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Ali H, Lupo P, Cristiano E, Nicolì L, Foresti S, De Ambroggi G, Anderson RH, De Lucia C, Turturiello D, Paganini EM, Bessi R, Farghaly AAA, Butera G, Cappato R. Chiari network for the interventional cardiologist: A hidden enemy at the heart gate - A systematic review of the literature. Int J Cardiol 2023; 375:23-28. [PMID: 36587656 DOI: 10.1016/j.ijcard.2022.12.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 12/20/2022] [Accepted: 12/23/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND This study aimed to collect and analyze the literature data regarding Chiari network (CN) and other right atrium (RA) remnants comprising the Eustachian and Thebesian valves (EV, ThV) as a potential entrapment site during different percutaneous cardiac procedures (PCP). METHODS AND RESULTS A systematic search was conducted using Pubmed and Embase databases following the PRISMA guidelines to obtain available data concerning PCP associated with entrapment of inserted materials within CN-EV-ThV. The final analysis included 41 patients who underwent PCP with reported material entrapment within these RA remnants. The PCP was atrial septal defect (ASD)/patent foramen ovale (PFO) closure, catheter ablation, and pacemaker/defibrillator implantation in 44%, 22%, and 17% of patients, respectively. The entrapped materials were ASD/PFO devices, multipolar electrophysiology catheters, passive-fixation pacing leads, and J-guidewires in about 30%, 20%, 15%, and 10% of patients, respectively. Intraprocedural transthoracic, transoesophageal and intracardiac echocardiography showed sensitivity to reveal these structures of 20%, ∼95%, and 100%, respectively. A percutaneous approach successfully managed 70% of patients, while cardiovascular surgery was required in 20% and three patients died (7.3%). CONCLUSIONS CN and other RA remnants may cause entrapment of various devices or catheters during PCP requiring right heart access. The percutaneous approach, guided by intraprocedural imaging, appears safe and effective in managing most patients. Prevention includes recognizing these anatomical structures at baseline cardiac imaging and intraprocedural precautions. Further studies are needed to analyze the actual incidence of this condition, its clinical impact and appropriate management.
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Affiliation(s)
- Hussam Ali
- Arrhythmia & Electrophysiology Centre, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy.
| | - Pierpaolo Lupo
- Arrhythmia & Electrophysiology Centre, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Ernesto Cristiano
- Arrhythmia & Electrophysiology Centre, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Leoluca Nicolì
- Arrhythmia & Electrophysiology Centre, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Sara Foresti
- Arrhythmia & Electrophysiology Centre, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Guido De Ambroggi
- Arrhythmia & Electrophysiology Centre, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Robert H Anderson
- Institute of Genetic Medicine, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Carmine De Lucia
- Arrhythmia & Electrophysiology Centre, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Dario Turturiello
- Arrhythmia & Electrophysiology Centre, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Edoardo Maria Paganini
- Arrhythmia & Electrophysiology Centre, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Riccardo Bessi
- Arrhythmia & Electrophysiology Centre, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Ahmad Abdelrady Abdelsalam Farghaly
- Arrhythmia & Electrophysiology Centre, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy; Cardiovascular Department, Assiut University, Assiut, Egypt
| | - Gianfranco Butera
- Department of Paediatric Cardiology, Cardiac Surgery and Heart Lung Transplantation, ERN GUARD HEART: Bambin Gesù Hospital and Research Institute, IRCCS, Rome, Italy; Department of Paediatric and Adult Congenital Heart Disease, Evelina London Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Riccardo Cappato
- Arrhythmia & Electrophysiology Centre, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
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Bruce L, Gunston G, Myburgh A, Keet K, Augoustides JG, Pulton DA, Thalappillil R, Rong LQ, Garner C, Fernando RJ. The Anatomy of the Eustachian Valve-Navigating the Implications for Right-Sided Surgical and Transcatheter Cardiac Interventions. J Cardiothorac Vasc Anesth 2020; 35:1215-1224. [PMID: 33455884 DOI: 10.1053/j.jvca.2020.12.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 12/09/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Louren Bruce
- Division of Clinical Anatomy and Biological Anthropology, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Geney Gunston
- Division of Clinical Anatomy and Biological Anthropology, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Adriaan Myburgh
- Department of Anesthesia and Perioperative Medicine, Groote Schuur Hospital, Cape Town, South Africa
| | - Kerri Keet
- Division of Clinical Anatomy, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - John G Augoustides
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Danielle A Pulton
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Lisa Q Rong
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY
| | - Chandrika Garner
- Cardiothoracic Section, Department of Anesthesiology, School of Medicine, Wake Forest University, Winston Salem, NC
| | - Rohesh J Fernando
- Cardiothoracic Section, Department of Anesthesiology, School of Medicine, Wake Forest University, Winston Salem, NC
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Abstract
Patent foramen ovale (PFO) is considered a risk factor for serious clinical syndromes, the most important of which is cryptogenic stroke in the setting of paradoxic embolism. The safety and feasibility of transcatheter PFO closure have been addressed in several studies; this procedure is performed worldwide with excellent results. Variations in the atrial septal configuration and PFO are frequent and have an impact on the technical aspects and success in transcatheter PFO closure. To minimize the rate of complications of percutaneous closure of PFO, patients must be carefully selected on the basis of morphology and location of the interatrial defect.
