Transcatheter closure of residual atrial septal defect following implantation of buttoned device

We report a case in which residual shunting after a buttoned device occlusion of atrial septal defect (ASD) was eliminated by transcatheter retrieval of a portion of the device, followed by implantation of a second device. This method may be helpful for those patients with residual ASDs who decline surgical device retrieval and defect closure.     

Transcatheter closure of atrial septal defect

Isolated secundum atrial septal defect is one of the most common congenital heart defects. Surgical closure is the treatment of choice but is associated with a chest scar, some morbidity and a relatively long recovery and the use of cardiopulmonary bypass. Transcatheter closure of secundum atrial septal defect is therefore an attractive approach. 3 children, aged 5-10 years, underwent successful transcatheter closure of moderate to large central atrial septal defects with the Cardioseal device. The procedures were performed under x-ray and transesophageal echocardiographic guidance. Our initial experience, and that of others, indicates that transcatheter occlusion of secundum atrial septal defects is safe and effective and can be an appropriate alternative in approximately 60% of patients.     

Transvasal closure of interatrial defects using the Babic double-umbrella occluder system

The purpose of the study was to assess the feasibility and safety of closure of atrial septal defects and patent foramen ovale by means of a new interventional technique. Transvasal closure of ostium secundum atrial septal defect and patent foramen ovale was performed in 18 patients using an occluder system for atrial septal defects. Two patients had undergone unsuccessful direct surgical closure years before. Implantation and follow-up were controlled using radiographic views both with and without contrast injection, transthoracic and multiplane transesophageal echocardiographic imaging, color Doppler sonography, and computed tomography. The defect was closed in 16 patients using 19 procedures. Removal of the devices through the sheath was indicated in 4 patients because of placement failure. Intraprocedural complications were ventricular fibrillation in one patient and fixation of the device in Chiari's network in an additional one. During 7-26 months follow-up occluder damage was seen in two patients and perforation of the left atrium in one patient. Thickening on the occluder surface was observed in two patients. There was no death. The system for closure of atrial septal defect is feasible and safe in patients with defects < or = 27 mm in diameter. Long-term observation of outcome is limited yet.     

Identification of a human heart FABP pseudogene located on chromosome 13

Between June 1992 and January 1996, 27 patients aged 3.9 to 74 years with an ostium secundum (22 patients) or patent foramen ovale with right-to-left shunts (5 patients) underwent percutaneous closure of their atrial septal defects with the Sideris occluder. After a thromboembolic complication, transesophageal echocardiography was performed routinely after the procedure in 15 patients between 1 month and 2 years, and in 6 patients on the 15th day. Two patients died, on the 2nd day and 21st month, of non-related causes. After an average follow-up of 33 months, 59% of patients had complete occlusion of the atrial septal defects or only a minimal residual shunt. Displacement of the prosthesis was defects or only a minimal residual shunt. Displacement of the prosthesis was observed in 7 cases with no relationship to size: 4 parallel to the septum with reappearance or increase in shunt, 3 with tilting of the prosthesis. All of these patients had a large residual defect compared with 20% with a normally positioned prosthesis (p < 0.05). Tilting of the occluder was associated with left atrial thrombosis (present in 40% of these patients), complicated by systemic embolism in one case: there were no cases of left atrial thrombus in the 9 with complete occlusion and the 5 patients with an isolated residual defect (p < 0.05). Occlusion of atrial septal defect with the Sideris device is effective and a safe method in the majority of cases. However, a badly positioned prosthesis with a residual shunt should be extracted as seen as possible or within three weeks if displacement is observed at control echocardiography.     

Closure of atrial septal defects with the Amplatzer occlusion device: preliminary results

OBJECTIVES: This study reports our clinical experience with transcatheter closure of secundum atrial septal defects (ASDs) in children, using the Amplatzer, a new occlusion device. BACKGROUND: None of the devices previously used for transcatheter closure of interatrial communications has gained wide acceptance. METHODS: We examined the efficacy and safety of the Amplatzer, a new self-centering septal occluder that consists of two round disks made of Nitinol wire mesh and linked together by a short connecting waist. Sixteen patients with secundum ASD met established two- and three-dimensional echocardiographic and cardiac catheterization criteria for transcatheter closure. The Amplatzer's size was chosen to be equal to or 1 mm less than the stretched diameter. The device was advanced transvenously into a 7F long guiding sheath and deployed under fluoroscopic and ultrasound guidance. Once its position was optimal, it was released. RESULTS: The mean ASD diameter by transesophageal echocardiography was 14.1+/-2.3 mm and was significantly smaller (p < 0.001) than the stretched diameter of the ASD (16.8+/-2.4 mm). The mean device diameter was 16.6+/-2.3 mm. No complications were observed. After deployment of the prosthesis, there was no residual shunt in 13 (81.3%) of 16 patients. In three patients there was trivial residual shunt immediately after the procedure that had disappeared in two of them at the 3-month follow-up. CONCLUSIONS: The Amplatzer is an efficient prosthesis that can be safely applied in children with secundum ASD. However, a study including a large number of patients and a longer follow-up period are required before this technique can be widely used.     

