Complicaciones a corto plazo del cierre percutáneo de comunicación interauricular / Short-term complications of percutaneous atrial septal defect closure

Resumen Introducción: El cierre percutáneo de la comunicación interauricular ostium secundum ha pasado a ser una alternativa a la cirugía convencional. En ese caso, los dispositivos de autocentrado son los más usados entre los cardiólogos intervencionistas. El tipo y la tasa de complicaciones difieren para los distintos dispositivos. Objetivo: Reportar las complicaciones a corto plazo del cierre percutáneo de la comunicación interauricular ostium secundum. Método: Entre abril de 2001 y diciembre de 2017, 129 pacientes (media de edad: 26 años; desviación estándar: 20,39 años) fueron sometidos a cierre percutáneo de comunicación interauricular ostium secundum. Las complicaciones fueron identificadas y clasificadas como mayores y menores. Resultados: 14 pacientes experimentaron complicaciones menores durante la hospitalización y en el primer año de seguimiento (10.85 %), y uno tuvo una complicación mayor que requirió cirugía electiva 4 meses después para la remoción del dispositivo mal posicionado. Entre los que presentaron complicaciones menores, dos tuvieron shunt residual leve, cinco presentaron arritmias interoperatorias, uno refirió dolor torácico y seis tuvieron migraña posimplante. Conclusiones: Esta serie de pacientes muestra que el cierre percutáneo de la comunicación interauricular ostium secundum es un procedimiento seguro y efectivo en casos bien seleccionados. Con el fin de reducir la tasa de complicaciones, están indicados el diagnóstico y el tratamiento tempranos, así como la observación de los criterios de selección de acuerdo con la morfología de la comunicación interauricular ostium secundum. La profilaxis antiagregante con clopidogrel para todos los pacientes requiere mayor investigación.

Abstract Introduction: Percutaneous closure of ostium secundum atrial septal defects has become an alternative to conventional surgery. Self-centering devices are the ones most used by interventional cardiologists in these cases. The type and rate of complications varies according to the various devices. Objective: To report the short-term complications of percutaneous closure of ostium secundum atrial septal defects. Method: Between April 2001 and December 2017, 129 patients (mean age: 26; standard deviation: 20.39 years) underwent percutaneous closure of ostium secundum atrial septal defects. Complications were identified and classified as major or minor. Two types of devices were used: the Amplatzer™ Septal Occluder in 98 patients, and the Figulla® Septal Occluder in 31 patients. Results: 14 patients had minor complications during hospitalization and the first year of follow up (10.85%), and one had a major complication which required elective surgery four months later to remove the misaligned device. Of those who experienced minor complications, two had mild residual shunting, five had intraoperative arrhythmias, one reported chest pain, and six had post-implant migraines. Conclusions: This series of patients shows that percutaneous closure of ostium secundum atrial septal defects is a safe and effective procedure in carefully selected cases. Early diagnosis and treatment are needed to decrease the rate of complications, along with adherence to the selection criteria according to the morphology of the ostium secundum atrial septal defect. Antiplatelet prophylaxis with clopidogrel for all patients requires further study.

Platypnea-Orthodeoxia Syndrome Two Decades after Definitive Surgical Repair of Pulmonary Atresia with Intact Ventricular Septum

A 20-year-old female had undergone definitive surgical repair for pulmonary atresia with intact ventricular septum soon after birth. She was referred to our institution with the chief complaint of clubbing fingers. A thorough examination revealed platypnea-orthodeoxia syndrome due to an interatrial right-to-left shunt through a secundum atrial septal defect. Percutaneous closure with an Amplatzer Septal Occluder resulted in resolution of the syndrome.

Transcatheter Treatment of Atrial Septal Defect Presenting with Platypnea-Orthodeoxia Syndrome

A 29-year-old woman was referred to our institute for symptomatic hypoxemia. Her dyspnea was aggravated while sitting or standing and relieved while in supine position. She did not have any pulmonary disease. Transthoracic echocardiography and heart computed tomography revealed an underestimated small atrial septal defect (ASD) with a left-to-right shunt. A cardiac catheterization was performed to evaluate pulmonary hypertension. It revealed a normal pulmonary artery pressure and a large ASD with bidirectional shunt during Valsalva maneuver by intracardiac echocardiogram. Her arterial oxygen saturation decreased from 93% while supine to 79% while at a 15degrees sitting position. Thus, the patient was diagnosed with platypnea-orthodeoxia syndrome. The ASD was successfully closed with Amplatzer(R) (St. Jude Medical) septal occluder and both platypnea and orthodeoxia were resolved immediately after the procedure.

