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TCTAP C-242 Stent Migration After Right Ventricular Outflow Tract Stenting in the Severe Cyanotic Tetralogy of Fallot Patient
S396
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 67, NO. 16, SUPPL S, 2016
Relevant test results prior to catheterization. Transthoracicechocardiography demonstrated a ratio of pulmonary blood flow to systemic bloodflow of 1.5. The defect size on TEE was 1.76 cm. Usually ASD defect size is underestimated on TEE. As a result of this measurement, we chose a 2.2cm sized Amplatzer device. Relevant catheterization findings. After the Amplatzer device has been fully opened, we performed the TEE and confirmed that both atrial disks are flattened or nearly flattened and that the left atrial disk is entirely in the left atrium and the right atrial disk entirely in the right atrium without remnant shunt. After the stability of the device has been confirmed, the delivery cable was released by counterclock wise rotation. Amplatzer spetal occluder device is a useful treatment option of ASA with multiple ASD. [INTERVENTIONAL MANAGEMENT] Procedural step. After general anesthesia, an 8Fr sheath was inserted through right femoral vein. Intraprocedural TEE wasused for guidance in the catheterization laboratory. Initially multi purpose catheter was advanced into left atrium through ASD. And then the multi purpose catheter was replaced with a 0.035inch J-tipped exchange length guidewire, thetip of which is preferably located in a left upper lobe pulmonary vein forstability. The defect size on TEE was 1.76 cm. Usually ASD defect size is underestimated on TEE. As a result of this measurement, we chose a 2.2cm sized Amplatzer device. Selected Amplatzer device was loaded into the delivery tube. And then, delivery sheath, a long dilator, was inserted into left atrium over a 0.035 inch guidewire. After which the prepared device was loaded into delivery sheath. Most important procedural point is to puncture the central area of the shunt (figure 3, 4). Because of multiple shunt and aneurysmal change make it difficult to cover the whole defect area if the guiding sheath was positioned obliquely. After positioned the sheath at left atrium through the central area of the defect site, the Amplatzer device was advanced until it reached the tip of the sheath and then deploy the Amplatzer device (figure 5, 6).
Case Summary. As the atrial septum returns to its natural position, the device typically springs superiorly and leftward radiologically and significant interatrial shunting through the device on TEE was eliminated on color Doppler. We think central puncture of the ASA with multiple ASD and using enough big size Amplatzer spetal occluder device is a useful treatment option of ASA with multiple ASD. TCTAP C-242 Stent Migration After Right Ventricular Outflow Tract Stenting in the Severe Cyanotic Tetralogy of Fallot Patient Tamaki Hayashi,1 Saleem Akhtar,2 Mazeni Alwi1 1 Institut Jantung Negara, Malaysia; 2Aga Khan University Hospital, Pakistan [CLINICAL INFORMATION] Patient initials or identifier number. 338939 Relevant clinical history and physical exam. A one-month-old baby was referred to our hospital with severe cyanosisand mild tachypnea. The body weight was 3.3kg and SpO2 was 69%. Theechocardiography revealed tetralogy of Fallot with Patent ductus arteriosus (PDA) and patent foramen ovale. The infundibular stenosis was severe and hypoxia wassignificant. The patient was brought in the intervention alcatheterizationlaboratory as an emergency case for PDA or right ventricular outflow tract(RVOT) stenting. [INTERVENTIONAL MANAGEMENT] Procedural step. Right ventricle angiography showed pulmonary stenosis. Valve annulus was3.7mm (Z score -3.09) and it was difficult to localize the narrowest part inthe infundibulum by fluoroscopy. Echocardiography revealed the infundibularstenosis as 2.1mm. Valve was crossed with a coronary guide wire. PTCA balloon5mm X 12mm was placed over the coronary wire and balloon dilatation of thepulmonary valve was done. However, no significant improvement in the saturationwas observed. Then, test angiogram in the RVOT was done. Thepre-mountedcoronary stent 3.5mm x 12mm was deployed. Initially the stent appeared stablebut once guide wire was removed, the stent migrated proximally to the tricuspidvalve and caused heart block in the child. Saturation also did not improve.Temporary pacemaker was inserted. PDA stenting was done subsequently, andsaturation improved. Heart block resolved spontaneously and the temporarypacemaker was removed after 72 hours of procedure. On
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 67, NO. 16, SUPPL S, 2016
S397
follow up, the stent isstable but at displaced position and not causing any valve regurgitation orstenosis.
