Atrial septal defect Ventricular septal defect. Anatomy, phisiology and indications to transcatheter treatment

Transcript

1 Atrial septal defect Ventricular septal defect Anatomy, phisiology and indications to transcatheter treatment

2 DIFFERENT TYPES OF ASD Proper assessment is crucial to determine the strategy of treatment TTE, TEE, ICE, 3D Echo, MR

3 DIFFERENT TYPES OF ASD Ostium secundum defect Ostium primum Coronary sinus defect Sinus venosus defect

4 DIFFERENT TYPES OF ASD Development of the atrial septum Septum primum from the superior aspect of the atria towards the endocardial cushions

5 DIFFERENT TYPES OF ASD Development of the atrial septum After the fusion, the superior part of the septum primum disappears and the inferior part becomes the flap valve of the fossa ovalis

6 DIFFERENT TYPES OF ASD Development of the atrial septum After the integration of the pulm veins into the left atrium, the superior wall of the atria infolds creating the so called septum secundum that overlaps the flap valve

7 DIFFERENT TYPES OF ASD Ostium secundum ASD or fossa ovalis defect

8 DIFFERENT TYPES OF ASD LA RA AO Ostium secundum ASD Balu Vaidyanathan et al, JACC:CARDIOVASCULAR IMAGING 2009

9 DIFFERENT TYPES OF ASD

10 DIFFERENT TYPES OF ASD Short postero-inferior rim

11 DIFFERENT TYPES OF ASD Short superior rim

12 DIFFERENT TYPES OF ASD Short aortic rim

13 DIFFERENT TYPES OF ASD Multiple ASDs

14 DIFFERENT TYPES OF ASD Multifenestrated aneurysm

15 DIFFERENT TYPES OF ASD Multifenestrated aneurysm

16 DIFFERENT TYPES OF ASD Ostium primum

17 DIFFERENT TYPES OF ASD Superior Sinus Venosus Defect

18 DIFFERENT TYPES OF ASD Coronary sinus defect Joffe D et al ANESTHESIA & ANALGESIA 2009

19 DIFFERENT TYPES OF ASD RA LA IVC Inf. SVD Inferior Sinus Venosus Defect

20 Difetti settali atriali DIA secundum 6-10% di tutte le anomalie cardiache F/M 2:1 1 per 1500 nati vivi Soprattutto sporadico, ma anche familiare per mutazione genetica.

21 Fisiopatologia Atrio sinistro Vene polmonari Ventricolo sinistro (Qp) Arteria polmonare Flusso di shunt Aorta (Qs) Ventricolo destro Circolo sistemico Atrio destro

22 DIA secundum Fisiopatologia e quadro clinico: Sovraccarico dx con dilatazione AD e VD Iperafflusso polmonare Soffio da eiezione polmonare Sdoppiamento fisso II tono Ipertensione polmonare

23 ECG

24 RX torace

25 Ecografia

26 Ecografia

27 Ecografia

28 Ecografia

29 Ecografia

30 DIA seno venoso Cavale superiore Cavale inferiore o seno coronarico

31 Eco TEE cavale superiore DIA seno venoso

32 eco DIA seno venoso

33 Eco TEE cavale inferiore DIA seno venoso

34 eco DIA ostium primum

35 Trattamento interventistico del difetto settale atriale

36 Occlusion

37 Amplatzer septal occluder device

38 ASD occlusion ASD ostium secundum type ASD diameter larger than 10 mm Left to right shunt > 1,5 No pulmonary hypertension Paradoxical embolism

39 Tecnica della procedura Anestesia generale, ventilazione assistita Ecografia transesofagea Approccio venoso femorale Angiografia in vena polmonare superiore dx nel DIA, atrio destro nel FOP Misurazione del difetto Impianto device, controllo angio - TEE

40 Ecocardiografia Transtoracica/transesofagea Margini del difetto interatriale

41 Ecocardiografia transesofagea 0 Rim anteriore e posteriore

42 Ecocardiografia transesofagea 90 Rim cavale superiore e inferiore

43 Ecocardiografia transesofagea Rim posteroinferiore Long axis 70-90

44 Ecocardiografia transesofagea Centrale Deficit rim aortico e posteriore Deficit rim aortico Difetti multipli :anteriore e posteriore

