Intracardiac echocardiography: gross anatomy and magnetic resonance correlations and validations

Clinical Outcomes and Quality of Life after Patent Foramen Ovale (PFO) Closure in Patients with Stroke/Transient Ischemic Attack of Undetermined Cause and Other PFO-Associated Clinical Conditions: A Single-Center Experience

INTRODUCTION

The aim of this study was to assess clinical outcomes and quality of life after PFO closure in patients with previous stroke/TIA of undetermined cause and in patients with other complex PFO-associated clinical conditions.

METHODS

Between July 2009 and December 2019 at our University Cardiology Department, 118 consecutive patients underwent a thorough diagnostic work-up including standardized history taking, clinical evaluation, full neurological examination, screening for thrombophilia, brain magnetic resonance imaging (MRI), ultrasound-Doppler sonography of supra-aortic vessels and 24 h ECG Holter monitoring. Anatomo-morphological evaluation using 2D transthoracic/transesophageal echocardiography (TTE/TEE) color Doppler and functional assessment using contrast TTE (cTTE) in the apical four-chamber view and contrast transcranial Doppler (cTCD) using power M-mode modality were performed to verify the presence, location and amount of right-to-left shunting via PFO or other extracardiac source. Completed questionnaires based on the Quality-of-Life Short Form-36 (QoL SF-36) and Migraine Disability Assessment (MIDAS) were obtained from the patients before PFO closure and after 12 months. Contrast TTE/TEE and cTCD were performed at dismission, 1, 6 and 12 months and yearly thereafter. Brain MRI was performed at 1-year follow-up in 54 patients.

RESULTS

Transcatheter PFO closure was performed in 106 selected symptomatic patients (mean age 41.7 ± 10.7 years, range 16-63, 65% women) with the following conditions: ischemic stroke (n = 23), transient ischemic attack (n = 22), peripheral and coronary embolism (n = 2), MRI lesions without cerebrovascular clinical events (n = 53), platypnea-orthodeoxia (n = 1), decompression sickness (n = 1) and refractory migraine without ischemic cerebral lesions (n = 4). The implanted devices were Occlutech Figulla Flex I/II PFO (n = 99), Occlutech UNI (n = 3), Amplatzer PFO (n = 3) and CeraFlex PFO occluders (n = 1). Procedures were performed under local anesthesia and rotational intracardiac monitoring (Ultra ICE) alone. The devices were correctly implanted in all patients. The mean fluoroscopy time was 15 ± 5 min (range = 10-45 min) and the mean procedural time was 55 ± 20 min (range = 35-90 min). The total occlusion rate at follow-up (mean 50 months, range 3-100) was 98.1%. No recurrent neurological events were observed in the long-term follow-up.

CONCLUSIONS

The data collected in this study demonstrate that percutaneous PFO closure is a safe and effective procedure, showing long-term prevention of recurrent cerebrovascular events, significant reduction in migraine symptoms and substantial improvement in quality of life.

Catheterization in Adults With Congenital Heart Disease: A Primer for the Noncongenital Proceduralist

Currently in the United States, more than 1 million adults have congenital heart disease. Therefore, it will be inevitable for providers performing cardiac catheterization to be faced with adults with repaired congenital heart abnormalities. Moreover, a meticulous approach to every cardiac catheterization procedure is mandatory to avoid missing unrecognized congenital lesions presenting in adulthood. The authors provide a primer for cardiac catheterization procedures in adults with congenital heart disease, reviewing key procedural components: flow calculation, detection of shunts according to different lesions, and, when indicated, ventricular angiography and coronary angiography.

Interatrial shunts: technical approaches to percutaneous closure

INTRODUCTION

Interatrial shunt closure is considered the first-line therapy for congenital simple communications such as patent forame ovale (PFO), atrial septal defect (ASD), and post surgical interatrial communications.

AREAS COVERED

Anatomical, functional, and technical details useful for planning a transcatheter-based closure procedure are discussed as well as the available equipments and their use and the procedural routes and the specific closure techniques.

EXPERT COMMENTARY

Anatomical and functional details, appreciated at both pre-procedural and intraprocedural steps, are of paramount importance for planning interatrial shunts transcatheter - based closure procedures. Rims of the defects, borders of the fossa ovalis, presence and relevance of atrial septal aneurysm, persistence of Eustachian valve or cor triatriatum dexter, and interatrial septum hypertrophy or lipomatosis are all factors to be investigated when planning the procedure and selecting the device. Routes for interventions should include femoral, and eventually the jugular and hepatic vein approaches. Intraprocedural transoesophageal echocardiography (TTE) or intracardiac echocardiography (ICE) should be used at least in most complex cases to have the exact definition of the anatomy of the defects. Future developments of device material and imaging tools are expected to improve safety and long-term efficacy even in the most complex cases.

