Transcatheter correction of a "reverse Gerbode defect"
Presenter
Fabio V. Lima, MD, MPH, University of California, San Francisco, San Francisco, CA
Fabio V. Lima, MD, MPH1, Megan McLaughlin1, Rima Arnaout2, Aarthi Sabanayagam1, Tom C. Nguyen1, Michael Bunker3, Shafkat Anwar3, Neal Shah1 and Sammy Elmariah, M.D., FSCAI4, (1)University of California, San Francisco, San Francisco, CA, (2)Rima Arnaout, MD, San Francisco, CA, (3)The University of California, San Francisco, San Francisco, CA, (4)The University of California, San Francisco, Corte Madera, CA
Title:
Transcatheter correction of a "reverse Gerbode defect"
Introduction:
An acquired Gerbode defect, a communication between the left ventricle and the right atrium, is uncommon but known surgical complication that may occur following mitral and tricuspid valve replacement. Whereas a communication between the left atrium (LA) and right ventricle (RV) following surgery is exceptionally rare. We present here the first-known description of a transcatheter approach to closing such a defect in a patient with acute decompensated heart failure following surgical mitral and tricuspid valve replacement.
Clinical Case:
54-year-old man with complete AV canal defect underwent atrial septal defect closure, mitral and tricuspid valve replacement. Two months later, he presented with heart failure and was found to have a bidirectional LA to RV shunt, with 60 mmHg gradient across the defect. CT 3D reconstruction localized the defect as superior to endocardial cushion and measuring 27.3 x 13.5 x 8.8 mm. Invasive hemodynamics showed Qp:Qs ~1.3 with RV oxygen step-up. Via transesophageal echocardiography (TEE) a mid-superior transseptal puncture was performed with radiofrequency and Versacross. A 6Fr Agilis™ (Abbott) small curved steerable sheath was placed across into the LA. Contrast injection helped to define the ostium of the septal defect adjacent to the mitral valve. Using a JR4 guide within the Agilis in the LA, the defect was crossed using an angled 0.035 Termo Glidewire
® into the RV. JR4 brought across and further stabilized with a V18 wire. A 6Fr pigtail catheter was exchanged for the JR4, a ventriculogram was performed, and then a SAFARI
2 wire (Boston Scientific) was placed into the RV alongside the V18 wire. A 7Fr Amplatzer™ (Abbott) delivery sheath was introduced over the SAFARI
2 wire and subsequently an Amplatzer 12mm-ventricular septal defect closure device was deployed across the septal defect. On TEE the defect appeared to completely seal after the closure device was deployed. LAP decreased from 28mmHg to 15mmHg. There were no complications, the closure device did not interact with the prosthetic valves, and the patient tolerated the procedure well. Sixty days post-procedure, the patient noted remarkable improvement in his breathing. Echocardiogram showed no evidence of leak or shunting across the septum.
Discussion:
This is the first known percutaneous closure of a LA-RV septal defect, a condition we coined “reverse Gerbode defect.” This case illustrates a safe, technical approach via catheter-wire based strategy to close a unique septal defect in a patient deemed too high risk for open surgery. We utilized a mid-superior transeptal puncture to gain the necessary height and angulation to then direct equipment trajectory steadily across the defect.