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Affiliation(s)
- Eustaquio Onorato
- Clinica Montevergine, Via M. Malzoni, 83013 Mercogliano (Av), Italy; Humanitas Gavazzeni, Bergamo, Italy.
| | - Francesco Casilli
- Emodinamica e Radiologia Cardiovascolare, Policlinico San Donato, Piazza Edmondo Malan-20097 San Donato Milanese, Milano, Italy
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5
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Butera G, Montinaro A, Carminati M. The “pull–push” technique to deal with a redundant eustachian valve interfering with placement of a PFO occluder. Catheter Cardiovasc Interv 2006; 68:961-4. [PMID: 17086524 DOI: 10.1002/ccd.20903] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To evaluate the role of a new technique to deal with a redundant Eustachian valve (EV) interfering with placement of a patent foramen ovale (PFO) occluder. BACKGROUND The EV is a remnant of the embryonic valve of the sinus venosus. In rare occasions, it is large and redundant and it may interfere with catheters and devices used in cardiac catheterization. METHODS We have developed a new technique to control the EV in order to avoid interferences with the device for closure of atrial septal defects and PFO's. This technique is called "pull-push" technique and consists in pulling down on the inferior vena cava the redundant EV by using a 6 Fr pigtail catheter while a second operator pushes the right atrial disc out of the long sheath. RESULTS Here, we report on two patients with a patent foramen ovale, in whom the EV prevented the right atrial disc of an Amplatzer PFO occluder to be completely flat against the interatrial septum. Finally, we used this technique in one more patient to avoid any interference of a very redundant EV during placement of a Starflex device. CONCLUSIONS In conclusion. the so called "pull-push" technique is an alternative and easy technique to control the EV in order to avoid interferences with the device for closure of atrial septal defects and PFO's
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Affiliation(s)
- Gianfranco Butera
- Pediatric Cardiology, Istituto Policlinico San Donato, San Donato Milanese, Italy.
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El Said HG, McMahon CJ, Mullins CE, Pignatelli RH, Grifka RG, Nihill MR, Vincent JA. Patent foramen ovale morphology and impact on percutaneous device closure. Pediatr Cardiol 2005; 26:62-5. [PMID: 15793654 DOI: 10.1007/s00246-004-0686-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
We sought to evaluate the effects of atrial septal and patent foramen ovale (PFO) morphology on the efficacy of transcatheter closure. We performed a retrospective analysis of all patients who underwent PFO device closure from January 1997 to January 2002. Forty-seven patients underwent percutaneous closure of a PFO with a median age of 45 years (range, 8-75) and weight of 76 kg (range 28-115). The septal morphology was flat in 33 and aneurysmal in 14 patients. The PFO morphology was a simple flap in 20 and complex in 27 patients. Complex morphologies included long-tunnel PFO (n = 15), coexistent small atrial septal defect (ASD) (n = 5), and aneurysmal septum without a tunnel or ASD (n = 7). Nonstretched PFO diameters were significantly smaller than stretched (4.8 +/- 1.1 mm vs 11.6 +/- 3.8 mm, p < 0.01). Median device size: stretched diameter ratio (DS:SD) was 3.7:1 (range, 2.2-9.1). The DS:SD ratio was significantly higher in patients with complex PFO (mean, 3.9:1 vs 2.6:1; p < 0.05). Device placement was successful in all patients. Five patients required transeptal puncture of the foraminal flap in long-tunnel PFOs. Effective closure on follow-up was achieved in 45 patients (95%). Of the 2 patients with residual shunts, 1 had a complex PFO and the other a simple PFO. Two patients (5%) experienced recurrent neurologic symptoms after device closure despite having no residual shunt by echocardiography. Complex PFO did not increase risk of residual shunt or recurrent neurologic symptoms after device closure.
