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Case of the Week
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Case-of-the-Week Information
The Case-of-the-Week is a presentation of 8 or more video loops to present an important topic in echocardiography. Please reveiw the image or video loops and then answer the questions below. After you have answered the questions you can view the explanation and obtain CME credit (if available).

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Loop Text Key  
Preop Preop TEE or TTE
Intraop An Intraop TEE
IntraopPreOp Intraop TEE or TTE before Operation
IntraopPostOp Intraop TEE or TTE after Operation
IntraopEnd Intraop TEE or TTE at End of Anesthesia
Post Op Postop TEE or TTE
Case of the Month Information Table
IntraopEnd is usually a TEE after the Operation and after some event occured to show a change in the TEE
Just a CABG?
Case#: 32
AMA CME Units: 0.25 Units
Estimated Time: 15 minutes. You need more cme units to do this COTW for CME (not required). Purchase CME Credits
53 yo male for a CABG. Hx HTN ECG: LAFB QRS 112 msec, QTi 400 msec, QTc 470 msec Cath: LVEF 60%, LAD 80%, PDA 50% ? of a small PF.....

Case Discussion/CME Questions
The patient had a LIMA -> LAD SVG -> Ramus SVG -> PDA
The TEE showed a PFO defect that was 0.626 cm in diameter in one view and about 0.5 cm diameter in a perpendicular view. The VTI of the PFO was 28.8 cm with flow from left-to-right of about 9 mls per cardiac cycle. The PFO was oval. A small Pericardial Effusion was present.  Stomach Ridges, RVE, Calcified AMVL/Chordae Tendinae at P3 and  Distal Anterior HK with  Mild MR, Trace TR and an interatrial septal aneursym (IASA) with LAP and RAP about the same.

There are three questions on this case. What factors indicate that a PFO should be closed? What are the factors determining if a PFO can be closed with a device? Should the surgeon close the PFO? Does 3D echocardiography help in this decision compared to 2D echocardiography alone?

PFO can remain asymptomatic throughout the life of a patient. However, PFOs have been associated/implicated in paradoxical embolism of thrombus, fat, air, or even desaturated blood which can lead to cerebral ischemia, TIAs, stroke, infections, migraine headaches, and the platpnoea-orthodexia syndrome (rare syndrome of postural hypoxaemia accompanied by breathlessness). With respect to migraines, a right-to-left shunt is associated with the aura and migraine headaches.

zA PFO occurs in about 27% of patients and while the prevalence decreases with each decade of life, the size increases with each decade of life from 0.34 cm to 0.58 cm from the first to the 10th decade of life.

A PFO is associated with Chiari networks and interatrial septal aneurysms (IASA).

A PFO is the one factor associated with cryptogenic (idiopathic) ischemic stroke. A PFO with an IASA raises the risk of cryptogenic stroke. IASA alone has a lower risk than PFO alone. Warfarin therapy does not seem to decrease the risk of stroke over aspirin therapy. Percutaneous closure with a device may decrease the incidence of CVAs/TIAs but the devices may have incomplete closure and/or thrombus formation which increases the risk to about the risk of aspirin therapy alone. Of all of the devices the Amplatzer device had not thrombus formation in two studies but other devices had a higher incidence of thrombus formation. Surgical closure, while definitive, did not decrease the incidence of recurrent stroke better than the percutaneous closure devices. Recurrence of stroke after surgical closure was more common in older (> 45 yrs old) patients. Another study of surgical closure of a PFO showed excellent results with a double continuous closure technique for residual shunt and recurrent strokes (there were none).

For a device to work properly, mismatch of the device and the PFO must be minimized. 3D TEE has be instrumental in defining the anatomy, compared to 2D TEE, to prevent PFO-Device mismatch. Residual shunts are more likely with an IASA - but this may be because of the anatomy of the PFO. A typical PFO is located at the anterior and superior portion of the interatrial septum and is crescent shaped. A large eustachian valve, particularly if a Chiari network is present may increase the difficulty of the device deployment. Factors that increase the complexity of a percutaneous closure are:

  • Long Tunnel Length
  • Multiple Openings
  • Atrial Septal Aneurysm
  • Hybrid Defect
  • Thick Secondary Septum (> 10 mm)
  • Eustachian Ridge
  • Eustachian Valve or Chiari Network
A simple PFO has a tunnel length < 8 mm. A long tunnel length may cause a device with a short waist to sit in the tunnel unfolded. When the device is deployed, folds of the long tunnel may be trapped causing leaks. If the PFO is in an IASA, the rim of the device may end up catching the IASA and not the primary septum thus increasing the mobility of the device and risk of rupture of fragile tissue. A hybrid defect is the presence of other defects in the atrial whereas multiple defects is an condition where the multiple defects are in the interatrial septum and may be fenestrated. Multiple defects increase the difficult of placement whereas hybrid defects may not all be closed by a single device because of their location. A Eustachian ridge or valve may increase the difficulty of directing the device towards the PFO. A Chiari Network may entangle the device.

This case was simply a judgement call because of the IASA with the PFO. Since the PFO was a single orifice that was small and oval and the Chiari Network was not extensive in that it did not extend to the interatiral septum, and that surgical closure results in older patients were not shown to be better than percutaneous closure of the PFO, we elected to not perform a surgical closure.

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