Case Summary. The pulmonary valve sizewas acceptable in our case and the narrowest part was in the proximal rightventricular outlet tract. Therefore, we decided to preserve the valve function, and the stent was placed in the right ventricular outlet tract. This contributedthe instability of stent because the infundibulum is made from a contractilemuscle and ended up with migrating. PDA stenting was performed as analternative remedy. TCTAP C-243 Percutaneous Retrieval of Migrated Atrial Septal Defect Occluder After Implantation of Device Sang Jin Ha,1 Won-Kyung Lee,1 Yeo-Jeong Song,1 Woo Dae Bang,1 Sang-Yong Yoo,1 Sangsig Cheong1 1 GangNeung Asan Hospital, Korea (Republic of) [CLINICAL INFORMATION] Patient initials or identifier number. PSJ Relevant clinical history and physical exam. A 45-year-old female presented with mild dyspnea andpapitation. Physical examinations were non-specific except for the fixedsplitting of second heart sound on auscultation. Electrocardiography showednormal sinus rhythm with non-specific intraventricular conduction delay.
Relevant test results prior to catheterization. Transthoracic(TTE) and transesophagealechocardiography (TEE) revealed dilated right ventricle and atrium, abnormalleft to right shunt flow through maximally 20 mm-sized Atrial septal defect ofsecundum type, and the calculated ratio of pulmonary (Qp) to systemic bloodflow (Qs) was 1.8. A defect showed the 8 mm sized anterio-superior rim, 11mmsized anterio-inferior rim, and 15mm sized posterior-inferior rim.
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 67, NO. 16, SUPPL S, 2016
Relevant test results prior to catheterization. Transthoracicechocardiography demonstrated a ratio of pulmonary blood flow to systemic bloodflow of 1.5. The defect size on TEE was 1.76 cm. Usually ASD defect size is underestimated on TEE. As a result of this measurement, we chose a 2.2cm sized Amplatzer device. Relevant catheterization findings. After the Amplatzer device has been fully opened, we performed the TEE and confirmed that both atrial disks are flattened or nearly flattened and that the left atrial disk is entirely in the left atrium and the right atrial disk entirely in the right atrium without remnant shunt. After the stability of the device has been confirmed, the delivery cable was released by counterclock wise rotation. Amplatzer spetal occluder device is a useful treatment option of ASA with multiple ASD. [INTERVENTIONAL MANAGEMENT] Procedural step. After general anesthesia, an 8Fr sheath was inserted through right femoral vein. Intraprocedural TEE wasused for guidance in the catheterization laboratory. Initially multi purpose catheter was advanced into left atrium through ASD. And then the multi purpose catheter was replaced with a 0.035inch J-tipped exchange length guidewire, thetip of which is preferably located in a left upper lobe pulmonary vein forstability. The defect size on TEE was 1.76 cm. Usually ASD defect size is underestimated on TEE. As a result of this measurement, we chose a 2.2cm sized Amplatzer device. Selected Amplatzer device was loaded into the delivery tube. And then, delivery sheath, a long dilator, was inserted into left atrium over a 0.035 inch guidewire. After which the prepared device was loaded into delivery sheath. Most important procedural point is to puncture the central area of the shunt (figure 3, 4). Because of multiple shunt and aneurysmal change make it difficult to cover the whole defect area if the guiding sheath was positioned obliquely. After positioned the sheath at left atrium through the central area of the defect site, the Amplatzer device was advanced until it reached the tip of the sheath and then deploy the Amplatzer device (figure 5, 6).
