Disclosures Atrial Septal Defect and Patent Foramen Ovale: Not the - - PDF document

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Atrial Septal Defect and Patent Foramen Ovale: Not the Same Thing

Jared Oyama, MD

Interventional Cardiology The Queen’s Medical Center Assistant Clinical Professor of Medicine University of Hawaii John A Burns School of Medicine

Disclosures

— No financial disclosures — Off-label device use will be discussed

Overview

— Development of the interatrial septum — Pathophysiology in atrial septal defect — Pathophysiology in patent foramen ovale — Imaging the interatrial septum — Treatment of atrial septal defect — Treatment of patent foramen ovale

Overview

— Development of the interatrial septum — Pathophysiology in atrial septal defect — Pathophysiology in patent foramen ovale — Imaging the interatrial septum — Treatment of atrial septal defect — Treatment of patent foramen ovale

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Septal Development

Adapted from Nat Rev Cardiol. 2011;8:148-60

Septal Development

Adapted from Nat Rev Cardiol. 2011;8:148-60

Septal Development

OS OS

OP OP

Adapted from Nat Rev Cardiol. 2011;8:148-60

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Septal Development

Adapted from Nat Rev Cardiol. 2011;8:148-60

SS SS

Septal Development

Adapted from Nat Rev Cardiol. 2011;8:148-60 J Am Soc Echocardiogr 2015;28:910-58 J Am Soc Echocardiogr 2015;28:910-58

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Overview

— Development of the interatrial septum — Pathophysiology in atrial septal defect — Pathophysiology in patent foramen ovale — Imaging the interatrial septum — Treatment of atrial septal defect — Treatment of patent foramen ovale

Consequences

— Right-sided chamber enlargement and HF — Atrial arrhythmias — Elevation in pulmonary pressures

Overview

— Development of the interatrial septum — Pathophysiology in atrial septal defect — Pathophysiology in patent foramen ovale — Imaging the interatrial septum — Treatment of atrial septal defect — Treatment of patent foramen ovale

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PFO-Associated Conditions

— Paradoxical embolism including

cryptogenic stroke

— Platypnea/orthodeoxia — Decompression sickness — Migraines

Overview

— Development of the interatrial septum — Pathophysiology in atrial septal defect — Pathophysiology in patent foramen ovale — Imaging the interatrial septum — Treatment of atrial septal defect — Treatment of patent foramen ovale

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Transthoracic Echocardiography

— Good for:

• Gross visualization of defect
• Doppler evaluation of flow
• Evaluation of right-to-left shunt
• Evaluation of chamber sizes
• Estimation of pulmonary pressures
• Assessment of device stability post-procedure

Transthoracic Echocardiography

— Not adequate for:

• Accurate assessment of dimensions
• Determining if multiple defects present
• Presence/absence of adequate rims
• Intraprocedural guidance

10/1/16 7 Transesophageal Echocardiography

— Good for:

• Detailed visualization of defect

– Dimensions, number of defects, fenestrations – Adequacy of rims

• Doppler evaluation of flow
• Evaluation of right-to-left shunt
• Evaluation of chamber sizes
• Intraprocedural guidance

J Am Soc Echocardiogr 2015;28:910-58

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J Am Coll Cardiol Img. 2010;3:749-60 Catheter Cardiovasc Interv. 2010;75:570-77

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Intracardiac Echocardiography

— Good for:

• Intraprocedural guidance
• Reasonable visualization of defect

– Fewer views compared to TEE

• Doppler evaluation of flow
• Evaluation of right-to-left shunt

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Overview

— Development of the interatrial septum — Pathophysiology in atrial septal defect — Pathophysiology in patent foramen ovale — Imaging the interatrial septum — Treatment of atrial septal defect — Treatment of patent foramen ovale

• Circulation. 2008;118:2395-2451

Indications for Closure

— Class I

• Right sided chamber enlargement with or

without symptoms

— Class IIa

• Paradoxical embolism
• Orthodeoxia-platypnea

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Percutaneous Closure

— Only for secundum ASDs — Need TEE evaluation of size and rims — Most closures can be performed with

sedation and ICE guidance

Devices Available

Amplatzer Septal Occluder

Devices Available

Gore Cardioform Septal Occluder

Technique

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Overview

— Development of the interatrial septum — Pathophysiology in atrial septal defect — Pathophysiology in patent foramen ovale — Imaging the interatrial septum — Treatment of atrial septal defect — Treatment of patent foramen ovale

PFO Closure

— No FDA approved device for PFO closure — Continues to be investigated — Remains a contentious issue

Percutaneous Closure

— PFO closure is currently off label

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Devices Being Used

Amplatzer Cribriform Septal Occluder

Devices Being Used

Gore Cardioform Septal Occluder

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10/1/16 18 PFO Closure in Cryptogenic Stroke

— CLOSURE I (NEJM 2012)

• 909 patients, STARFlex vs ASA or OAC
• Composite endpoint:

– Stroke/TIA at 2 years – 30 day mortality – Neurologic mortality past 30 days

• No significant difference

PFO Closure in Cryptogenic Stroke

— PC Trial (NEJM 2013)

• 414 patients, Amplatzer vs medical therapy
• Composite endpoint:

– Death – Nonfatal stroke – TIA – Peripheral embolism

• No significant difference

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— RESPECT Trial (NEJM 2013)

• 980 patients, Amplatzer vs medical therapy
• Composite endpoint:

– Recurrent nonfatal ischemic stroke – Fatal ischemic stroke – Early death

• No significant difference in intention to treat
• However, as-treated analysis favored closure
• Stroke. 2014;45:2160-2236
• Stroke. 2014;45:2160-2236
• Stroke. 2014;45:2160-2236

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• Stroke. 2014;45:2160-2236

HOWEVER…

— Device safety: 15 to 1 yes — Effectiveness: 9 to 7 yes — Benefits outweigh risks: 11 to 5 yes

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Conclusion

— Embryology is boring but important in

understanding the interatrial septum

— Echocardiographic imaging is critical to

evaluation of ASD and PFO

— Percutaneous closure of secundum ASDs

is first line therapy in most cases

— Percutaneous closure of PFOs remains

controversial but may be gaining ground

Thank You!