<v Coylewright>Thank you so much, Dr. Molly Szerlip,</v> structural interventional cardiologist from Dallas, in her hometown. Worked with Dr. Messe on the guidelines with which he just presented as did I. And she's gonna tell us the structuralist view. There's a lot of digs on cardiologists there. I don't know, I hope you get a few in Dr. Szerlip, but we'll see. <v Messe>I didn't think I, did I?</v> <v ->No, I'm the kinder, gentler cardiologist.</v> Actually, I think this is gonna be something that happens more often is that you'll see the structuralist with the neurologist so that we can give the best treatment for our PFO patients. All right, so when we get PFO referrals, it's more about the question is, what's the likelihood that this patient's stroke was associated with this patient's PFO? And so, we as Structuralists will look at the age. Was there evidence on CT or MRI that there actually was a stroke? 'Cuz we often get referrals for patients to close their PFO and there's no stroke on any imaging. What's the anatomy of the PFO? So that we know what device to put in if we're going to close it or if we know that we're gonna get a good result. And whether or not they're in a hypercoagulable state. You saw in the SCAI guidelines, if a patient had a hypercoagulable state, despite the fact that they were on anticoagulation, we still recommended PFO closure. And really that's because these patients are not a hundred percent always on their anticoagulation, especially when they come into the hospital for other reasons. And then calculating the RoPE score and the PASCAL score as they have mentioned before me and then the Heart-Brain team. And this is something that I know Megan is gonna talk about after me because this is a newer concept but one that's catching on in almost all aspects of what we do as structuralists. And if you don't have a heart-brain team getting the neurologist involved if they're not already involved. And then when we have a PFO referral, we at least need to have some sort of imaging to show that there was a positive bubble study or a positive PFO and whether that be a transthoracic or a TEE is good. And then, not all or not many cardiologists actually have access to TCDs. And so, if you don't have your neurologist involved, you may not have this study. So here's that video that he was trying to play. (background laughter) <v Messe>That's it.</v> <v ->And there's your intraatrial septal aneurysm.</v> So this is exactly what it looks like. And just for those of you who may not have seen this, we really have to look at when the bubbles cross because if there is a delay like greater than five, or four or five heartbeats then that could be anomalous pulmonary veins and closing the PFO is not gonna make a difference. You gotta look for the anomalous pulmonary venous circulation. Okay, so when is the anatomy malignant? And this was already kind of presented earlier so I'll go over it fast. If you have an intraatrial septal aneurysm or if you have a large shunt and a large shunt can be caused because you have a big tunnel length or a very wide tunnel. And then if you have a prominent eustachian ridge or valve and if you have a large Chiari network. So, Horst Sievert gave us this sort of classification of Tunnel Length, that's type one, type two, and type three. And type one is just sort of your functional tunnel length. That's the normal PFO that you would see. Type two is you have sort of an aneurysmal septum but it doesn't quite meet the criteria for an atrial septal aneurysm. And then type three is when you really have no tunnel length because you have a big atrial septal aneurysm. And that's important because of what device you're gonna pick. The definition for atrial septal aneurysm is excursion of the septum primum of greater than 15 millimeters or greater than 10 millimeters from the midline. And then we talk about large shunt. And so I tried to explain this to my patients when they come in because they'll come in and say "I have a really big PFO," and it's not really a big PFO, it's whether or not you have a big tunnel or an intraatrial septal aneurysm. And then a large shunt is how many bubbles have gone across. And this is actually important because a lot of the insurance companies will deny patients if you don't tell 'em how many bubbles went across. I mean like do you really sit there and count how many bubbles go across? I'd like make it up. I'm like, yeah, a hundred went across, I don't know, a bunch. But they will deny it. Or at least here in Texas, I don't know about other places. And the same thing with the transcranial doppler is also by the embolic tracks the number. So these are your two FDA approved devices. This is the Amplatzer PFO Occluder and the Gore Cardioform Occluder. So what are the difference between the two? Well, the amplatzer looks like a clamshell. It has two self-expanding nitinol discs. It has polyester fabric in it, which is hand woven in. So, if