Development of aorta-to-right atrial fistula following closure of secundum atrial septal defect using the Amplatzer septal occluder

Descending aorta to right atrial fistula: Transcatheter embolization of a very rare anomaly with coils

Key Clinical Message

Descending aorta to right atrial (RA) fistula is a rare and distinct clinical entity mimicking patent ductus arteriosus (PDA) and it may lead to rapid development of pulmonary vascular disease. Correct diagnosis and treatment, especially in the presence of other congenital heart defects, is very important. Interventional management is the treatment of choice.

Abstract

We present a case report of a trisomy 21 infant with atrial and ventricular septal defects and small patent ductus arteriosus (PDA) complicated by the presence of descending aorta to right atrial (RA) fistula with large left to right shunt leading to rapid increase in pulmonary vascular resistance. Transcatheter occlusion of the fistula followed by closure of the PDA with Nit-Occlud coil systems led to decreased pulmonary pressure and resistance permitting successful surgical repair of the patient's intracardiac defects with good outcome over 3 years of follow-up. Descending aorta to RA fistula is a rare and distinct clinical entity mimicking PDA and its correct diagnosis and treatment, especially in the presence of other congenital heart defects, is very important as it may lead to rapid development of pulmonary vascular disease.

Role of Echocardiography in the Diagnosis and Interventional Management of Atrial Septal Defects

This review centers on the usefulness of echo-Doppler studies in the diagnosis of ostium secundum atrial septal defects (ASDs) and in their management, both in children and adults. Transthoracic echocardiography can easily identify the secundum ASDs and also differentiate secundum ASDs from other kinds of ASDs, such as ostium primum ASD, sinus venosus ASD and coronary sinus ASD, as well as patent foramen ovale. Preliminary selection of patients for device occlusion can be made by transthoracic echocardiograms while final selection is based on transesophageal (TEE) or intracardiac (ICE) echocardiographic studies with optional balloon sizing of ASDs. TEE and ICE are extremely valuable in guiding device implantation and in evaluating the position of the device following its implantation. Echo-Doppler evaluation during follow-up is also useful in documenting improvements in ventricular size and function, in assessing the device position, in detecting residual shunts, and in identifying rare device-related complications. Examples of echo images under each section are presented. The reasons why echo-Doppler is very valuable in diagnosing and managing ASDs are extensively discussed.

Migration of PFO closure device and entrapment within tricuspid valve leading to tricuspid regurgitation: surgical correction of an extremely rare complication after transcutaneous PFO closure

A 41-year-old woman was referred to tertiary cardiothoracic surgery centre following embolisation of the Amplatzer patent foramen ovale (PFO) closure device to septal leaflet of tricuspid valve with reopening of PFO. Two years earlier, she presented with thalamic stroke, and she was found to have a PFO following investigations. The following year she underwent transcatheter closure. Six months after the percutaneous closure, she presented again with significant periods of shortness of breath. Imaging studies revealed the migration and embolisation of PFO closure device to the septal leaflet of tricuspid valve with reopening of the foramen and significant tricuspid valve regurgitation. She underwent open heart surgery using cardiopulmonary bypass for retrieval of the device, closure of the foramen and repair of the tricuspid valve. The patient recovered well without any significant issues following surgery.

Outcomes of Device Closure of Atrial Septal Defects

Several devices have been designed and tried over the years to percutaneously close atrial septal defects (ASDs). Most of the devices were first experimented in animal models with subsequent clinical testing in human subjects. Some devices were discontinued or withdrawn from further clinical use for varied reasons and other devices received Food and Drug Administration (FDA) approval with consequent continued usage. The outcomes of both discontinued and currently used devices was presented in some detail. The results of device implantation are generally good when appropriate care and precautions are undertaken. At this time, Amplatzer Septal Occluder is most frequently utilized device for occlusion of secundum ASD around the world.

Current practice in atrial septal defect occlusion in children and adults

INTRODUCTION

Atrial septal defect (ASD) is one of the most common congenital heart diseases (CHD) in children and adults. This group of malformations includes several types of atrial communications allowing shunting of blood between the systemic and the pulmonary circulations. Early diagnosis and treatment carries favorable outcomes. Patients diagnosed during adulthood often present with complications related to longstanding volume overload such as pulmonary artery hypertension (PAH), atrial dysrhythmias, and right (RV) and left (LV) ventricular dysfunction.

