Development of severe intrapulmonary shunting in a patient with carcinoid heart disease after closure of a persistent foramen ovale: a case report

Background Neuroendocrine tumors (NETs) can affect the cardiopulmonary system causing carcinoid heart disease and valve destruction. Persistent foramen ovale (PFO) occlusion is indicated in patients with carcinoid heart disease and shunt-related left-heart valve involvement. Case Summary We report the case of a 54-year-old female patient with metastatic NET originating from the small bowel. The patient was on medication with octreotide and telotristat. One year after diagnosis, cardiac involvement of carcinoid developed with regurgitation of right-sided and, due to PFO, left-sided heart valves. Closure of PFO was performed (Occlutech 16/18 mm). One year later she presented with recurrent severe dyspnoea. The PFO-occluder was in situ without residual shunt. Valvular heart disease, including left-sided disease, and metastatic spread of NET were stable. Blood gas analysis revealed arterial hypoxemia (pO2 = 44 mmHg/5.87 kPa), which was related to extensive intrapulmonary shunting (31% shunt fraction) confirmed using contrast-enhanced echocardiography. The patient was prescribed long-term oxygen supplementation as symptomatic therapy and anti-tumoral therapy was intensified with selective internal radiotherapy of the liver metastases in order to improve biochemical control of the carcinoid syndrome. Discussion An echocardiographic assessment of the presence of a PFO is recommended in patients with NET as PFO closure minimizes the risk of left-sided carcinoid valve disease. Deterioration of symptomatic status in metastasized NET might also be due to a hepatopulmonary-like physiology with intrapulmonary shunting and arterial desaturation thought to be caused by vasoactive substances secreted by the tumor. This is a rare case describing the development of this syndrome after PFO closure.

Outcomes of Tricuspid Valve Detachment for Isolated Ventricular Septal Defect Closure

Partial detachment of the septal and anterior leaflets of the tricuspid valve (TV) is a technique to visualize a perimembranous ventricular septal defect (VSD) for surgical closure in cases where the VSD is obscured by TV tissue. However, TV incision bears the risk of causing relevant postoperative TV regurgitation and higher degree atrioventricular (AV) block. A total of 40 patients were identified retrospectively in our institution who underwent isolated VSD closure between January 2013 and August 2015. Visualization of the VSD was achieved in 20 patients without and in 20 patients with additional partial detachment of the TV. The mean age of patients with partial tricuspid valve detachment (TVD) was 0.7 ± 0.1 years compared with 1 ± 0.3 years (p = 0.22) of patients without TVD. There was no difference in cardiopulmonary bypass time between patients of both groups (123 ± 11 vs. 103 ± 5 minutes, p = 0.1). Cross-clamp time was longer if the TV was detached (69 ± 5 vs. 54 ± 4 minutes, p = 0.023). There was no perioperative mortality. Echocardiography at discharge and after 2.5 years (2 months–6 years) of follow-up showed neither a postoperative increase of tricuspid regurgitation nor any relevant residual shunt. Postoperative electrocardiograms were normal without any sign of higher degree AV block. TVD offers enhanced exposure and safe treatment of VSDs. It did not result in higher rates of TV regurgitation or relevant AV block compared with the control group.

Clinical analysis of percutaneous closure atrial septal defects guided by thoracic echocardiography (Report of 90 cases)

Objective :The purpose of this research is to explore the clinical application prospect of percutaneous closure atrial septal defects guided by thoracic echocardiography. Methods : Selected 90 inpatients who were pure atrial septal defects from sep 2014 to December 2019, Under local anesthesia via femoral vein puncture closure atrial septal defects guided by thoracic echocardiography, Real-time evaluatie plugging result.The patients underwent follow-up echocardiography at 3 days, 3 months, 6 months, 12 months after surgery．Results Intraoperative occlusion was not successful in 3 cases（The plug is not fixed firmly, so withdraw the plug）， Occluder were successfully implanted in 87 patients, there were no serious complications such as valvular injury、pericardial effusion、occluder off,five patients had a little residual shunt in 3 days after surgery, residual shunt disapper after 3 months underwent follow-up echocardiography, the rest of the patients does not appear residual shunt.. Conclusion :Percutaneous closure atrial septal defects guided by thoracic echocardiography had Superiority such as simplicity of operator、shorter operator time、less-injury、safety、fast recovery,the surgery has a broad clinic prospects．

Multimodality imaging in delineation of complex sinus venous defects and treatment outcomes over the last decade