45 Ecocardiografia transesofagea

46 Difetto interatriale

47 DIA multipli e aneurisma del setto

48 Difetto interatriale

49 Difetti interatriali multipli

50 Difetti interatriali multipli

51 Difetti interatriali multipli 13 mm

52 Difetti interatriali multipli

53 Difetto interatriale Ipertensione polmonare

54 ASD occlusion

55 ASD occlusion

56 ASD occlusion

57 ASD occlusion

58 ASD occlusion

59 ASD occlusion Major complications 2% Perforation Thrombosis Arrhythmias Malpositioning/Embolization Erosion Infective endocarditis Minor complications 5%

60 ASD occlusion Success rate 80-96% Late occlusion rate %

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62 Difetti settali ventricolari 20% dei pazienti con cardiopatia congenita 5-50 per mille neonati Alta incidenza di chiusura spontanea

63 Difetti settali ventricolari

64 Difetti settali ventricolari Fisiopatologia e quadro clinico: Iperafflusso polmonare Sovraccarico atriale e ventricolare sinistro Ipertensione polmonare Soffio sistolico

65 Difetti settali ventricolari Atrio sinistro Vene polmonari Ventricolo sinistro (Qp) Arteria polmonare shunt Aorta(Qs) Ventricolo destro Circolo sistemico Atrio destro

66 ECG Difetti settali ventricolari

67 RxTorace Difetti settali ventricolari

68 Difetti settali ventricolari ECO: dilatazione sezioni sinistre

69 ECO: DIV PM Difetti settali ventricolari

70 ECO: DIV PM Difetti settali ventricolari

71 ECO DIV muscolare Difetti settali ventricolari

72 ECO DIV muscolare Difetti settali ventricolari

73 ECO DIV muscolare Difetti settali ventricolari

74 ECO DIV infundibulare Difetti settali ventricolari

75 Trattamento interventistico del difetto settale ventricolare

76 VSD occlusion VSD with significant shunt Reversible pulmonary hypertension

77 VSD occlusion

78 VSD occlusion

79 VSD occlusion Success: % Mortality: 0.2 % Major complications 6.7% BAV 2,6% for PM VSD Malposition, embolization, erosion, infective endocarditis Minor complications 5%

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81 Transcatheter closure of the patent arterial duct

82 Closure of the patent arterial duct PDA

83 Closure of the patent arterial duct PDA PA AO PDA

84 Closure of the patent arterial duct Angiographic classification Toronto angiographic classification A type B type C type D type E type conic short, window like tubular complex elongated

85 Closure of the patent arterial duct Variables Anatomy Shunt size PA pressure Age at presentation Clinical presentation

86 Closure of the patent arterial duct Indications for intervention Indications Continouos murmur, CTI > normal echo LV volume overload IE profylaxis?? silent duct??

87 Closure of the patent arterial duct Conditions for intervention Conditions Normal/moderately elevated PA pressure Body weight > 5 kg (ADO II???) Ductal anatomy (mostly type A??) Narrowest diameter < 2,5 3 mm (coil) Narrowest diameter > 2,5 3 mm (ADO I / II)

88 Closure of the patent arterial duct Technique General / local anaesthesia Intracardiac pressures Oxymetry? Aortic arch angiography, angulation Measurements of the duct Device implantation Control angiography

89 Technique PDA Measurements A: ao.amp.d. B: ao.amp.length C: ao.amp.mid.d. D: narrowest d. E: pulm.amp.d. E pulmonary D C B aorta A

90 Closure of the patent arterial duct Amplatzer ductal occluder

91 Closure of the patent arterial duct Devices and delivery systems Introducer: 5-8 F (Amplatzer) Device: 6/4, 8/6, 10/8, 12/10, 14/12 Retetntion disk diameter + 4 mm

92 Dotto di Botallo pervio Ecocardiografia transtoracica

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