Page 20 - Journal of Structural Heart Disease Volume 3, Issue 2

Case Report 46
Figure 4. Preoperative medication with two diuretics and an inotropic agent. Although right atrium pressure was decreased, pulmonary artery pressure was not changed by the treatment. ASO = Amplatzer septal occluder; m = mean; PA = pulmonary artery; PAR = pulmonary artery resistance; PCW = pulmonary capillary wedge; Qp/Qs = pulmonary-to-systemic blood ow ratio; RA = right atrium; s/d/m: systolic/ diastolic/mean.
Figure 5. Angiographic (left panel) and TEE (right panel) ndings during implantation of an Amplatzer septal occluder.
1 month before the operation. Although severe pulmo- nary hypertension was observed in this case, pulmo- nary artery dilators were not used before the procedure contrary to current recommendations for surgical treat- ment [6]. This is because a possible increase in left-to- right shunt due to a reduction in pulmonary artery resis- tance might increase left ventricular in ow, leading to left ventricular heart failure due to masked left ventricu- lar restriction [7] at the time of ASD closure. In this case, ASD closure with an ASO was safely performed without
any hemodynamic deterioration.
As the massive left-to-right shunt was completely
eliminated by ASO implantation, pulmonary artery pressure was expected to decrease after the proce- dure, but this did not occur. Therefore, potent pulmo- nary artery dilators such as a PDE5 inhibitor, endo- thelin receptor blocker, and PGI2 analog were started incrementally after the procedure. The present case is considered to be high risk because the PVR was great- er than 5 Woods units m2, and pulmonary artery pres-
Journal of Structural Heart Disease, April 2017
Volume 3, Issue 2:43-48