Aspetti anatomici del forame ovale:
quanto contano nella chiusura
percutanea del forame
Sulle Sponde del Ticino
Emoclinic Symposium
Patrizia Presbitero
Novara, 15 gennaio 2010
History
Percutaneous transvenous closure of atrial septal defects (ASDs)
was first successfully performed in 1974
King TD, Mills NL. Non-operative closure of atrial septal defects. Surgery 1974; 75: 383-388
Early devices were difficult to deploy, required large-bore delivery
sheaths, and were prone to complications:
– Incomplete closure (20%)
– Device malposition
– Embolism
– Fracture
– Late erosion
ASD
is a
“HOLE”
PFO
is a
“TUNNEL”
Anatomic variability of PFO
•
•
•
•
•
Nature of septum primum
Nature o f septum secundum
Degree of septal overlap (tunnel lenght)
Location of PFO
Presence of Chiari Network or Eustachian
Valve
Transcatheter Closure of PFO:
The size and type of device change based on:
• Size of PFO and left atrium
•Lenght of the Channel
•Presence of ASA
• Multiple Holes
PFO : the size
Sept. I
Sept. I
Sept.II
Sept.II
Ampio PFO chiuso con
Amplatzer Septal
Occluder 14 mm (device
da DIA) dopo sizing
PFO : the length
Sept. I
Sept. I
Sept.II
Sept.II
PremereTM
PFO Closure Device
PFO: Aneurysm
AS ANEURYSM
I A: right shaped concavity
I B: septal excursion
II : left shaped concavity
PFO associato ad
ASA chiuso con
Amplatzer Cribriform
Occluder 25 mm >
shunt residuo postprocedurale
Cribriform PFO
PFO with crybriform ASA: two
guides are positioned
Amplatzer crybriform occluder- 35 mm
is inserted through the central hole
PFO and Aortic Rim
RIM
Anatomic variations
“Absence of aortic rim”
Virtually absent secundum
HELEX Septal Occluder
LA
Lipomatosis septum secundum
RA
LA
RA
Amplatzer PFO Occluder 35 mm
PFO and Eusatchian valve
PFO and Chiari Network
PFO Anatomic Variations:
Istituto Clinico Humanitas (MI)
202 pts (2004
(2004--2008)
1. PFO simple with visible central/superior eccentric shunt or
with valve mechanism = 44%
2. Reduntant septum primum:
- widely reduntant or pseudoaneurysmatical = 22%
- Atrial Septal Aneurysm (Ø 15-15 mm) = 11%
- Entire Atrial Septal Aneurysm (EASA) = 1%
3. Cribriform septum primum = 8%
4. Tunnellized PFO (tunnel between septum primum and
septum secundum >10mm) = 10%
5. Lipomatosis septum secundum = 2%
956 anni, F
9stroke ischemico con deficit stenico emisoma sx
9assetto trombofilico (mutazione protrombina e MTHFR)
9emicrania con aura
PFO
Shunt postpost-procedurale
Chiusura percutanea di MAV
Chiusura percutanea di PFO:
risultati a distanza (ICH)
202 pts, follow up medio: 36 mesi
• Recidive
0.8%
•Aritmie atriali
2.1%
•Shunt residui (6 mesi)
9.6%
•Erosione tardiva
0%
(vers. pericardico)
• Endocardite
0%
•Trombosi
0%
(2 TIA)
Conclusions: PFO closure
BENEFITS:
• Embolic Stroke, Migraine
<55years
• Ipercoagulability state
• Big Hole + ASA Chiari
network,Eustachian valve
RISKS:
Center
Operator
Device
Conclusions: PFO closure
RISKS:
BENEFITS:
• Embolic Stroke, Migraine
<55years
• Ipercoagulability state
• Big Hole + ASA Chiari
network,Eustachian valve
Center
Operator
Device
GRAZIE
Sulle Sponde del Ticino
Emoclinic Symposium
Patrizia Presbitero
Novara, 15 gennaio 2010