AREA COVERED

This article intended to review all aspects of ASD; anatomy, pathophysiology, clinical presentation, natural history, and indication for treatment. Also, we covered the transcatheter therapy in detail, including the procedural aspect, available devices, and outcomes.

EXPERT OPINION

There has been a remarkable improvement in the treatment strategy of ASD over the last few decades. Transcatheter closure of ASD is currently accepted as the treatment of choice in most patients with appropriately selected secundum ASDs. This review will focus on the most recent advances in diagnosis and treatment strategy of secundum ASD.

Risk Factors and Predictors of Cardiac Erosion Discovered from 12 Japanese Patients Who Developed Erosion After Atrial Septal Defect Closure Using Amplatzer Septal Occluder

Cardiac erosion is a rare serious complication following Amplatzer septal occluder (ASO) placement for atrial septal defect. Although multiple risk factors have been found, a useful predictor to prevent it has not been established yet. In 12 patients who developed erosion between 2005 and 2016 in Japan, we retrospectively observed patients' characteristics and transesophageal echocardiography findings immediately before and after ASO placement and at erosion onset. We compared risk factors of erosion, including absent aortic rim, device size/body weight ratio, device shape, or Valsalva sinus wall deformation pressed by either disk-edge, the maximum depth of which from the standard curve of the Valsalva wall was defined as Dent, between the 12 patients and 95 patients with Valsalva sinus wall deformation immediately after placement who did not develop erosion for 5 ± 3 years. Of the 12 patients, nine developed pericardial effusion with eight cardiac tamponade and three aorta-atrium fistula; all were surgically rescued. Surgical findings revealed that erosion in all patients occurred at the right and/or left atrial roof beside the Valsalva in the non-coronary cusp on which the disk-edge seemed to be pressing. The mean Dent immediately after the placement in patients with erosion was significantly deeper than without (2.48 ± 0.32 vs. 1.28 ± 0.38; p < 0.001). There were no differences in the other risk factors between the two groups. Dent is believed to be a useful indicator of erosion development after ASO placement. If Dent is > 2.0 mm, it is desirable to change the size or to replace the device.

State-of-the-Art Atrial Septal Defect Closure Devices for Congenital Heart

This article describes current devices and indications for transcatheter device closure of atrial septal defect (TC-ASD) and patent foramen ovale in children and young adults. TC-ASD has a proven record of efficacy and safety, but device erosion raises questions about the relative safety of TC-ASD versus operative open heart surgical ASD closure. New devices for ASD closure with properties to reduce risk of erosion are being developed. Recent studies demonstrating superiority of patent foramen ovale device closure over medical therapy for cryptogenic stroke may lead to changes in practice for structural/interventional cardiologists. Care should be taken in extrapolating data to children and younger adults.

Transcatheter device closure of atrial septal defects: more to think about than just closing the hole

PURPOSE OF REVIEW

To review current controversies in the transcatheter device closure of ostium secundum atrial septal defects (ASD).

RECENT FINDINGS

Transcatheter device closure of ASD (TC-ASD) has well established efficacy and safety. For most individual patients with suitable anatomy, TC-ASD is the preferred method for treating ASD. The availability of large multicenter data sets has made it possible to study practice patterns at a range of hospitals across the United States. These studies have revealed differences in practice that were not previously appreciated. Interpretation of the indications for TC-ASD, specifically the definition of right ventricular volume overload varies between hospitals. In response to concern about device erosion, an increasing proportion of patients are being referred for operative ASD closure. Over the last decade, the average age at which ASD closure occurs has decreased. These trends demonstrate previously underappreciated differences in opinion between cardiologists across the country and suggest that further research is necessary to address knowledge gaps limiting consistency of practice.

SUMMARY

As TC-ASD and congenital interventional cardiology mature as a field, studies of real-world practice provide increasingly valuable information about aspects of care in which there are disagreements about best practices and in which further research is necessary.

Acquired aortocameral fistula occurring late after infective endocarditis: An emblematic case and review of 38 reported cases

AIM

To delineate the features and current therapeutic option of congenital and acquired aortocameral fistulas (ACF) secondary to iatrogenic or infectious disorders.

