Patent Foramen Ovale and AtrialSeptal Defect Closure

Question 1

What is the foramen ovale?

Answer 1

An interarterial communication defect present in up to 20% of normal adults

It is a small channel between the septum secundum and septum primum that may allow passage of blood or thrombotic emboli from the right atrium to the left atrium (paradoxical embolism).

Question 2

What is the FDA-approved indication for PFO closure?

Answer 2

To reduce the risk of recurrent ischemic stroke in patients aged 18 to 60 who have had a cryptogenic stroke due to presumed paradoxical embolism

None of the other listed conditions are FDA-approved indications.

Question 3

Define an atrial septal aneurysm.

Answer 3

A floppy interatrial septum resulting from abundant tissue in the septum primum

A total septal excursion of >15 mm is widely accepted as the definition for this entity.

Question 4

What device is FDA-approved to reduce stroke risk related to PFO?

Answer 4

Amplatzer PFO occluder

It is the only device approved for patients with prior cryptogenic stroke believed to be caused by a PFO-related paradoxical embolism.

Question 5

What defines a cryptogenic stroke?

Answer 5

Brain infarction not clearly attributable to a definite cardioembolism, large artery atherosclerosis, or small artery disease despite extensive investigation.

Question 6

What is the significance of high-risk anatomy in patients with PFO?

Answer 6

Indicates evidence for recurrent paradoxical embolism

Other patients may have different potential causes for stroke or accepted indications for chronic anticoagulation.

Question 7

True or False: Lipomatous septum secundum is a factor for recurrent paradoxical embolism.

Answer 7

False

All other characteristics have been associated with recurrent paradoxical embolism.

Question 8

What is the standard ICE image projection orientation?

Answer 8

Transducer in the right atrium looking across the septum to the left atrium

Feet to the left and head of the patient to the right.

Question 9

List the advantages of ICE over TEE for ASD closure.

Answer 9

• Avoidance of general anesthesia
• Better visualization of the left atrium and posteroinferior part of the septum
• Shorter procedure times
• Ability for the interventionist to perform the procedure without additional echocardiographic personnel.

Question 10

What are the four types of ASDs?

Answer 10

• Ostium secundum
• Ostium primum
• Coronary sinus defects
• Sinus venosus defects.

Question 11

What percentage of ASDs are ostium secundum?

Answer 11

75%

They are usually located at the level of the fossa ovalis.

Question 12

What is a common consequence of ASDs if left uncorrected?

Answer 12

Pulmonary hypertension may result from increased blood flow.

Question 13

What is the expected chest X-ray finding in a patient with ASD?

Answer 13

Increased lung vascularity.

Question 14

True or False: LV dysfunction is common in younger patients.

Answer 14

False

The incidence is as high as 15% in patients older than 50 years.

Question 15

What is the traditional cutoff for surgical closure in asymptomatic patients with ASD?

Answer 15

QP:QS ratio > 2.

Question 16

What is pulmonary arterial hypertension (PAH)?

Answer 16

Mean pulmonary arterial pressure of more than 25 mm Hg with normal left atrial pressure and resting cardiac output

PVR of more than 3 Wood units.

Question 17

What is a positive vasoreactivity response?

Answer 17

Reduction of mean pulmonary artery pressure (PAP) of >10 mm Hg with resultant mean PAP of 40 mm Hg or less, without a fall in cardiac output.

Question 18

What is the role of the balloon in percutaneous ASD closure?

Answer 18

Forces the defect into a circular configuration and is expanded until left-to-right shunting ceases.

Question 19

What are the components of postprocedural assessment following ASD closure?

Answer 19

• Stable device position
• Closure of the defect with no residual shunt
• Lack of procedural complications.

Question 20

What is the expected procedural success rate for ASD closure?

Answer 20

More than 97%.

Question 21

List the usual pre-procedure methods for ASD closure.

Answer 21

• ICE
• Indocyanine green dye dilution curves
• Imaging modalities with contrast injections.

Question 22

What are sinus venosus defects associated with?

Answer 22

Anomalous pulmonary vein drainage into the right atrium.