Balloon Occlusive Diameter of Non-Circular Atrial Septal Defects in Transcatheter Closure with Amplatzer Septal Occluder

BACKGROUND AND OBJECTIVES: The aim of this study was to investigate the balloon occlusive diameter (BOD) of non-circular defects in the transcatheter closure of atrial septal defect (ASD). SUBJECTS AND METHODS: A total of 67 patients who had undergone transcatheter closure of an ASD were reviewed retrospectively. A non-circular defect was defined as the ratio of the short diameter to the long diameter of the defect on the en-face image less than 0.75. The BOD was compared with the long diameter of the defect and then compared between the two groups. RESULTS: There were 22 patients with circular defects and 45 patients with non-circular defects. The difference in BOD measuring from the long diameter of the defect was quite different between the two groups and significantly smaller in non-circular morphology (0.1+/-4.0 vs. 2.3+/-2.1, p=0.006). The difference in BOD measurement from the long diameter of ASD showed a positive correlation with the ratio of the short diameter to the long diameter of ASD (b/a) (r2=0.102, p=0.008). In the non-circular morphology of ASD, the difference in BOD measured from the long diameter had a significant negative correlation with the long diameter of ASD (r2=0.230, p=0.001), whereas in circular ASD, no significant correlation was found between the difference in BOD and the long diameter of ASD (p=0.201). CONCLUSION: The BOD compared with the long diameter measured from three-dimensional transesophageal echocardiography was smaller in non-circular ASD than in circular ASD. This difference was much smaller in non-circular ASD with a large long diameter.

A New Method for Patent Foramen Ovale Closure: Delivering Sheath Over Coronary Sinus Catheter into Left Atrium

Patent foramen ovale (PFO) is a frequent condition. It usually does not pose any threat to life, but in certain circumstances, it can open and serve as a conduit for thrombi causing paradoxical embolism. Herein, we report a case of PFO in a patient with ischemic cerebrovascular accident, due to paradoxical embolism, which could not be passed via general practice; hence it was crossed with coronary sinus catheter, through which the delivery sheath was placed into the left atrium, and it was successfully closed.

A New Method for Patent Foramen Ovale Closure: Delivering Sheath Over Coronary Sinus Catheter into Left Atrium

Patent foramen ovale (PFO) is a frequent condition. It usually does not pose any threat to life, but in certain circumstances, it can open and serve as a conduit for thrombi causing paradoxical embolism. Herein, we report a case of PFO in a patient with ischemic cerebrovascular accident, due to paradoxical embolism, which could not be passed via general practice; hence it was crossed with coronary sinus catheter, through which the delivery sheath was placed into the left atrium, and it was successfully closed.

Morphologic Characteristics and Relating Factors to the Need of Technical Modification in Transcatheter Closure of Large Atrial Septal Defect (> or =25 mm)

BACKGROUND AND OBJECTIVES: The rigid coupling between the delivery wire and the right atrial disk has been occasionally encountered during transcatheter closure of atrial septal defect (ASD). Therefore the device frequently makes a perpendicular angle, and the leading edge of left atrial disk slips through the defect and prolapses into right atrium (RA) before it is properly placed in the septum. The purpose of this study is to investigate relating factors to the need of technical modification in transcatheter closure of large ASD and to evaluate relevant morphologic characteristics of atrial septal rim in this situation. SUBJECTS AND METHODS: From July, 2003 to May, 2007, 312 patients underwent transcatheter occlusion of ASD with Amplatzer Septal Occluder(R) (ASO, AGA medical corporation, Golden Valley, MN, USA) at Yonsei Cardiovascular Center and among them 109 patients had large ASD (> or =25 mm) and these patients were enrolled in our study. Patients were divided into two groups according to the deploying methods of the device (Group I: standard method, Group II: modified methods). Assessments of the defects and its surrounding rims were made by echocardiography. RESULTS: There were no differences between 2 groups in age, body weight and height except for balloon-stretched diameter (stop-flow technique) and device size. Group II patients with modified methods showed larger balloon-stretched diameter and device size than group I patients with standard method. The mean length of anterosuperior (AS) rim in group II was significantly shorter than group I (p<0.05). As the size of the device used in procedure increased, there was a trend towards increase in the need of modified methods. CONCLUSION: This study shows that AS rim deficiency and the size of ASD may be the relating factors to the need of technical modification in transcatheter closure of ASD. Therefore, when the initial try with standard method is not successful in large ASD with deficient AS rim, we suggest that changing strategy of implantation may save time and efforts and possibly reduce the risk of complications associated with prolonged procedure.

