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Shammas NW, Keyes K, Witcik W, Robken J, Coyne E, Wong H. Hypoxia Due to a Large Right to Left Interatrial Shunt with Normal Right-Sided Filling Pressures in the Setting of a Separation between the Septum Primum and Secundum: A Case Report. Int J Angiol 2023; 32:202-205. [PMID: 37576531 PMCID: PMC10421673 DOI: 10.1055/s-0042-1749075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2023] Open
Abstract
Hypoxia secondary to right to left interatrial shunting in the setting of normal right-sided filling pressure is an uncommon clinical presentation. We present a case of persistent hypoxia irrespective of body position in a patient with a wide separation between the septum primum and secundum, creating a tunnel channeling flow from the right to the left atrium. Hypoxia resolved instantly following closure of the defect with an Amplatzer occluder under intracardiac echocardiography guidance. Although platypnea-orthodeoxia leads to hypoxia in the setting of normal right-sided filling pressures, the finding of a coexisting wide gap between the septum primum and secundum is likely to have worsened the hypoxia making it severe irrespective of body position. Closure of the interatrial septal defect led to immediate and sustained resolution of the hypoxia.
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Affiliation(s)
- Nicolas W. Shammas
- Genesis Medical Center, PC, Davenport, Iowa
- Midwest Cardiovascular Research Foundation, PC, Davenport, Iowa
- Cardiovascular Medicine, PC, Davenport, Iowa
| | | | | | - Jon Robken
- Cardiovascular Medicine, PC, Davenport, Iowa
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Udelson JE, Barker CM, Wilkins G, Wilkins B, Gooley R, Lockwood S, Potter BJ, Meduri CU, Fail PS, Solet DJ, Feldt K, Kriegel JM, Shaburishvili T. No-Implant Interatrial Shunt for HFpEF: 6-Month Outcomes From Multicenter Pilot Feasibility Studies. JACC Heart Fail 2023; 11:1121-1130. [PMID: 37115132 DOI: 10.1016/j.jchf.2023.01.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 01/24/2023] [Accepted: 03/24/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND Most approaches to the creation of an interatrial shunt require placement of a permanent implant to maintain patency. OBJECTIVES The goal of this study was to investigate the safety and efficacy of a no-implant interatrial shunt for patients with heart failure with preserved ejection fraction (HFpEF) and heart failure with mildly reduced ejection fraction (HFmrEF). METHODS This was a multicenter, uncontrolled study of patients with HFpEF/HFmrEF and NYHA functional class ≥II, ejection fraction >40%, and pulmonary capillary wedge pressure (PCWP) during supine exercise ≥25 mm Hg with PCWP-to-right atrial gradient ≥5 mm Hg. Follow-up was through 6 months with imaging to assess shunt durability. RESULTS A total of 28 patients were enrolled: mean age was 68 ± 9 years, and 68% were female. Baseline resting and peak exercise PCWP were 19 ± 7 mm Hg and 40 ± 11 mm Hg, respectively. All procedures displayed technical success with confirmation of left-to-right flow (shunt diameter 7.1 ± 0.9 mm). At 1 month, peak exercise PCWP decreased 5.4 ± 9.6 mm Hg (P = 0.011) with no change in right atrial pressure. There were no serious device or procedure-related adverse events through 6 months. Mean 6-minute walk distance increased 101 ± 71 meters (P < 0.001); Kansas City Cardiomyopathy Questionnaire Overall Summary Score increased 26 ± 19 points (P < 0.001); N-terminal pro-B-type natriuretic peptide decreased 372 ± 857 pg/mL (P = 0.018); and shunt patency was confirmed with unchanged diameter. CONCLUSIONS In these feasibility studies of a no-implant interatrial shunt, HFpEF/HFmrEF shunts exhibited stability with favorable safety and early efficacy signals. The results show promise toward this new approach for treating patients with HFpEF/HFmrEF and an appropriate hemodynamic profile. (Evaluation of the Safety and Feasibility of a Percutaneously Created Interatrial Shunt to Alleviate Heart Failure Symptoms in Patients With Chronic Heart Failure and Preserved or Mid-Range Left Ventricular Ejection Fraction [ALLEVIATE-HF-1]; NCT04583527; Evaluation of the Safety and Effectiveness of a Percutaneously Created Interatrial Shunt to Alleviate Heart Failure Symptoms in Patients With Chronic Heart Failure and Preserved or Mid-Range Left Ventricular Ejection Fraction [ALLEVIATE-HF-2]; NCT04838353).
