Transcatheter closure of atrial septal defects with multiple devices in adults: procedural and clinical outcomes.

OBJECTIVE: This study reports the procedural, short and medium term outcomes in patients receiving multiple implants for device closure of secundum atrial septal defects (ASD). DESIGN AND SETTING: From the database of the Toronto Congenital Cardiac Centre, 36 consecutive patients (mean age 46+/-15 years; 23 females) received >1 implant for closure of an interatrial communication. Short term (mean 97+/-77 days) and medium term (mean 2.5+/-1.4 years) follow-up data were analyzed. Procedures were performed under intracardiac echo (ICE) and fluoroscopic guidance. RESULTS: The Amplatzer Septal Occluder (ASO) was implanted in all except one. Thirty-one patients had 2, and 4 patients, 3 ASO devices. There were no major adverse events at implantation or on follow-up. Patients with >NYHA class I symptoms fell from 44% to 6% (p<0.05) at 3 months. Right ventricular (RV) systolic pressure fell from 39+/-7 to 32+/-4 mm Hg in the short term (p<0.05), and to 30+/-4 mm Hg in the medium term (p<0.05, compared to baseline) and RV diameters fell from 48+/-5 to 40+/-5 (p<0.05) in the short term and to 38+/-8 mm (p=ns) in the medium term. Small residual leaks were present in 22% at 3 months and 12% (p<0.05) at 1 year. CONCLUSION: Multiple ASD device implants can be safely employed with excellent outcomes. Significant reductions in RV pressure and diameter occur in the short term with a continued trend to benefit.

Predictors of atrial arrhythmias after device closure of secundum type atrial septal defects in adults.

Atrial tachyarrhythmias (ATs) contribute substantially to morbidity in adult patients with secundum atrial septal defects (ASDs). The purpose of this study was to prospectively determine the incidence of AT in adults with an ASD and identify predictors of AT occurrence after closure. This was a prospective study of 200 adult patients undergoing closure of a secundum ASD. Arrhythmic events were defined as sustained or symptomatic AT requiring treatment. Twenty percent of patients (mean age 50 +/- 17 years; 26% men) referred for ASD closure had a history of AT. Early follow-up was available for 90% of patients, and the prevalence of AT was 17%. Of 171 patients with late follow-up (mean 1.9 +/- 0.9 years), data were available for 90%. AT was detected in 16% of these patients. Closure resulted in alleviation of symptoms (p <0.001), but symptoms alone did not identify patients at risk of recurrent AT. After closure of the ASD, the likelihood of remaining arrhythmia free was highest in patients without a history of AT (p = 0.001) and those <40 years at closure (p = 0.04). In conclusion, transcatheter ASD closure in patients without a history of arrhythmias and those <40 years of age conferred the highest likelihood of a patient remaining arrhythmia free in follow-up. An arrhythmia-specific treatment strategy should be considered for patients with documented established AT before ASD closure, in addition to shunt relief.

The adult with repaired coarctation of the aorta.

Coarctation of the aorta is a common congenital lesion that may often be repaired or intervened upon early in life. The management of patients with this disorder revolves around the concept that although the coarctation may be treated, what remains is a diffuse systemic cardiovascular disorder. Careful clinical care and investigation is required to reduce morbidity from recurrent disease and residual lesions. The natural and modified history of the disorder is reviewed. This article focuses on the clinical care of adults with repaired coarctation and includes a review of clinical goals and investigation as well as indications for reintervention.

Transcatheter closure of aortic sinus to left atrial fistula caused by erosion of Amplatzer septal occluder.

One year after Amplatzer device closure of an atrial septal defect, an aortic to left atrial fistula was diagnosed in a patient who developed a new onset murmur with no other symptoms. The fistula was closed with a 4-mm Amplatzer Septal Occluder during a transcatheter procedure, avoiding the need for cardiac surgical repair.

Atrial septal defect closure in a patient with "irreversible" pulmonary hypertensive arteriopathy.

The presence of irreversible pulmonary hypertension in patients with atrial septal defect (ASD) is thought to preclude shunt closure. We report the case of a woman with plexiform pulmonary arteriopathy secondary to an ostium secundum ASD who was able to successfully undergo percutaneous shunt closure following therapy with chronic intravenous prostacyclin (Flolan). One year after closure, the patient was weaned off Flolan over a period of 7 months following the institution of oral Bosentan therapy. Our case illustrates how aggressive vasodilator therapy with prostaglandins may be capable of reducing pulmonary artery pressure and permitting shunt closure in a patient once considered to have "inoperable" pulmonary arteriopathy.

N-acetylcysteine reduces contrast-associated nephropathy but not clinical events during long-term follow-up.

BACKGROUND: Contrast-associated nephropathy (CAN) is associated with increased morbidity and mortality following percutaneous coronary intervention (PCI). N-acetylcysteine (NAC) has been shown to reduce the risk of nephropathy; however, the impact of NAC on long-term clinical outcomes has not been assessed. METHODS: This randomized, double-blind, placebo-controlled trial enrolled 180 patients with moderate renal dysfunction undergoing PCI or coronary angiography with a high likelihood of ad hoc PCI; 171 patients completed the clinical follow-up. Patients received oral NAC (2000 mg/dose, n = 95) or placebo (n = 85) twice a day for 3 doses if randomized the night prior to the procedure, and 2 doses if randomized the day of the procedure. The primary end point was the incidence of a > or =25% increase in serum creatinine level 48 to 72 hours after PCI. Secondary end points were the inhospital incidence of death, nonfatal myocardial infarction, or urgent dialysis, and the 9-month incidence of death, nonfatal myocardial infarction, need for dialysis, or repeat hospitalization for cardiac reasons. RESULTS: CAN occurred in 9.6% of patients assigned to NAC and 22.2% of patients assigned to placebo (P =.04); 1 patient receiving NAC required urgent dialysis. The inhospital composite end point occurred in 7 (7.4%) NAC-treated and 3 (3.5%) placebo-treated patients, P = NS. At 9 months, the composite end point occurred in 23 (24.2%) NAC-treated patients and 18 (21.2%) placebo-treated, P = NS. CONCLUSION: Although high-dose NAC prevented periprocedural CAN, this benefit did not translate into a decrease in adverse outcomes over 9 months. Further studies to determine the clinical utility of this drug are required.

