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Assessing for Baffle Stenosis using
Intravascular Ultrasound
CRT Interesting Case 2017
Benes LB, Rosenberg JR, Tharian TS, Shah AP
Patient Information
•
34 year-old-male with episodes of presyncope, chest pain, fatigue
and dyspnea
•
Known history of d-transposition of the great arteries status post
Mustard procedure at age 18 months
•
Followed in clinic for recurrent atrial arrhythmias, sinus node
dysfunction and reduced systemic ventricular ejection fraction (EF)
of 30%
•
Dual chamber ICD indicated given his symptomatic bradycardia and
elevated risk of sudden cardiac death1
Mustard Procedure
Great arteries
Baffle
Pulmonic veins
lead to right
atrium
To pulmonic
ventricle
Hospital Course and Management
•
Cardiac MRI was
performed to assess
anatomy, showing
significant narrowing of
the SVC and IVC baffle
to 5-6 mm at the
narrowest dimension
Hospital Course and Management
•
Cardiac MRI was
performed to assess
anatomy, showing
significant narrowing of
the SVC and IVC baffle
to 5-6 mm at the
narrowest dimension
Hospital Course and Management
•
Cardiac MRI was
performed to assess
anatomy, showing
significant narrowing of
the SVC and IVC baffle
to 5-6 mm at the
narrowest dimension
Hospital Course and Management
•
Referred for invasive baffle assessment using intravascular ultrasound
(IVUS)
• 0.035” Volcano Eagle Eye catheter
revealed a patent baffle with no
significant stenosis
• With injection of saline, baffle
cross-sectional diameter
measured at 21 mm
• Baffle pressure normal at
8 mmHg throughout
Hospital Course and Management
•
Referred for invasive baffle assessment using intravascular ultrasound
(IVUS)
• 0.035” Volcano Eagle Eye catheter
revealed a patent baffle with no
significant stenosis
• With injection of saline, baffle
cross-sectional diameter
measured at 21 mm
• Baffle pressure normal at
8 mmHg throughout
Respirophasic variation and injection of saline into baffle further
demonstrate patency
Treatment and Outcome
•
Given baffle patency, successfully underwent device implantation
•
At 1 month follow-up, reported significant symptom improvement
Case Implications
•
IVUS has been described to better visualize baffle anatomy in
patients who have previously undergone stent placement to relieve
stenosis and to accommodate pacemaker leads2
•
This case demonstrates its additional usefulness in patients for
whom the concern for baffle stenosis on imaging prior to lead
implantation requires more definitive evaluation
References
1. Dos L, Teruel L, Ferreira IJ, et al. Late outcome of Senning and Mustard
procedures for correction of transposition of the great arteries. Heart.
2005 May;91(5):652-6.
2. Chintala K, Forbes TJ, Karpawich PP. Effectiveness of transvenous
pacemaker leads placed through intravascular stents in patients with
congenital heart disease. Am J Cardiol. 2005 Feb 1;95(3):424-7.