288.3 🏥 內科專科考前版

288.3.1 Mechanistic Deep Dive

288.3.1.1 Shunt Hemodynamics

  • Qp:Qs = pulmonary flow / systemic flow
  • Qp:Qs > 1.5 = significant shunt
  • Calculated from O2 step-up at cath
  • Determines closure benefit

288.3.1.2 Pulmonary Vascular Reactivity

  • Pre-Eisenmenger: reactive (lowered with NO, prostaglandin)
  • Post-Eisenmenger: fixed remodeling
  • Closure futile or harmful in fixed disease
  • Vasoreactivity testing during cath (small role in CHD)

288.3.2 Recent Trials & Updates

288.3.2.1 CLOSE (2017) — Cryptogenic Stroke + PFO

  • N = 663 cryptogenic stroke < 60 yo with PFO + atrial septal aneurysm or large shunt
  • PFO closure + antiplatelet vs antiplatelet alone
  • ↓ recurrent stroke (HR 0.03)
  • Class I for cryptogenic stroke with PFO

288.3.2.2 RESPECT (2017 extended)

  • 10-year follow-up confirms benefit

288.3.2.3 DEFENSE-PFO (2018)

  • Korean trial
  • PFO closure for high-risk PFO (large shunt or ASA)
  • Reduced stroke

288.3.2.4 REDUCE (2017)

  • PFO closure + antiplatelet vs antiplatelet alone
  • ↓ stroke

288.3.2.5 2024 Updates

  • AHA/ACC: closure Class I in selected
  • Considering closure age > 60 in select (REDUCE-2 ongoing)
  • LAA closure for AF in patients post PFO closure being studied

288.3.3 High-Yield Specialist Points

288.3.3.1 RoPE Score

  • Risk of Paradoxical Embolism
  • 10 points: age, vascular RF, PFO features
  • Higher RoPE = higher likelihood PFO is causative
  • Validates patient selection

288.3.3.2 ASD Closure Techniques

  • Amplatzer Septal Occluder (most common)
  • Helex (now retired in some markets)
  • GORE Cardioform Septal Occluder
  • DAPT 6 months post-closure

288.3.3.3 Sinus Venosus ASD

  • Anomalous pulmonary venous return common (RUPV to SVC)
  • Surgical baffle repair
  • Warden procedure: redirect SVC

288.3.3.4 Coronary Sinus ASD

  • Unroofed CS — RA to LA via coronary sinus
  • Surgical
  • Persistent L SVC association

288.3.3.5 VSD with Aortic Regurgitation

  • Subaortic VSD (supracristal): aortic cusp prolapse into VSD → AR
  • Surgical repair to prevent progressive AR

288.3.3.6 Acquired (Post-Surgical) Shunts

  • Patent surgical patch with residual shunt
  • Re-operation or transcatheter repair
  • Endocarditis risk

288.3.3.7 Future Therapies

  • Biodegradable devices for atrial closure
  • Personalized device sizing with 3D CT / 4D MRI
  • AI-guided procedural planning

288.3.4 Pearls

  • ASD secundum most common; fixed split S2; percutaneous device closure
  • VSD perimembranous most common; holosystolic LLSB; surgical patch
  • PDA continuous “machinery”; percutaneous coil first-line
  • PFO closure: CLOSE, RESPECT, DEFENSE-PFO for cryptogenic stroke < 60 yo
  • Eisenmenger = absolute contraindication to shunt closure
  • AVSD strongly associated with Down syndrome
  • Differential cyanosis in Eisenmenger PDA (cyanotic feet, pink arms)