METHODS

From a PubMed search using the term "aortocameral fistula", 30 suitable papers for the current review were retrieved. Reviews, case series and case reports published in English were considered. Abstracts and reports from scientific meetings were not included. A total of 38 reviewed subjects were collected and analyzed. In addition, another case - an adult male who presented with ACF between commissures of the right and non-coronary sinuses and right atrium as a late complication of Staphylococcus aureus infective endocarditis of the AV - is added, the world literature is briefly reviewed.

RESULTS

A total of thirty-eight subjects producing 39 fistulas were reviewed, analyzed and stratified into either congenital (47%) or acquired (53%) according to their etiology. Of all subjects, 11% were asymptomatic and 89% were symptomatic with dyspnea (21 ×) as the most common presentation. Diagnosis was established by a multidiagnostic approach in 23 (60%), single method in 14 (37%) (echocardiography in 12 and catheterization in 2), and at autopsy in 2 (3%) of the subjects. Treatment options included percutaneous transcatheter closure in 12 (30%) with the deployment of the Amplatzer duct or septal occluder and Gianturco coil and surgical correction in 24 (63%).

CONCLUSION

Acquired ACF is an infrequent entity which may occur late after an episode of endocarditis of the native AV. The management of ACF is generally by surgical correction but non-surgical device intervention has recently been introduced as a safe alternative.

Device closure of secundum atrial septal defect's and the risk of cardiac erosion

Cardiac erosion related to transcatheter atrial septal defect closure devices is of increasing concern. Erosion is reported to have occurred with most of currently available occluder devices. Perhaps due to the very large number of implants worldwide, the Amplatzer (St Jude) occluder is associated with the majority of cardiac erosion events reported in the literature. Best current estimates of the incidence of erosion with the St Jude device are between one and three cases per 1000 implants. Most events occur early after implantation and it is rare, although not unheard of, for events to occur after a year following device insertion. It is important that those involved with closure programmes are vigilant for the problem, because device-related erosion is associated with a significant mortality risk. Despite considerable debate, the risk factors (either patient or device) for erosion remain unclear and require further investigation. Currently available data sets have focussed largely on erosion cohorts and are unable to place these cases in appropriate context with non-erosion closure cases. What is certain is that programmes implanting these devices must take care to implant appropriately sized devices and have in place plans to ensure that patients are both well informed and can access help and advice in the event of developing symptoms.

Evaluation of Valsalva sinus wall deformation due to compression by the Amplatzer septal occluder and the potential for erosion development

OBJECTIVES

We studied whether the pressure exerted by the Amplatzer septal occluder (ASO) disk on the Valsalva sinus wall (VW) is a risk factor for erosion and attempted to determine the pressure that may trigger erosion.

BACKGROUND

The causes and mechanisms of erosion after ASO placement remain unclear.

METHODS

We reviewed 665 consecutive patients with atrial septal defects who underwent ASO closure at our hospital from 2005 to 2012. We used transesophageal echocardiography and other tests to evaluate disk-related VW deformation as a risk factor for erosion.

RESULTS

Immediately after ASO placement, intermittent VW deformation from either disk was determined in 54 of the 665 patients (8%). Of these 54 patients, only 1 exhibited late erosion (0.15%) during a follow-up of more than 4 years (0.035% a year). The maximum VW deformation depth relative to the standard curve, or dent, was 2.6 mm in this patient, whereas that in the remaining patients ranged from 0.5 to 2.0 mm. The dent values were significantly deeper in patients with contact between the left atrial disk and posterior atrial wall than in those without contact (P = 0.03). There was a significant negative correlation between dent and the aortic side-maximum device thickness (DT)/middle part-DT ratio (P = 0.04).

CONCLUSION

Although VW deformation, particularly deep VW deformation caused by pressure from either disk after ASO placement must be a recognized risk for erosion, which deformation level carries a stronger risk for erosion could not be concluded.

Delayed aorto-right atrial fistula following percutaneous closure of atrial septal defect

We present the case of a 27-year-old man who underwent percutaneous atrial septal defect (ASD) repair using the Amplatzer(®) (St Jude Medical, St Paul, MN, US) septal occluder (ASO). Six weeks later, he presented with heart failure and was found to have an aorto-right atrial fistulation. He required urgent surgical device explantation and repair of the existing ASD using a pericardial patch repair technique. This is the first case to be reported from the UK describing a delayed aorto-right atrial fistula following percutaneous closure using ASO.

