Transcatheter closure of secundum atrial septal defects in adults with the Amplatzer septal occluder: Intermediate and long-term results

Systematic review of multiple versus single device closure of Secundum atrial septal defects in adults

INTRODUCTION

Multiple device closure (MDC) strategy has been used in treating of complex Atrial septal defects (ASDs) in adults. The safety profile of MDC compared to conventional single device closure (SDC) is unknown in this population. This report represents the first review examining the outcomes of single versus multiple device ASD closure in adults with ostium secundum defects.

METHODS

Literature databases and manual search from their inception until June 30th, 2017 followed the Preferred Reporting Items of Systemic Review and Meta-Analysis (PRISMA) guideline. Main outcomes are 1) overall complication incidence, 2) arrhythmia incidence, 3) residual shunt rate. Each outcome profile was pooled by MDC and SDC, respectively and chi-square analysis was applied to examine statistical significance between MDC and SDC strategies (two-sided and p < .050).

RESULTS

A total of 1806 + studies were initially screened, and 20 studies were finally selected (MDC group, 147 patients; SDC group, 1706 patients). There was no difference in overall complication incidence (χ2 = 1.269; p = .259) and arrhythmia incidence (χ2 = 0.325; p = .568) between MDC and SDC. There was no difference in residual shunt rate between the SDC (4.10 %; 70/1706) and MDC groups (6.80 %; 10/147; χ2 = 2.387; p = .122).

CONCLUSIONS

The outcomes of percutaneous multiple ASD closure (MDC) seem to be safe and effective as compared to conventional single ASD (SDC) closure in terms of device - related complications and technical success of the procedure. Prospective registry data and randomized trials are needed to determine the long-term outcomes of percutaneous ASD closure using MDC.

Transcatheter Closure of Atrial and Ventricular Septal Defects: JACC Focus Seminar

The field of congenital interventional cardiology has experienced tremendous growth in recent years. Beginning with the development of early devices for transcatheter closure of septal defects in the 1970s and 1980s, such technologies have evolved to become a mainstay of treatment for many atrial septal defects (ASDs) and ventricular septal defects (VSDs). Percutaneous device closure is now the preferred approach for the majority of secundum ASDs. It is also a viable treatment option for selected VSDs, though limitations still exist. In this review, the authors describe the current state of transcatheter closure of ASDs and VSDs in children and adults, including patient selection, procedural approach, and outcomes. Potential areas for future evolution and innovation are also discussed.

Transthoracic echocardiography monitoring during atrial septal defect and ventricular septal defect device closures using a three-dimensional printed transducer holder

Transthoracic echocardiography (TTE) is noninvasive but can only be performed intermittently during fluoroscopy. In a prior study, we created a transducer holder device to allow for hemodynamic monitoring in the intensive care unit. The current study is the first instance of the use of a three-dimensional (3D)-printed TTE transducer holder, which is easily customized and personalized to a previous transducer holder at relatively low cost and short production time, to enable continuous TTE monitoring during device closure of an atrial septal defect (ASD) and ventricular septal defect (VSD). There were 14 ASD patients and 9 VSD patients scheduled to undergo device closure. The study's real-time TTE monitoring was performed by using a 3D-printed transducer holder over the course of the entire implantation procedure. There were 23 patients who successfully underwent septal closures using the 3D-printed holder that enabled real-time images over the entire procedure. The median duration for real-time TTE guidance was 15 minutes for the ASD and 36 minutes for the VSD and the median fluoroscopy time was 11 minutes for the ASD and 30 minutes for the VSD. One migrating VSD occluder and one case of aortic regurgitation after occluder deployment were noted by real-time TTE monitoring during the procedure. Our novel 3D-printed transducer holder can provide transesophageal echocardiography-like real-time imaging during device closure of an ASD and a VSD and may become a new alternative method in ASD and VSD closures. It can also prevent radiation exposure for the intervention team who would otherwise need to perform TTE during live fluoroscopy.

Transthoracic echocardiography monitoring during ASD closure using an artificial hand system

Aim

Continuous real-time echocardiographic monitoring is essential for guidance during ASD closure. However, transthoracic echocardiography (TTE) can only be implemented intermittently during fluoroscopy. We evaluate a novel approach to provide real-time imaging during the entire procedure.