Case Summary. As the atrial septum returns to its natural position, the device typically springs superiorly and leftward radiologically and significant interatrial shunting through the device on TEE was eliminated on color Doppler. We think central puncture of the ASA with multiple ASD and using enough big size Amplatzer spetal occluder device is a useful treatment option of ASA with multiple ASD. TCTAP C-242 Stent Migration After Right Ventricular Outflow Tract Stenting in the Severe Cyanotic Tetralogy of Fallot Patient Tamaki Hayashi,1 Saleem Akhtar,2 Mazeni Alwi1 1 Institut Jantung Negara, Malaysia; 2Aga Khan University Hospital, Pakistan [CLINICAL INFORMATION] Patient initials or identifier number. 338939 Relevant clinical history and physical exam. A one-month-old baby was referred to our hospital with severe cyanosisand mild tachypnea. The body weight was 3.3kg and SpO2 was 69%. Theechocardiography revealed tetralogy of Fallot with Patent ductus arteriosus (PDA) and patent foramen ovale. The infundibular stenosis was severe and hypoxia wassignificant. The patient was brought in the intervention alcatheterizationlaboratory as an emergency case for PDA or right ventricular outflow tract(RVOT) stenting. [INTERVENTIONAL MANAGEMENT] Procedural step. Right ventricle angiography showed pulmonary stenosis. Valve annulus was3.7mm (Z score -3.09) and it was difficult to localize the narrowest part inthe infundibulum by fluoroscopy. Echocardiography revealed the infundibularstenosis as 2.1mm. Valve was crossed with a coronary guide wire. PTCA balloon5mm X 12mm was placed over the coronary wire and balloon dilatation of thepulmonary valve was done. However, no significant improvement in the saturationwas observed. Then, test angiogram in the RVOT was done. Thepre-mountedcoronary stent 3.5mm x 12mm was deployed. Initially the stent appeared stablebut once guide wire was removed, the stent migrated proximally to the tricuspidvalve and caused heart block in the child. Saturation also did not improve.Temporary pacemaker was inserted. PDA stenting was done subsequently, andsaturation improved. Heart block resolved spontaneously and the temporarypacemaker was removed after 72 hours of procedure. On
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 67, NO. 16, SUPPL S, 2016
S397
follow up, the stent isstable but at displaced position and not causing any valve regurgitation orstenosis.
Case Summary. The pulmonary valve sizewas acceptable in our case and the narrowest part was in the proximal rightventricular outlet tract. Therefore, we decided to preserve the valve function, and the stent was placed in the right ventricular outlet tract. This contributedthe instability of stent because the infundibulum is made from a contractilemuscle and ended up with migrating. PDA stenting was performed as analternative remedy. TCTAP C-243 Percutaneous Retrieval of Migrated Atrial Septal Defect Occluder After Implantation of Device Sang Jin Ha,1 Won-Kyung Lee,1 Yeo-Jeong Song,1 Woo Dae Bang,1 Sang-Yong Yoo,1 Sangsig Cheong1 1 GangNeung Asan Hospital, Korea (Republic of) [CLINICAL INFORMATION] Patient initials or identifier number. PSJ Relevant clinical history and physical exam. A 45-year-old female presented with mild dyspnea andpapitation. Physical examinations were non-specific except for the fixedsplitting of second heart sound on auscultation. Electrocardiography showednormal sinus rhythm with non-specific intraventricular conduction delay.
Relevant test results prior to catheterization. Transthoracic(TTE) and transesophagealechocardiography (TEE) revealed dilated right ventricle and atrium, abnormalleft to right shunt flow through maximally 20 mm-sized Atrial septal defect ofsecundum type, and the calculated ratio of pulmonary (Qp) to systemic bloodflow (Qs) was 1.8. A defect showed the 8 mm sized anterio-superior rim, 11mmsized anterio-inferior rim, and 15mm sized posterior-inferior rim.