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Closing Holes

Closing Holes. Dr Rob Martin Consultant in Paediatric & Adult Congenital Heart Disease Bristol. Bristol. BRI. BRI. BRI. New Cardiac Unit. New build adult cardiac and cardiac surgical unit linked in to current facilities Integrated facilities for adults with congenital heart disease.

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Closing Holes

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  1. Closing Holes Dr Rob MartinConsultant in Paediatric & Adult Congenital Heart DiseaseBristol

  2. Bristol

  3. BRI

  4. BRI

  5. BRI

  6. New Cardiac Unit • New build adult cardiac and cardiac surgical unit linked in to current facilities • Integrated facilities for adults with congenital heart disease

  7. Closing Holes • Should we? • Which patients should we treat? • Who should? • What are the service requirements?

  8. Should We?ASD closure • Established practice in children and adults • Surgery has low mortality but moderate complication rate and exposes patient to cardiopulmonary bypass

  9. Common Fallacies • Older patients with ASD are pulmonary hypertensive • Old patients do not benefit from ASD closure

  10. Pulmonary hypertension • Mild PHT secondary to elevated LA pressure common – TR 3m/s • Care with co-morbidity such as pulmonary or airways disease • Beware of primary pulmonary hypertension with “bystander” ASD

  11. Too Old! • LVEDP rises 2mmHg per decade • As LV stiffens with age left to right shunt increases, right heart dilates and ability to increase systemic output falls • Most centres close defects in 70 and 80 year olds and often have good improvement in exercise tolerance

  12. ASD closure pros • Quick procedure with overnight stay or possibly day case treatment • Exercise tolerance likely to improve • May improve arrhythmia control in those with paroxysmal AF • Reduce thrombo-embolic risk

  13. ASD closure cons • Increased short term risk of AF • Atrial or aortic erosion • Migraine

  14. Which patients should we treat? • RV volume loading on echo • Thromboembolic disease • AF + significant defect

  15. Case to treat ? • 14 year old girl presents with respiratory illness (cough + fever) • Previously fit – competitive gymnast + swimmer • CXR

  16. Case to treat?

  17. Case to treat? • CT scan and lung function studies suggested diffuse interstitial process in lungs ? Cause • Echo showed dilated RV and ASD • Some improvement in respiratory symptoms but persistent exercise limitation and desaturates during exercise test • Echo 12-13mm ASD with mild RV dilation

  18. Case to treat?

  19. Case to treat?

  20. Case to treat? • Elected not to close defect • Within 6 months suprasystemic PA pressure with biopsy proven pulmonary vascular disease

  21. Which patients not to treat • Partial AVSD • Sinus venosus ASD • Partial anomalous pulmonary venous drainage • Defects > 40mm

  22. Who should treat? • Experience of congenital heart disease • Experience of closing defects, especially if multiple or large. • Need on site cardiac surgery to deal with potential complications • Need to be able to deal with problems & have kit to deal with them (large sheaths + retrieval kit)

  23. Large defects

  24. Large defects

  25. Multiple defects

  26. Multiple defects

  27. Multiple defects

  28. Multiple defects

  29. Service requirements • Good stock of kit • Surgery • Good TOE or ICE • Funding would be nice!

  30. Patent Foramen Ovale • Normal structure in early childhood • PFO typically closes in first few months of life – typically catheter patent in first year • 25% of adults have openable foramen

  31. Complications of PFO • Systemic embolism – usually stroke • Decompression sickness in divers – the bends • Platypnoea-orthodeoxia syndrome – desaturation varying with change in posture

  32. Stroke and PFO • 25% of adults have openable PFO • 600,000 ischaemic strokes per year in USA • 10-40% of stroke cryptogenic • 50% incidence of PFO in cryptogenic stroke • 30,000- 100,000 strokes per year in USA may relate to presence of PFO

  33. Evidence for stroke being related to PFO • Observation of thrombus in PFO • High incidence of demonstrable venous thrombosis in patients with stroke and PFO • Association of cerebrovascular events with straining or other events that cause a valsalva manoeuvre • Higher incidence of PFO in those with cryptogenic stroke

  34. Risk factors • Size of shunt • Size of atrial communication • Presence of atrial septal aneurysm. 3x risk factor

  35. Evidence for benefit from closure • Platypnoea- orthodeoxia syndrome cured by closure • Safe to dive after PFO closure in those previously affected by bends • Possible benefit in stroke patients • Post closure 1-2% annual risk of stroke/TIA • Closure rate 95-99% with Amplatzer device

  36. Recurrence risk • 5-7% annual incidence of stroke if PFO and atrial septal aneurysm • 2% annual incidence in patients on warfarin • Antiplatelet agents relatively little benefit

  37. Comparison of medical + cath therapy • Windecker et al JACC 2004;44:750-758 • 308 pts with cryptogenic stroke and PFO • Non significant trend for benefit from closure versus warfarin. Higher incidence of recurrence in those treated with antiplatelet agents

  38. Who should do it? • Experience of device closure • Unlikely to have other congenital problems • May be multiple defects • Rare risk of erosion and device embolism so on site surgery recommended • Report to CCAD

  39. Headache • Migraine studies under way and should report soon. • Likely to be benefit from PFO closure in patients with migraine and aura

  40. ASD + PFOShould we? • Yes • Correct placement of the device important

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