you go to their facilities, there are people who are actually sewing in by hand all of this material. It's pretty interesting to see. They have a screw in cable and that's how you put the device or unscrew the device. And then it's done by disc size. So you have the left atrial disc and the right atrial disc. The standard is really a 25 millimeter device, which has a left atrial disc of 18 millimeters. But you have 18, 30 and 35 sizes as well depending on the complexity of the PFO. And so, a 30 or 35 device is used for more complex PFOs which is defined as a long tunnel or a wide tunnel or septal aneurysm or a big thick septums secundum. For the Cardioform, it's also nitinol. It's a nitinol wire frame but it has ePTFE fabric in it. The two discs are the same size, unlike the amplatzer, which has a smaller disc on the right side, I mean on the left side, excuse me. And then, it's based on when you measure the size by ballooning the actual septum and then measuring the sort of divot that it makes and depending on what that size is will depend on the device that you pick. Both of these are done either by TEE or ICE. I will tell you, most of us use Intracardiac echo so that we don't have to sedate our patient. I mean we don't have to use general anesthesia for our patients. The cardioform device has almost no erosion risk where the amplatzer device had some erosion risk and really, that was early on when we didn't know the correct sizing and there was a higher rate of erosion into the aorta. Again, during the procedure we use TEE or ICE, most commonly ICE. And then, things that we think about, we think about malposition of the device because you don't wanna have residual shunts or device embolization. It's very rare to have a device embolization in a non-complex PFO and even in a complex PFO. But it can happen and we think about the wide tunnels or the long tunnels or if they have a thick septum or a eustachian valve. The eustachian valve can flick thrombus up into across the PFOs. Same thing with Chiari formation. And then the atrial septal aneurysm itself. So, this is a procedure of a 30 millimeter device. This was a floppy septum, not really atrial septal aneurysm but you can see the septum secundum is pretty thick. So we used a a bigger device, a 30 to be able to capture that. And then that's what it looks like on the bicom view. This is what a eustachian valve will look like. It actually can flick or the thought is it flicks thrombus across the PFO. And then the same thing with the Chiari network. It can flick across as well. That's why those are complex PFOs. So things we think about for adverse events, again, not really that much. We have access issues, we have to recognize erosion 'cuz if there is erosion, you need to do a pericardiocentesis. If it embolizes, you have to know how to snare. And you can do this with snare or forceps. And you also have to know when not to retrieve. If the device gets caught in the chordae or the subvalvular apparatus, it's best to take them to surgery. I don't think I know of anyone who's had to do vascular stenting. These devices can cause atrial fibrillation. Actually, the cardioform device has a little bit more risk of atrial fibrillation because of its big discs on both sides. And then you often have to think about whether or not the patient does have or will develop atrial fib because you have to get back across the septum and you you want to do that away from the device if you're gonna put in a LAAO device. And then endocarditis. So the multidisciplinary team shared decision making. This gained traction with the introduction of TAVR and now it's applied to TAVRs, mitral valve repairs and left atrial appendage closures. So it only makes sense to apply to PFO as well which is why we're all here together. So, defined, The Patient-Centered Care is defined by Institute of Medicine. I'm not going to read this in the interest of time. And then Megan had asked me to talk about the inpatient to outpatient. And I will have to say that this is really young. I mean, I know there's heart brain teams developing and Megan's gonna talk about it later. But I will tell you that I would say the predominant amount, it hasn't reached this far yet. There's collaboration between the two departments; neurologists and cardiologists. But, I think it's still in its infancy. And so, it will be fun to actually get this more formalized and then even include the LAAO, because it's really stroke prevention, correct? So that's what we're all about. And then, actually forming an outpatient, PFO clinic or Heart Brain clinic or however you wanna talk about it so that we can give shared decision making to our patients. Because yes, we like to put devices in but we don't know stroke like you guys know strokes. So, putting the two together I think will give the best patient care. Thank you. (audience claps)

structuralist view

PFO

collaboration

closure devices

multidisciplinary team