Experience with transcatheter closure of secundum atrial septal defects using the Amplatzer septal occluder: a single centre study in 236 consecutive patients

Transcatheter closure of complex atrial septal defects: feasibility and mid-term results

OBJECTIVE

Transcatheter closure of atrial septal defects (ASDs) is currently a reliable alternative to surgery, even though challenging in the case of complex septal anatomy. The aim of this study was to evaluate the feasibility and mid-term results of percutaneous closure of complex ASDs in a tertiary referral centre compared with simple ASD closure.

METHODS

Between April 2000 and November 2004, 209 patients were submitted to transcatheter ASD closure; 83 patients (39.7%) presented with a complex defect (large ASDs with a deficient rim or a multifenestrated/aneurysmal septum) and were treated using different devices tailored to the atrial septal anatomy.

RESULTS

The transcatheter procedure was successful in 72 patients (86.8%), using a single device in 69 patients and two devices in the remaining three patients. Overall, 71 Amplatzer septal occluders, two multifenestrated Amplatzer septal occluders and two Cardioseal/Starflex devices were used. Procedural and fluoroscopy times were 141 +/- 45 min and 28 +/- 22 min, respectively (P < 0.0001 vs. simple ASD closure for both comparisons). Procedure-related complications were recorded in nine patients (12.5%) (P < 0.01 vs. simple ASD closure). One patient required surgical repair of a femoral arteriovenous fistula and another developed mitral valve dysfunction. Immediate ASD occlusion was recorded in 59.7% of patients, reaching 95.9% at the last follow-up control (P = NS vs. simple ASD closure for both comparisons).

CONCLUSIONS

Percutaneous closure of complex ASDs may be considered technically feasible, relatively safe and highly effective, although the procedure is still significantly more demanding than transcatheter closure of simple ASDs.

Surgical Versus Percutaneous Occlusion of Ostium Secundum Atrial Septal Defects

OBJECTIVES

We compared the effectiveness and cost of percutaneous occlusion using an Amplatzer septal occluder (ASO) (AGA Medical Corp., Golden Valley, Minnesota) device compared with surgical closure of an ostium secundum atrial septal defect (ASD II) in Guatemala.

BACKGROUND

The percutaneous occlusion of ASD II in first-world nations seems to offer better clinical results and lower cost compared with surgical closure.

METHODS

We reviewed the clinical course of 111 patients referred to our institution for closure of isolated ASD II. Successful closure was assessed immediately after the procedures and at 12 months. Actual hospital costs were calculated for every patient who underwent either of the two procedures.

RESULTS

Eighty-three patients with ASD II (75%) were selected for percutaneous occlusion with the ASO device, and the remaining 28 patients (25%) underwent surgical closure. In the device group, in 72 patients (86.7%) devices were successfully deployed. At immediate and 12-month follow-up, the complete closure rate was 87.5% (63 of 72 patients) and 97.2% (70 of 71 patients), respectively. In the surgical group, all patients had successful closure immediately after the procedure and at 12 months. Surgical closure offered a 27% cost savings in comparison with percutaneous occlusion (U.S. 3,329.50 dollars +/- 411.30 dollars and U.S. 4,521.03 dollars +/- 429.71 dollars; p < 0.001, respectively). Cost of the device (U.S. 2,930.00 dollars) proved to be the main cause for this difference.

CONCLUSIONS

We confirmed the clinical advantages of percutaneous occlusion over surgical closure of ASD II. However, percutaneous occlusion costs were higher compared with surgical closure. In Guatemala, where health care resources are limited, ASD II closure with the ASO device did not prove to be cost-effective.