Atrial Septostomy: A Contemporary Review

Pulmonary arterial hypertension (PAH) is a rare disease, but it boasts significant morbidity and mortality. Although remarkable achievements have been made in the medical treatment of PAH, there is a role for invasive or surgical procedures in patients with progressive disease despite optimal medical therapy or with no access to such therapy. Atrial septostomy creates a right-to-left intracardiac shunt to decompress the overloaded right ventricle. Despite significant advances to validate and improve this palliative procedure, as well as recent reports of improved outcomes, it is only slowly being adopted. This article aims to detail the history, indications, contraindications, procedural techniques, and outcomes of atrial septostomy. We will also shed light on some of the newer interventions, inspired by the same physiological concept, that are being evaluated as potential palliative modalities in patients with PAH.

Usefulness of intracardiac echocardiography with a mechanical probe for catheter-based interventions: a 10-year prospective registry

BACKGROUND

The clinical outcome benefit of intracardiac echocardiography (ICE) with a mechanical probe during congenital heart disease interventions has not been fully investigated. We reported the long-term results of a prospective registry of interatrial shunt closure guided by mechanical ICE.

METHODS

We enrolled 537 patients (mean age 48 ± 19.0 years, 378 females) submitted to ICE-aided procedures in a prospective registry over a 10-year period (September 2003-September 2013). All patients underwent transesophageal echocardiography (TEE) before the planned procedure. We evaluated (1) structure identification capability, (2) fossa ovale and interatrial septum component measurement, (3) procedure monitoring capability, (4) procedural and fluoroscopy times, and radiograph dose, (5) probe-related complications.

RESULTS

ICE was successfully performed and was able to correctly identify the structures previously assessed by TEE in all patients. In 24 patients (4.5%), ICE allowed better anatomy definition than TEE. In 35 other patients (6.5%), ICE identified structures not observed by TEE, which led to change indications to interventions or the operative technique to be used. In 131 patients (24.4%), ICE evaluation led to change the planned device to be implanted. There was only one probe-related complication (0.2%).

CONCLUSIONS

Mechanical ICE may offer a valid alternative to conventional TEE in guiding congenital heart disease interventional procedures.

Transcatheter interatrial shunt closure as a cure for migraine: can it be justified by paradoxical embolism-risk-driven criteria?

BACKGROUND

Some ongoing trials have suggested that closure of the patent foramen ovale (PFO) may reduce migraine symptoms. We sought to assess the safety and effectiveness of migraine treatment by means of PFO transcatheter closure using paradoxical embolism risk-driven criteria.

METHODS

We enrolled 75 patients (48 women and 27 men, mean age 40 +/- 3.7 years) who were referred to our center over a 12-month period for a prospective study to evaluate severe disabling migraine, despite antiheadache therapy and the PFO. Migraine Disability Assessment Score (MIDAS) was used to assess the incidence of migraine headache and severity. Criteria for intervention included all of the following: basal shunt, curtain shunt pattern on transcranial Doppler, presence of interatrial septal aneurysm, 3 to 4 class MIDAS score, symptomatic significant aura, coagulation abnormalities, migraine refractory to conventional drugs.

RESULTS

On the basis of the inclusion criteria, we shortlisted 20 patients (12 women, mean age 35 +/- 6.7 years, mean MIDAS score 38.9 +/- 5.8) for transcatheter closure of PFO and excluded the rest who were referred to the neurologist for medical therapy. The procedure was successful in all of the patients with no perioperative or in-hospital complications. After a mean follow-up of 10 +/- 3.1 months (range 6-14), all patients' migraine symptoms improved (mean MIDAS score 3.0 +/- 2.1, P < 0.03) with PFO complete closure in all patients on transesophageal and transcranial Doppler ultrasound.

CONCLUSION

In this small pilot series, we adopted the criteria which in our opinion best reflected the risk of paradoxical embolism in these patients. By adopting the proposed criteria, primary transcatheter closure of the PFO resulted in a significant reduction in migraine.

