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Challenges in percutaneous transvenous mitral commissurotomy
Published in Neeraj Parakh, Ravi S. Math, Vivek Chaturvedi, Mitral Stenosis, 2018
Ravi S. Math, Cholenahally Nanjappa Manjunath
Traditionally, Lutembacher’s syndrome has been treated by open heart surgery. With the advent of percutaneous therapies for the treatment of MS and atrial septal defect (ASD), a definitive percutaneous therapy is now possible for Lutembacher’s syndrome as well.48,49 The choice between PTMC (with device closure of ASD when suitable) versus surgical closure of ASD with open mitral valvotomy (OMV)/MVR has its pros and cons. A primary percutaneous therapy avoids a sternotomy, leaving an option for a future first surgery at lower risk in the event of mitral restenosis. The percutaneous approach may, however, preclude future repeat PTMC following the placement of an ASD device. A TSP may be attempted through the native septum around the ASD device, if available. In addition, TSP through an amplatzer septal occluder device (with placement of 11F sheath) has been reported in patients undergoing AF ablation. This study was performed with ICE guidance and did not report any device embolization.50 As of now, we are not aware of any reported case of PTMC in the presence of an ASD device. In such cases, a retrograde approach is still feasible.
Is combined use of radiofrequency ablation and balloon dilation the future of interatrial communications?
Published in Expert Review of Cardiovascular Therapy, 2022
Inspired by Lutembacher syndrome (which involves a combination of mitral stenosis and atrial septal defect), a percutaneously created interatrial communication is used for left atrial decompression and reduction of pulmonary congestion in patients with HFpEF or HFmEF [3,4,52–54]. Short- to mid-term follow-up suggested that there was hemodynamic amelioration with significant improvements in the New York Heart Association functional class, exercise tolerance and quality of life [16–18,52]. Despite a mild increase in pulmonary blood flow and a slight reduction of left ventricular cardiac output, pulmonary vascular function improved at rest and during exercise [55]. However, limited information exists regarding the long-term outcomes of interatrial communication, and there are still some controversies [56,57]. A recent study suggested that the interatrial shunt did not reduce heart failure events or improve health status in these patients [58]. It might be associated with latent pulmonary vascular disease, and a more robust signal of clinical benefit was observed in patients without latent pulmonary vascular disease [59]. It remains uncertain whether its beneficial effects will wear off with time, and further research is required to confirm the long-term benefits of this novel therapeutic approach. Given that the population of patients with HFpEF and HFmEF is large and effective medical therapy is still unavailable, multiple clinical trials of atrial septostomy are ongoing relating to different specialty devices [18,19,60–62]. In patients with heart failure with reduced ejection fraction or candidates for heart transplantation, atrial septostomy also shows the benefits of improved hemodynamic parameters and clinical symptoms [60–63].