Reduction of a previous atrial septostomy in a patient with end-stage pulmonary hypertension by a manually fenestrated device

A case of profound sistemic oxigen desaturation after atrial septostomy in a patient with primitive pulmonary hypertension is reported. A new method to correct such severe complication of atrial septostomy is described, consisting in a graded reduction of the right to left atrial shunt by deployment of a manually perforated atrial septal closure device.     

Phased-Array intracardiac echocardiography to guide radiofrequency ablation in the left atrium and at the pulmonary vein ostium

INTRODUCTION: We sought to evaluate the utility of a phased-array intracardiac echocardiography (ICE) device to identify left atrial (LA) and pulmonary vein (PV) anatomy; accurately guide radiofrequency ablation (RFA) to the right or left PV ostium and LA appendage (LAA); and evaluate PV blood flow before and after RFA using Doppler parameters. METHODS AND RESULTS: Twelve adult sheep were anesthetized and an Acuson 10-French, 7-MHz ICE transducer introduced via the internal jugular vein into the right atrium. The LA was imaged and PV anatomy and blood flow documented using two-dimensional and pulsed-wave Doppler. Mean LA dimensions were 4.6 +/- 0.4 x 3.5 +/- 0.5 cm; mean single right and left main PV ostium diameters were 1.5 +/- 0.2 and 1.3 +/- 0.3 cm; and mean right and left PV first-order branch diameters were 0.8 +/-0.2 and 0.6 +/- 0.1 cm. Mean PV maximum inflow velocity for the right PV were 0.30 +/- 0.05 m/sec and for the left PV were 0.35 +/- 0.04 m/sec. The PV ostia and LAA could be targeted accurately for RFA using ICE guidance. At pathologic evaluation, the mean distance of the lesion center to the right or left PV-LA junction was 3.0 +/- 2.0 mm. The mean distance of the lesion center to the posterior margin of the LAA was <4 mm in all cases. There was no significant increase in PV maximum inflow velocity or decrease in PV diameter following RFA at the PV ostium. Absence of PV obstruction was confirmed at pathology. CONCLUSION: Phased-array ICE allows detailed assessment of LA and PV anatomy when imaged from the right atrium; accurate guidance of RFA to the PV ostium and LAA; and immediate evaluation of PV patency after RFA.     

Atrial septostomy using a butterfly stent in a patient with severe pulmonary arterial hypertension.

We describe a patient with severe pulmonary artery hypertension and refractory right heart failure who underwent "butterfly" stent atrial septostomy guided by intracardiac ultrasound. This technique may be superior to previously reported blade and balloon septostomy because it allows creation of an atrial septal defect of a precise predetermined diameter. The patient's systemic blood flow and clinical status improved significantly after the procedure, allowing her to be accepted as a candidate for lung transplantation.     

Effects of atrial septostomy in patients with terminal cor pulmonale due to pulmonary vascular disease

Fourteen patients with pulmonary vascular disease, either primary pulmonary hypertension or the result of cardiac defects, underwent balloon atrial septostomy (BAS) over the period of July 1981 to June 1988 because of symptoms of syncope, fatigue, right heart failure, and cardiac arrest. Ages ranged from 4 mo to 50 yr. Two moribund patients died within 24 h of the septostomy due to severe hypoxemia and unrelieved low cardiac output; three others died 2 wk to 35 mo later; the remaining 9 patients have improved symptomatically and are alive 11 to 96 mo after septostomy. One received a heart and lung transplant 19 mo later. We conclude that, in patients with symptomatic cor pulmonale secondary to pulmonary vascular disease, atrial septostomy can improve symptoms and may serve as a palliative bridge to heart and/or lung transplantation.     