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Affiliation(s)
- H G El Said
- Department of Pediatric Cardiology, Rumailah Hospital, Qatar.
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Harper RW, Mottram PM, McGaw DJ. Closure of secundum atrial septal defects with the Amplatzer septal occluder device: techniques and problems. Catheter Cardiovasc Interv 2002; 57:508-24. [PMID: 12455087 DOI: 10.1002/ccd.10353] [Citation(s) in RCA: 117] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Percutaneous transvenous closure of atrial septal defects (ASDs) has become feasible in recent years, as later-generation devices have largely overcome initial difficulties in device deployment and complication rates. The Amplatzer septal occluder (ASO) is one such device that we have used extensively and is, in our opinion, the most versatile and practical to use. It is capable of closing defects up to 40 mm in diameter via a relatively low-profile delivery sheath. More importantly, the ASO may be easily withdrawn into the sheath after deployment but prior to release, which is essential in safely closing difficult defects where successful positioning on the initial deployment is not guaranteed. In this article based on our experience, review of the literature, and communications with other operators, we describe the various problems encountered in closing atrial septal defects and make suggestions as to the best way of overcoming these difficulties.
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Affiliation(s)
- Richard W Harper
- Centre for Heart and Chest Research, Monash University and Monash Medical Centre Clayton, Victoria, Melbourne, Australia.
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Onorato E, Pera IG, Melzi G, Rigatelli G. Persistent redundant Eustachian valve interfering with Amplatzer PFO occluder placement: anatomico-clinical and technical implications. Catheter Cardiovasc Interv 2002; 55:521-4. [PMID: 11948904 DOI: 10.1002/ccd.10141] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
A 28-year-old man with patent foramen ovale and a prominent Eustachian valve with a history of transient ischemic attack underwent transcatheter closure using Amplatzer patent foramen ovale occluder. During deployment, some of the prominent valve tissue was entrapped on the delivery cable and a piece of the valve was extracted unintentionally. Anatomico-clinical and technical implications are discussed.
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Affiliation(s)
- Eustaquio Onorato
- Division of Cardiology, Clinica San Rocco di Franciacorta, Ome, Brescia, Italy.
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Strotmann JM, Voelker W, Schanzenbaecher P. Persistence of the eustachian valve in secundum atrial septal defects: possible implications for cerebral embolism and transcatheter closure procedures. BRITISH HEART JOURNAL 2001. [DOI: 10.1136/hrt.86.1.e5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Transcatheter closure of large secundum atrial septal defects is now accepted clinical practice. With the introduction of easily applicable closure devices the indications for this procedure have been expanded to include the closure of patent foramen ovale after cerebral stroke of unknown origin. In some of these patients a persistent eustachian valve is present. The clinical relevance of this finding is still unclear. A 36 year old patient with a brainstem stroke of unknown origin and a secundum atrial septal defect in combination with a persisting prominent eustachian valve is reported. The potential role of the eustachian valve in the genesis of the stroke and the difficulties during transcatheter closure of the defect because of the persisting valve are discussed.
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Strotmann JM, Voelker W, Schanzenbaecher P. Persistence of the eustachian valve in secundum atrial septal defects: possible implications for cerebral embolism and transcatheter closure procedures. Heart 2001; 86:E5. [PMID: 11410582 PMCID: PMC1729818 DOI: 10.1136/heart.86.1.e5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Transcatheter closure of large secundum atrial septal defects is now accepted clinical practice. With the introduction of easily applicable closure devices the indications for this procedure have been expanded to include the closure of patent foramen ovale after cerebral stroke of unknown origin. In some of these patients a persistent eustachian valve is present. The clinical relevance of this finding is still unclear. A 36 year old patient with a brainstem stroke of unknown origin and a secundum atrial septal defect in combination with a persisting prominent eustachian valve is reported. The potential role of the eustachian valve in the genesis of the stroke and the difficulties during transcatheter closure of the defect because of the persisting valve are discussed.
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Affiliation(s)
- J M Strotmann
- Medical University Clinic, Josef-Schneider-Str 3, 97080 Würzburg, Germany.
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