Transcatheter closure of a residual postmyocardial infarction ventricular septal defect with the Amplatzer septal occluder

Acute ventricular septal rupture following myocardial infarction carries a high mortality. Early surgery improves survival but long term outcome depends on residual shunting and left ventricular function. Residual shunting is common despite apparently successful closure and may require reoperation. Transcatheter closure is an established method of treating selected congenital defects but clinical experience of transcatheter closure in postinfarction ventricular septal rupture is minimal. Transcatheter closure of a residual ventricular septal defect was successfully done using a new device, the Amplatzer septal occluder, in a 50 year old Indian man who had previously undergone emergency surgical repair for postinfarction acute ventricular septal rupture. The technique is described and its potential as a treatment in postinfarction ventricular septal rupture, its possible complications, and the important aspects of case selection and device design are discussed.     

IGF system components as prognostic markers in breast cancer

Device closure of oval fossa atrial septal defects with the Amplatzer Septal Occluder was performed in 26 patients ranging in age from 0.89 to 60.44 years. In eight additional patients no device implant was performed because of the presence of multiple defects or because the defect was of a size unsuitable for closure with the devices currently available. The stretched diameter of the defects that were closed ranged from 4 to 23 mm (mean 14+/-5.4 mm) and device sizes ranged from 4 to 24 mm. Two devices were unstable, of which one embolized to the right atrium after release. Both devices were retrieved at the same procedure. One of these patients subsequently underwent a successful device closure of his defect using a larger (24-mm) device. Three patients had multiple defects, which were successfully closed with a single device. At 1-month follow-up 23/26 (88%) and at 3-month follow-up 22/24 (92%) patients had complete closure of their defects, while two had residual shunts. One further patient who had complete closure of his defect at 1-month post-implant had his device removed and his atrial septal defect patched surgically 8 weeks after device closure. This was done as a result of the development of a vegetation affecting the device after an episode of septicaemia, which was not related to the cardiac problems. There was no procedure-related morbidity or mortality and all patients remain well at the present time.     

Transcatheter closure of atrial septal defects within the oval fossa: medium-term results in children using the 'ASDOS'-technique

OBJECTIVES: The purpose of this study was to evaluate the safety and efficacy of the ASDOS-technique (Sulzer-Osypka GmbH, Germany) for transcatheter closure of atrial septal defects within the oval fossa. BACKGROUND: Although several attempts have been made to occlude defects within the oval fossa by transcatheter techniques, none of these has gained general acceptance. METHODS: Patients with a defect in the oval fossa measuring equal to or less than 20 mm diameter, with a residual septal rim of 5 mm or greater, body weight greater than 10 kg, with clinical indications for surgical closure were considered for transcatheter closure. Follow-up investigations were performed at discharge, after 1, 3, 6 and 9 months, as well as after 1 and 2 years. RESULTS: Of 78 patients considered for closure, a device was inserted in 41 patients (53%), with success being achieved in 40 patients (98%). The ages ranged from 1.1 to 15 years (7.8 +/- 1.92 years), the 'stretched' diameter of the defect from 10 to 20 mm (14.7 +/- 2.60 mm), and the diameters of the inserted devices from 25 to 45 mm (33.2 +/- 5.43 mm). Transient impairment of atrioventricular conduction occured in 4 patients. During the follow-up of 23.0 +/- 5.6 months elective surgical closure of a residual shunt was performed 26 months after insertion of the device in one patient. None of the other patients required surgery, hospitalisation or medical treatment, and none is requiring further treatment of the defect within the oval fossa. Fracture of one arm of the device occurred in 4 patients, but the fractured arms are in an unchanged and stable position after a period of at least 19 months. CONCLUSIONS: Our medium-term data show that transcatheter closure in children of defects within the oval fossa can be performed with a high efficacy and safety using the ASDOS-device.     

