1. Challenging Case Presentation For Structural Heart Disease Program
SCAI Structural Heart Disease
December 7, 2012
Jonathan Tobis, MD
Professor of Medicine
Director of Interventional Cardiology
UCLA

2. Orthodeoxia Platypnea post Op
67-year old male anesthesiologist referred for endovascular repair of thoracic aneurysm.
1990- while at work in OR: ascending aortic dissection, hemopericardium, cardiac arrest, with emergent repair complicated with perioperative CVA
1997- Aortic valve insufficiency: aortic valve replacement (29 mm St. Jude valve) and Bentall procedure.
2012-Thoracic aorta distal to the graft enlarged to 5.9 cm. The patient was referred for staged endovascular repair.

3. CT of Residual Aortic Dissection

4. Orthodeoxia Platypnea post op
1st Stage: R carotid to L carotid shunt 8mm dacron graft. Connect L subclavian to L carotid.
Post-op hypoxemia. O2 Sat=86% Pulmonary w/u shows L hemi-diaphragm paralysis (presumed trauma to phrenic nerve). R to L shunt on TTE bubble study at atrial level. Referred for PFO closure.
Hx visual aura w/o headache since 20’s.
Hx of low O2 Sat =92% “for years”

5. Presence of clubbing
indicates a chronic condition of RLS with exacerbation due to diaphragm paralysis and opening up PFO
TCD = 4 at rest
5 Valsalva

6. With balloon inflated across PFO, the O2 Sat inc to 98% off O2

7. Baseline angiogram shows large R-L shunt
14mm by balloon sizing so 30mm Helex chosen

8. Final bubble study
30mm Helex disk in place

9. pre
post
O2 Sat = 95% on room air

10. 3-month post PFO closure
2 weeks post implant, pt strained while using a wrench and felt “something in his heart.”
Hypoxemia worsened. TEE showed significant residual right to left shunt with Helex 30 mm device in correct position.
3-month post PFO closure

11. Clinical Options Remove previous Helex device
Place a second Helex device
Place an Amplatzer ASD device
Surgical closure of PFO

12. 2nd attempt at PFO closure
RA gram
Agitated saline injection shows significant residual shunt

13. 2nd attempt at PFO closure
GW crossing Helex device
GW across Helex device

14. Balloon sizing of the residual shunt
SaO2 = 100% with sizing balloon across the septum next to Helex device. The PFO looks larger?

15. Delivery and release of a 15mm Amplatzer ASO

16. Agitated saline injection after Amplatzer ASO placement
Final RA gram
Agitated saline injection after Amplatzer ASO placement
Post-procedure Sa O2 was 93%

17. Discussion
Chronic orthodeoxia through a PFO produced digital clubbing, exacerbated by phrenic nerve damage
This case demonstrates the ability to cross a Helex device that is not completely endothelialized.
30mm Helex device, although appropriately sized for this PFO (14 mm diameter), did not have sufficient closure force
Should 30 mm Helex devices be used for PFO closure?

18. UCLA experience with Helex devices
Percent of patients with shunting on TCD
Months since closure procedure
Larger Helex device size associated with greater frequency of residual shunting
106 patients with Helex device
95 patients had TCD every 3months after PFO closure
Average time of the PFO closure occurred at month 5.2±3.5
Helex 30mm device demonstrated the lowest closure rate = 60%