Amplatzer septal occluder found in the thoracic descending aorta by transesophageal echocardiography: A case report / 대한마취과학회지

Percutaneous device closure of atrial septal defect (ASD) has proven to be safe and effective, and become a widely accepted option to the surgical repair. However, the embolization of Amplatzer septal occluder (ASO) occurs in about 0.55% to 3.5% of cases, regardless of ASD size, device size, or the physician's expertise. We report a case of embolization of an ASO into the thoracic descending aorta, successfully removed through a surgical approach.

Late Cardiac Perforation after Atrial Septal Defect Closure with the Amplatzer Septal Occluder / 日本心臓血管外科学会雑誌

Percutaneous transcatheter closure of ostium secundum atrial septal defect (ASD) has become an alternative to conventional open surgical repair. Cardiac perforation is a rare complication after transcatheter closure of ASD by an Amplatzer Septal Occluder (ASO). We present a patient with hemodynamic collapse secondary to cardiac perforation occurring 5 months after placement of the ASO and discuss the complications of this device. A 14-year-old girl underwent transcatheter closure of ASD by the ASO in our institution. Transesophageal echocardiography showed ASD sized 17.4×15.0mm, with no aortic rim. The placement of the ASO was performed without complications, but 5 months after the procedure she started to complain of chest pain and subsequent syncope. She was brought to a local emergency department. Transthoracic echocardiography showed an important cardiac effusion with signs of cardiac tamponade. Emergency pericardial drainage was performed under echocardiographic control from the subxiphoidal region. Once she was hemodynamically stabilized, the patient was transferred to our institution immediately for the necessary emergency surgical procedure. The operation was performed through a median sternotomy and the bleeding source was identified. The left-side of the ASO disc had cut through the roof of the left atrium between the superior vena cava and the aortic root, creating a 5-mm perforation. There was another perforation at the aortic root in the region of the non-coronary sinus of Valsalva, approximately 5 mm. The metallic rim of the ASO could be easily seen protruding through the roof of the left atrium. Cardiopulmonary bypass was established and cardiac arrest induced. After opening the right atrium we found the ASO, which was positioned well. The ASO was removed and the perforations of the aortic root and the left atrium were closed with 5-0 polypropylene directly. Then the ASD was closed using an autopericardial patch. The patient was weaned off bypass without difficulty. The postoperative course of the patient was uneventful and free of neurologic events. Finally, we conclude that patients with an aortic rim defect may be at higher risk for device perforation. Such a patient should be carefully followed up by echocardiography.

The role of transthoracal echocardiography in closing secundum atrial septal defects with Amplatzer Septal Occluder.