Finding

We developed a custom-made TTE monitoring apparatus using artificial hand (AH-TTE) that enables real-time TTE images during atrial septal defect (ASD) closure. Thirty-two patients underwent successful device implantation using AH-TTE monitoring without complications. The median duration for real-time AH-TTE monitoring was 22 min and the median fluoroscopy time was 7.2 min. One case of pericardial effusion and one of transient bradycardia event due to air embolism was detected. All patients had uneventful recoveries.

Conclusions

Our simple and novel monitoring technique with AH-TTE provides TEE-like monitoring and may be a new alternative method for ASD closure. It gives real-time stable TTE images and minimizes radiation exposure for the interventional team during fluoroscopy.

Developing High Medical Technology, a Challenge for Developing Countries: The Percutaneous Closure of Atrial Septal Defects Using Nit-Occlud ASD-R: Early and Mid-term Results

Objective:

To assess the efficacy and safety of the Nit-Occlud ASD-R (PFM S.R.L, La Paz, Bolivia) in the percutaneous closure of secundum atrial septal defects (ASD).

Patients and Methods:

Fifty-three consecutive patients with median age of 11 years (range 3-67) and mean weight 27.1 kg (range 13-75 kg), treated in two cardiology centers between May 2007 and March 2011.

Results:

Mean fluoroscopy time was 14 minutes (5-53), mean procedure time was 70 minutes (45-150), mean defect size, as measured by the stop-flow technique, was 17.8 mm (5.6-31), and mean stent size of the implanted device was 18 mm (6-28), which is 0.98 times the defect size. Successful closure of the ASD without major complications was achieved in 49 of 53 patients. In 71.4% of patients in whom device implantation was accomplished, there was no evidence of a persistent shunt at the completion of the procedure. This closure rate increased to 91.7% after 24 hours, with 95.8% closure after three months and 100% closure after six months. Device embolization occurred in one patient within 24 hours of implantation and required surgical device removal and ASD closure. There were no other major complications and no deaths during the period of follow-up (average 72 months; range 59-105 months).

Conclusion:

The Nit-Occlud ASD-R device is safe and effective with very good closure rates.

Atrial septal defect closure in adulthood is associated with normal survival in the mid to longer term

Objective

The prognostic benefit of atrial septal defect (ASD) closure in adulthood, particularly in advanced age, remains uncertain. The aim of our study was to examine the impact of ASD closure in a contemporary adult cohort on mid to longer term survival as compared with expected survival in the general population.

Methods

We study herewith all consecutive patients (≥16 years of age) who underwent ASD closure, catheter or surgical, at our tertiary centre between 2001 and 2012. Furthermore, we compare survival of our ASD closure cohort with expected survival in age and gender-matched general population and standardised mortality ratios (SMR) were calculated.

Results

A total of 608 patients (mean age 45.4±16.7 years) underwent ASD closure (catheter 433(71.2%), surgical 175(28.8%)). There was no 30-day mortality and periprocedural complications were low (n=40, 6.6%). During a median follow-up of 6.7 (IQR 4.2–9.3) years 16 (2.6%) patients died; survival was similar to the general population (p=0.80) including patients >40 or >60 years of age at ASD closure (p=0.58 and p=0.64, respectively). There was no survival difference between gender (male: SMR 0.93; 95% CI 0.52 to 1.64, p=0.76; female: SMR 0.99; 95% CI 0.58 to 1.66, p=0.95) or mode of closure compared with general population (catheter: SMR 1.03; 95% CI 0.68 to 1.55, p=0.89; surgical: SMR 0.65; 95% CI 0.22 to 1.88, p=0.38).

Conclusion

Perioperative mortality and morbidity in a large contemporary adult cohort undergoing ASD closure, catheter or surgical, is extremely low. Mid to longer term survival is excellent irrespective of age, gender and mode of closure, and similar to matched general population.

Transcatheter Retrieval of Embolized Atrial Septal Defect Occluder Device by Waist Capture Technique

This case study describes the successful percutaneous transcatheter retrieval of an embolized Amplatzer occluder device using the "waist capture technique" in a patient with an atrial septal defect. This technique allowed for stability of the Amplatzer device, compression of the atrial discs for easier removal, prevention of further embolization, and minimal injury to vasculature during device retrieval. This novel and effective technique can be used safely for the retrieval of Amplatzer devices in the venous system.

Incidence and predictors of asymptomatic pericardial effusion after transcatheter closure of atrial septal defect

AIMS

Pericardial effusion (PE) without obvious periprocedural complications (e.g., cardiac perforation, device erosion) may occur after transcatheter closure of secundum atrial septal defects (ASD). The aim of the study was to investigate the incidence and predictors of PE unrelated to procedural complications.