Electro-anatomic mapping systems in arrhythmias

Electroanatomic mapping systems have permitted and facilitated difficult interventional ablation procedures for more than a decade. Initially, their use has been in arrhythmias in which the ablation target is difficult to identify, such as ventricular tachycardias in structural heart disease, atypical atrial flutters, or arrhythmias in patients with complex congenital heart defects. In the recent years, electroanatomic mapping systems have also been used to guide catheter-based isolation of the pulmonary veins, an important component of the modern management of atrial fibrillation (AF). Electroanatomic mapping systems integrate three important functionalities, namely (i) non-fluoroscopic localization of electrophysiological catheters in three-dimensional (3D) space; (ii) analysis and 3D display of activation sequences computed from local or calculated electrograms, and 3D display of electrogram voltage ('scar tissue'); and (iii) integration of this 'electroanatomic' information with non-invasive images of the heart (mainly computed tomography or magnetic resonance images). Although better understanding and ablation of complex arrhythmias mostly relies on the 3D integration of catheter localization and electrogram-based information to illustrate re-entrant circuits or areas of focal initiation of arrhythmias, the use of electroanatomic mapping systems in AF is currently based on integration of anatomic images of the left atrium and non-fluoroscopic visualization of the ablation catheter. Their use in the treatment of AF is mainly driven by safety considerations such as shorter fluoroscopy and procedure times, or visualization of cardiac (pulmonary veins) and extra-cardiac (oesophagus) structures that need to be protected during the procedure. In the future, the use of magnetic resonance images, and potentially of high-quality 3D ultrasound images, could provide anatomic information without ionizing radiation and may be helpful to visualize left atrial scar tissue.

Randomized study comparing mechanical with electronic 2-dimensional intracardiac ultrasound monitoring (MEDIUM) during percutaneous closure of patent foramen ovale in adult patients with cryptogenic stroke

BACKGROUND

Previous studies have shown that mechanical and electronic intracardiac echocardiography (ICE) improves ultrasound monitoring during transcatheter patent foramen ovale (PFO) interventional closure.

OBJECTIVES

This study sought to compare the procedural data, clinical imaging quality, and effectiveness PFO closure by using two different ICE monitoring modalities.

METHODS

Patients referred for PFO closure (n = 82) were randomly assigned to mechanical (group 1) or electronic (group 2) ICE monitoring of Amplatzer device implantation. The digital ICE images were evaluated offline by means of absolute visual grading analysis score (VGAS(abs)), and the residual shunting at follow-up were assessed by means of contrast echocardiographic studies, all blinded regarding the ICE closure monitoring modality.

RESULTS

The two groups were comparable with respect to clinical baseline characteristics, intracardiac fossa ovalis measurements, and procedural data (fluoroscopy time, procedure time and measurement of the amount of radiation that the patients absorbed). The total VGAS(abs) ranked the mechanical clinical images in a higher order than the electronic ones (3.78 +/- 0.09 vs 3.58 +/- 0.12, P = 0.005); additionally, three patients (7.3%) of group 2 needed to cross over to mechanical ICE monitoring because a right-convex atrial septal aneurysm configured itself incompletely. No differences in rates of residual shunting were observed at 12 months follow-up between the two groups (97.5% vs 94.7%, P = 0.951).

CONCLUSIONS

Electronic monitoring of PFO closure performed a less diagnostic impact than the mechanical one while maintaining comparable procedural data and clinical outcome. These results represent an important step in validating these new intracardiac ultrasound imaging modalities.

Nickel allergy in interatrial shunt device-based closure patients

BACKGROUND

The possibility of nickel toxicity has been raised with interatrial shunt closure devices constructed of nitinol. This study is aimed to assess the potential adverse symptoms in terms of incidence, duration, and significance, in patients with interatrial shunt and nickel allergy who underwent nitinol device-based closure.

METHODS

We prospectively enrolled 46 consecutive patients (mean age 35 +/- 28.8 years, 30 female) over a 12-month period referred to our center for catheter-based closure of interatrial shunts. Patients were investigated for previous hypersensivity to nickel and were required to test potential nickel allergy with cutaneous patch test (TRUE test) before device implantation. Routinely, clinical visit with laboratory examinations, and TTE were scheduled at 1, 6, and 12 months.

RESULTS

Nine patients (19.5%, mean age 31.3 +/- 13.2 years) had proved symptomatic and instrumental nickel allergy as showed by cutaneous patch skin test but preferred to be implanted. All patients underwent successful transcatheter closure with an immediate occlusion rate of 100% without intraoperative complications. Between the 2nd and 3rd postoperative day, 8 out of 9 patients developed a sort of 'device syndrome' that included concurrent chest discomfort, exertional dyspnea and asthenia, and mild leukocytosis. The syndrome was treated with Prednison and Clopidogrel and in all was resolved after 1-week therapy. Interestingly, none of the patients without nickel allergy developed postclosure symptoms (P < .001).

