus Venosus ASD
SVCPericardial Patch
Sewn on top of Prox SVC
RA
STEP 1 STEP 2
SVC
SVC
RA
STEP 3
SVC
SVC
Baffling of Anom.Pulm Vein
Through ASD to LA
SVC SVC
RA
STEP 4
Stewart RD, et al. Ann Thorac Surg 2007;84:1651
Reattachment of SVC
To RA
Opening of RA
Prox SVC closed
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Sinus Venosus ASD Followup
SVC obstruction (esp from prior surgical
procedures)
SA node dysfunction
Atrial arrhythmias
Residual defects
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Sites of
Anomalous Pulmonary Venous Return
RUPV
May be Assoc. with
Sinus Venosus ASD
RUPV
To
RA
RLPV to IVC
Scimitar
LUPV
To Persistent LSVC
Vertical Vein
RVRA
RSVC
IVC
LSVC
INNOMINATE
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Classic Chest X-rays
Snowman*Vertical
Vein
*Ferguson EC et al. Radiographics 2007;27:1323, **Zylak CJ et al. Radiographics 2002;22:525
Scimitar Syndrome**
RLPV
Hypoplasia Right Lung
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Anomalous Pulmonary Venous Connection
IVC
PV
SCIMITAR
RLPV CONNECTION
SVC
RA
Vertical Vein
Lung
VERTICAL VEIN
LUPV CONNECTION
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Anomalous Pulmonary Venous Return
Clinical Pearls
Have high index of suspicion if RA and RV
size out of proportion to other clinical findings
Easiest to surgically correct is RUPV acrossSinus Venosus. Rest are more of a challenge
Pulmonary HBP rare (10-15%)
May be missed during routine echo orcatheterization unless sought
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Ostium Primum ASD
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AV Septal Defects
Complete and Partial
Primum ASD VSDBoth ASD and VSD
Shinebourne EA et al., Gatzoulis MA, Webb GD, Daubeney PEF. eds. Diagnosis and Management of Adult Congenital HD. Second Ed. page 196
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AV Septal Defects
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AV Septal Defect
Gooseneck Deformity on LV Angiogram
Outlet is longer than inletHo SY et al .Atlas of Congenital HD; Mosby, 1995, p 69.
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AV Septal Defects
Clinical Pearls The AV valves are divided into 5 leaflets with variouschordal attachments to each ventricle or top of
septum. Some of this results in cleft appearance.
If complete AVSD, 70-80% have Downs syndrome ECG- first degree AV block, with RBBB, LAFB. CHB
not uncommon.
Eisenmengers usual if unrepaired complete AVSD
Decision to repair may be difficult based on socialsituation and mental status. Generally done if only
primum ASD and cleft valves, but more extensive
surgery requires clinical judgment as to quality of life.
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Atrial Septal Defect Closure Guidelines
Closure of an ASD either percutaneously or surgically is
indicated for right atrial and RV enlargement with or
without symptoms. (LOE B)
A sinus venosus, coronary sinus, or primum ASD should
be repaired surgically rather than by percutaneous
closure. (LOE B)
Surgeons with training and expertise in CHD should
perform operations for various ASD closures. (LOE C)
Class 1
Warnes CA et al JACC 2008;52:1890-1947
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Surgical closure of secundum ASD is reasonable when
concomitant surgical repair/replacement of a tricuspid
valveis considered or when the anatomy of the defect
precludes the use of a percutaneous device. (LOE C)
Closure of an ASD, either percutaneously or surgically is
reasonable in the presence of:
a) Paradoxical embolism (LOE C)
b) Documented platypnea-orthodeoxia(LOE B)
Atrial Septal Defect Closure Guidelines
Class 2a
Warnes CA et al JACC 2008;52:1890-1947
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Closure of anASD in PULMONARY HYPERTENSION if left-
to-right shuntand
PA pressure < 2/3 Systemic pressure or
PVR
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Question 3A 20 year old is referred to you because of a murmur. He
appears healthy, and he denies any symptoms. Hisexamination is normal except for a harsh holosystolic
murmur along the LSB associated with a palpable thrill.
You order an echocardiogram and the results are
consistent with a muscular VSD in the mid ventricularseptum.