METHODS AND RESULTS

We included all patients who had undergone successful percutaneous ASD closure from June 2009 to April 2014 (n=2,652) with no pre-existing PE or cardiac perforation or erosion. Transthoracic echocardiography (TTE) was performed during the procedure and one, three, and six months postoperatively. After device implantation, fifty patients (1.9%) developed new-onset PE (37 immediately, 13 during follow-up). These patients were asymptomatic, stable haemodynamically, and had no new arrhythmias. PE appeared mild (5.1±1.9 mm) and homogeneously echolucent by TTE. PE diminished spontaneously. Compared with 2,602 patients without PE, factors independently predicting asymptomatic PE were the device touching the atrial free wall, device size, patient age, and total defect size. Areas under the receiver operating characteristic curves were 0.78 (p<0.001), 0.66 (p<0.001) and 0.77 (p<0.001) for device size, patient age, and total defect size, respectively.

CONCLUSIONS

This is the first systematic report of a new type of PE. Our data provide new insights into new-onset PE after percutaneous ASD closure.

Mid-Term Outcomes after Percutaneous Closure of the Secundum Atrial Septal Defect with the Figulla-Occlutech Device

OBJECTIVES

To evaluate the mid-term outcomes after percutaneous closure of the secundum atrial septal defects (ASD) using the Figulla-Occlutech device (FOD).

BACKGROUND

Transcatheter closure has become the method of choice for most patients with ASD. Although the FOD may have some advantageous characteristics there is a paucity of data on later outcomes after the use of this relatively new device.

METHODS

Observational, single arm study including 200 non-consecutive patients who underwent ASD closure between 04/09 and 07/15 in 2 centers. Device performance, deployment technique, and immediate and mid-term outcomes were assessed.

RESULTS

Median age and weight were 24 years (4-72) and 58 kg (15-92), respectively. Single defects were observed in 171 patients (median size of 19 mm). The remainder had multiple or multifenestrated defects. Implantation of FOD (median size of 24 mm) was successful in all (99%), but 2 patients (1 with deficient postero-inferior rim; 1 with a large ASD for the size of the child). Embolization with device retrieval occurred in 2 (1%). Median follow-up of 36 months was obtained in 172 patients. Serial echocardiographic assessment showed complete closure in all but 2 patients, in whom an additional small non-significant posterior defect was purposely left untouched. There have been no episodes of late arrhythmias, device embolization, cardiac erosion, endocarditis, thromboembolism, wire fracture, or death.

CONCLUSIONS

Transcatheter closure of ASDs in older children, adolescents, and adults using the FOD was highly successful in a wide range of anatomical scenarios with high closure rates and no complications in mid-term follow-up.

Transcatheter Closure of Atrial Septal Defects in a Center With Limited Resources: Outcomes and Short Term Follow-Up

Background:

Transcatheter closure of atrial septal defects (ASD) has been accepted world-wide as an alternative to surgical closure with excellent results. This interventional, non-surgical technique plays an important role in the treatment of ASD mostly in the developing world where resources are limited.

Objectives:

To report the outcomes and short term follow-up of transcatheter closure of ASD over a 12-year period at our institution with limited resources.

Patients and Methods:

This retrospective study included all patients with the diagnosis of secundum ASD and significant shunting (Qp/Qs > 1.5:1) as well as dilated right atrium and right ventricle who had transcatheter closure at Integrated Cardiovascular Center (PJT), Dr. Cipto Mangunkusumo Hospital between October 2002 and October 2014. One hundred fifty-two patients enrolled in this study were candidates for device closure. Right and left heart cardiac catheterization was performed before the procedure. All patients underwent physical examination, ECG, chest X-ray and transthoracal echocardiography (TTE) prior to device implantation.

Results:

A total of 152 patients with significant ASD underwent device implantation. Subjects’ age ranged from 0.63 to 69.6 years, with median 9.36 years and mean 16.30 years. They consisted of 33 (21.7%) males and 119 (78.3%) females, with mean body weight of 29.9 kg (range 8 to 75; SD 18.2). The device was successfully implanted in 150 patients where the majority of cases received the Amplatzer septal occluder (147/150; 98%) and the others received the Heart Lifetech ASD occluder (3/150, 2%), whereas two other cases were not suitable for device closure and we decided for surgical closure. The mean ASD size was 19.75 (range 14 - 25) mm. During the procedure, 5 (4.9%) patients had bradycardia and 3 (2.9%) patients had supraventricular tachycardia (SVT), all of which resolved.

