ΔΙΑΧΕΙΡΙΣΗ ΑΣΘΕΝΩΝ ΜΕ ΜΕΣΟΚΟΛΠΙΚΗ ΕΠΙΚΟΙΝΩΝΙΑ ΖΑΧΑΡΑΚΗ ΑΓΓΕΛΙΚΗ ΚΑΡΔΙΟΛΟΓΟΣ ΗΡΑΚΛΕΙΟ - ΚΡΗΤΗ European Accreditation in TTE, TEE and CHD Echocardiography
NOTHING TO DECLARE
ATRIAL SEPTAL DEFECT TYPES SECUNDUM 80 % PRIMUM 15 % SINUS VENOSUS 5% UNROOFED CORONORY SINUS 1% ESC Guidelines for the management of grown-up congenital heart disease (2010)
CLINICAL PRESENTATION PATHOPHYSIOLOGY Asymptomatic until adulthood Symptoms beyond the fourth decade reduced functional capacity exertional shortness of breath atrial arrhythmias pulmonary infections right heart failure paradoxical embolism Eisenmenger < 5% Left to right shunt RV / LV compliance Defect size >10 mm LA / RA pressure RV volume overload Pulmonary overcirculation ESC Guidelines for the management of grown-up congenital heart disease (2010)
DIAGNOSTIC WORK - UP Key diagnostic technique ECHOCARDIOGRAPHY Diagnosis Location Number Shunt functional effect Rim size and quality Associated lessions CMR and CT can serve as an alternative if echocardiography is insufficient, particularly for assessment of RV volume overload and pulmonary venous connection. Cardiac catheterization is required in cases of high PAP (PAP>50% of systemic pressure) on echocardiography to determine PVR
CLINICAL CASE 1 F 23 years, asymptomatic
CLINICAL CASE 1 F 23 years, asymptomatic
CLINICAL CASE 1 Secundum ASD significant shunt ESC Guidelines for the management of grown-up congenital heart disease (2010)
CLINICAL CASE 2 M 37 years, stroke, deep veins thrombosis
CLINICAL CASE 2 M 37 years, stroke, deep veins thrombosis Qp/Qs=1.3
CLINICAL CASE 2 M 37 years, stroke, PARADOXICAL EMBOLISM Orthodeoxia - Platypnea IIa ACC/AHA 2008 Guidelines for the Management of Adults With Congenital Heart Disease ESC Guidelines for the management of grown-up congenital heart disease (2010)
CLINICAL CASE 3 M 50 y, dyspnea, right heart failure symptoms, intermittent AF
CLINICAL CASE 3 M 50 y, dyspnea, right heart failure symptoms, intermittent AF Right heart catheterization PAP=45 mmhg SAP=115 mmhg PVR= 5 WU SVR= 9 WU
CLINICAL CASE 3 M 50 y, sinus venosus defect, PAPV, Pulmonary hypertension PAP< 2/3 SAP PVR < 2/3 SVR
CLINICAL CASE 4 F 55 years, cyanosis, dyspnea, right heart failure
CLINICAL CASE 4 F 55 years, cyanosis, dyspnea, right heart failure
CLINICAL CASE 4 F 55 years, Right heart catheterization EISENMENGER ESC Guidelines for the management of grown-up congenital heart disease (2010)
CLINICAL CASE 5 M 60 years, tachyarrhythmia, dyspnea, fatigue
CLINICAL CASE 5 M 60 years, partial atrioventricular septal defect, cleft mv ESC Guidelines for the management of grown-up congenital heart disease (2010)
CLINICAL CASE 6 F 70 years, DM, Arterial hypertension, atrial fibrillation, dyspnea, edema
CLINICAL CASE 6 F 70 years, DM, Arterial hypertension, atrial fibrillation, dyspnea, oedema Cardiac Catheterization, Normal Coronary arteries, ASD Device Closure Acute Pulmonary Edema Left heart failure after ASD closure in elderly Acute volume loading Aging related LV diastolic dysfunction Ventricular systolic and vascular stiffening Comorbidities Journal of Cardiac Failure 2011;17:957-963 Mean LA Pressure >10 mmhg- occlusion test Anti - heart failure therapies before ASD closure Fenestrated device Journal of Cardiac Failure 2011;17:957-963 Poor LV function (systolic and diastolic) may cause pulmonary congestion after ASD closure and may require pre-interventional testing (balloon occlusion with reassessment of haemodynamics) and treatment. ESC Guidelines CHD (2010) Further studies are needed to construct a clear algorithm that can identify and treat high-risk patients
DEVICE CLOSURE Is applicable only to secundum ASDs Diameter < 38 mm Sufficient rim of 5 mm except towards the aorta Applicable in 80% of patients Antiplatelet therapy for at least 6 months I. Endocarditis prophylaxis for 6 months ESC Guidelines for the management of grown-up congenital heart disease (2010)
ANATOMY OF THE ASD: NOMENCLATURE OF THE RIMS TEE at 0 : Posterior and Anterior Rims TEE at 90 : SVC and IVC Rims TEE at 45 : Posterior and Aortic Rims J A C C : C A R D I O V A S C U L A R I M A G I N G V O L. 2, N O. 1 0, 2 0 0 9
3D TEE LA VIEW RA VIEW
PERCUTANEOUS CLOSURE ASD LA VIEW RA VIEW LA VIEW LA VIEW
3D TEE Spiral spatial orientation of the margin of the ASD J Am Soc Echocardiography 2013;26:192-9
POST INTERVENTION FOLLOW - UP Residual shunt, RV size and function, TR & PASP, Arrhythmias, ECG, Holter monitoring After catheter intervention Trivial residual shunt After surgical intervention Echo Frequency: 24 h, 1 month, 6 months, 1 year, periodically there after Patients repaired under the age of 25 years without relevant sequelae or residuae (no residual shunt, normal PAP, normal RV, no arrhythmias) do not require regular follow-up. POSSIBLE late occurrence of tachyarrhythmias. Patients with residual shunt, elevated PAP, or arrhythmias (before or after repair) and those repaired at adult age (particularly > 40 years) should be followed on a regular basis. After device closure, regular follow-up during the first 2 years and then, depending on results, every 2 4 years is recommended ACC/AHA 2008 Guidelines for the Management of Adults With Congenital Heart Disease
COMPLICATIONS Minor complications 3-6% Inflammatory reactions Cardiac arrhythmias Femoral access site complications Serious complications 1-2% Impingement on adjacent structures Thrombosis Migration Erosion Pericardial Tamponade Endocarditis Other JACC 2012;60:1722-32
COMPLICATIONS Migration and dislodgement Circulation. 2008;118:e93-e96
COMPLICATIONS AORTIC WALL EROSION J Am Soc Echocardiogr 2011;24:227.e5-227.
TAKE HOME MESSAGES Patients benefit from closure at any age with regard to morbidity (exercise capacity, shortness of breath, right heart failure) Outcome is best with repair at age < 25 years 25 41 years the survival is reduced > 40 years appears not to affect the frequency of arrhythmia development during follow-up The age is the single most important predictor of long term outcomes ευχαριστώ ESC Guidelines for the management of grown-up congenital heart disease (2010)