Based on these data alone, your next step would be to:
1. Refer him for percutaneous VSD closure
2. Refer him for surgical closure
3. Follow him with yearly echocardiograms and physical
examinations
4. Intitiate afterload reduction therapy
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Ventricular Septal Defects
Normal Anatomy VSD Locations
Uebing A et al., Gatzoulis MA, Webb GD, Daubeney PEF. eds. Diagnosis and Management of Adult Congenital HD. Second Ed. page 189
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Ventricular Septal Defect
Perimembranous VSD
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VSD with Large Windsock Deformity
Windsock VSD with No Shunt Windsock with Bicuspid Valve
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Ventricular Septal Defects
Small Muscular VSD Large VSD
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Ventricular Septal Defect
Clinical Pearls Generally, the smaller the VSD the louder the murmur and themore gradient between the LV and RV
VSDs often spontaneously close in childhood as the heart grows
Chamber enlargement includes RV, PA, LA and LV
Sudden AR may be due to aortic leaflet prolapse intoperimembranous or outlet VSD
Windsock deformity in perimembranous VSD is due to tricuspid
valve tissue
VSDs are restrictive(Qp/Qs 75% aorta)
Moderate or large VSDs result in pulmonary hypertension and
should be closed before that occurs
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Ventricular Septal Defect
Percutaneous Closure
Surgical Closure for most
Muscular VSD
Occluders
Perimembranous VSD
Occluder
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Surgical Ventricular Septal Defect Closure
Surgeons with training and expertise in CHD should
perform VSD closure operations (LOE C)
Closure of a VSD is indicated when there is a Qp/Qs
(pulmonary-to-systemic blood flow ratio) of 2.0or more
andclinical evidence of LV volume overload (LOE B)
Closure of a VSD is indicated when the patient has ahistory of IE (LOE C)
Class 1
Warnes CA et al JACC 2008;52:1890-1947
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VSD with Endocarditis
Colorflow
LV
VSD with vegs
LV
LA
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Surgical Ventricular Septal Defect Closure
Closure of a VSD is reasonable when
Net left-to-right shunting is present at a Qp/Qs >1.5
and PA pressure
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Device closure of a muscular VSD may be
considered, especially if the VSD is remote fromthe tricuspid valve and the aorta, if the VSD is
associated with severe left-sided heart chamber
enlargement or if there is PAH (LOE C)
Catheter-based Closure of VSD
Class 2b
Warnes CA et al JACC 2008;52:1890-1947
Question 4
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Question 4
Observe the hemodynamic tracing above.
Based on the tracing, you would conclude which of the following is
correct?
1. There is severe pulmonary stenosisand no regurgitation2. There is severe pulmonary stenosisand mild regurgitation
3. There is mild pulmonary stenosis and severe regurgitation
4. There is mild pulmonary stenosis and mild regurgitation
PA
RV
50
25
0
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The Problem of Low Pressure Pulmonary Regurgitation
PA
PA
RV
RV
Low Pressure PR High Pressure PR
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Tetralogy of Fallot
Babu-Narayan et al., Gatzoulis MA, Webb GD, Daubeney PEF. eds. Diagnosis and Management of Adult Congenital HD. Second Ed. page 316
VSD- usually large. 80% perimembranous
Subpulmonic stenosis- significant in most casesPulmonary valve- bicuspid. May or may not be stenotic
Over-riding aorta- if >50% over the RV, called double outlet RV
LAD from RCA crossing RV outflow in 3-7%
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Initial Palliative Procedures in TOF
Bashore TM. Circulation 2007;115:1933-1947
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Tetralogy Repair
Bashore TM. Circulation 2007;115:1933-1947
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Tetralogy of Fallot Clinical Pearls
Most common form of cyanotic congenitalheart disease (10% of all)
Most adults have had repair
After repair- pulmonary regurg, aortic regurg, LV
dysfunction, RV dysfunction, pulmonary branch
stenosis (native and acquired)
Arrhythmias- atrial and ventricular
Ventricular arrhythmias from RV outflow related to VSD
patch, tricuspid annulus and RVOT patch
Greatest risk for ICD shocks is an elevated LVEDP*
Decision regarding when pulmonary valve
replacement required usually major issue
* Khairy P et al. Circ 2008;117:363
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Prognosis and QRS Width
Gatzoulis MA et al Circulation 1995;92:231
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Pulmonary Valve Replacement After Tet Repair
Class 1- Severe PR and
Symptoms (LOE B)
Class 2a- Severe PR and
Moderate to severe RV dysfunction or RV enlargement or TR
(Upper limit of RV EDV= 140 ml/m2* to 170 ml/m2**)
Symptomatic or sustained atrial or ventricular arrhythmias Surgery also reasonable if any of following:
Residual RVOT gradient >50 mmHg
RV/LV systolic pressure ratio >0.7
Residual RVOT gradient with progressive RV enlargement of dysfunction
Residual VSD with Qp/Qs >1.5 Severe AR with sx or LV dysfunction
A combination of residual lesions leading to RV dysfunction
*Frigola A, et al. Circ 2008;118:S182-S190
** Canadian Guidelines 2010 Warnes CA et al JACC 2008;52:1890-1947
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Anomalous Coronary Arteries
Occur in about 1% of coronary angiograms Only a few are of importance
LCX from RCA occurs in up to 0.5%. Essentially always
posterior to aorta
LAD from RCA coursing anteriorly occurs in 3-7% oftetralogy of Fallot
Most important anomaly is LM or LAD from RCA
coursing between PA and aorta
CT or MRI emerging as excellent complement to cardiaccatheterization angiography and preferred to confirm
diagnosis. Frequently first found incidentally at coronary
angiography.