Conclusions:

In our center with limited facilities and manpower, transcatheter closure of atrial septal defect was effective and safe as an alternative treatment to surgery. The outcome and short-term follow-up revealed excellent results, but long-term follow-up is needed.

Migration of Amplatzer Septal Occluder to the Deep Aortic Arch in a Patient With Multiple Anatomic Anomalies

Atrial septal defect closure using the Amplatzer septal occluder (AGA Medical Corp, Golden Valley, MN) device is an established treatment option with excellent clinical outcome. However, several structural characteristics have been reported to be prognostic factors for failure of catheter interventional treatment. We report successful surgical removal of an Amplatzer septal occluder that had become dislocated and had migrated into the deep aortic arch. Compatible with previous reports, the patient presented with an atrial septal defect complicated by multiple anatomic deformities that were considered to be a contraindication for interventional treatment. Detailed structural assessment of the atrial septal defect is mandatory for successful treatment using the Amplatzer septal occluder.

Quality of life of patients with atrial septal defect following percutaneous closure

INTRODUCTION

Quality of life has become an important outcome measure in addition to mortality and morbidity in patients with congenital heart disease. Atrial septal defect is a common congenital heart disease, and transcatheter atrial septal defect closure has become an accepted treatment modality. The aim of this study is to assess the quality of life of patients with atrial septal defect who underwent percutaneous closure.

MATERIALS AND METHODS

We examined the quality of life of 69 patients with atrial septal defect and 69 healthy controls matched according to age, sex, educational level, and economic, marital, and employment status. Quality of life was investigated using the Turkish version of Short Form-36.

RESULTS

The mean age of the patients was 39.7 ± 14.2 and 26% were male. The quality of life assessment was performed at a mean follow-up time of 18.0 ± 13.8 months after the intervention. The mean scores of the domains of the Short Form-36, namely, physical functioning, role functioning, social functioning, mental health, vitality, pain, and general health, were similar in patients with atrial septal defect who underwent percutaneous closure and the control group.

CONCLUSION

Adult patients who underwent percutaneous atrial septal defect closure perceive their quality of life to be as good as their healthy counterparts.

Atrioventricular block subsequent to intraoperative device closure atrial septal defect with transthoracic minimal invasion; a rare and serious complication

OBJECTIVES

Atrioventricular block (AVB) is a infrequent and serious complication after percutaneous ASD closure. In this study, we report on the incidence of AVB associated with intraoperative device closure of the ASD with transthoracic minimal invasion, and the outcomes of this complication in our center.

METHODS

Between May 2006 and January 2011, a total of 213 secundum-type ASD patients were accepted in our hospital for intraoperative and transthoracic device closure with a domestic occluder. All patients were assessed by real-time transthoracic echocardiography (TTE) and electrocardiograph (ECG).

RESULTS

All patients were occluded successfully under this approach. Immediate postprocedure third-degree AVB was observed in two patients. Since heart rates were in the range of about 50 to 55 beats per minute, no intervention was needed except for close observation for one patient. Another patient who recovered sinus rhythm intermittently during the operation was fitted with a temporary pacemaker. Approximately one week following glucocorticoid treatment, the AVB resolved spontaneously in these two patients. Mobitz type II AVB occurred in three patients during the procedure. Two patients developed post-operative cardiac arrest and were rescued successfully with cardiopulmonary resuscitation. One other patient changed to Mobitz type I AVB after three days. During the follow-up period, which ranged from six months to five years, no further occurrence of AVB was found.

CONCLUSIONS

Intraoperative and transthoracic device closure of secundum ASDs with domestic occluder resulted in excellent closure rate. AVB is an infrequent but serious complication during and after device closure of a secundum ASD. AVB is a complication that warrants greater attention and long-term follow-up.

Intermediate and long-term followup of percutaneous device closure of fossa ovalis atrial septal defect by the Amplatzer septal occluder in a cohort of 529 patients

Objectives:

The aim of present study is to analyze the intermediate and long-term follow up results of percutaneous closure of fossa ovalis atrial septal defect (ASD) with Amplatzer septal occluder (ASO) in a large cohort of patients including children and adults.