The impact of interventional cardiology for the management of adults with congenital heart defects

The objective of this study is to assess the impact of interventional cardiology procedures for the management of ACHD. The interventional approach to the management of CHD in the adult population is becoming increasingly recognized as the preferred treatment option for a wide number of congenital cardiac conditions. The files of all consecutive patients over 18 years of age who were hospitalized in our department from January 2000 to December 2004 were reviewed. Over the study period, 1,115 ACHD (583 women; mean age 41 +/- 13.8, years, range 18-72 years) were hospitalized in our department; 752 patients underwent cardiac catheterization and 82.4% of them had an interventional procedure carried out. ASD (329/620) and PFO (159/620) closure account for 78% of all the procedures carried out, with a 2.7% of major complications incidence (all of them closing ASDs). Other procedures such as stenting aortic coarctation (40/620), ventricular septal defect closure (33/620), patent ductus arteriosus embolization (30/620), pulmonary valvuloplasty (12/620), stenting pulmonary artery branches (8/620), etc (5/620) were carried out. The most important complication was one death, which occurred in the case of a 22-year-old woman after stent implantation for a recurrent aortic coarctation. A trivial residual shunt was detected in only 5% of the patients who had a 6-month follow-up after VSD closure; no residual shunt was found after PDA embolization during the 12-month follow-up. In conclusion, we believe that the interventional approach is a safe and successful treatment option for a wide number of congenital cardiac conditions. The increasing use of catheter interventions for these patients will be responsible for an increase of complex cases in surgery.

Time-course of cardiac remodeling following transcatheter closure of atrial septal defect

BACKGROUND

Right chamber dilatation and right-to-left volumetric unbalance are well-known cardiac consequences of atrial septal defect (ASD) shunt, accounting for most of its long-term complications. Thus, cardiac volumetric unloading is a major aim of ASD closure. Different from surgery, transcatheter option might be considered as an "unbiased" tool to evaluate the cardiac geometric remodeling following ASD closure.

METHODS

Extent and time-course of cardiac geometric changes were assessed by echocardiography 24 h, 1 and 6 months after percutaneous closure of large ASD (mean diameter 17+/-6 mm, QP/QS 2.2+/-0.9) in 42 asymptomatic patients (age 22+/-18 years).

RESULTS

Transcatheter closure was accomplished using the Amplatzer Septal Occluder device (mean 23+/-7 mm, median 24 mm), achieving a complete occlusion in all patients at the 6-month follow-up control. After ASD closure, right atrial (RA) volume reduced from 45+/-24 to 28+/-12 ml (-37.8%, p<0.001), while left atrial (LA) volume did not significantly change. Inlet and infundibulum right ventricular (RV) end-diastolic diameters reduced by 23+/-2% and 23+/-3%, respectively (p<0.001 for both measurements), although with a different time-course of changes. Finally, transverse left ventricular (LV) end-diastolic diameter increased from 39+/-7 to 44+/-5 mm (+11.4%, p<0.01). These geometric changes resulted in an RV/LV diameter ratio decrease by 34+/-3% (p<0.001). Nearly 90% of cardiac remodeling ensued within 1 month from shunt disappearance (50% within 24 h).

CONCLUSIONS

Percutaneous ASD closure results in early and striking cardiac geometric changes that almost completely revert the right-to-left volumetric unbalance. Most of this geometric remodeling ensues within a few weeks from ASD closure.

Transcatheter closure of atrial septal defects improves right ventricular volume, mass, function, pulmonary pressure, and functional class: a magnetic resonance imaging study

OBJECTIVE

To characterise prospectively by magnetic resonance imaging (MRI) changes in right ventricular (RV) volume, function, and mass after transcatheter closure of atrial septal defects (ASDs) and to evaluate the course of pulmonary pressure and functional class criteria.

METHODS

In 20 patients with secundum-type ASD and dilated RV diameter, MRI was performed to quantify RV end diastolic (RVEDV) and end systolic volumes (RVESV), RV mass, tricuspid annular diameter, and RV ejection fraction before and 6 and 12 months after transcatheter closure of the ASD. RV systolic pressure was measured during follow up by transthoracic echocardiography.

RESULTS

Functional class improved in the majority of patients after ASD closure. RVESV (from 81 (18) ml/m2 to 53 (15) ml/m2, p < 0.001), RVEDV (from 127 (17) ml/m2 to 99 (18) ml/m2, p < 0.001), and RV mass (from 79 (10) g to 63 (8) g, p < 0.01) decreased significantly during follow up, although tricuspid annular diameter did not. RV ejection fraction improved (by 9% compared with baseline, p < 0.05) and RV systolic pressure decreased significantly (from 33 (8) mm Hg to 24 (6) mm Hg, p < 0.001) after closure.