Cardiopulmonary physiology after surgical closure of asymptomatic secundum atrial septal defects in childhood. Exercise performance is unaffected by age at repair

AIMS: Most secundum atrial septal defects, once diagnosed, are corrected at a young age. The evidence to justify early vs delayed or even non-closure is equivocal and little is known regarding long-term effects of later closure. This is particularly pertinent to those patients awaiting transcatheter closure of their defect for whom a device is only just becoming available. We examined the exercise cardiorespiratory physiology of children surgically treated for an isolated secundum defect. METHODS AND RESULTS: One hundred and six healthy control children and 22 children more than 6 months after surgical repair for an isolated secundum atrial septal defect were studied. All were asymptomatic. Measurements of effective pulmonary blood flow, stroke volume, arteriovenous oxygen difference, minute ventilation, heart rate, oxygen consumption and carbon dioxide production were made using a quadrupole mass spectrometer during rest and graded exercise. Data from the normal children allowed calculation of z scores for the atrial septal defect group matched for age, sex, pubertal stage and surface area. Maximal exercise performance was equal between control and atrial septal defect groups, however, the atrial septal defect group had a significantly greater effective pulmonary blood flow and stroke volume but a lower heart rate than controls at a given exercise stage. Stroke volume abnormalities were most closely related to duration of follow-up (29% of the variance explained, P < 0.01) rather than age at surgery. CONCLUSIONS: We were unable to show a medium term benefit from early surgery for an asymptomatic secundum atrial septal defect during exercise. The clinical relevance of the haemodynamic differences that do exist remains unclear.     

Multicentric Castleman''s disease in HIV infection: a clinical and pathological study of 20 patients

Techniques of transcatheter device placement for treatment of pediatric congenital heart disease have developed substantially since their introduction 20 years ago. Patent ductus arteriosus occlusion can be accomplished by umbrella deployment or coil placement. Intracardiac defects can be closed with umbrella or buttoned devices. Stenoses of vessels or conduits that are only temporarily relieved with balloon dilation can be effectively expanded with intravascular stents. Recent procedural modifications have been introduced in an attempt to minimize the size of the delivery sheath and reduce complications that can arise from device embolization. Transcatheter device placement can be an important adjunct to surgery for correction or palliation of congenital heart lesions.     

Per-catheter ASD closure

Per-catheter devices for atrial septal defect (ASD) closure have been evolving since 1974. The four major devices available for use on a limited basis in early 1997 are reviewed. These include (in alphabetical order) the Angel Wing device, the ASDOS device, the Buttoned device, and the CardioSeal device (successor to the Clamshell). Sufficient data have been collected to indicate that transcatheter ASD closure is a viable alternative to surgery in selected patients. The advantages of the concept of per-catheter closure over surgical closure should lead to the continued development of devices and techniques for per-catheter treatment of ASD and other septal defects in the years to come.     

Residual shunts after application of the Rushkind occlusion system in closure of persistent ductus arteriosus. Insertion of a second device

From May 1991 to August 1994, we performed transcatheter closure of patent ductus arteriosus with Rashkind umbrella system in 25 patients. In one, the device had embolism, to the right pulmonary artery and was operated 24 hs afterwards without complications. Seven had residual shunts, two had subsequent surgery, two are being followed (one for mild and one for moderate residual shunt). In the other three cases we inserted a second device. We used a 12 mm device in two cases and a 17 mm device in the other. Two cases had total occlusion 24 hrs after and in one had mild residual shunt without clinical repercussion. There were no complications. All had electrocardiographic and clinical improvement, take no medication, and their cardiomegaly had decreased (Cardiac index pre 61 vs post 54%). In conclusion the insertion of a second device is safe and effective alternative for residual shunt after first Rashkind occluder.     

Secundum atrial septal defect. Nonoperative closure during cardiac catheterization

A 17-year-old girl had clinical and cardiac catheterization findings compatible with a secundum atrial septal defect. During cardiac catheterization, the atrial septal defect was sized and closed using a transvenous umbrella technique.     