Transcatheter closure of atrial septal defects

Transcatheter closure of atrial septal defects has evolved significantly over the last 20 years. Transcatheter closure has replaced surgical closure for the treatment of most secundum atrial septal defectsat the current time. A major reason for this is the lower morbidity of transcatheter closure procedures. Several closure devices have come into clinical use. The Amplatzer septal occluder (AGA Medical Co.) currently has the largest reported experience and subsequently the best-established safety and efficacy features. Clinically challenging situations, such as larger atrial septal defects, atrial septal defects with deficient rims and multiple atrial septal defects, are increasingly being addressed using the transcatheter approach, with improved results. The incidence of most complications has significantly reduced over time, and serious side effects are relatively uncommon. In this review, the literature is summarized regarding the current role of transcatheter closure, the evolution of the different available devices for clinical use and the complications that occur with their use. A comparison is also made with surgical closure techniques.

Midterm results of percutaneous closure of very large atrial septal defects in children: role of multislice computed tomography

AIMS

The aim of this study was to assess the midterm results of percutaneous closure of very large atrial septal defects (ASD) in children with transthoracic echocardiography (TTE) and multislice computed tomography (MSCT).

METHODS AND RESULTS

Among 142 children who underwent percutaneous ASD closure with the AMPLATZER® Septal Occluder (ASO) (AGA Medical Corporation, Plymouth, MN, USA) during an eight year period, 51 patients with very large defects, were evaluated by TTE and MSCT after a period of at least two years following ASD closure. Median age at ASD closure was six years (range 4-10), with mean ASD size 20.9±2.9 mm. Median device size was 20 mm (range 15-26) and median device: septal length ratio 0.95 (range 0.8-1). Early complications included one transient complete atrioventricular block and one device embolisation. At a median follow-up of 55 months (range 25-92) all patients were clinically asymptomatic and had a normal ECG. TTE did not demonstrate device protrusion across the lumen of either the systemic or pulmonary veins. The mean device: septal length ratio had decreased from 0.96±0.05 to 0.8±0.02 (p<0.001). There was good correlation between the measure of atrial septum length by TTE and MSCT (r: 0.79, p<0.001). MSCT identified moderate dynamic device protrusion into the lumen of systemic or pulmonary veins in five patients and partial device malpositioning in two patients.

CONCLUSIONS

Occlusion of very large ASD in children can be performed with low complications rate. MSCT provides detailed information regarding the location of the device with respect to surrounding anatomic structures and reveals anomalies not evident by TTE.

Atrial septum defect closure device in a beating heart, from the perspective of a researcher in artificial organs

Transcatheter closure of atrial septum defect (ASD) with a closure device is increasing, but the history of clinical use of this procedure is still short, and the efficacy and long-term safety remain unproved. The total number of closure devices implanted throughout the world has not been counted accurately. Therefore, the probability of complications occurring after implantation is uncertain. Device-related complications that occur suddenly late after implantation are life-threatening, and quite often necessitate emergency surgical intervention. In Japanese medical journals, authors reporting closure devices have mentioned no complications and problems in their facilities. Detailed studies of device-related complications and device removal have not been reported in Japan. In fact, this literature search found an unexpectedly large number of reports of various adverse events from many overseas countries. When follow-up duration is short and the number of patients is small, the incidence of complications cannot be determined. Rare complications may emerge in a large series with a long observation period. Consequently, the actual number of incidents related to ASD closure devices is possibly several times higher than the number reported. Guidelines for long-term patient management for patients with an implanted closure device are necessary and post-marketing surveillance is appropriate. Development of a national database, a worldwide registration system, and continuous information disclosure will improve the quality of treatment. The devices currently available are not ideal in view of reports of late complications requiring urgent surgery and the need for life-long follow-up. An ideal device should be free from complications during life, and reliability is indispensable.

Intravascular hemolysis secondary to aorto-atrial fistula presenting as red urine

Intravascular hemolysis is a rare but potentially life threatening cause of red urine characterized by brisk hemolysis and release of large amounts of hemoglobin into the urine. We present an unusual case of red urine in a 20-year-old male who was subsequently diagnosed with intravascular hemolysis due to an aorto-atrial fistula. Fistula formation was likely secondary to a recently implanted atrial septal occluder, which is a reported but exceedingly rare complication of the device. We discuss the diagnostic approach to hemolytic anemia and conclude with a literature review of other cases of device associated fistula formation and hemolysis.

