Heart, Lung and Circulation (2014) 23, 385–386 1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2013.11.010
LETTER TO THE EDITOR
PFO Closure Following Tricuspid Valve-in-Valve Implantation Keywords
Patent foramen ovale TAVI Valve-in-valve Tricuspid valve Percutaneous Transcatheter
The case of a 60 year-old woman who underwent successful tricuspid valve-in-valve implantation for an early degenerated bioprosthesis was previously described [1]. After 14 months of well-being the patient experienced once again exertional dyspnoea. Clinical examination was unremarkable: there were neither heart murmurs nor peripheral oedema. A cardiopulmonary test showed mild depression of functional capacity (VO2 peak of 19.7 ml/kg/min, 85% of the theoretical expected value), and moderate desaturation (SO2 88% after four minutes). At the transthoracic echocardiogram the Sapien XT prosthesis in tricuspid position was found to have a mean gradient of 4 mmHg, and minimal, physiological, central regurgitation (Fig. 1A). A bubble-contrast showed a rightto-left shunt at rest, through a patent foramen ovale (PFO)
(Fig. 1B). We therefore decided to proceed with percutaneous closure of the PFO. Intra-procedural cavography (308 left anterior oblique projection) confirmed the right-to-left shunt (Fig. 2A). The mean right atrial pressure was 6 mmHg. The PFO was easily closed with a 9-025-PFO Amplatzer (Fig. 2B). The following day her arterial saturation measured after climbing four flights of stairs remained normal at 98% and the patient was discharged. The cardiopulmonary test, performed nine months after the PFO closure, showed a normal functional capacity (VO2 peak of 21.8 ml/kg/min, 94% of the theoretical expected value) and no desaturation (SO2 97% at the end of the test with a minimum of 94% at the stress peak). This case shows that even after successful right heart surgery, a PFO can allow a right-to-left shunt of sufficient
Fig. 1 Transthoracic echocardiography (A) perfect functioning of the Sapien XT prosthesis in tricuspid position with a mean gradient of 4 mmHg and (B) bubble contrast in the left cavities.
© 2013 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved.
386
S. Salizzoni et al.
Fig. 2 (A) The white arrow points to contrast through the formaen ovale during the cavography. (B) Final result after the Amplatzer deployment.
magnitude as to provoke dyspnoea [2]. Under such circumstances, therefore, a PFO should be systematically searched for and, if present, closed. Stefano Salizzoni* Fulvio Orzan Mauro Rinaldi University of Torino, Citta` della Salute e della Scienza ‘‘Molinette’’, Department of Surgical Sciences, Corso Bramante 88, 10126 Torino, Italy *Corresponding author. Tel.: +39 011 6335511; fax: +39 011 6336130. Emails: [email protected], [email protected] (S. Salizzoni)
Received 21 October 2013; received in revised form 18 November 2013; accepted 19 November 2013; online published-ahead-of-print 28 November 2013
References [1] Salizzoni S, La Torre M, Barbero C, Marra WG, Moretti C, D’Amico M, et al. Transjugular tricuspid valve-in-valve implantation. Heart Lung Circ 2013;(May). http://dx.doi.org/10.1016/j.hlc.2013.04.113. pii:S1443-9506 (13)00323-5 [Epub ahead of print]. [2] Oakley CM, Braimbridge MV, Bentall HH, Cleland WP. Reversed interatrial shunt following complete relief of pulmonary valve stenosis. Br Heart J 1964;26:662–70.
LETTER TO THE EDITOR
PFO Closure Following Tricuspid Valve-in-Valve Implantation Keywords
Patent foramen ovale TAVI Valve-in-valve Tricuspid valve Percutaneous Transcatheter
The case of a 60 year-old woman who underwent successful tricuspid valve-in-valve implantation for an early degenerated bioprosthesis was previously described [1]. After 14 months of well-being the patient experienced once again exertional dyspnoea. Clinical examination was unremarkable: there were neither heart murmurs nor peripheral oedema. A cardiopulmonary test showed mild depression of functional capacity (VO2 peak of 19.7 ml/kg/min, 85% of the theoretical expected value), and moderate desaturation (SO2 88% after four minutes). At the transthoracic echocardiogram the Sapien XT prosthesis in tricuspid position was found to have a mean gradient of 4 mmHg, and minimal, physiological, central regurgitation (Fig. 1A). A bubble-contrast showed a rightto-left shunt at rest, through a patent foramen ovale (PFO)
(Fig. 1B). We therefore decided to proceed with percutaneous closure of the PFO. Intra-procedural cavography (308 left anterior oblique projection) confirmed the right-to-left shunt (Fig. 2A). The mean right atrial pressure was 6 mmHg. The PFO was easily closed with a 9-025-PFO Amplatzer (Fig. 2B). The following day her arterial saturation measured after climbing four flights of stairs remained normal at 98% and the patient was discharged. The cardiopulmonary test, performed nine months after the PFO closure, showed a normal functional capacity (VO2 peak of 21.8 ml/kg/min, 94% of the theoretical expected value) and no desaturation (SO2 97% at the end of the test with a minimum of 94% at the stress peak). This case shows that even after successful right heart surgery, a PFO can allow a right-to-left shunt of sufficient
Fig. 1 Transthoracic echocardiography (A) perfect functioning of the Sapien XT prosthesis in tricuspid position with a mean gradient of 4 mmHg and (B) bubble contrast in the left cavities.
© 2013 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved.
386
S. Salizzoni et al.
Fig. 2 (A) The white arrow points to contrast through the formaen ovale during the cavography. (B) Final result after the Amplatzer deployment.
magnitude as to provoke dyspnoea [2]. Under such circumstances, therefore, a PFO should be systematically searched for and, if present, closed. Stefano Salizzoni* Fulvio Orzan Mauro Rinaldi University of Torino, Citta` della Salute e della Scienza ‘‘Molinette’’, Department of Surgical Sciences, Corso Bramante 88, 10126 Torino, Italy *Corresponding author. Tel.: +39 011 6335511; fax: +39 011 6336130. Emails: [email protected], [email protected] (S. Salizzoni)
Received 21 October 2013; received in revised form 18 November 2013; accepted 19 November 2013; online published-ahead-of-print 28 November 2013
References [1] Salizzoni S, La Torre M, Barbero C, Marra WG, Moretti C, D’Amico M, et al. Transjugular tricuspid valve-in-valve implantation. Heart Lung Circ 2013;(May). http://dx.doi.org/10.1016/j.hlc.2013.04.113. pii:S1443-9506 (13)00323-5 [Epub ahead of print]. [2] Oakley CM, Braimbridge MV, Bentall HH, Cleland WP. Reversed interatrial shunt following complete relief of pulmonary valve stenosis. Br Heart J 1964;26:662–70.
