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Transcatheter Covered Stent Exclusion of Sinus Venosus Defects
Quick Takes
- Transcatheter closure of sinus venosus defects with covered stent can be accomplished with a high procedural success rate at an experienced center.
- The procedural approach has evolved over the course of the center’s experience, with changes in intraprocedural imaging as well as strategies to monitor and protect the right upper pulmonary vein.
Study Questions:
What are the outcomes of transcatheter occlusion of sinus venosus defects (SVD) with covered stent?
Methods:
A single-center experience was reported over 8 years. Patients were included if balloon occlusion of the cavo-atrial junction confirmed closure of the SVD and redirected right upper pulmonary vein (RUPV) to the left atrium. Early in the experience, RUPV monitoring was performed using direct access via the SVD. Later in the experience, RUPV monitoring was performed using retrograde cannulation with an arterial catheter or anterograde cannulation through a transseptal sheath. If there was evidence of RUPV obstruction, RUPV protection was performed by inflating a 12-14 mm balloon in the RUPV orifice.
Results:
A total of 100 patients including nine children with a median age of 35 years (range 4-69 years) underwent SVD closure after balloon interrogation. Among 57 patients balloon interrogated in the first 5 years, 70% underwent device closure with two failures due to RUPV occlusion. In the subsequent 65 balloon interrogations, implantation was attempted in 94% of patients after implementation of RUPV protection with one failure. Stent embolism caused the three failures requiring surgery. Over the course of the analysis, procedural modifications included limited transesophageal echocardiography without anesthesia, avoiding veno-venous circuit, interrogation with semi-compliant balloons, transseptal pulmonary vein protection, and overlapping stent to permit additional vein drainage to the SVC.
Conclusions:
The authors conclude that procedural success was 97%. Recent modifications increased the number of patients who were candidates for the procedure, reduced complications, and simplified the procedure.
Perspective:
Surgery has long been the preferred approach for intervention on sinus venosus defects. This paper reports a large single-center experience for a transcatheter approach and demonstrated a high procedural success rate. This highly experienced center has gradually modified the procedure, and advocates for continuous monitoring of the right upper pulmonary vein, as well as balloon inflation in the RUPV to protect the vein when there is concern. As additional centers move towards a transcatheter approach, there is likely to be a learning curve. This paper describes procedural modifications learned by this center with its extensive experience, which can hopefully be applied by other centers.
Clinical Topics: Congenital Heart Disease and Pediatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Congenital Heart Disease, CHD and Pediatrics and Interventions, Interventions and Structural Heart Disease
Keywords: Heart Defects, Congenital, Stents
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