Analysis of the US Food and Drug Administration Manufacturer and User Facility Device Experience database for adverse events involving Amplatzer septal occluder devices and comparison with the Society of Thoracic Surgery congenital cardiac surgery database

OBJECTIVE

Amplatzer (AGA Medical Corporation, Plymouth, Minn) septal and vascular occluder devices have significantly altered the care of patients with congenital heart disease. The relative frequency and consequence of complications resulting from the attempted placement of such devices, however, have not been well assessed. The purpose of this study is to use large databases to assess the frequency and severity of such complications and compare them with those of surgical atrial septal defect closure.

METHODS

The US Food and Drug Administration Manufacturer and User Facility Device Experience database was quarried for all adverse events for Amplatzer septal occluder devices, which were categorized and analyzed with particular emphasis on management and outcome. The Society of Thoracic Surgery database was likewise quarried for the same data regarding atrial septal defect closures over a contemporaneous time period. By using a literature-derived denominator for total Amplatzer implant numbers, the results of the 2 therapies were compared.

RESULTS

Since July 1, 2002, 223 adverse events in patients undergoing Amplatzer atrial septal defect closure were submitted to the Food and Drug Administration, resulting in 17 deaths (7.6%) and 152 surgical rescue operations (68.2%). Society of Thoracic Surgery data demonstrated 1537 primary operations with 2 deaths (0.13%) and 6 reoperations (0.39%). By extrapolating on published estimates of Amplatzer implantation to provide an implant denominator (n = 18,333), there was no difference between overall mortality for surgical (0.13%) and device closure (0.093%, P = .649). Rescue operation for device adverse events (0.83%) was 2.1 times more likely than reoperation for surgical closure (0.39%, P = .063). Mortality per adverse event was higher for device closure (7.6%) than for surgical closure (1.2%, P = .004), and the need for surgery per adverse event was higher for device closure (68.2%) than for surgical closure (3.6%, P < .001). The mortality for surgical management of a device adverse event (2.6%) was 20-fold higher than for primary elective atrial septal defect closure (0.13%, P < .0001).

CONCLUSION

Overall crude mortality for device and surgical closure atrial septal defect closure is equivalent, and the need for subsequent operation (surgical rescue) is more common in patients undergoing device closure than reoperation is in patients undergoing surgical closure. Complications from device closure tend to be serious and most often require urgent or emergency operative management, whereas the mortality for surgical management of a device complication appears higher than that of elective atrial septal defect closure. Further information is required in the form of postmarketing surveillance, such as a mandatory user registry with periodic end-user notification.

Amplatzer septal occluder associated with late pulmonary venous obstruction requiring surgical removal with acquired aorta to left atrial fistula

The Amplatzer septal occluder is currently the preferred device for the transcatheter closure of secundum atrial septal defects. Multiple studies have shown that device complications with the Amplatzer occluder are rare and often acute in presentation. The investigators describe the first reported case of late obstruction of the right pulmonary veins with an Amplatzer septal occluder and, in the same patient, an unusual intraoperative finding of a noncoronary aortic sinus to left atrium fistula after device removal.

Clinical results of percutaneous closure of large secundum atrial septal defects in children using the Amplatzer septal occluder

We reviewed our experience using the Amplatzer septal occluder (AGA Medical, Golden Valley, MN, USA) to close large, secundum-type atrial septal defects (ASDs) in children. Between June 2002 and December 2005, 52 patients (mean age 13.5 +/- 8.7 years) underwent transcatheter closure of large (> or =25 mm), secundum ASDs with the use of the Amplatzer septal occluder (ASO). Groups 1 and 2 included patients with a retroaortic rim of <5 mm (n = 39) or > or =5 mm (n = 13), respectively. All procedures were performed with general anesthesia and transesophageal echocardiographic guidance except for 10 patients, which involved local anesthesia and three-dimensional transthoracic echocardiography. Successful device implantations, device sizes, approaches, complications, and closure rates were assessed. Device implantation was successful in 50 patients (96.1%), with no difference between groups (95% vs 100%, P>0.05). In 2 patients, implantation failed because of embolism or deployment failure. Device were larger in group 1 than in group 2 (29.7 +/- 4.2 vs 26.7 +/- 3.8 mm, P = 0.04). The right upper pulmonary-vein approach was more common in group 1 than in group 2 (P = 0.0001). Complications and closure rates did not differ between the groups (P > 0.05). Transcatheter closure of large, secundum ASD by using the ASO device was feasible, and complication rates were low. A deficient retroaortic rim did not preclude successful device implantation; however, a large device may be needed to close large ASD. Close long-term follow-up is necessary to determine the safety of transcatheter closure of large ASDs in children.