Transesophageal echocardiography (TEE) under general anesthesia has become a routine procedure as guidance in implanting Amplatzer septal occluder (ASO) for closing secundum atrial septal defects (ASDs) together with fluoroscopy in cardiac catheterization laboratory. To simplify the procedure and reduce the cost, recently we used transthoracal echocardiography (TTE) in guiding the ASO implantation. Aim of this study is to evaluate accuracy and performance of ASO procedure guided by TTE compared to ASO procedure guided by TEE. This is a comparative study. Ninety-one patients with ASDs referred for transcatheter closure with ASO in National Cardiovascular Center Harapan Kita Hospital Jakarta were reviewed. In the 22 patients, TTE were used as guidance instead of TEE. Patients selection were performed in the outpatient clinic by TEE. The stretched diameter was measured by TEE or TTE and fluoroscopy. Patients were divided into two groups, TEE group consisted of procedures guided by TEE, and TTE group guided by TTE. From 91 patients, 83 can be evaluated. It consisted of 61 patients in TEE group and 22 in TTE group. Measurement of defects sizes with TTE and TEE have a high correlation with fluoroscopic measurements (r=0.837 and r=0.853, respectively). There were no significant differences between the accuracy of TTE and TEE sizes measurement (p=0.085) compared to fluoroscopy. Fluoroscopy time in ASO procedures guided by TEE was significantly longer than those guided by TTE (33.2 ± 21.3 min vs. 22.8 ± 19.3 min, P=0.014). There was also no significant differences in the failure of devices implantation between TEE and TTE guidance. All patients were in good condition at follow-up. ASO procedures guided by TTE have similar accuracy to those guided by TEE, with shorter fluoroscopy time. TTE guidance also has no difference in failure rate compared to TEE guidance.

Complications related to transcatheter occlusion of atrial septal defect with Amplatzer septal occluder in children / 中国介入心脏病学杂志

Objective To probe into the causes,therapeutic and preventive methods of complications associated with transcatheter occlusion of atrial septal defect using the Amplatzer septal occluder in children. Methods Complications occurred in 9 of 211 cases. The complications in procedure of occlusion were those in which there appeared systemic circulatory systemic air embolism in 2,pulmonary air embolism in 1,pericardial tamponade in 1,ASO malposition requiring emergency surgical removal in 1,transient atrial extrasystoles in 1 and sizing balloon rupture in 1 case. Two cases with postoperative complications were found in the follow-up studies. These included perforation of mitral valve and ASO partially dislodged. In this study,5 children with intra-procedure complication received emergency therapy including surgical intervention,and others were needed only in the follow-up,as the complications were transient or asymptomatic. Results There were no children′s deaths in this study. The 5 cases that received treatment completely healed,and the others with intra-procedure complications were also had no sequela. Cases with mitral valve perforation and ASO partially dislodged were still in our follow-up studies,as the 2 patients had no symptoms. Conclusion Air embolisms occurred easily in atrial septal defect cases that received ASO therapy. Complications were mainly caused by inappropriate operative procedure and some complications needed emergency treatments. Follow-up studies were important to cases with transcatheter occlusion therapy.

Transcatheter Closure of Atrial Septal Defect Using Amplatzer Septal Occluder

BACKGROUND AND OBJECTIVES: Transcatheter occlusion (TCO) may be an alternative method for the surgical closure of a secundum atrial septal defect (ASD) below 20 mm in diameter. We performed this study in order to evaluate the safety and feasibility of an Amplatzer septal occluder for closing ASD bigger than 20 mm in diameter percutaneously. SUBJECTS AND METHODS: Thirty three of 39 patients presenting with ASD were included in this study (3 patients with a large defect over 32mm and 3 with multiple defects were excluded). The median age was 8.6 years (2.2 - 54) and median weight was 27 kg (10.7 - 85). The mean defect size was 15+/-3 mm as measured by transthoracic echocardiogram, 17+/-5 mm by transesophageal echocardiogram, and 21+/-6 (11 - 32) mm by balloon stretched diameter. The balloon stretched diameter was larger than 20 mm in 20 of 33 patients. The mean Qp/Qs was 2.3+/-0.7. The mean device size was 22+/-6 mm and the mean fluoroscopic time was 13+/-7 min. RESULTS: The device was successfully implanted in 29 of 33 patients. The 4 patients in which implantation failed showed a left disc protrusion into the right atrium. Three of these patients were treated surgically, and one underwent a successful second attempt of TCO 12 months after the first trial. Complete closure was obtained in 30 patients in follow-up. The complications encountered included;cobra-shaped deformity of the device (3), transient AV block (Wenckebach) (1), embolization of the radioopaque marker into the left atrial appendage (1), failure in the first device (1), and mild mitral regurgitation at 3 months follow-up due to device protrusion into the mitral valve (1). CONCLUSION: The Amplatzer septal occluder appears to be a promising device for TCO of ASD up to 32 mm in diameter, however, long-term follow-up in a large number of patients is warranted.