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Origin of LM or RCA from PA
Digital subtraction
LM from PA. RCA injectionRCA from PA
LM injection
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LM or LAD between PA and Ao
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LM or LAD Between PA and Ao
LVgram (RAO) PA injection and Ao Levophase
With LM injection each time
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Coronary Fistulae
Preclosure Post-closure
RA
Coils
Occluder device
LAD
Fistulae
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Potentially Clinically Important Coronary Anomalies
Anomalies of Coronary OriginAnomalous coronary origin from opposite coronary sinus with course between
aorta and PA (Left main from right cusp more likely a cause of ischemia than
RCA from left).
Associated with supravalvular aortic stenosis
D-transposition of the Great Vessels following arterial switch procedure
Anomalous origin of LM from the pulmonary artery (ALCAPA orBland-Garland-White)
Rarely, single coronary from right cusp
Anomalies of Coronary Course
Myocardial bridging with documented ischemia
Anomalies of the vessel wall
Congenital ostial stenosis
Coronary ectasia or aneurysm of large size
Anomalies of coronary destinat ion
Large coronary fistula
LM b t PA d A
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LM between PA and Ao
Surgical Repair Options
Gulati R et al. J Thorac CV Surg 2007;134:1171
Reimplantation Unroofing
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Anomalous Cors Guideline Recommendations
Anomalous OriginClass 1
Surgical coronary revascularization should be performed in patients with the following
indications:
Anomalous left main coronary artery coursing between the aorta and pulmonary artery (LOE B)
Documented ischemia when either coronary courses between the great vessels or in an
intramural fashion (LOE B)
Class IIa
Surgical coronary revascularization can be beneficial in the setting of documented vascular wallhypoplasia, coronary compression or obstruction to coronary flow, regardless of documented
ischemia(LOE C)
Class IIb
Surgical revascularization may be reasonable in patients with anomalous LAD coursing between
the aorta and pulmonary artery (LOE C)
Coronary FistulaClass I
A large fistula should be closed, regardless of symptomatology, via either a transcatheter or
surgical approach if feasible (LOE=C)
A small or moderate fistula should be closed if there is evidence for myocardial ischemia,
arrhythmia or otherwise unexplained systolic or diastolic dysfunction or enlargement, or
endarteritis, if feasible (LOE=C)
Warnes CA et al JACC 2008;52:1890-1947
Question 5
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Question 5
You are seeing a 50 y.o patient with a bicuspid aortic valve and known
coarctation of the aorta. His echo/Doppler suggests only mild aortic
stenosis and regurgitation. His peak coarctation gradient is estimatedat 30 mmHg. He has mild systemic hypertension that is currently
medically controlled.
Which of the following statements is correct regarding repair of his
coarctation of the aorta?
1. After age 30, the repair should be surgical and not
not percutaneous
2. The coarctation gradient suggests he should proceed to an
intervention at this time
3. Repair of his coarctation should await need for
simultaneous AVR
4. Repair of his coarctation will ensure he no longer needs
any anti-hypertensive medications
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Coarctation of the Aorta
Coarctation of the Aorta Pseudo-coarctation
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Coarctation of the Aorta
Native Coarct Pre Native Coarct Post Stent
C t ti f th A t
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Coarctation of the Aorta Clinical Pearls and Guidelines
Bicuspid aortic valve in up to 85%. Often associated with other
malformations.
Multiple surgical approaches as infant- resection and end-to-end anast.,
interposition graft or patch used most commonly
Figure 3 aortic shadow on CXR with rib notching
In adults follow for systemic HBP, bicuspid valve, recoarctation, aortic
aneurysm, CAD, possible berry aneurysm Stenting now preferred for restenosis (often for primary lesion)
BP may not fall after repair of aortic coarctation in adults. At times
rebound HBP after surgery.