CONCLUSION

MRI studies showed significant improvement of RV volumes, mass, and function after transcatheter closure of ASDs. Restoration of the RV leads to decreased pulmonary pressure resulting in a better functional class in the majority of patients.

Complications of transcatheter closure of atrial septal defects

Transcatheter device closure of atrial septal defects has proved to be remarkably successful, and is usually preferred by both patients and parents. But how does it compare with the gold standard of surgical closure?

Morphogenetic differences of secundum atrial septal defects

It is generally considered that the development of secundum atrial septal defect (ASDII) or oval fossa defect is the result of excessive resorption of the embryological atrial septum primum, but this does not seem to explain all defects. We investigated 58 postmortem hearts with an ASDII and 22 normal hearts from patients ranging in age from 1 day to 49 years. The different structures of the oval fossa were examined. In 86% of the specimens, the defects were the result of a malformation of the valvula foraminis ovalis or embryological atrial septum primum, and in 14% an absent superior limbus (septum secundum) was the cause of the interatrial communication. The "septum primum" ASDs were divided into four subgroups based on the degree of deficiency of the septum primum and position of the ostium secundum within the septum primum. We conclude that the morphogenesis of ASDII is variable and both septum primum and septum secundum defects occur, which may be relevant in view of genetic studies that may lead to further differentiation of patients with and without genetically determined ASDIIs.

Atrial Septal Defect Treatment Options

Atrial septal defects have traditionally been repaired by surgical closure. Recently, transcatheter device closure has increasingly been used with excellent results. Although there is limited comparative research evaluating long-term outcomes of the transcatheter technique, preliminary data reveal significantly fewer complications and shorter hospital stays than those reported for surgical repair. This article reviews relevant literature comparing efficacy, cost, and complications of the transcatheter device procedures with the surgical closure of ASDs.

Long-term outcome of transcatheter secundum-type atrial septal defect closure using Amplatzer septal occluders

OBJECTIVES

The aim of this study was to assess long-term results of percutaneous closure of secundum-type atrial septal defect (ASD II) using Amplatzer septal occluders (ASO).

BACKGROUND

Only immediate-, short-, and intermediate-term results of ASO implantation are known so far.

METHODS

Between September 1995 and January 2000, 151 patients underwent a successful percutaneous closure of ASD II in our institution. All were included in the present study and were followed up until September 2004.

RESULTS

This group of patients was followed up from 56 to 108 months (median 78 months). The mean stretched defect diameter was 15.9 +/- 4.8 mm. There were no deaths or significant complications during the study. At three years of follow-up, all defects were completely closed and remained closed thereafter.

CONCLUSIONS

Since the first human implantations in September 1995, the Amplatzer septal occluder proved as a safe and effective device for percutaneous closure of ASD II.

Late coil displacement after interventional closure of a perimembranous ventricular septal defect: A case report

Muscular and perimembranous ventricular septal defects can be closed with nitinol plugs or spiral coils. Displacement and embolization of the device are well known complications that usually occur during or early after the procedure. We present the case of a 12-year-old boy with asymptomatic coil displacement detected at a routine examination 5 months after closure of a perimembranous ventricular septal defect.

Closure of a moderately large atrial septal defect with a self-fabricated fenestrated Amplatzer septal occluder in an 85-year-old patient with reduced diastolic elasticity of the left ventricle

Percutaneous closure of an atrial septal defect (ASD) in the elderly with reduced diastolic elasticity of the left ventricle poses a significant management challenge. We report on the case of an 85-year-old patient who was admitted for percutaneous device closure of a moderately large secundum atrial septal defect. Hemodynamic evaluation documented an increase in left atrial pressure from a mean of 12 mm Hg to a mean of 32 mm Hg after balloon test occlusion of the ASD. Two months later, after adequate pretreatment with diuretics and afterload-reducing substances, he underwent successful closure of the ASD using a self-fabricated fenestrated Amplatzer septal occluder, which resulted in a postimplantation left atrial pressure of a mean of 18 mm Hg. Recovery was unremarkable and the fenestration has remained patent for 3 months since implantation of the device. This unique case highlights the feasibility of using a self-fabricated fenestrated Amplatzer septal occluder to close interatrial communications in elderly patients with diastolic dysfunction of the left ventricle.