Cardiac perforation 6 weeks after percutaneous atrial septal defect repair using an Amplatzer septal occluder

A 14-year-old boy presented to the emergency department unaccompanied by his parents with a decreased level of consciousness, bradycardia, and hypotension after a syncopal episode. The patient's electronic chart revealed a percutaneous closure of a secundum atrial septal defect using an Amplatzer septal occluder (AGA Medical, Golden Valley, MN) 6 weeks before this presentation. An urgent echocardiogram revealed a moderate pericardial effusion, and 320 mL of fresh blood was evacuated by subxiphoid pericardiocentesis. The child underwent surgical exploration and was found to have a perforation in the superior-posterior aspect of the right atrium, which was corrected. The septal occluder was extracted, and the atrial septal defect was closed with a pericardial patch. This case illustrates a rare but life-threatening complication of percutaneous closure of atrial septal defect using an Amplatzer septal occluder and the importance of timely access to patient records when available history and physical examination are limited.

Repair of aortic-left atrial fistula following the transcatheter closure of an atrial septal defect

We describe the surgical treatment of an aortic-left atrial fistula that appeared 6 months after the placement of an Amplatzer septal occluder for closure of a large secundum atrial septal defect. Successful repair of the fistula was accomplished by a combined transatrial-transaortic approach similar to that used to repair the rupture of a sinus of Valsalva aneurysm.

Aortic sinus-left atrial fistula after interventional closure of atrial septal defect

A 3-year-old boy underwent interventional closure of an atrial septal defect using an Amplatzer septal occluder. After 4 weeks, an aortic sinus-to-left atrial fistula was detected by echocardiography in an asymptomatic child. The device was surgically explanted with fistula and atrial septal defect closure. Follow-up was uneventful.

Transcatheter atrial septal defect closure: modified balloon sizing technique to avoid overstretching the defect and oversizing the Amplatzer septal occluder

The objective of this study was to evaluate a new technique of sizing atrial septal defects (ASDs) for transcatheter device closure. ASD closure using the Amplatzer septal occluder (ASO) device is commonly performed. Complications, including arrhythmias, pericardial effusions, and perforations, may be related to oversizing ASDs and choosing larger devices. Two methods were used to size ASDs using a compliant balloon. In some patients, the balloon was inflated until a waist was visible [(+)waist]; in others, only until no shunting was demonstrable by echocardiogram [echo; (-)waist]. The device was selected and implanted using standard procedure and echo guidance. One hundred seventeen patients underwent secundum ASD closure with an ASO device. There were 43 patients in the (-)waist group and 74 in the (+)waist group. All devices were implanted successfully. The initial echo ASD diameter was larger in the (-)waist group compared to the (+)waist group (P = 0.01). There was a smaller difference between the initial echo and balloon-sized ASD diameters in the (-)waist group (P < 0.02). ASO device size implanted (in mm greater than echo ASD diameter) was smaller in the (-)waist group (P < 0.01). There were 0/43 complications in the (-)waist group and 5/74 in the (+)waist group. The complete closure rate was the same in both groups. Sizing an ASD by inflating a compliant balloon just until shunting is eliminated, and not until a waist is visible, results in less overstretching of the ASD and selection of a smaller ASO device, achieving similar closure rates and potentially fewer complications.

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.

Aorta to right atrial fistula following transcatheter closure of an atrial septal defect

The percutaneous transcatheter closure of atrial septal defects (ASDs) has become an acceptable alternative to surgical repair. The investigators present a case of aorta-to-right atrial fistula after the closure of an ASD using the Amplatzer septal occluder (ASO). After the surgical removal of the ASO, the ASD patch closure, and the repair of the fistula, the patient eventually recovered.

