Device closure of diverse layout of multi-hole secundum atrial septal defect: different techniques and long-term follow-up.

BACKGROUND: There are no unanimous reports on different layouts and classifications of multi-hole secundum atrial septal defects (MHASD) and subsequent standardized occlusion techniques. The MHASD can be isolated or cribriform with variable inter-defects distance. In this retrospective study, experience-based classification and two approaches-based occlusion results are presented. METHODS: We retrospectively collected and analyzed data of 150 MHASD patients from 1320 patients who underwent atrial septal defect occlusion in our institute. The MHASD patients were categorized into 4 types; type A, B, C and D and occluded under exclusive transesophageal echocardiographic guidance. According to different types, 122 patients were occluded using peratrial approach and 28 patients via percutaneous approach. In type A, single device implantation is performed to occlude the large hole and squeeze the small one. For type B single or double-device deployment was performed depending on an inter-defects distance. In type C and D, a patent foramen-ovale (PF) device was selectively positioned to the central defect to occlude the central defect and cover the peripheral ones. In peratrial approach, 8 patients underwent inter-defects septal puncture technique to achieve single-device occlusion. The intracardiac manipulation time, procedural time, double device deployment, redeployment rate, residual shunt, and proportions were analyzed between (and within peratrial technique) two techniques. RESULTS: Successful occlusion was achieved in all 150 patients. Single device occlusion was applied in 78/84 type A and 22/37 type B patients (p < 0.05). Double device occlusion was more applicable to type B than A patients (p < 0.01). Sixteen of 21 type C and all type D patients used PF device for a satisfactory occlusion. Redeployment of the device occurred frequently in type B patients than A (p < 0.01). The intracardiac manipulation time and procedural time were shorter in type A than B (p < 0.05). The intracardiac manipulation time was also shortened in type A peratrial than type A percutaneous group (p < 0.05). Complete occlusion rate for all patients at discharge was 70% and rose to 82% at 1 year follow up. CONCLUSIONS: The diverse layouts and classification of MHASDs can help to choose different techniques and proper devices of different kinds to achieve better occlusion results.

Peratrial Device Closure of Different Locations of Mitral Paravalvular Leaks.

BACKGROUND: The current approaches of transcatheter closure of mitral paravalvular leak (MPVL) have different drawbacks. The challenges come from transseptal puncture, accessing the MPVL site, and the absence of dedicated delivery systems. This study introduces a novel peratrial approach for device closure of different locations of MPVLs using a probe-assisted delivery system under three-dimensional transesophageal echocardiography. METHODS: A 4.0-cm minithoracotomy incision was made in the fourth right interspaces. The right atrium and the interatrial septum were punctured and dilated, followed by a guidewire passing through the septum. A specially designed J-shaped bendable hollow probe was advanced into the left atrium. The steerable probe was adjusted to cross the MPVL and introduced a stiff guidewire into the left ventricle. A 7F short delivery sheath was advanced over the wire through the MPVL into the left ventricle. A proper-sized muscular septal occluder was then selected and deployed. RESULTS: Transesophageal echocardiography revealed complete occlusion in 7 of 8 patients after a follow-up of 6 months to 4 years. Mild residual paravalvular regurgitation occurred in an early patient. In 2 patients with a crescent-shaped MPVL, two guidewires were advanced into the left ventricle across the leak, and double devices were deployed sequentially. All patients' symptoms improved by at least one New York Heart Association functional class. CONCLUSIONS: The peratrial technique can access and close MPVLs at different locations through a right minithoracotomy approach. This technique has the advantages of easy transseptal puncture, easy access to the MPVL site, and no exposure to radiation.

Surgical repair of sinus of Valsalva aneurysm in Asian patients.

BACKGROUND: Sinus of Valsalva aneurysm is a rare cardiac anomaly, and the difference between Asian and Western countries in its occurrence is not well established. This study was designed to investigate the difference between Asian and Western patients. METHODS: Between September 1988 and February 2006, 83 patients with sinus of Valsalva aneurysm underwent surgical repair in our institute. The aneurysms originated from the right and noncoronary sinus in 74 and 9, respectively, and ruptured into the right ventricle in 52 patients, the right atrium in 30, and the left ventricle in 1. Ventricular septal defect (n = 38), aortic regurgitation (n = 21), and bicuspid aortic valve (n = 4) were the common coexisting anomalies. To compare the differences between Asian and Western patients in sinus of Valsalva aneurysm, 1049 cases (654 Asian patients versus 395 Western) were collected from the literature. RESULTS: Sixty-six patients were followed up for 9.6 +/- 3.8 years. The cardiac function of 15 patients with aortic regurgitation was worse than that of those with no aortic regurgitation (p < 0.05). There was no difference between the direct closure and the patch closure (p > 0.05). Analysis of all collected cases revealed that aneurysm of the sinus of Valsalva in Asian patients compared with Western series is characterized by a higher incidence, more aneurysms originating from the right coronary sinus (85.8% versus 67.9%), more aneurysm rupture into the right ventricle (72.5% versus 60%), a higher incidence of association with ventricular septal defect (52.4% versus 37.5%), and lower incidence of association with bicuspid aortic valve (0.6% versus 7.8%). However, both Asian and Western patient series have similar incidence of combination with aortic regurgitation (33.6% versus 32.7%). CONCLUSIONS: Long-term results of ruptured sinus of Valsalva aneurysm are associated with preoperative aortic regurgitation. The difference between Asian and Western patients with ruptured aneurysm of the sinus of Valsalva is significant.