Indication for intervention:
Class 1- peak gradient >20 mmHg. Stenting for discrete lesions,surgery for long lesions. Collaterals may be huge at times.
Class 2b- surgery preferred for long lesions, but stenting can be
considered if anatomy reasonable.
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Discrete Subaortic Stenosis
Subaortic Membrane Associated AR
Turbulence Below Ao Valve
Di t S b ti St i
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Discrete Subaortic Stenosis Clinical Pearls and Guidelines
Spectrum from membrane to tunnel. Occasionally due toaccessory mitral chordae or post-op
Shone Syndrome- multiple levels of obstruction (coarct, bicuspid
aortic valve, subaortic stenosis, parachute mitral, mitral ring)
Thought to be acquired over time. Not seen in neonates.
Progressive lesion. Often recurs after surgical resection.
Jet lesion results in AR in many patients
Percutaneous balloon dilatation not effective
At times LV outflow tract opening required (Konno procedure)
Surgical indications:Class 1- peak gradient of 50 mmHg with mean of 30 mmHg.
May do if less gradient if AR severe or LVESD>5.0 cm or EF
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Pulmonary Valve Stenosis
RV
PA
Doming
Pulm ValveRV
PA
Doming
Pulm Valve
AP VIEW LATERAL VIEW
P l V l St i
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Pulmonary Valve Stenosis Clinical Pearls and Guidelines
Most common RVOT obstructive lesion. Fusion of cusps. Severity from mild to atresia. Most have doming valve- some with
dysplasia. Dysplasia more common in Noonans phenotype.
In mild to moderate severity,-well tolerated for a long time
RVH can be significant. If cyanotic, likely due to opening of PFO
Pulmonic click is only right sided auscultatory event that decreases withinspiration. Decrease due to premature valve opening.
Preferential flow to left PA and left lung occurs.
Balloon valvuloplasty very effective in doming valve PS and preferred.
Intervene:
Class 1-Asymptomatic- peak echo gradient >60 mmHg and mean >40mmHg. Symptomatic- peak >50 mmHg and mean>30 mmHg.
Class 1- Surgery if associated PR, subvalvular or supravalvular stenosis.
Also for most dysplastic valves.
Class 2b- balloon valvuloplasty in rare patients with dysplastic valve
Class 3- if severe PR or asymptomatic with mean gradient
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Sinus of Valsalva Aneurysm
LV
Worm-like
Sinus of Valsalva
Aneurysm
RA
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Sinus of Valsalva Aneurysm
Clinical Pearls and Guidelines Almost never affects left coronary aortic cusp. 65-85% right, 10-30%
noncoronary
Rupture essentially always into right heart structure, rarely the LA. RV
in 90%.
Rupture may follow trauma. Clinically dramatic. Loud to and fro murmur when ruptures
Unruptured-can lead to RVOT obstruction, coronary ostial obstruction,
ventricular arrhythmias, TIA, AV block
Ruptured-CHF, tamponade, aortic or tricuspid regurg, acute coronary
disruption
All ruptured leaking should be repaired surgically. Transcatheter
closure has been described, but no long term data.
Therapy for nonruptured aneurysms unclear and left to clinical judgment
regarding size, etc. All need serial assessment.
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Question 6
Wald R, Crean A . Canadian MAJ 2010;182:E380
PDA with Pulmonary HBP
Not clubbed
Clubbed
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Patent Ductus Arteriosus
Pre Ductal Closure Post Ductal Closure
Ao AoPDA
Ductal Occluder
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Patent Ductus Arteriosus Clinical Pearls and Guidelines
Usually an isolated lesion in the adult
Size generally based on physical exam and consequences:
Silent-tiny PDA. Usually found on echo.
Small-audible PDA but no hemodynamic evidence for volume overload
Moderate-audible and dynamic pulses. LA, LV, RV and PA are enlarged.
Some degree of pulmonary hypertension frequent Large-Eisenmengers present. Pulmonary regurg. Reversed shunt (pink
hands, blue clubbed toes)
Repaired ductus as child usually without major sequela as adult
Percutaneous occlusion preferred if feasible. In older adult calcium
makes surgical repair greater risk as well.
Unrepaired guidelines: Class 1- Closure indicated if audible and evidence
for LA or LV enlargement or PAH or prior endarteritis. Surgical closure if
too large or anatomically unfavorable for device. Class 2a- reasonable to
close small PDA in asymptomatic or in those with PAH if net left-to-right
shunt. Class 3- PAH with net right-to-left shunt
Warnes CA et al JACC 2008;52:1890-1947
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Ebsteins Anomaly
Tricuspid Valve
Displacement
ASD
Mild Ebsteins
Associated ASD
Severe Ebsteins
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Ebsteins Anomaly Clinical Pearls and Guidelines
Displacment of septal and posterior leaflets, not anterior.
