Η δ ι ά τ ρ η σ η τ ο υ μ ε σ ο κ ο λ π ι κ ο ύ δ ι α φ ρ ά γ μ α τ ο ς ε ί ν α ι υ π ό θ ε σ η τ ο υ Επεμβατικού Ηλεκτροφυσιολόγου; Πώς θα

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1 Η δ ι ά τ ρ η σ η τ ο υ μ ε σ ο κ ο λ π ι κ ο ύ δ ι α φ ρ ά γ μ α τ ο ς ε ί ν α ι υ π ό θ ε σ η τ ο υ Επεμβατικού Ηλεκτροφυσιολόγου; Πώς θα επιλέξουμε την κατάλληλη συσκευή για σύγκλειση μεσοκολπικής επικοινωνίας;

2 Ηλεκτροφυσιολογικές επεμβάσεις Aπομόνωση πνευμονικών φλεβών - PVI Διαδερμικές επεμβάσεις μιτροειδούς βαλβίδας Βαλβιδοπλαστική, επιδιόρθωση, αντικατάσταση, σύγκλειση PVL Σύγκλειση ωτίου ΑΡ κόλπου - LAA Υποστηρικτική θεραπεία Tandem Heart

3 71cm BRK/BRK1 & 67cm SL1

4 Dilator Ross needle Sheath Sheath

6 Radinovic et al., Annals of Card Anesth, 2016 O Brien et al, IJC, 2017

7 Antero posterior view G. Joseph CCVD 42:138,1997

8 Lateral view 90 degree lateral G. Joseph CCVD 42:138,1997

9 Bicaval view: LA RA SVC Short axis view LA 4 chamber view LA RA AO SVC LV RV G. Joseph CCVD 42:138,1997

10 Bicaval view. Short-axis view Puncture at the center of the septum, in order to have room for the occluder Observe the tenting of the fossa ovalis at its mid portion (bicaval view) Short-axis view to assess antero-posterior position The tenting should be as central as possible always paying attention to keep a safe distance from the aorta

12 MA Sherif et al, Neth Heart J, 2017

TEE in 4-chamber view tenting of the atrial septum can be seen as the transseptal needle is pushed against it, ideally in the superior and posterior part of the

positioning of the MitraClip delivery system in the left atrium.

13 TEE in 4-chamber view tenting of the atrial septum can be seen as the transseptal needle is pushed against it, ideally in the superior and posterior part of the interatrial septum with the aim of obtaining adequate working space and distance above the mitral annulus MA Sherif et al, Neth Heart J, 2017 Steering and positioning of the MitraClip delivery system in the left atrium. The Clip Delivery System (CDS) is advanced until its tip is even with the guide tip under fluoroscopic guidance. The CDS is further advanced until the guide radiopaque tip ring marker is centered between the sleeve alignment markers with confirmation on fluoroscopy (straddling)

when the clip is adequately positioned above the middle segments of the mitral valve and

14 After grasping of the leaflets, leaflet capture is evaluated by lowering the gripper and partially closing the clip to secure leaflet insertion 3D en face view allows to determine when the clip is adequately positioned above the middle segments of the mitral valve and whether orientation is perpendicular to the line of mitral valve coaptation MA Sherif et al, Neth Heart J, 2017

15 MJ Earley, Heart 2009;95: doi: /hrt

16 Ακριβής τοποθέτηση Αποφυγή παρακέντησης του οπίσθιου τοιχώματος ή του ανωτέρου τοιχώματος του αρ. κόλπου Πρώιμη διάγνωση περικαρδιακής συλλογής Posterior Puncture S. Kar, Cedars Sinai, SCAI

17 Α Πανεπιστημιακή Καρδιολογική Κλινική

18 Α Πανεπιστημιακή Καρδιολογική Κλινική

19 TS puncture Αιμορραγία Περικαρδιακή συλλογή

20 Η παρακέντηση είναι βασική για πολλές διαδερμικές επεμβάσεις Είναι αναγκαία η χρήση ΤΕΕ και ακτινοσκόπησης Η επιτυχής παρακέντηση βασίζεται: Στον τύπο της επέμβασης Στην τοποθεσία της βλάβης Στο μέγεθος του αριστερού κόλπου Απαιτείται εγρήγορση για πιθανές επιπλοκές

22 One of the most common CHD seen in pediatric cardiology 1/1500 live births 7-10% of all patients with congenital heart disease Twice as frequent in females than males Most are sporadic but there are familial forms too

Stage II: the remaining part of the opening between the RA and LA closed by septum secundum.