Background: Diagnosis of sinus venosus defects, not infrequently associated with complex anomalous pulmonary venous drainage, may be delayed requiring multimodality imaging. Methods: Retrospective review of all patients from February 2008 to January 2019. Results: Thirty-seven children were diagnosed at a median age of 4.2 years (range 0.5−15.5 years). In 32 of 37 (86%) patients, diagnosis was achieved on transthoracic echocardiography, but five patients (14%) had complex variants (four had high insertion of anomalous vein into the superior caval vein and three had multiple anomalous veins draining to different sites, two of whom had drainage of one vein into the high superior caval vein). In these five patients, the final diagnosis was achieved by multimodality imaging and intra-operative findings. The median age at surgery was 5.2 years (range 1.6−15.8 years). Thirty-one patients underwent double patch repair, four patients a Warden repair, and two patients a single-patch repair. Of the four Warden repairs, two patients had a high insertion of right-sided anomalous pulmonary vein into the superior caval vein, one patient had bilateral superior caval veins, and one patient had right lower pulmonary vein insertion into the right atrium/superior caval vein junction. There was no post-operative mortality, reoperation, residual shunt or pulmonary venous obstruction. One patient developed superior caval vein obstruction and one patient developed atrial flutter. Conclusion: Complementary cardiac imaging modalities improve diagnosis of complex sinus venosus defects associated with a wide variation in the pattern of anomalous pulmonary venous connection. Nonetheless, surgical treatment is associated with excellent outcomes.

Late-onset total anomalous pulmonary venous connection in a 70-year-old woman

Total anomalous pulmonary venous connection (TAPVC) is a rare congenital cardiac anomaly. There are a few reports of untreated TAPVC diagnosed in patients older than 60 years. Herein, we report the successful surgical treatment of TAPVC in a 70-year-old woman. A 70-year-old woman with TAPVC presented with symptoms of acute heart failure. We closed an atrial septal defect and performed tricuspid annuloplasty and commissurotomy of the pulmonary valve. Postoperative CT showed no residual shunt, and the pulmonary veins drained into the left atrium. She had an uneventful postoperative course. This report describes the case of the oldest known patient who underwent surgical treatment for TAPVC. Surviving into adulthood with little or no symptoms is uncommon in patients with TAPVC, and cases of late-onset TAPVC, such as our case, are rare. Nevertheless, close vigilance is necessary to prevent misdiagnosis in patients with this clinical presentation.

Percutaneous occlusion of ductus arteriosus with Amplatzer™ Duct Occluder II AS

Background Percutaneous occlusion of ductus arteriosus is well established as the method of choice to treat this structural heart defect. A new generation of Amplatzer™ Duct Occluder II Aditional Sizes prostheses, with lower profile and greater flexibility, in addition to smaller retention discs, was developed for percutaneous treatment of patent ductus arteriosus. This study intended to demonstrate the experience of one center with the use of this device, evaluating technical aspects, immediate occlusion rates, and complications. Methods A retrospective study of a cohort of patients with patent ductus arteriosus treated with Amplatzer™ Duct Occluder II Aditional Sizes. Between October 2018 and March 2021, 27 patients with patent ductus arteriosus, types A and E according to the Krichenko classification, were treated with Amplatzer™ Duct Occluder II Aditional Sizes. The prosthesis was implanted by the usual anterograde approach in 25 patients, and retrograde in two cases. The prosthesis chosen were 2mm larger than the core of the defect, and the length of the prosthesis was 2mm for shorter lesions and smaller infants, and between 4 and 6mm for longer lesions. Results Out of 27 patients, 52% were female, with a mean age and weight of 44.2 months (1 to 135 months) and 15.8kg (2,0 to 29kg), respectively. In the sample, 11 patients presented type A patent ductus arteriosus, and 16 type E, with a mean ratio of 1.9:1 between the prosthesis waist and the central diameter. In all patients, the device was successfully implanted, and only one patient remained with residual shunt, presenting embolization of the prosthesis. This patient had the ductus arteriosus closed by another prosthesis. Conclusion Amplatzer™ Duct Occluder II Aditional Sizes demonstrated safety, versatility, and efficiency in cases of appropriate anatomy. The experience demonstrated here is from a single center, with the Amplatzer™ Duct Occluder II Aditional Sizes. Its increased flexibility and softness demand greater operator expertise.

Spontaneous resolution of a tentorial dural arteriovenous fistula fed by the artery of Wollschlaeger and Wollschlaeger after embolization of the main shunting point

Background: Tentorial dural arteriovenous fistula (TDAVF) is a rare intracranial vascular shunt. A TDAVF can be supplied by the Artery of Wollschlaeger and Wollschlaeger (AWW). However, a limited number of cases of TDAVF fed by the AWW have been reported to date. Case Description: A 70-year-old woman complaining of the right motor weakness underwent magnetic resonance imaging. A vascular lesion beneath the cerebellar tentorium was incidentally found with chronic infarction of the left corona radiata. Angiographically, the vascular lesion was a TDAVF supplied by the bilateral posterior meningeal arteries. No other apparent feeders were detected. The TDAVF had a shunting point on the inferior surface of the cerebellar tentorium with venous retrograde flow (Borden type III, Cognard type III). To prevent vascular events, endovascular embolization was performed using n-butyl-2-cyanoacrylate. Following embolization of the shunting point, a residual shunt fed by the AWW was identified. The shunt supplied by the AWW was not observed preoperatively. Follow-up angiography performed 1 week later revealed spontaneous disappearance of the residual shunt. The patient was followed-up in our outpatient clinic, and no recurrence of the TDAVF was confirmed postoperatively. Conclusion: Detection of mild feeding from the AWW to a TDAVF can be elusive preoperatively. Following embolization of the main shunting point, residual shunting from the AWW can resolve spontaneously.