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A novel minimal invasive approach The way forward
Dr. Uditha Hewarathna
Ajith Kularatne, Gnanamoorthi Mayurathan,Uditha Hewarathna, Shanike Karunaratne,Narada Kodithuwakku
Teaching Hospital, Kandy,
Sri Lanka
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Mr. K
14 years old
Presented with a infected wound in left leg
Incidentally found to be having polycythaemia (Hb - 19.9 g/dl)
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On Examination
◦ Cyanosed
◦ Plethoric
◦ Clubbing in B/L UL and LL
◦ Oxygen saturation 62% on air
CRP - negative
ESR - 3 mm/ 1st hour
Blood picture - secondary polycythemia
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Transthoracic 2D echo ◦ Normal size cardiac chambers
◦ EF > 60%
◦ No ASD, VSD or PDA
◦ No evidence of PHT or TAPVD
◦ ? Fistulous connection between pulmonary artery and left atrium
TOE
◦ No ASD or VSD
◦ Normal pulmonary venous drainage
Normal Lung function test
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Surgical closure
Transcatheter closure
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Major operation
Has potential surgical and anesthetic complications
Patient and mother not given consent for the surgery
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Has two options
◦ Use a covered stent across the fistula in the right pulmonary artery
◦ Device AV fistula closure
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Mechanism
◦ Fistula will have no feeding
Problems
◦ Covered stent more expensive and patient couldn’t afford
◦ Due to stagnation of blood in AV fistula connection there is a risk of thrombosis
◦ Risk of embolization of the thrombus
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Problems
◦ Largest Amplatzer vascular plug device available is 22mm and fistula was 18 ×20mm in size (They recommend 50% oversizing for these type of fistula)
◦ When a larger device is used, it is very long and device will be jutting out into LA and RPA
◦ Risk of thrombus formation
◦ Risk of obstruction
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Finally planned to use atrial septal occluder device to close the fistula
Atrial septal occluder device in LA is safe
Available in different sizes
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9F long guiding sheath and dilator were advanced over the guide wire through IVC, RA, RV, MPA, RPA, fistulous connection to left atrium
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Sending ASO device through delivery system
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Deploying 16mm ASO device -unsuccessful
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Deploying 20mm ASO device
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Deployed 20 mm device obstructing right pulmonary artery
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Deployed 20 mm device obstructing right pulmonary artery
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Successful deploying of 16mm ASO device
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Soon after deploying the device
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Soon after deploying the device checking the pulmonary flow and closure of AV fistula
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Soon after deploying the device checking the pulmonary flow and closure of AV fistula
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Patient’s saturation improved from 62% to 94% on air
Transthoracic echo confirmed there was no turbulence or pressure gradient in the right pulmonary artery
TOE confirmed normal pulmonary venous drainage.
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10 min after deploying the device checking the pulmonary flow and closure of AV fistula
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10 mm after deploying the device checking the pulmonary flow and closure of AV fistula
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10 mm after deploying the device checking the pulmonary flow and closure of AV fistula
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Releasing of device by counterclockwise rotation of the delivery cable after checking the stability
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After releasing of the device
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Bubble contrast echo after the procedure
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Dual antiplatelets for 1 month followed by 6 month single antiplatelet used to prevent thrombo-embolism
At 6 months
◦ Patient asymptomatic
◦ Fluoroscopy show ASO device in same position
◦ No shunt in transthoracic echo
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Direct communication between the right pulmonary artery and the left atrium is an unusual variation of a pulmonary arteriovenous fistula1
In fact, there are only about 50 cases reported in the literature2
This is one condition in which clinical examination may reveal only cyanosis1
Contrast echocardiography may show only right-to-left shunt, and only angiography is truly diagnostic
1Vladimir AM, Ingo D, Stanislav O, Roland H. Right pulmonary artery to left atrium communication, a rare cause of systemic cyanosis. Texas Heart Inst J 2001;28:122–124. 2Krishnamoorthy KM, Rao S. Pulmonary artery to left atrial fistula. Eur J Cardiothorac Surg 2001;20:1052–1053
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Two treatment options were available either surgical closure or transcatheter closure
Most of patient has underwent surgical closure1
Coil embolization, Amplatzer vascular plug device have been used to close the AV fistulae2,3
1Zeebregts CJ, Nijveld A, Lam J, van Oort AM, Lacquet LK. Surgical treatment of a fistula between the right pulmonary artery and left atrium: presentation of two cases and review of literature. Eur J Cardiothorac Surg 1997;11:1056 –1061. 2Slack MC, Jedeikin R, Jones JS., Transcatheter coil closure of a right pulmonary to left atrial fistula in an ill neonate. Catheter Cardiovasc Interv 2000;50:330–333. 3Francis E, Sivakumar K, Kumar RK. Transcatheter closure of fistula between the right pulmonary artery and left atrium using the Amplatzer duct occluder. Cathet Cardiovasc Interv 2004;63:83–86.
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Our patient has 18×20mm fistulous connection and largest Amplatzer vascular plug device available is 22mm (They recommend 50% oversizing for these type of fistula)
So, fistulous connection in our patients were too wide to be closed safely and completely using the above devices
We chose ASO because it was the only large enough device available to us to occlude the large fistulous connection seen in our patients.
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The other reasons were ◦ Availability in different sizes
◦ Easy implantation
◦ Anchorage stability offered by both the discs
◦ Retrieval as well as repositioning capability before the final release
Our case is unique because the communication was closed in an antegrade fashion without transseptal puncture
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Large and short Pulmonary AV fistule can be closed safely, effectively, and nonsurgically with atrial septal occluder device
Placing a atrial septal occluder device in pulmonary artery without obstructing the flow is safe
It is a effective method for our country with poor resource setting
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“I cant put into word the comfort and consolation I feel now. It like been in the heaven from hell”
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Ajith Kularatne and Gnanamoorthi Mayurathan who are primary operators in this case
My trainers in TH Kandy ◦ Dr. Rohini Tennakoon
◦ Dr. Subhashini Jayawickreme
◦ Dr. Gamini Weerakoon
◦ Dr. Srinath Dolapihilla
All doctors in cardiology unit Kandy
All staff in the Cath lab TH Kandy
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Device Size/ Waist Diameter (mm) A
Waist Length (mm) B
Right Atrial Disc Diameter (mm) C
Left Atrial Disc Diameter (mm) D
15 4 25 29
16 4 26 30
17 4 27 31
18 4 28 32
19 4 29 33
20 4 30 34
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Device Diameter (mm) A
Unconstrained Device Length (mm) B
12 9
14 10
16 12
18 14
20 16
22 18
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