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Affiliation(s)
- James E Udelson
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, Massachusetts, USA.
| | - Colin M Barker
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | | | | | | | - Brian J Potter
- Centre hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | | | - Peter S Fail
- Cardiovascular Institute of the South, Houma, Louisiana, USA
| | - Darrell J Solet
- Cardiovascular Institute of the South, Houma, Louisiana, USA
| | - Kari Feldt
- Karolinska University Hospital, Stockholm, Sweden
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Kuntz G, Kumar N, Gray L, Whitson, Vijayakumar A, Boudoulas KD, Iyer M, Gorelik L, Graul T, Hussain N, Awad H, Essandoh M. Concomitant Percutaneous Atrial Septal Defect Closure With an Amplatzer Septal Occluder and HeartMate 3 Implantation for High-Risk Heart Failure Patients: A Novel Hybrid Strategy. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00464-0. [PMID: 37507307 DOI: 10.1053/j.jvca.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 07/05/2023] [Indexed: 07/30/2023]
Affiliation(s)
- George Kuntz
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Nicolas Kumar
- Department of Anesthesiology, Pain Medicine, and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Logan Gray
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Whitson
- Division of Cardiac Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Ammu Vijayakumar
- Division of Cardiac Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | | | - Manoj Iyer
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Leonid Gorelik
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Thomas Graul
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Nasir Hussain
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Hamdy Awad
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Michael Essandoh
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH.
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Rodés-Cabau J, Panagides V. Iatrogenic Atrial Septal Defects and Heart Failure: The Chicken or Egg Causality Dilemma. JACC Cardiovasc Interv 2021; 14:2695-7. [PMID: 34949393 DOI: 10.1016/j.jcin.2021.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 10/19/2021] [Indexed: 11/21/2022]
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Mahfoud F, Ewen S, Kulenthiran S. Levoatrial-to-Coronary Sinus Shunting in Heart Failure Therapy: Getting Off the Beaten Track? JACC Cardiovasc Interv 2020; 13:1248-1250. [PMID: 32438997 DOI: 10.1016/j.jcin.2020.03.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 03/24/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Felix Mahfoud
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany; Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts.
| | - Sebastian Ewen
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany
| | - Saarraaken Kulenthiran
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany
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Guimaraes L, Del Val D, Bergeron S, O'Connor K, Bernier M, Rodés-Cabau J. Interatrial Shunting for Treating Acute and Chronic Left Heart Failure. Eur Cardiol 2020; 15:e18. [PMID: 32419849 PMCID: PMC7215499 DOI: 10.15420/ecr.2019.04] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 08/09/2019] [Indexed: 12/19/2022] Open
Abstract
The creation of an interatrial shunt has emerged as a new therapy to decompress the left atrium in patients with acute and chronic left heart failure (HF). Current data support the safety of this therapy, and promising preliminary efficacy results have been reported in patients who are refractory to optimal medical/device therapy. This article aims to provide an updated overview and clinical perspective on interatrial shunting for treating different HF conditions, and highlights the potential challenges and future directions of this therapy.
