Contemporary Management Strategies of Baffle Leaks in Adults with a Failing Systemic Right Ventricle Late after Atrial Switch: A Case Series and Literature Overview

Figures

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  Figure 1. Baffle leak visualisation and closure in patient A. (A,B) Apical four chamber and subcostal views, respectively show the atrial baffle (arrow) that directs blood from the systemic venous atrium (SVA) to the subpulmonary left ventricle (LV) and from the pulmonary venous atrium (PVA) to the dilated systemic right ventricle (sRV). (C) Agitated saline contrast echocardiography confirms significant interatrial shunting from the SVA to the PVA during Valsalva, with bubbles filling the sRV cavity within 3 heart beats. (D–F) Anterior-posterior (D,E) and right inferior oblique (F) fluoroscopy projections during intracardiac echocardiography (ICE, probe indicated with an asterisk (*) in (D)) guided closure of the baffle leak with a 10 mm Amplatzer Septal Occluder (arrow in F). Note the two atrial pacing wires and an implantable cardioverter-defibrillator (ICD) lead in the LV. (G–I) ICE imaging during closure of the baffle leak. Note the shunting from the SVA to the PVA during Valsalva through the baffle defect (G), the discs of the Amplatzer Septal Occluder in situ (H, arrow) and the alleviation of the interatrial shunt (I).

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  Figure 2. Baffle leak visualization and closure in patient B. (A) Apical four chamber view shows that the atrial baffle (arrow) directs systemic venous return atrium (SVA) to the subpulmonary left ventricle (LV) and the pulmonary venous return atrium (PVA) to the systemic right ventricle (sRV). The baffle leak is indicated by an asterisk (*). (B) Color Doppler apical four chamber view demonstrates SVA to PVA shunting through the baffle leak. (C) Significant interatrial shunting confirmed by agitated saline contrast echocardiography. Note the contrast opacification of the SVA and subpulmonary LV, and the jet crossing the baffle leak into the PVA. (D) Axial slice through a computed tomography scan at the level of the atria shows the baffle leak (arrow). (E,F) Left anterior oblique and right superior oblique fluoroscopy projections, respectively show the Occlutech Figulla Flex II Atrial Septal Defect (ASD) Occluder (arrow) projecting over the interatrial baffle. Note the presence of one ventricular (LV) and two atrial (SVA) pacemaker leads.

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  Figure 3. Baffle leak visualization in patient C. (A) Apical four chamber view shows the systemic venous return atrium (SVA), left ventricle (LV), the dilated and hypertrophied systemic right ventricle (sRV), and the pulmonary venous atrium (PVA). There is a suspicion of a baffle defect (asterisk (*) in (A)). (B) A small mobile structure suspicious of a vegetation (asterisk (*) in (B)) can be seen on the SVA side of the baffle defect. Note the atrial lead (arrow). (C) Color flow Doppler apical four chamber view demonstrates a PVA to SVA shunt over the baffle defect (arrow).