A long tunnel PFO defect best closed with trna septal puncture and closure with a PFO device that would appose the two atrial margins adequately.
PFO tunnel in a 65 year old man presenting with cyanosis (sats 70-80%) after a fall. Treated initially with 10L/min mask oxygn and subsequently requiring ventillation and tracheostomy. Past history of pulmonary valvotomy in 1959. Echocardiogram showed residulal RVOT obstruction and predominantly right to lefting PFO. Transcarheter balloon valvuloplasty with closure of Atrial communication restored normal saturations without the need for ventillatory support.
Video1: 3D profile of a spiral secundum atrial septal defect.
Spiral ASD with widely seperated margins
This 3D image reveals the extra ordinary morphology of the secundum defect illustrating the wide gap between the primum and secundum component of the atrial septal defect. the inferior margin of the secundum septum is thin and has a small second defect at the infero-medial aspect. Though the 2D images are tempting and reassuring to go for a devcice closure the anatomy of the margins clearly demonstrate that this is a no go area for device closure.
A single secundum atrial septal defect with floppy inferior margin.
Image of a patient with multiple fenestrations along the margins of the oval fossa. A catheter is seen introduced through one of the larger defects.
The first view is from the left atrium showing the ASD and PFO as labelled. As the image moves, you can see the PFO flap more clearly and the tongue of atrial tissue partially dividing the ASD into two. As the images is turned to view from the right atrium, you can appreciate the oval fossa and its opeing flap on its top. On live 3D it is interesting to note that the flap opens only during atrial systole in to the left atrium giving rise to right to left shunt. The ASD is seen at the posterio inferior aspect as described.
A 68 year old lady with an aneurismal fenestrated secondum atrial septal defect and a PFO defect (PFOD). The secundum defect is cup shaped and protrodes into the right atrium. This video starts from a LA view. There is a catheter placed in the aneurismal defect which was selectively entered from the IVC through the fenestration.
Dynamic imaging of the atrial septum shows the PFO defect at the usual position and the aneurismal defect below it. There is an echo dropout between the thicker inferior margin of the defect and the atrial wall. This region is thin and aneurismal . As this rgion has relatively less support it protrudes into the left atrium during atrial systole and give a false impression of an additional defect.
The ASD is now clossed with a double umbrella device and the PFO defect remains open. This was subsequently clossed with a second device..
Another case of two ASDs in secondum position: A catheter is placed in defect 1 (D1). The second image illustrates the second device in position with a small residual shunt which will enable decompression of the LA.
The image below is from a 9 year old boy with pulmonary atresia and intact septum. He had RF perforation of the pulmonary valve in the neonatal period and subsequently he undervent Cavopulmonay anastomosis. Later he had an RV overhaul and a 17mm pulmonary contegra graft placement in the RVOT. However, recently he developed deep desaturation with exercise. He also has bilateral femoral vein oclusion. A planned Hybrid PFO closure was abandoned due to the unusual atrial morphology as shown below.
PFO Pouch: The video begins from the right atrial view, The roof of the RA is blind ending as the SVC is detached from it. The atrial septum is well demonstrated with the limbus of the fossa ovalis and the oval fossa defect. When the image is rotated to view from the Left Atrial (LA) side, the aorta is seen anteriorly. Below the left atrial aspect of the aorta is a walled pouch into which the Oval fossa defect is opening. Wall of the pouch is partial, formed by the extension of attachment of the primum septum, seperating it from the left pulmonary veins (seen opening into the LA). Attempt close the defect without knowing 3Dimensional morphology may lead to inappropriate intervention, distorsion of the device due to incomplete opening or other serious complications..
ASD: Assessment post device embolization
3D echocardiographic assessment of a large PFO. This defect is charecterized by the letterbox like morphology and absent SCV and aortic rim. The defect was closed at another centre. The device was found embolized into the thoracic aorta prior to discharge and patient was sent for device retrieval and assessment. After the device (Amplatzer (TM) 15mm ASD device) was retieved, detailed 3D imaging was performed. A 33mm PFO device (Occlutech TM ) was succesfully deployed at the same time.
Please study the images
2D images with angiograms to follow
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