Phased-array intracardiac echocardiography during pulmonary vein isolation and linear ablation for atrial fibrillation

INTRODUCTION: Fluoroscopic imaging provides limited anatomic guidance for left atrial structures. The aim of this study was to determine the utility of real-time, phased-array intracardiac echocardiography during radiofrequency ablation for atrial fibrillation. METHODS AND RESULTS: In 29 patients undergoing pulmonary vein isolation (n = 16) or linear (n = 13) left atrial radiofrequency ablation for atrial fibrillation, intracardiac phased-array echocardiography was used to visualize left atrial anatomy and the pulmonary veins, as well as ablation and mapping catheters during ablation procedures. In the 16 pulmonary vein isolation patients, the mean pulmonary vein ostial diameters measured by venography and intracardiac echocardiography were similar for all veins positions, except that left common pulmonary vein diameters were larger as measured by echocardiography (2.50 +/- 0.29 cm) than by venography (1.79 +/- 0.50 cm, P = 0.001). The ostial diameters measured by echocardiography and venography were not correlated, however (r = 0.23, P = 0.19). As directed by echocardiography, only 1 of 25 circular mapping catheters (4%) used in 16 patients was replaced due to inappropriate sizing of the pulmonary veins. Mean pulmonary vein Doppler flow velocities increased after ablation for left-sided veins but ostial diameters were unchanged. In the linear ablation patients, the entire extent of the linear electrode array could be visualized in only 3 of 52 of catheter positions (6%) in the 13 patients. A portion of the catheter could be seen in only 50% of all target catheter positions. CONCLUSION: Phased-array intracardiac echocardiography (1) allows sizing and positioning of pulmonary vein mapping catheters, (2) provides measures of pulmonary vein ostial diameters, (3) continuously monitors pulmonary vein Doppler flow velocities, and (4) has limited use in positioning linear ablation catheters in the left atrium.     

Balloon dilation atrial septostomy for advanced pulmonary hypertension in patients on prostanoid therapy

Methods : All patients had progressive symptoms despite prostanoid therapy at the time of their first BDAS. Sixteen patients who underwent a total of 23 septostomies between 2004 and 2014 were included in this retrospective case series. Conclusions : BDAS may be an alternate therapy for select PH patients who have symptomatic progression despite prostanoid therapy. Survival is comparable to prior reports of BDAS in the pre‐prostanoid era. © 2014 Wiley Periodicals, Inc.     

Use of intracardiac echocardiography for prediction of chronic pulmonary vein stenosis after ablation of atrial fibrillation

INTRODUCTION: Measurements of pulmonary vein (PV) flow with intracardiac echocardiography (ICE) immediately before and after PV isolation may be a useful method for predicting which patients will develop chronic PV stenosis. METHODS AND RESULTS: We assessed preablation and postablation flows in each of the four PVs using a phase-array ICE catheter in 95 patients (mean age 52 +/- 13) undergoing atrial fibrillation ablation. The ostium of each of the PVs was defined using angiography, electrical mapping, and ICE imaging. Ostial electrical isolation of all PVs was achieved using a 4-mm cooled-tip radiofrequency ablation catheter. Change in PV flow, when present, was examined as both an absolute value and as a percentage of the baseline flow. All patients underwent spiral computed tomography (CT) scans of the PVs 3 months after the procedure for detection of stenosis. The average preablation diastolic flows for the left superior, left inferior, right superior, and right inferior veins were 0.56, 0.54, 0.47, and 0.45 m/sec, respectively. These values increased to 0.74, 0.67, 0.58, and 0.59 m/sec postablation (P < 0.001). Of 380 PVs ablated, the CT scans revealed 2 (1%) with severe (>70%) stenosis, 13 (3%) with moderate (51%-70%) stenosis, and 62 (16%) with mild (< or = 50%) stenosis. The r value between flow and stenosis was only 0.09 (P = NS). CONCLUSION: Acute changes in PV flow immediately after ostial PV isolation do not appear to be a strong predictor of chronic PV stenosis.     

