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Cardiology from another dimension: 3D printing in a complex case of rheumatic mitral stenosis
Session:
Sessão de casos clínicos
Speaker:
João Borges Rosa
Congress:
CPC 2021
Topic:
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Theme:
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Session Type:
Sessão de Casos Clínicos
FP Number:
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Authors:
João Borges Rosa; Luís Puga; Rogério Teixeira; Manuel Oliveira-Santos; Marco Costa; António Pires; Lino Gonçalves
Abstract
<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="color:#000033">Rheumatic valvular heart disease is still responsible for high burden of morbidity and mortality. Percutaneous mitral balloon valvuloplasty (PMBV) is the first-line therapy for isolated significant rheumatic mitral stenosis, if anatomic characteristics are suitable. Despite its success rate, complex cases increase the risk of complications and suboptimal results. Transseptal puncture is critical, particularly in children due to right atrium’s distorted anatomy. We report a challenging case of a child with rheumatic mitral stenosis that illustrates the applicability of three-dimensional (3D) printing.</span></span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="color:#000033">A 10 years-old boy presented with signs of heart failure in NYHA III and a grade III/VI systolic murmur in the left sternal border. Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) revealed a severely dilated left atrium with a markedly shifted atrial septum towards the right side and a typical severe rheumatic mitral valve stenosis with transmitral gradients of 30/20 mmHg and 3D-derived area of 0.8 cm2 with a Wilkins score of 7-8 points. Despite multiple attempts, PMBV was unsuccessful due to failed transeptal puncture. The patient underwent cardiac computed tomography with 3D segmentation and then, a 3D- realistic model of the right atrium was printed (Figure 1). After careful simulation of the PMBV in the 3D-printed model using different guiding sheaths and puncture needles, the procedure was repeated guided by 3D-TEE. Transeptal puncture was successful and balloon valvuloplasty was performed with three sequential dilatations, without complications. Immediate 3D-TEE showed an increase in mitral valve area to 1.2 cm<sup>2</sup>.<sup> </sup>One month later, the patient improved clinically and the TTE showed a decrease in the peak and mean transmitral gradients to 14 mmHg and 7 mmHg, respectively, and no mitral regurgitation. Surgical intervention at a young age was delayed.</span></span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="color:#000033">This case highlights the advantages of 3D printing technology in complex cases of Interventional Cardiology, allowing a safer practice and selection of the best treatment approach. </span></span></span></p> <p style="text-align:justify"> </p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="color:#000033"><strong>Figure 1:</strong> </span></span></span><strong><span style="font-size:11.0pt"><span style="font-family:"Calibri",sans-serif"><span style="color:#000033">A. </span></span></span></strong><span style="font-size:11.0pt"><span style="font-family:"Calibri",sans-serif"><span style="color:#000033">3D-printed model of the right atrium with guiding sheath and brockenbrough puncture needle (anterior view, interior of right atrium seen through tricuspid valve opening). <strong>B. </strong>3D-TEE of AS (right atrium view). Arrow indicates guiding sheath for transeptal puncture without tenting to the AS. <strong>C</strong>. 3D-model and guiding sheath and puncture needle simulation with added curvature to allow good tenting and transeptal puncture. <strong>D</strong>. 3D-TEE of AS (right atrium view). Arrow indicates guiding sheath and transeptal puncture needle pointing to the AS with tenting. </span></span></span><span style="font-size:11.0pt"><span style="font-family:"Calibri",sans-serif"><span style="color:#000033">AS-atrial septum, CS-coronary sinus, IVC-inferior vena cava, RAA-right atrial appendage, SVC-superior vena cava.</span></span></span></p>
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