Assessment of patient radiation doses during transcatheter closure of ventricular and atrial septal defects with Amplatzer devices

The purpose of this study was to estimate the radiation dose to which children are exposed during cardiac catheterizations for the treatment of ventricular and atrial septal defects. Radiation doses were estimated for 46 children aged 1-18 years. These children were treated for secundum atrial septal defects (ASD group) for perimembranous ventricular septal defects (VSD group) or underwent a routine diagnostic catheterization (diagnostic group). Thermoluminescent dosimeters (TLDs) were attached in locations, representing the lateral entrance dose, the posterior entrance dose, the thyroid dose, and the gonad dose, respectively. A dose area product (DAP) meter was also attached externally on the posterior-anterior (PA) tube to give a direct value in cGy cm(2) for each procedure. The patient's entrance dose from the PA field ranged from 1.5 to 185.0 mGy for all patients, while the lateral entrance dose varied from 0.9 to 204 mGy. Radiation exposure to the thyroid and the gonads was found to vary from 0.4 to 8.3 and 0.1 to 2.1 mGy, respectively. The DAP meter recorded DAP values for the posterior tube, between 46 and 3,700 cGy cm(2). The mean effective dose was found to be 7.7, 16.2, and 33.3 mSv for the diagnostic, the ASD, and the VSD group, respectively. Very strong correlation was found between the DAP values and the entrance radiation dose measured with TLDs. The mean entrance dose received from therapeutic cardiac catheterizations using the Amplatzer devices was found approximately twice the dose received from a diagnostic one. Even for the most complex procedures, the maximum entrance dose was at least 10 times lower than the threshold, associated with skin erythema.

Interventional cardiac catheterisation in congenital heart disease

As a result of recent technological advances, more types of congenital heart disease are amenable to treatment in the cardiac catheter laboratory than ever before.1 Improved imaging techniques allow for better selection of patients, and the development of a wide range of devices specifically for use in children means that many patients can avoid surgery altogether, while those with complex congenital heart disease may require fewer or less complex surgical procedures.2 This allows for a quicker recovery and a shorter hospital stay, and gives many patients an improved quality of life in the short to medium term. However, the long term outcome for many of the newer forms of intervention is still unknown.

Echocardiographic characteristics of secundum-type atrial septal defects in adult patients: Implications for percutaneous closure using Amplatzer septal occluders

The aim of the study was to analyze echocardiographic characteristics of isolated secundum-type atrial septal defects (ASD II) in adult patients and their implications for percutanous closure using Amplatzer septal occluders. The study population consisted of 64 consecutive adult patients with isolated ASD II (mean age 43.6 +/- 15.9 years). Patients were evaluated using both transthoracic and transesophageal echocardiography. Defects in 29 of 64 patients (45.3%) fulfilled the echocardiographic criteria for percutaneous closure. The mean defect diameter in the study was 22.2 +/- 9.5 mm. In all, 13 morphologic variations of ASD II were detected. A statistically significant correlation between defect size and the number of deficient defect rims was found. Less than 50% of ASD II in adult patients fulfilled the echocardiographic criteria for percutaneous closure using Amplatzer septal occluders. Because others have demonstrated growth of ASD II over time, we presume that in some patients, defect growth is associated with attenuation or even disappearance of defect rims causing changing defect morphology with increasing defect size.

Blade consolidation of multiple atrial septal defects: a novel approach to transcatheter closure

The Amplatzer atrial septal defect occlusion device has gained popularity for the nonoperative closure of secundum-type defects. We describe a case of multiple atrial septal defects that were "consolidated" into a single defect using blade atrial septostomy for successful closure with single Amplatzer device.