CONCLUSIONS

In conclusion, nickel allergy is still a problematic issue in patients scheduled for transcatheter closure of intracardiac shunts; however, our brief study suggests that nickel allergy is not per se a contraindication to nitinol device closure.

Incidence of extracerebral paradoxical embolisms in patients with intracardiac shunts

BACKGROUND

Although extracerebral embolism accounts for 5-10% of all paradoxical embolisms, it still remains a ghostlike entity in cardiovascular pathophysiology. The aim of this brief report was to analyze the profile of patients with paradoxical extracerebral embolism and intracardiac shunts, and the role of shunt closure on the recurrence of extracerebral paradoxical embolism (EPE) in a population of patients evaluated for patent foramen ovale (PFO)/atrial septal defect (ASD) transcatheter closure.

METHODS

From July 2003 to December 2006, 150 patients (mean age 51.4+/-15.1 years, range13-78 years, M/F=49/101) were planned for transcatheter closure of PFO/ASD at our institutional program of Adult Congenital Heart Disease Management. Clinical history and medical records of all patients were reviewed searching for association of PFO/ASD, stroke, and presumptive EPE.

RESULTS

Association of PFO with presumptive EPE was found in nine patients (6%, mean age 40.1+/-14 years, M/F=3/6). Five patients had ST-elevation myocardial infarction (mean value of troponin was 15.3+/-2.1 ng/ml), while four patients had inferior limb acute ischemia. In patients with coronary embolism, coronary angiography was performed immediately after chest pain onset revealing normal coronary artery and only a mild hypokinesia. In patients with peripheral acute ischemia, early (>4 h from symptoms onset) angiography demonstrated normal main peripheral vessel and an embolic closure of popliteal artery (one patient), distal tibial artery (two patients), or peroneal artery (one patient) that normalized with heparin therapy in a few hours except in one patient. Migraine with aura was present in seven of nine patients. Cerebral MRI revealed previous ischemic areas in four of nine patients. Coagulation disorders were detected in six of nine patients. Echocardiography demonstrated a large to medium PFO in seven patients and a cribrosus ASD in two patients.

CONCLUSION

Although a large study is required to assess optimal diagnosis and clinical implications of EPE, the clinical profile emerging from our study may help to identify some easy criteria of diagnosis in order to improve diagnosis and decrease the recurrence of such probably underestimated manifestations of PFO/ASD.

Surgical therapies for pulmonary arterial hypertension

Surgical therapies for the treatment of pulmonary arterial hypertension typically are reserved for patients who are deemed to be refractory to medical therapy and have evidence of progressive right-sided heart failure. Atrial septostomy, a primarily palliative procedure, may stave off hemodynamic collapse from right-sided heart failure long enough to permit a more definitive surgical treatment such as lung or combined heart-lung transplantation. This article discusses indications for and results of atrial septostomy and lung and heart-lung transplantation in patients who have pulmonary arterial hypertension.

Transesophageal Echocardiography and Intracardiac Echocardiography Differently Predict Potential Technical Challenges or Failures of Interatrial Shunts Catheter-Based Closure

We sought to prospectively assess the role of transesophageal (TEE) and intracardiac echocardiography (ICE) in detecting potential technical difficulties or failures in patients submitted to interatrial shunts percutaneous closure. We prospectively enrolled 46 consecutive patients (mean age 35+/-28, 8 years, 30 female) referred to our center for catheter-based closure of interatrial shunts. All patients were screened with TEE before the intervention. Patients who met the inclusion criteria underwent ICE study before the closure attempt (40 patients). TEE detected potential technical difficulties in 22.5% (9/40) patients, whereas ICE detected technical difficulties in 32.5% (13/40 patients). In patients with positive TEE/ICE the procedural success (92.4% versus 100% and, P = ns) and follow-up failure rate (7.7% versus 0%, P = ns) were similar to patients with negative TEE/ICE, whereas the fluoroscopy time (7 +/- 1.2 versus 5 +/- 0.7 minutes, P < 0.03), the procedural time (41 +/- 4.1 versus 30 +/- 8.2 minutes, P +/- 0.03), and technical difficulties rate (23.1% versus 0%, P = 0.013) were higher. Differences between ICE and TEE in the evaluation of rims, measurement of ASD or fossa ovalis, and detection of venous valve and embryonic septal membrane remnants impacted on technical challenges and on procedural and fluoroscopy times but did not influence the success rate and follow-up failure rate.