Methods:

Between May 1998 and July 2008, 529 patients (age group 2-77 years, median 28 years) underwent successful device closure with an ASO at single tertiary referral cardiac center in India.. This was out of an attempted 543 cases. The procedure was carried out in catheterization laboratory under transesophageal echocardiographic and fluoroscopy guidance. The mean size of ASD was 20 mm (7-40 mm) while size of septal occluder was 10-40 mm (mean 24 mm). Two devices were deployed in four patients. Three patients developed transitory pulmonary edema in immediate postprocedure period requiring ICU care for 48 hrs. All patients were advised for Aspirin (3-5 mg/kg, maximum 150 mg) once daily for 6 months. In patients with device 30 mm or larger, Clopidogril ( 75 mg once daily) was given for 3 months in addition to Aspirin. Clinical evaluation, echocardiogram were done on 3 months, 6 months and then at 1, 3, 5, 7 and 10 years of follow up. Transesophageal echocardiography (TEE) was performed in case of any doubt on clinical evaluation or on transthoracic echocardiography (n=10).

Results:

Followup data is available for 496 patients (93.7%). Followup period is from 12 months to 120 months (median 56 months). On followup, device was in position in all patients, no residual shunt and no evidence of thrombosis. Interventricular septal motion normalized on day of procedure in 89% patients, in 6% over 3 months while flat septal motion persisted in 5% (n=25, all in age group > 40 years) of cases, though right ventricular dilatation persisted in 10% (n=50, age more than 40 years) of patients. Symptom-free survival was 96.7 % (480/496) in patients who came for followup. Only one 68 year old patient with preexistent tricuspid regurgitation developed congestive heart failure, and one patient (58 years old) had a history of hemiparesis after 1 year of device on telephonic interview. Ten patients were in atrial fibrillation (AF) before the procedure and remained in AF on followup.

Conclusions:

Our study showed that percutaneous closure of fossa ovalis ASD is a safe and effective procedure on intermediate and long-term followup in both the children as well as adults.both. Technical factors during the procedure and proper follow up are important. Our single centre intermediate and long term experience in a large number of patients support the use of device closure as an alternative to surgery.

Long-term outcome of percutaneous closure of secundum-type atrial septal defects in adults

AIMS

Transcatheter closure of the secundum-type atrial septal defect (ASD) is widely practised. We report complications and efficacy of percutaneous ASD closure in adults using the Amplatzer ASD occluder and the Cardioseal/Starflex device during long-term follow-up.

METHODS AND RESULTS

Between 1996 and 2008 percutaneous ASD closure was performed in 133 patients (mean age 46.8 ± 16.9 years; 36 men) by using the Amplatzer(r) device in 104 patients and the Cardioseal/Starflex device in 29. During a mean follow-up of 3.4 ± 2.8 years the occurrence of major complications was higher in patients with the Cardioseal/Starflex compared to patients with the Amplatzer(r) devices (17.2 vs. 2.9%, log rank, P=0.005), due to a higher embolisation rate (13.8 vs. 1.0%, log rank, P=0.002). In univariable analysis, the implantation of a Cardioseal/Starflex device (OR 6.0 (CI 1.4-25.2); P=0.01) and a larger device diameter (OR 1.1 (CI 1.0-1.2); P=0.04) were found to be predictors of the occurrence of major complications. Minor complications occurred in 10.5%, recurrent thrombo-embolism in 2.3% and residual shunting at six months was 13.9% without differences between devices. NYHA class improved from 1.8 ± 0.6 before to 1.2 ± 0.4 after closure (P<0.001) without differences between devices.

CONCLUSIONS

During long-term follow-up, percutaneous ASD closure in adults is safe and effective when using the Amplatzer(r) device. Larger Cardioseal/Starflex devices are related to a higher embolisation rate. Randomised trials are needed.

Comparison of the response of the right ventricle with endovascular occlusion and surgical closure in adults with atrial septal defect one year after intervention

BACKGROUND

Use of the Amplatzer septal occluder (ASO) for the closure of secundum atrial septal defect (ASD) has recently become the procedure of choice, while earlier the only treatment for ASD was surgical closure. This study compares the right ventricular indices of the ASO group with the surgical closure group one year after intervention in adults.

METHODS

From January 2008 to February 2010, 38 patients with isolated atrial septal defect of the secundum type one year after surgical (n = 20, age = 27 ± 4 years, 13 females, 7 males) or Amplatzer septal occluder closure (n = 18, age = 25 ± 4 years, 12 females, 6 males) were studied. At the same time, thirty-one age-matched normal subjects (age = 26 ± 6 years, 23 females, 9 males) were included as the control group. Strain and strain rate of the right ventricle were measured.

