Percutaneous device closure of the patent foramen ovale during pregnancy.

OBJECTIVE: To review the procedures, results and follow-up of patients who underwent percutaneous device closure of a patent foramen ovale (PFO) during pregnancy. We report modifications made to the established technique that allowed absolute minimization of radiation exposure. Relevant management issues of this unusual presentation of cardiac disease in pregnancy are discussed. BACKGROUND: Stroke during or immediately prior to pregnancy is a catastrophic event. Paradoxical embolism may be more frequent due to the hypercoagulable state and increased incidence of venous thromboembolism. Treatment strategies must take into account the competing risks to mother and fetus. METHODS: Three patients, aged 34, 27, and 39, presented with ischemic neurological events during or immediately preceding pregnancy. Due to evidence of recurrent events or relative contraindication to anticoagulation they proceeded to percutaneous device closure during the second trimester. The Helex device (WL Gore and Associates) was used in all patients. Procedures were performed with local anesthesia under intra-cardiac echocardiography guidance. RESULTS: Successful closure was achieved with the Helex device in all three patients. Radiation doses, as assessed by dose area product, were 260, 58, and 19 cGy/cm(2), with estimated uterine (fetal) dose of <0.005 mGy, <0.001 mGy, and <0.0005 mGy. There were no peri-procedural complications. Despite one patient subsequently developing pre-eclampsia and another major post-partum hemorrhage all pregnancies were successful and free of further neurologic events. CONCLUSIONS: Percutaneous device closure of the PFO is a feasible option for selected patients with cryptogenic stroke believed secondary to paradoxical embolism. The procedure can be performed safely and effectively under local anesthesia using intra-cardiac echocardiography and with trivial fetal radiation exposure.

Percutaneous closure of an atrial septal defect in a patient with congenitally corrected transposition.

Congenitally corrected transposition of the great arteries can be associated with other congenital cardiac abnormalities. The development of percutaneous closure devices potentially offers the opportunity to close related cardiac defects without exposing patients to the increased risks of cardiac surgery. This case report describes the successful closure of an atrial septal defect in a patient with congenitally corrected transposition of the great arteries using an Amplatzer septal occluder.

What is the role of balloon dilatation for severe aortic stenosis during pregnancy?

BACKGROUND AND AIM OF THE STUDY: Severe aortic stenosis in pregnancy creates several challenges for the physician. In recent years, balloon valvuloplasty has become more widely used, though the indications for its use in this setting are unclear. A review of the available evidence is presented, and a suggested management strategy illustrated. METHODS AND RESULTS: Available literature on the subject was reviewed via Medline search and reference lists from the identified articles. Particular attention was paid to prediction of risk, management options and outcome. The data suggest the importance of early symptoms in determining management, as there is a high risk of complications if left untreated. This group should be considered for valvuloplasty, whereas asymptomatic patients are at low risk, and can be managed expectantly. This is illustrated with two contrasting cases from the authors' practice: the symptomatic patient underwent aortic balloon valvuloplasty as a palliative procedure, using transesophageal and minimal fluoroscopic guidance, with good medium-term results. Both patients required aortic valve replacement in the medium to long-term. CONCLUSION: The use of aortic balloon valvuloplasty in pregnancy is useful as a palliative procedure, allowing deferral of valve replacement until after birth. Echocardiographic features alone are not enough to decide on management, and symptoms play a vital role in determining risk. The use of transesophageal echocardiography during the procedure significantly reduces fluoroscopy time.

Echocardiographic assessment and percutaneous closure of multiple atrial septal defects.

Atrial septal defect closure is now routinely performed using a percutaneous approach under echocardiographic guidance. Centrally located, secundum defects are ideal for device closure but there is considerable morphological variation in size and location of the defects. A small proportion of atrial septal defects may have multiple fenestrations and these are often considered unsuitable for device closure. We report three cases of multiple atrial septal defects successfully closed with two Amplatzer septal occluders.