Clinical outcomes of patent foramen ovale closure for paradoxical emboli without echocardiographic guidance.

The objective of this study was to determine the feasibility of device closure of patent foramen ovale (PFO) for presumed paradoxical emboli without echocardiographic guidance or balloon sizing and the clinical outcome after device closure. Closure of the PFO has been proposed as an alternative to anticoagulation in patients with presumed paradoxical emboli. At present, most centers perform device closure with transesophageal echocardiographic guidance and balloon sizing of the defect. Between May 1998 and April 2002, 92 consecutive patients underwent device closure for a PFO using fluoroscopic monitoring only. Procedural success and major complications were recorded. Follow-up outcomes were recurrence rate and residual atrial shunting on transthoracic echocardiography. All patients (mean age, 45 +/- 13 years; 52% male) had successful device deployment using either the CardioSeal (n = 78) and Amplatzer (n = 14) PFO occluders with no major complications. Mean procedure time and fluoroscopy time was 27 +/- 13 and 6 +/- 4 min, respectively. One patient had a residual shunt on echocardiography at 1 year. Cumulative event-free survival for recurrence of paradoxical embolus at 1 year was 97.3% +/- 1.8%. This study provides a basis for device closure of PFO becoming a safe, day-case procedure, resulting in a low rate of residual shunting and recurrent thromboembolic events.

Outcomes and alternative techniques for device closure of the large secundum atrial septal defect.

Outcomes of device closure of large and small secundum atrial septal defects (ASDs) as related to rim anatomy with the Amplatzer atrial septal occluder were compared. Rim adequacy (> or = 5mm) of the anterior, inferior, posterior, and superior rims was determined using transesophageal echocardiography. Balloon-stretched defect size defined patients into two groups: group 1, < or = 25 mm (n = 138); group 2, > 25 mm (n = 34). Rim deficiency (n = 62) was more frequent in group 2 compared to group 1 (50% vs. 33%; P = 0.07), especially inferior rim deficiency (35% vs. 2%; P = 0.005). Device deployment was successful in group 1 and group 2 (100% vs. 91%; P = 0.007). Unsuccessful deployment was associated with an ASD of > 25 mm (P = 0.007) and inferior rim deficiency (P = 0.001). At first follow-up (54 +/- 16 days), right ventricular systolic pressure had improved in both groups (P < 0.001). Closure of a large ASD associated with a lack of support in the inferior rim may warrant alternative strategies to position the device successfully.

Aortic dissection after stent dilatation for coarctation of the aorta: a case report and literature review.

A case of stenting for native coarctation is described in a 65-year-old female with a fatal dissection after implantation. The histology of the aorta in coarctation and in the elderly is described. The experience of stenting in older patients is reviewed and discussed.

Intracardiac echocardiography guided device closure of atrial septal defects.

OBJECTIVES: This study was designed to determine the feasibility and accuracy of intracardiac echocardiography (ICE) in guiding percutaneous closure of atrial septal defects (ASD). BACKGROUND: Intracardiac echocardiography is a novel imaging technique that might be used to guide interventional procedures. The sensitivity and specificity of ICE, compared to standard imaging techniques, in detecting potentially adverse procedural events and guiding remedial action will be an important consideration in its use. METHODS: In a prospective study, 24 patients underwent device closure of ASD using ICE as the primary echocardiographic imaging modality. Feasibility was expressed as proportion of cases in which complete diagnostic ICE imaging was achieved. Accuracy was expressed as the percent agreement between ICE and simultaneously performed transesophageal echocardiography (TEE). RESULTS: High-quality ICE images were acquired in all patients, though images were limited in two patients with aneurysmal septa. Intracardiac echocardiography successfully guided closure of 24 out of 25 ASDs (96%) in 23 patients. There was close agreement between ICE and TEE in their assessment of device position and the adequacy of septal capture before device release (98%) and in identifying the presence of significant residual shunts. Intracardiac echocardiography detected all potentially adverse events, including four malpositions, and guided appropriate remedial action. CONCLUSIONS: Intracardiac echocardiography guided device closure of secundum ASDs is feasible in the majority of patients and provides diagnostic data comparable to TEE. These data indicate that ICE may be used to guide routine closure of ASDs in adults without the need for TEE and general anesthesia.

Catheter interventions in adult patients with congenital heart disease.

Adult patients with congenital heart disease provide a wide variety of challenges for the interventional cardiologist. Procedures can broadly be divided into dilatation or closure. The most common interventions in our own practice are closure of atrial septal defects and patent foramen ovale, although closure of postoperative interatrial communications in Mustard, Senning, or Fontan patients is also possible. Transcatheter patent ductus arteriosus closure is also now routine, and occlusion of coronary artery fistulae can be safely attempted using coil embolisation. Balloon dilatation of pulmonary valve stenosis has excellent success rates, and dilatation or stenting of pulmonary artery stenoses is also beneficial in selected cases. Although aortic valve dilatation in adults has mixed results, dilatation or stenting of aortic coarctation is now becoming more widespread, and has promising results. Dilatation procedures may also be applicable to the postoperative patient with conduit or baffle stenosis.