Migration of an amplatzer septal occluder device for closure of atrial septal defect into the ascending aorta with formation of an aorta-to-right atrial fistula

The percutaneous closure of atrial septal defects is increasingly used. Serious complications of the procedure, such as cardiac perforation and tamponade, are rare and usually occur <72 hours after device placement. The investigators report the late development of the erosion of an Amplatzer septal occluder into the ascending aorta with associated aortic-to-right atrial fistula formation.

Cardiac perforation after device closure of atrial septal defects with the Amplatzer septal occluder

OBJECTIVES

Amplatzer septal occluder (ASO)-associated cardiac perforation (CP) at our institution prompted this retrospective review.

BACKGROUND

Cardiac perforation is a rare complication after transcatheter atrial septal defect (ASD) closure.

METHODS

To identify CP after transcatheter ASD closure with ASO, cardiac events (CE) describing definite CP, hemopericardium, pericardial effusion, cardiovascular collapse, or sudden death were analyzed. Cardiac events were identified from published literature (MEDLINE), medical device regulating agencies in North America and the European Commission, and AGA Medical Corporation (Golden Valley, Minnesota). Institutional cases were reviewed. Cardiac events were defined as early (pre-discharge) or late (post-discharge).

RESULTS

Twenty-nine CEs were identified. Five were excluded because findings were inconclusive for device-related CP. Ten patients were <18 years of age. Late CEs occurred in 66.6%; 25% presented weeks later (longest, three years). Three deaths were reported. Cardiac perforation occurred predominantly in the anterosuperior atrial walls and/or adjacent aorta.

CONCLUSIONS

Amplatzer septal occluder-associated CP uniquely involves the anterosuperior atrial walls and adjacent aorta. Pathophysiology remains poorly understood.

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.

Challenges encountered during closure of atrial septal defects

Since the introduction of transcatheter interventional occlusion of atrial septal defects (ASDs) by King and coworkers, the device closure has become the standard treatment of selected atrial defects. Although it has become routine for standard clinical practice, increasing knowledge of intracardiac anatomy, modification of implantation techniques, and improvements in device designs are making this treatment modality increasingly applicable to a wider range of selected patients. This report summarizes the current trends in patient selection, focusing on the anatomical limits of applicability for ASD device closure, and discusses the future possibilities. Furthermore, typical complications are described with regard to the rare erosion of the atrial roof or the aortic root. Current practice is to oversize the device if the anterior rim toward the aorta tends to be diminutive, achieving a secure position of the device around the aortic root. This and the shape memory of the device may play a major role in this serious complication and should be reconsidered. Although most interventional occlusions of interatrial defects with a device have become clinically routine, some situations remain highly challenging.

Techniques for percutaneous closure of prosthetic paravalvular leaks

Percutaneous transcatheter closure techniques are now routinely applied in the management of atrial and ventricular septal defects, patent ductus arteriosus, and other pathological cardiac and vascular communications. Recently, these same techniques have been applied to paravalvular defects. Reports are few; success variable and techniques vary widely. We review the current considerations and techniques of percutaneous transcatheter closure of paravalvular leaks.

Amplatzer atrial septal defect occluder for pediatric patients: radiographic appearance

PURPOSE

To describe the chest radiographic appearance of the Amplatzer septal occluder (ASO) (AGA Medical Corporation, Golden Valley, Minn) for atrial septal defects (ASDs) in pediatric patients.

MATERIALS AND METHODS

Two radiologists independently reviewed frontal and lateral chest radiographs obtained in young patients 24 hours after transcatheter ASD closure with the ASO. The appearance (flat disks or dots) and location of the ASO were recorded. The location was related to that of a thoracic vertebral body on frontal and lateral chest radiographs and to a line drawn between the anterior margin of the right hilum and the posterior margin of the inferior vena cava (hilar-caval line) on lateral radiographs; this line corresponded to the expected position of the interatrial septum. The relationship between ASO appearance and patient age was assessed with logistic regression and cumulative probability plots.