Expression of hepatocyte low-density lipoprotein receptor-related protein is post-transcriptionally regulated by extracellular matrix

A clinical trial was conducted to assess the feasibility, safety, and efficacy of the atrial septal defect (ASD) occlusion system for transcatheter closure of secundum ASD and patent foramen ovale (PFO) after episodes of cerebral embolism. Occlusion was attempted in 200 patients aged 1 to 74 years (mean 32). The procedure failed in 26 patients (13%); the device was retrieved through a catheter in 20 and through surgery in 6 patients. Procedure-related complications necessitating surgical removal of the device included device embolization in 2, device entrapment within the Chiari network in 1, frame fracture in 1, and perforation of atrial wall in 2. All 6 patients experienced an uneventful postoperative course. An additional 11 patients (6%) underwent surgical removal of the device during follow-up. There were 163 patients (81%) with an implanted ASD occlusion system at follow-up of from 6 to 36 months (mean 17). Thrombus formation around the device was detected by transesophageal echocardiography in 9 patients 1 to 4 weeks after implantation. One of these patients (who had a coagulation factor XII deficiency) suffered a cerebral thromboembolism. Late atrial wall perforation (5, 6, and 8 months after implantation) occurred in 3 adult patients. Infectious endocarditis developed in 2 adult patients (1%). No late device embolization and no atrioventricular valve injury occurred. An asymptomatic device frame fracture was found in 14% and frame deformity in 4% of all patients during the follow-up period of >230 patient-years. Immediately after closure, a moderate/large residual shunt remained in 8% and a small shunt in 29% of patients. After 1 year, a moderate/large shunt was present in 2% and a small one in 26% of patients. During a total follow-up of 49 patient-years, only 1 of 46 patients with PFO had a transient neurologic event after the closure. The study indicates that patients with centrally situated secundum ASD and those with PFO after cerebral embolism can be treated with this system with a high success rate and an acceptable morbidity.     

French experience in the closure of atrial septal defects of the ostium secundum type with the Sideris button occluder

From February 1992 to November 1995, four French teams used the Sideris button occluder to close 122 ostium secundum, foramen ovale or surgical fenestration atrial septal defects in 121 patients aged 2 to 79 years with body weights of 10 to 96 kg. a left-to-right shunt in 110 cases (average QP/QS = 2.09) or right-to-left shunt in 12 cases. The usual type of prosthesis was used in 115 cases, 8 centered on a guide wire, reverse type in 5 cases and the "centering-device" type in 2 patients. Nineteen implantation attempts were abandoned before releasing the prosthesis. The immediate results were: closure of the atrial septal defect in 116 patients: 59 were completely occluded, 43 had minimal residual shunts. Five patients were operated for non-buttoning or malposition of the prosthesis. In one other case, the device was removed by catheterisation. During follow-up ranging from 1 month to 3 years, 20 patients were operated for varying complications, the commonest of which was malposition of the prosthesis (17 cases) with a shunt of variable volume. In one other case, a second device was inserted. Seventy-seven patients were reviewed at 1 year, 28 a 2 years and 6 at 3 years. The residual shunts decreased with time but only completely disappeared in half the cases. Secondary fractures not requiring surgery were observed in 5 patients. Failures and complications were the result of various causes which are discussed. Successive technological improvements and the experience of the medical teams should reduce this incidence, but caution is required especially in the treatment of young children.     

Postpneumonectomy interatrial right-to-left shunt: successful percutaneous treatment

This report describes the case of a 67-year-old man in whom atrial right-to-left shunt developed after a right pneumonectomy, leading to dyspnea with severe arterial desaturation. Transcatheter occlusion of the patent foramen ovale was successfully performed using a buttoned device. Review of literature and mechanisms of these atrial right-to-left shunts are discussed.     

Unroofed coronary sinus syndrome

Unroofed coronary sinus syndrome or coronary sinus septal defect is a rare congenital cardiac anomaly. We performed corrective operations in 9 patients with such condition. Of them, seven patients had the completely unroofed coronary sinus and persistent left superior vena cava (PLSVC) directly draining into the left atrium (LA). One patient had PLSVC and the partially unroofed terminal portion of the coronary sinus (CS), or sinus ostium open into LA. Another patient had total anomalous pulmonary vein connection and the partially unroofed mid-portion of CS without PLSVC. The operative methods of the unroofed coronary sinus included: ligating PLSVC and repairing ostium primum or secundum atrial septal defects in 4 cases; creating an intra-atrial tunnel from PLSVC to the right atrium (RA) and repairing the atrial septal defect in 2 cases; reconstructing the intra-atrial septal with a patch as a baffle to guide PLSVC or sinus ostium respectively towards RA in 2 cases; enlarging the defect on the coronary sinus roof and repairing the atrial septal defect of the coronary sinus type in one case. No patient died in this group. Because unroofed coronary sinus syndrome has atypical clinical manifestation and usually complicates varied congenital anomalies, its preoperative diagnosis is very difficult in some times and may draw the reliable support from echocardiography and catheterization. The operative program and method must depend not only upon its type but also upon PLSVC presence of absence, and communication between PLSVC and RSVC.     