Modified wire atrial septostomy with a reverse transseptal puncture in an infant: Case report

We report a modified technique of wire atrial septostomy (WAS) with a reverse transseptal puncture (TSP) in an infant case of pulmonary atresia with intact ventricular septum. A radiofrequency (RF) wire was advanced to the septum through a 4 Fr pigtail catheter hooked on the left side of atrial septum and RF energy was applied while advancing the wire across the septum. Following that reverse TSP, WAS was performed to cut the septal tissue using a 0.010 microwire and RF wire. The atrial septum defect (ASD) was enlarged to a size of 15 mm. WAS with a reverse TSP could be a useful and safe method to enlarge ASD in infants with congenital heart diseases.     

Pulmonary artery thrombi detected by echocardiography in patients with pulmonary hypertension secondary to atrial septal defect.

This report presents three patients with severe pulmonary hypertension secondary to atrial septal defect associated with thrombus and spontaneous echo contrast within the pulmonary artery diagnosed by transthoracic and transoesophageal echocardiography. Clinical and echocardiographic features seem to suggest local thrombus formation within the pulmonary arteries as a direct consequence of pulmonary hypertension rather than venous thromboembolism.     

Atrial flow regulator for drug-resistant pulmonary hypertension in a young child

This case describes the successful implantation of an Occlutech Atrial Flow Regulator in a young child with idiopathic pulmonary hypertension and recurrent syncope despite targeted combination therapy, with subsequent relief of symptoms.     

Intracardiac echocardiography with ultrasound probe placed in the upper left pulmonary vein to guide left atrial appendage closure: First description

Intracardiac echocardiography (ICE) has become an effective alternative to trans‐esophageal echocardiography (TEE) as a guidance during interventional procedures for structural heart diseases, allowing to proceed under conscious sedation. To guide percutaneous left atrial appendage (LAA) closure, the ICE probe is usually placed in the right atrium, in the pulmonary artery or in the left atrium (LA); however, the views from the right atrium or the pulmonary artery are often suboptimal, debarring a complete visualization of the LAA and the surrounding structures, whereas the LA location requires trans‐septal puncture, may provoke LA wall mechanical stimulation and is often associated with unstable position of the ICE probe. In our case, after a second trans‐septal puncture, the ICE probe was placed in the upper left pulmonary vein; this was safely performed and provided an optimal imaging of the LAA, comparable to that obtained by TEE, thus warranting an adequate guide during all procedural steps.     

Atrial natriuretic factor in essential hypertension: echocardiographic and humoral correlates.

Aim of this study was to assess the relationship between plasma concentration of atrial natriuretic factor (ANF) and its two-dimensional echocardiographic (left ventricular mass, left atrium diameter) and humoral (plasma renin and aldosterone) variables in essential hypertension (EH). We evaluated 32 patients with uncomplicated mild to moderate EH and 10 controls. They were studied in the supine position after 7 days of constant dietary sodium intake and were off therapy since at least 3 weeks. ANF values overlapped between EH patients and controls (27.8 +/- 11.5 vs. 19.5 +/- 7.4 pg/ml, p = NS). In EH, no significant correlation was found between ANF values and left ventricular mass (r = 0.29), left atrial diameter (r = 0.04), mean arterial blood pressure (r = 0.26), plasma renin activity (r = 0.00), and aldosterone (r = 0.26). In EH, ANF values overlapped between the 15 patients with hypertrophy and the 17 patients with normal ventricular mass: 30.3 +/- 17 vs. 25.6 +/- 10.6 pg/ms (p = NS). We conclude that there is a substantial overlap in plasma ANF values between mild to moderate uncomplicated EH and controls, and left ventricular hypertrophy is not a major independent stimulus to ANF release in EH.     

Echocardiographic findings in a patient with primary pulmonary hypertension

This is a report of the echocardiographic findings in a 9-year-old white female with primary pulmonary arterial hypertension confirmed by catheterization and later at autopsy. The reported findings of an absent “a” wave, a flat diastolic E to F slope, and a midsystolic closure of the pulmonic valve were observed. In addition, tricuspid valve prolapse was noted. Prolapse of the tricuspid valve may be part of the mechanism of tricuspid insufficiency in a patient with pulmonary hypertension.