Transcatheter Correction of Superior Sinus Venosus Atrial Septal Defects as an Alternative to Surgical Treatment
Hansen JH, Duong P, Jivanji SGM, Jones M, Kabir S, Butera G, Qureshi SA, Rosenthal E.
J Am Coll Cardiol. 2020 Mar 24;75(11):1266-1278. doi: 10.1016/j.jacc.2019.12.070.
PMID: 32192652 Similar articles
Select item 32214047
Take Home Points:
- Transcatheter closure of sinus venosus defects is feasible and effective alternative to surgery in adult-sized patients.
- 3D modeling can help determine candidacy for this transcatheter approach.
Commentary by Dr. Arash Salavitabar (Ann Arbor MI) – section editor of Congenital Heart Disease Interventions Journal Watch: Sinus venosus defects (SVASD) have traditionally been approached surgically. However, transcatheter correction has been a recently evolving and enticing approach which has been reported by several centers over the last few years. The authors of this study report a single-center, early experience with transcatheter SVASD closure using covered stent implantation.
Following the first procedure at this center in March 2016, all patients 16 years of age who were being considered for surgical repair of a SVASD were also considered for transcatheter correction. Suitability of transcatheter closure was assessed in a systematic fashion using both 2D and 3D cross-sectional imaging (either cardiac MRI or CT) and ex vivo simulation of stent implantation on either virtual or printed 3D models. If an anomalous pulmonary vein was noted to be entering the SVC remotely, above the SVC/right atrial junction, and was thought to be too far for surgical redirection of those veins and the anticipated shunt volume was hemodynamically insignificant, this was not deemed a contraindication to this transcatheter approach.
All procedures were performed with TEE guidance. An angiographic catheter was placed in the RUPV for serial venography and pressure monitoring. The approach for RUPV access evolved from a retrograde approach to use of a transseptal puncture with an 8-French SRO Sheath (St. Jude Medical) being placed in the LA to allow simultaneous LA and RUPV monitoring. After a veno-venous “rale” was established between the RIJ and femoral veins, balloon testing of the region of the SVASD was performed, allowing for sizing and “testing” of stent implantation within the intended landing zone with confirmation of shunt elimination by TEE and SVC angiography, while also assessing RUPV patency by TEE, angiography, and pressure gradient.
The stent length was based mainly on pre-procedural imaging data and was selected based on having 2cm of the unexpanded stent in the SVC and 2cm protruding into the RA, below the level of the pulmonary veins. Balloon diameter was selected as 2-3mm larger than the diameter reached on balloon-sizing of the SVC. All patients received a 10-zig covered Cheatham Platinum (CP) stent in 5-8cm lengths, mounted balloon diameters of 18-30mm. Following deployment, flaring of the RA end of the stent was performed with the outer balloon of the balloon-in-balloon catheter and then, if needed, with a Coda balloon (Cook Medical, Bloomington, Indiana). If the RUPV was deemed at risk of compression, an Atlas PTA balloon (Bard Peripheral Vascular, Tempe, Arizona) was inflated within the RUPV to prevent obstruction during stent expansion. All patients were started on clopidogrel 75 mg and aspirin 75 mg for 2 months, followed by aspirin alone for a further 4 months, and those on anticoagulation continued them as monotherapy for at least 6 months.
Following initial stent deployment, additional stents were placed in 13 (52%) of the procedures, 9 of which received a bare CP stent to anchor the covered stent in the SVC. This was performed due to stent migration toward the RA in 5 of those 9 patients. Stent migration was associated with a shorter stent segment apposed to the SVC with a distance from the cranial end to the start of the flared segment of the stent measuring 17 mm (IQR: 12 to 20 mm) versus 21 mm (IQR: 18 to 24 mm) (p = 0.030).
A 2nd covered CP stent was implanted in 4 patients due to residual shunt. There remained a residual shunt in 11 (44%) patients by angiography and 15 (60%) by echocardiography, with only 6 (24%) patients showing a detectable shunt by TTE the following day. RUPV obstruction was suggested by balloon testing in 4 patients and the technique of balloon inflation within the RUPV was utilized to avoid compression during stent deployment and flaring. All patients had unobstructed pulmonary venous return at the end of the procedures.
Major complications included a hemopericardium in 1 patient 3 days after the procedure requiring surgical drainage and found to be related to transseptal puncture, rather than perforation secondary to the stent. Another patient had SVC stent embolization within hours following implantation, requiring surgical removal and repair of the SVASD.
On follow-up of a median 1.4 years (IQR 0.8-1.7 years), cardiac CT in the majority of patients and transcatheter angiography in 1 patient showed a well-positioned SVC stent with unobstructed pulmonary venous return. TTE showed improved RV size in all cases, which was confirmed by MRI in those who had it available at a 1 year follow-up visit. Only 1 patient had a discernible residual shunt by MRI. There were no late complications.
The authors report important information regarding this unique transcatheter approach to treating a lesion that has classically been approached surgically. They showed that with preprocedural planning using virtual and printed 3D models, as well as a collaborative vetting process with a surgical team, this procedure can be performed as a viable alternative to surgery and can be done safely and effectively in this early experience in adult-sized patients. Further studies are surely needed to further investigate its routine use for this indication.