Page 27 - Journal of Structural Heart Disease Volume 3, Issue 3
P. 27

Meeting Abstracts
There is also faster recovery with decreased length of hospital stay. Indications for percutaneous intervention in these patients include severe mitral stenosis causing hemodynamic instability that causes recurrent admission for the patients.
Intervention: The patient underwent pre - percutaneous mitral com- missurotomy transesophageal echocardiogram which showed a mitral valve area of 0.41 cm2 by planimetry with mild mitral regur- gitation. Left heart catheterization was done percutaneously using a 6 french pigtail catheter through a left femoral arterial sheath. The catheter was retrogradely advanced to the ascending aorta, aortic valve, and left ventricle. Pre-percutanous mitral commissurrotomy and atrial septal defect closure pressure recordings showed a low systemic arterial pressure of 89/60 mmHg and elevated LVEDP (17 mmHg). The PA pressure was elevated at 77/28 mmHg with no sys- tolic pressure gradient across the pulmonic valve during pullback. The transmitral mean gradient is 10 mmHg. The Mullins catheter was directly inserted into the LA thru the interatrial septal defect and the coiled guidewire was inserted through the catheter into the left atrium. A size 26 mm Mitrapath balloon catheter was inserted over the guidewire and maneuvered sequentially across the interatrial septum and the mitral valve with the aid of a stylet. The balloon was in ated thrice at 23, 24 and 26 mm. The  nal gradient across the mitral valve was at 6.3 mmHg. Right heart catheterization was done percutaneously using a 7 french Counard catheter through a right transfemoral venous sheath and was advanced anterogradely into the RA, RV, PA and LA through the ASD. An Amplatz sti  wire was introduced as an exchange wire through the Cournard cathe- ter and advanced into the right atrium and through the atrial septal defect into the left atrium with the tip extending beyond the level of the left upper pulmonary vein. The femoral vein sheath was then removed. The introducing sheath with the dilator was advanced over the exchanged wire into the left atrium and was positioned at the left atrium border while the dilator was removed. The delivery cable was passed through the loader and An ASD occluder was screwed clock- wise onto the tip of the delivery cable. The device and the loader were then immersed in a saline solution and the occluder was pulled into the loader. The loader was introduced into the delivery sheath and was advanced into the left atrium. The retention skirt was deployed and pulled  rmly against the interatrial defect. The position of the device was con rmed through transesophageal echocardiography. The device was adjusted until the retention skirt was well seated in the interatrial septum. The device was then released from the deliv- ery cable and the system removed. Post PTMC intra-procedural 2D echocardiogram showed a mitral valve area of 1.0 cm2 by planimetry.
Learning Points of the Procedure: Percutaneous transcatheter clo- sure of ASD and mitral valvotomy is the treatment of choice for Lutembacher syndrome until and unless the lesions are incongruous for the procedures. The patient was symptomatic with moderate to severe mitral stenosis with valve morphology favorable for PBMV.
Mae Dagooc, Bernadette Valdez, Jean Villareal, Juan Reganion Philippine Heart Center, Manila, Philippines
Aorticocameral tunnels are extremely rare congenital extracardiac vascular channels, which connect the ascending aorta above the sinutubular junction to any of the chambers of the heart. The ascend- ing aorta is reported to be the most common site of origin but rarely tunnel arising from the descending thoracic aorta has also been reported.
More than 90% of the aorticocameral tunnels communicate with the left ventricle, occasionally with the right ventricle, rarely with the atria. The most common of these infrequent conditions is the aorto-left ventricular tunnel (ALVT), followed in frequency by the aorto-right atrial tunnel (ARAT), aorto-right venticular tunnel (ARVT) and the aorto-left atrial tunnel. All of these conditions produce the physiology of congenital aortic insu ciency, but when the tunnel connects to a right heart chamber, an important left-to-right shunt is also produced1.
History: This is a case of a 20 year old female, born term, with no signs of failure to thrive. At 4 years old, had consult with a private doctor due to recurrent cough, and an incidental murmur was noted. She was managed as a case of Rheumatic Heart Disease with monthly Benzathine Penicillin G IM injections. She was asymptomatic since then with no history of hospitalizations. Until 2 years PTA, patient started to have chest pains and palpitations, but still can do her activi- ties of daily living without di culty of breathing. With the persistence of chest pain described as squeezing in character, she sought consult at Philippine Heart Center-OPD and several diagnostic work ups were done. She was then advised for coronary angiography.
Patient was a nonsmoker and non alcoholic beverage drinker. No his- tory of illicit drug intake.
Her current medications were Furosemide 20mg OD, and Enalapril 5 mg OD, with good compliance.
Physical Examination:
• Ambulatory and not in respiratory distress
• Vital Signs: CR: 70 bpm RR: 18 cpm O2Sat 99% BP: 90/ 60 mmHg Wt
43.7 kg Ht 153 cm BSA 1.36 m2
• Anicteric sclerae, Pink palpebral conjunctivae
• No neck vein engorgement, no carotid bruit
• SCE, no retraction, bronchovesicular breath sounds
• Dynamic precordium, AB 6th ICS LMCL, no thrill/heave, normal rate,
regular rhythm, S1 normal, S2 split, grade 3/6 continuous murmur
heard best at the right mid parasternal border
• Flat abdomen, soft, nontender, no hepatomegaly, no masses • No clubbing, no edema, equal peripheral pulses
• Grossly normal extremities
She was admitted at the wards. Complete blood count, protime, aPTT, serum creatinine were within normal limits. There was cardiomegaly with RA and RV prominence on the chest radiograph. Preoperative transthoracic echocardiogram showed anterior type of tunnel from the right coronary sinus to the right atrium.
A hemodynamic study with coronary arteriography was done and revealed angiographically normal coronary arteries. Ascending aor- togram showed an anterior type of aorto to right atrium tunnel with a constricted and small opening at the right atrial end.
Journal of Structural Heart Disease, June 2017
Volume 3, Issue 3:73-95

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