24 Forms at 4-6 gestational week of fetal development. Stage I: formation of the septum primum. Foramen primum (also called the ostium primum) stays open. Stage II: the remaining part of the opening between the RA and LA closed by septum secundum. The 2 tissue layers overlap like a flap, allowing blood flow to continue during fetal life. Changes in circulation at birth, closes the flap permanently.

35 Clinical Examination ECG Chest X-ray Echocardiography Sometimes cardiac catheterization and/or MRI

36 Physical Exam Findings - Fixed, split S2 -Murmur of increased flow across pulmonary valve ECG Findings - Often normal - Classic rsr in V1/V2 with slight QRS prolongation with slurring of terminal R

37 Enlargement of the right ventricle Enlargement of atrium Large pulmonary artery Increased pulmonary vascularity

38 Transthoracic echo Findings (besides seeing ASD) - Large right ventricle - Increased flow across RVOT

39 Shunt lesions - Atrial septal defect - Partial anomalous pulmonary venous return - Extracardiac shunt - Coronary artery fistula to right side Valve disease - Tricuspid regurgitation - Pulmonary regurgitation - Ebstein s Other - Ventricular aneurysm - ARVC

40 Vaidyanathan B. et al, J Am Coll Cardiol Img 2009; 2:

41 Size and site of shunt Anatomy of ASD (aneurysm, multiple defects ) Sufficiency of rims: MV, TV, IVC, SVC, RUPV, CS 0 SAX 45 LAX 90 Vaidyanathan B. et al, J Am Coll Cardiol Img 2009; 2:

42 In 45% of cases for ASD closure. Insufficient aortic rim is not a contraindication for closure A device >4mm from maximal stretched diameter is selected The most important rim is the posterior Reeves et al, J Am Soc Echocardiogr 2013;26:443-56

43 Balloon Oclusion Test Hemodynamic basal study: RA, LA, RV, LV, PA & Ao pressures // IVC/SVC; PV, PA, Ao oximetry ASD balloon occlusion during 15 minutes Hemodynamic assessment during occlusion: pressures, shunt and resistences Positive Response : PA & no AO & no ED RV/LV

44 Heart 2011:97:438 Cathet Cardiovasc Intervent 2005;64:513-8

46 European Heart Journal, 2010:31;

48 Asymptomatic Children Right Heart dilation ASD> 5mm No signs of Spontaneous Closure Older Patients Hemodynamically insignificant ASD with Qp/Qs<1.5 if concern for stroke Pulmonary Hypertension PA pressures> 2/3 systemic arterial resistance Pulmonary artery reactivity with vasodilator challenge Reversible changes on lung biopsy Net L->R Shunt of 1.5:1

50 1976, King et al published the first attempt to close an ASD with a double umbrella device Implantation of one or more devices via catheter method Eliminates need for cardio-pulmonary bypass No need to stop the heart with cardioplegic agents

52 Amplatzer Septal Occluder Size of the device(waist=a) RA disk (Β) LA disk(c) Length of intermediate zone(waist=d) Device Selection: In defects 38mm Rims 5mm Waist 2-4mm from the defect estimation

53 Sizing balloon - Stop flow technique

54 Sizing balloon - Stop flow technique

56 Οριζόντιος άξονας Τομή 4 κοιλοτήτων στις 0 POSTERIOR RIM ANTERIOR-INFERIOR RIM

57 Οριζόντιος άξονας στις 56 ANTERIOR-SUPERIOR RIM

58 Επιμήκης άξονας Τομή bicaval στις 95. POSTERIOR-SUPERIOR RIM POSTERIOR-INFERIOR RIM

60 Τοποθέτηση οδηγού καθετήρα (multipurpose, MP) στην αριστερή άνω πνευμονική φλέβα

67 Puncture of femoral vein. Position of a 7F femoral sheath. Position of a multipurpose, MP to right upper pulmonary vein Position of extra-stiff wire to right upper pulmonary vein. Position of the catheter to LA. Device in the catheter. Opening of the LA disk of the device to LA. Withdraw of the device at the septum. Opening of the RA disk of the device to RA.

68 Antiplatelet Therapy for 6 months Antimicrobial therapy 2 prior to intervention (vancomycin 1g) and 1 week after ( κεφουροξίμη 500mg x 2) Endocarditis prophylaxis for 6 months In pateints >40 years follow-up frequent for the 1 st 2 years and thereafter every 2-4 years In patients <25years no need for frequent follow-up

69 Krumsdorf U et al, J Am Coll Cardiol 2004;43:302

70 Incidence: % Associated with: - Device deposition failure - Delayed endothelization - Hypercoagulability syndrome Krumsdorf U et al, J Am Coll Cardiol 2004;43:302

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