Catheter treatment of congenital heart defects. Arterial septal defects and open ductus arteriosus

The results of new methods for catheter treatment of congenital heart defects are presented. Between 1989 and 1996 closure of a patent ductus arteriosus was performed in 66 instances on 63 patients, eight of which were with coils. Three patients were treated twice, one with an additional umbrella, two with coils. The overall complete closure rate for umbrellas was 75%, after two ducts, which were initially totally occluded, recanalized. In six more patients the procedure was either aborted or indication was not present. All six ducts treated with coils as the first procedure were completely closed. One of two patients who had residual leak after previous umbrella treatment achieved complete closure after subsequent coil implantation. Closure of atrial septal defects in the oval fossa was performed using the Amplatzer septal occluder in seven children. Complete closure was achieved in all of them. There have been no complications, in particular there have been no cases of embolization in any of the groups. The results seem to indicate that coil occlusion of a persistently patent duct may be at least as good as the umbrella in terms of complete closure. So far both methods have been safe, but experience with coils is limited. The closure of atrial septal defects shows encouraging results. We will continue to offer this treatment as an alternative to open heart surgery in carefully selected patients.     

Transvenous closure of secundum atrial septal defects: preliminary results with a new self-expanding nitinol prosthesis in a swine model

BACKGROUND: Our purpose was to evaluate a new prosthesis for percutaneous closure of secundum atrial septal defects (ASDs). METHODS AND RESULTS: Percutaneous closure of surgically created fossa ovalis ASD was attempted in 15 minipigs. The mean balloon-stretched ASD diameter was 12.3+/-2.3 mm (range, 10 to 16 mm). The self-expanding prosthesis was braided from 0.005-in Nitinol wires in the shape of two flat buttons with a short connecting waist with a diameter corresponding to that of the defect to be closed. Polyester filling was added to enhance thrombogenicity. Pulmonary arteriography with levo-phase was obtained before placement; immediately after placement; and at 1-week, 1-month, and 3-month follow-ups. Four animals were killed at 1 week, 1 month, and 3 months for histopathological correlation. Three deaths resulted from ventricular fibrillation (one during anesthesia and two during the placement procedure). Successful placement of the prosthesis was achieved in the remaining 12 animals. Overall immediate ASD closure on angiography occurred in 7 of 12 animals (all polyester-filled prostheses). Absent or trace shunt by angiography was present in 11 of 12 devices at 1 week, with the remaining one demonstrating a small shunt. All septal defects were completely closed at 1 month with the exception of one case in which delayed partial dislodgment of an undersized prosthesis into the right atrium had developed. Closure rate at 3 months was 100%. Neoendothelialization and fibrous incorporation of the prosthesis were completed within 1 to 3 months. CONCLUSIONS: Effective and permanent occlusion of secundum ASDs is feasible with a device that offers the advantages of easy placement, self-centering, and repositionability.     

Unidirectional valve patch for repair of cardiac septal defects with pulmonary hypertension

BACKGROUND: Congenital septal defects with a large left-to-right shunt often cause pulmonary hypertension, which complicates surgical repair of the defects. METHODS: Twenty-four patients with congenital cardiac septal defects and severe pulmonary hypertension had operation to close the septal defect using a unidirectional valve patch during a 3-year period. The ratio of systolic pulmonary artery pressure to systolic arterial blood pressure was near to or more than 1.0 in all patients. RESULTS: Two patients died in the hospital after operation, and there have been no deaths during intermediate term follow-up. Mean pulmonary artery pressure decreased from 80 +/- 12 mm Hg to 56 +/- 18 mm Hg. The ratio of pulmonary artery pressure to systemic arterial pressure dropped from 1.1 +/- 0.1 mm Hg to 0.7 +/- 0.1 mm Hg. The unidirectional valve patch functioned allowing right to left shunting in 4 patients with a systolic pulmonary artery pressure more than systolic arterial blood pressure immediately after closure of a septal defect. The patch sealed or was effectively closed by the third postoperative day. There was impressive improvement in symptoms and exercise tolerance after operation during the 3-month to 3-year (mean, 1.1 year) follow-up period. CONCLUSIONS: The unidirectional valve patch is useful for management of patients having operation to close cardiac septal defects in the presence of severe pulmonary hypertension.