Transcatheter closure of intracardiac shunts

Intracardiac shunts, such as atrial septal defects (ASDs), patent foramen ovales (PFOs), and ventricular septal defects (VSDs), are common forms of congenital or acquired heart disease. Traditional treatment has consisted of surgical closure. Transcatheter closure using implantable devices is now an alternative approach to the treatment of these lesions. Transcatheter closure offers advantages over surgical closure: 1) it is less invasive, resulting in shorter recovery times, less hospital time, and no scarring; 2) it avoids the deleterious neurocognitive effects of cardiopulmonary bypass; 3) it avoids the proarrhythmic effects of atrial or ventricular incisions; and 4) it is potentially less costly. Device closure of secundum ASDs is the procedure of choice. Device closure of PFOs can be performed under humanitarian device exemption (HDE) guidelines, although the indications for this procedure and its effectiveness compared with medical management remain controversial. Ongoing studies are addressing these issues. Transcatheter closure of muscular VSDs is an alternative to surgical treatment, especially for apical defects or those anterior to the moderator band. The CardioSEAL device (NMT Medical, Boston, MA) has HDE status for this purpose and the Amplatzer muscular VSD device (AGA Medical Corp., Golden Valley, MN) is being reviewed by the US Food and Drug Administration for market approval. Phase 1 investigations are underway for device closure of perimembranous VSDs using the Amplatzer perimembranous VSD device (AGA Medical Corp.). Until more data are available, surgical closure of perimembranous VSDs is still the procedure of choice. Closure of postinfarct VSDs can also be accomplished using intracardiac devices; however, this remains a high-risk procedure. Early experience compares favorably with surgical closure. Transcatheter device closure of intracardiac defects is a relatively new procedure. Long-term data for these procedures are currently lacking and, therefore, recommendations regarding the use of these devices will continue to evolve with time.

[Percutaneous closure of the inter-auricular communications, well defined indications]

POSSIBLITIES FOR PROGNOSTIC IMPROVEMENT: The inter-auricular communication (IAC) is the most frequent of congential malformations in adults and is responsible for enhanced morbidity and rduction in life expectancy. The closure of an IAC with volumic overload eradicates such morbidity and mortality. The technical progress in the conception of prosthesises that obstrue the interauricular communications via the percutaneous route make this technique a reliable alternative to surgery that, itself, leads to a certain degree of discomfort and considerable morbidity. DEPENDING ON THE ECHOCARDIOGRAPHICAL DATA: The selection of patients is crucial and relies on trans-thoracic echocardiography. It is indicated in isolated ostium secundum-type inter-auricular communications with a border of at least 4 mm separating it from the adjacent structures of the heart; the size on the echocardiography must not exceed 30 mm. FROM A TECHNICAL POINT OF VIEW: The closure is made under fluoroscopic and echocardiographic control via the trans-oesophageal route. It is rapid, simple, and induces a low rate of morbidity. With Amplatz's prosthesis, the percentage of complete closure is equivalent to that obtained with surgery but with less morbidity with regard to arrhythmia. Today the reliable percutaneous closure of an IAC will probably permit the extension of the indications for the closure of this congenital abnormality in adults.

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.

Transthoracic echocardiographic guidance of transcatheter atrial septal defect closure

This study examines the safety and efficacy of transthoracic echocardiographic (TTE) guidance of atrial septal defect (ASD) device closure. We evaluated 74 patients for TTE-guided ASD closure. Fifty-six patients had successful device implantation using TTE guidance. Twelve patients were referred for surgical ASD closure on the basis of TTE evaluation. Five patients with multiple ASDs or poor transthoracic acoustic windows had ASD device closure guided by transesophageal echocardiography (TEE).

Percutaneous closure of multiple atrial septal defects with three Amplatzer septal occluder devices

We report on the successful closure of three atrial septal defects with three Amplatzer septal occluders in a 55-year-old woman.

A constricting band: An unusual cause of incomplete expansion of Amplatzer septal occluder device

Various problems and complications have been reported during transcatheter closure of ostium secundum atrial septal defect with Amplatzer septal occluder. We report an unusual problem that was responsible for incomplete expansion of the waist of the device, not yet reported in world literature. A polyester band in continuation with the polyester mesh was found constricting the waist of the device, which after being cut led to successful redeployment of the device.