RESULTS

Sixty-eight pediatric patients (age range, 1 month to 18 years; mean age, 4.2 years; 24 boys and 44 girls) were included. On frontal radiographs, the ASO center projected between T7 and T9, either to the right of or over the spinous processes of the vertebral body. On lateral radiographs, the ASO projected over (n = 66) or anterior to (n = 2) the hilar-caval line. On frontal radiographs, it appeared as one or two flat disks (n = 61) or as two metallic dots (n = 7). On lateral radiographs, it appeared as two flat disks (n = 54) or as two metallic dots (n = 14). The relationship between increasing patient age and the metallic dot appearance on frontal and lateral radiographs and on the combination of frontal and lateral radiographs was highly significant in each case (P < .001, likelihood ratio chi(2) test), with r(2) values of 0.35, 0.20, and 0.28, respectively. ASDs were successfully occluded with the ASO in all patients except one, in whom trivial shunting was seen at 12-month follow-up.

CONCLUSION

The ASO in pediatric patients has a characteristic radiographic appearance when properly positioned.

Usefulness of three-dimensional echocardiographic reconstruction of the Amplatzer septal occluder in patients undergoing atrial septal closure

Eighty-eight patients referred for transcatheter closure of atrial septal or patent foramen ovale defects underwent 3-dimensional transesophageal echocardiography to correlate preclosure anatomy with the morphology and positioning of the atrial septal occluder. Despite the effectiveness of the trancatheter closure and absence of complications, 2 linear indentations of the aortic root by the 2 discs of the device were clearly demonstrated in 16 cases, suggesting caution in the choice of very large occluders.

Amplatzer septal occluder closure of secundum atrial septal defects in the presence of persistent left superior vena cava to coronary sinus

Secundum atrial septal defects (ASDs) are routinely closed using transcatheter devices. In patients with left superior vena cava (LSVC) draining to the coronary sinus (CS), the device must not obstruct CS drainage. We report five cases of successful ASD device closure without obstructing flow from the LSVC or dilated CS.

New developments in the transcatheter treatment of congenital heart disease

PURPOSE OF REVIEW

This review summarizes recent developments in the field of interventional paediatric cardiology. This is a rapidly evolving field with many new techniques that have been optimized or introduced during the past few years.

RECENT FINDINGS

Important new data have emerged on the device closure of atrial septal defects, ventricular septal defects and patent ductus arteriosus. The technology has been improved further and more results on complications and problems have become available. New technical developments in the treatment of stenosis of the pulmonary arteries and the aorta, such as the use of cutting balloons and (covered) stents, have resulted in new treatment options for congenital disorders that were not considered suitable for percutaneous treatment. Fascinating emerging technologies such as percutaneous aortic and pulmonary valve implantations have been introduced and the first results have been reported. Changes in imaging technology such as intracardiac echocardiography and magnetic resonance imaging affect interventional cardiology. These changes result in a new approach to congenital heart disease in which hybrid surgical and interventional procedures are used to treat complex disease.

SUMMARY

Interventional congenital cardiology is a rapidly growing field that offers new treatment options for patients with congenital heart disease.

Erosion of Amplatzer septal occluder device after closure of secundum atrial septal defects: Review of registry of complications and recommendations to minimize future risk

The objectives of this study were to identify possible risk factors that may lead to erosion of the Amplatzer septal occluder (ASO) and recommend ways to minimize future risk. There have been rare occurrences of adverse events with development of pericardial effusion after ASO placement. Identification of high-risk cases, early recognition, and prompt intervention may minimize the future risks of adverse events. In all patients who developed hemodynamic compromise after ASO placement, echocardiograms (pre-, intra-, and postprocedure), atrial septal defect (ASD) size (nonstretched, stretched), size of the device used, cineangiograms, and operative records were reviewed by a panel selected by AGA Medical Corporation. The findings were compared to the premarket approval data obtained from FDA-approved clinical trials that were conducted in the United States, before the device was approved. A total of 28 cases (14 in United States) of adverse events were reported to AGA Medical. All erosions occurred at the dome of the atria, near the aortic root. Deficient aortic rim was seen in 89% and the defect described as high ASD, suggesting deficient superior rim. The device to unstretched ASD ratio was significantly larger in the adverse event group when compared to the FDA trial group. The incidence of device erosion in the United States was 0.1%. The risk of device erosion with ASO is low and complications can be decreased by identifying high-risk patients and following them closely. Patients with deficient aortic rim and/or superior rim may be at higher risk for device erosion. Oversized ASO may increase the risk of erosion. The defect should not be overstretched during balloon sizing. Patients with small pericardial effusion at 24 hr should have closer follow-up.