Anterior leaflet large. When closes a sail sound may be heard.
TV displacement into the RV by 20 mm (8 mm/m2) compared to MV plane
Atrialized RV is thin and dilated. ASD occurs in 50%.
Maternal lithium has been implicated in fetal cases
Cause of AV valve regurg in congenitally corrected TGV (systemic RV).
Right sided WPW pathway present in 15%. May need ablation.
Clinical survival dependent on severity of TR and how much good RV
remains. Some have assoc. TS.
Exercise cyanosis not uncommon with associated PFO or ASD
Surgical repair may be difficult- ASD closure, plication and RA atrioplasty,
creation of monocuspid valve with ant. leaflet, cone reconstruction, TVR
Surgical intervention*: Class 1- symptoms. Can be related to ASD , TR/TS,
right heart failure, bioprosthetic TV replacement (LOE B)
*Warnes CA et al JACC 2008;52:1890-1947
Gerbode Defect
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Gerbode Defect
LV to RA
LV
RA
L Transposition
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L-Transposition
(Congenitally Corrected Transposition of the GA)
Pulmonary
LV Systemic
RV Ao
Systemic RV
LA
L Transposition
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L-Transposition
(Congenitally Corrected Tranposition of the Great Arteries)
Clinical Pearls and Guidelines L means the RV is on the left side of the LV (actually anterior)
Circuit OK except that RV supports systemic circulation. Often picked
up incidentally as adult (if no other malformations)
VSD and PS common in children. TV (systemic AV valve) resembles
Ebstein-like malformation in 50% and prone to regurg. AR often seen aswell. In 2-5% an accessory pathway present.
Pulmonary ventricle is anatomic LV. 50% have outflow obstruct. to PA.
Dual AV nodes common. Complete heart block rate about 2% per year
In children, consideration for atrial and arterial dual switch procedures
In adults, options usually revolve around CHF therapy, CRT, pacing,TVR and cardiac transplantation. Surgical correction usually not an
option. No clear guidelines.
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D-Transposition of the Great Arteries
From www.yorksandhumberhearts.nhs.uk/template/page.aspx?id=415
D T iti E h
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D-Transposition Echo
Systemic RV Pulmonary LV
Ao
PA
Systemic RV
RV is on Right Side
Supports Systemic Circulation
Aorta Anterior
D-Transposition
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D Transposition
Surgical Procedures
www.yorksandhumberhearts.nhs.uk/template/page.aspx?id=415
Atrial Switch (Mustard) Arterial Switch (Jalene)
Gaca AM et al. Radiology 2008;247:617
D T i i f h G A i
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D-Transposition of the Great Arteries Clinical Pearls and Guidelines
Atria connected to correct ventricles, but ventricles connected to wrongarteries. RA to RV to AO; LA to LV to PA. Need VSD or ASD to
survive. Atrial septostomy required shortly after birth if no ASD or VSD
VSD in 40-45%. LVOT obstruction in 25% (usually in those with VSD)
Atrial switch procedure (Mustard or Senning) baffles SVC and IVC to
mitral valve. Pulmonary flow around baffles to tricuspid valve. Arterial switch procedure now preferred. Chest pain can be due to
coronary ostial stenosis.
In atrial switch procedures, RV remains systemic ventricle and will
eventually fail. Other problems include tachy and bradyarrythmias,
baffle obstruction (and often with associated baffle leaks), systemic AV
valve regurgitation. Rastelli (RV to PA conduit) used if VSD plus severe PS.
Guideline recommendations complex and dependent upon surgical
procedure. For many the only long-term option is transplantation.
At i l S it h C li ti
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Atrial Switch Complication
Azygous
Occluded
Superior
Baffle Stented
Superior
Baffle
Inferior Baffle
Superior Baffle Occlusion Stenting of Baffle
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Bonnet D. et al.; J Thorac Cardiovasc Surg 1999;117:352-357
LM lesion afterarterial switch
Surgical Repair
Arterial Switch Complication
LAD
LCX
LCX
RCA
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Summary for Boards
Focus on broad concepts Understand anatomy of the most common
lesions and the associated surgery to
repair them Be aware of clinical quirks for each lesion.
These make good test questions
Be aware of guideline recommendationsfor surgery or for intervention in the more
common lesions