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Affiliation(s)
- Leonardo Guimaraes
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University Quebec City, Quebec, Canada
| | - David Del Val
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University Quebec City, Quebec, Canada
| | - Sebastien Bergeron
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University Quebec City, Quebec, Canada
| | - Kim O'Connor
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University Quebec City, Quebec, Canada
| | - Mathieu Bernier
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University Quebec City, Quebec, Canada
| | - Josep Rodés-Cabau
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University Quebec City, Quebec, Canada
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Kaye D, Shah SJ, Borlaug BA, Gustafsson F, Komtebedde J, Kubo S, Magnin C, Maurer MS, Feldman T, Burkhoff D. Effects of an interatrial shunt on rest and exercise hemodynamics: results of a computer simulation in heart failure. J Card Fail 2014; 20:212-21. [PMID: 24487087 DOI: 10.1016/j.cardfail.2014.01.005] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Revised: 11/20/2013] [Accepted: 01/03/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND A treatment based on an interatrial shunt device has been proposed for counteracting elevated pulmonary capillary wedge pressure (PCWP) in patients with heart failure and mildly reduced or preserved ejection fraction (HFpEF). We tested the theoretical hemodynamic effects of this approach with the use of a previously validated cardiovascular simulation. METHODS AND RESULTS Rest and exercise hemodynamics data from 2 previous independent studies of patients with HFpEF were simulated. The theoretical effects of a shunt between the right and left atria (diameter up to 12 mm) were determined. The interatrial shunt lowered PCWP by ~3 mm Hg under simulated resting conditions (from 10 to 7 mm Hg) and by ~11 mm Hg under simulated peak exercise conditions (from 28 to 17 mm Hg). Left ventricular cardiac output decreased ~0.5 L/min at rest and ~1.3 L/min at peak exercise, with corresponding increases in right ventricular cardiac output. However, because of the reductions in PCWP, right atrial and pulmonary artery pressures did not increase. A majority of these effects were achieved with a shunt diameter of 8-9 mm. The direction of flow though the shunt was left to right in all of the conditions tested. CONCLUSIONS The interatrial shunt reduced left-sided cardiac output with a marked reduction in PCWP. This approach may reduce the propensity for heart failure exacerbations and allow patients to exercise longer, thus attaining higher heart rates and cardiac outputs with the shunt compared with no shunt. These results support clinical investigation of this approach and point out key factors necessary to evaluate its safety and hemodynamic effectiveness.
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Affiliation(s)
- David Kaye
- Baker IDI Heart and Diabetes Institute and Alfred Hospital, Melbourne, Australia
| | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Barry A Borlaug
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Finn Gustafsson
- Department of Cardiology, Heart Center, Rigshospitalet and Copenhagen University, Copenhagen, Denmark
| | | | - Spencer Kubo
- Division of Cardiology, University of Minnesota, Minneapolis, Minnesota
| | | | - Mathew S Maurer
- Division of Cardiology, Columbia University, New York, New York
| | - Ted Feldman
- Cardiology Division, Evanston Hospital, Evanston, Illinois
| | - Daniel Burkhoff
- Division of Cardiology, Columbia University, New York, New York.
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Vargas-Beal F, Coulter SA, Yendamuri S, Contreras A, Duncan JM. Right-to-left interatrial shunt with hypoxemia caused by a right atrial thrombus. Tex Heart Inst J 2007; 34:225-9. [PMID: 17622375 PMCID: PMC1894698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
A right-to-left shunt in the presence of normal pulmonary artery pressure is an unusual cause of hypoxemia in an adult who has a patent foramen ovale. We report a rare case of such a shunt-the result of a right atrial thrombus that formed in a hypercoagulable patient after placement of an indwelling central venous catheter for chemotherapy. In order to ascertain the nature of the right atrial mass and to decrease the risk of systemic embolization, the thrombus was surgically removed with the patient on cardiopulmonary bypass.
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Affiliation(s)
- Franco Vargas-Beal
- Department of Cardiovascular Surgery, The Texas Heart Institute at St. Luke's Episcopal Hospital, Houston, Texas 77030, USA
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