RESULTS

The mean values of strain of the midportion were -26% ± 11.7%, -8.9% ± 4.2%, and 24.5% ± 7.4% (P < 0.001). Strain rates of the midportion were -2.19 ± 0.6 s(-1), -1.2 ± 0.4 s(-1), -1.9 ± 0.6 s(-1) (P < 0.001) in ASO, surgery, and control groups, respectively.

CONCLUSION

This study showed that the right ventricle might show better performance in the ASO than the surgery group in adults with ASD in midterm follow-up.

Closure of ostium secundum atrial septum defect with the Atriasept occluder: early European experience

OBJECTIVES

This multicentre study sought to report the safety and efficacy of the ATRIASEPT septal occluder to repair atrial septal defect (ASD).

BACKGROUND

The ATRIASEPT is a low profile, flexible, double disk occluder with centering system specifically designed for closure of ostium secundum ASD.

METHOD

Patients were enrolled from four participating European sites and followed up for 12 months post procedure. Outcomes were evaluated, including closure success and incidence of adverse events.

RESULTS

Seventy-six patients received the ATRIASEPT device. Mean size of the defect was 15 +/- 4 mm. Closure success was observed in 69 patients (89%) at the end of the procedure. Sixty-four patients had a six-month follow up with a complete closure by 58 patients (90%). Minor adverse events occurred in two patients. Significant functional improvement was reported by all symptomatic patients.

CONCLUSION

Percutaneous closure of ASD ostium secundum type defects with the ATRIASEPT is safe and effective with high success rate and excellent mid-term outcome.

Cardiac remodeling and effects on exercise capacity after interventional closure of atrial septal defects in different adult age groups

BACKGROUND

Interventional closure of atrial septal defects (ASD) has become a standard procedure in pediatric and adult patients. We report immediate and mid-term results in different adult age groups.

METHODS

A retrospective analysis of 332 patients undergoing percutaneous ASD closure between 1998 and 2008 was performed. Beside echocardiographic and hemodynamic measurements, the NYHA functional class was assessed before and after ASD closure. The peak oxygen uptake (VO(2peak)) was available in a subgroup of 154 patients.

RESULTS

The different age groups did not differ significantly in shunt volume or defect diameter, but a significant increase could be detected in mean pulmonary arterial pressure, mean left atrial pressure and pulmonary vascular resistance (PVR9 with increasing age). Right ventricular enlargement was present in all age groups, but the degree of enlargement increased with age. Transcatheter ASD closure was successful in 99.4%, major adverse events occurred in four patients (1.2%). At 3 months from closure, 123 patients reported an improvement, 7 of worsening and 163 of no change in their functional capacity. A significant increase in VO(2peak) could be registered in all subgroups after ASD closure. When classified by shunt volume no change could be detected in VO(2peak) in the patients with a Q(p):Q(s) < 2, whereas patients with a Q(p):Q(s) > 2 had a highly significant VO(2peak) increase.

CONCLUSION

Patients benefit from interventional closure of hemodynamically significant ASD regardless of their age. However, the defect should be repaired as early as possible to prevent hemodynamic complications, such as the development of pulmonary hypertension and cardiac arrhythmias.

Interventional closure of two fistulas after aortic valve surgery

INTRODUCTION

Paravalvular fistulas may complicate the clinical course after heart valve surgery. Medical treatment may be ineffective, repeated surgical revisions may be associated with increased morbidity and mortality.

CASE REPORT

After valve sparing surgery in bicuspid aortic valve, a significant aorto-left atrial fistula was diagnosed in a 72-year-old patient causing heart failure and catecholamine-dependency. Due to the critical hemodynamic state, percutaneous closure was performed with an AGA Amplatzer duct occluder. Secondary to this closure, a second fistula between the aortic root and the right atrium appeared which was closed during the same procedure implanting a second duct occluder beneath the first device.

CONCLUSION

Percutaneous closure of paravalvular fistulas is feasible and a safe method for the treatment of significant shunts after valve surgery. Even in multiple fistulas, the implantation of small devices allows for a focussed interventional closure of such leaks. This procedure should be considered for such defects as it represents a safe method for the causative treatment in paravalvular lesions after valve surgery especially in patients with critical hemodynamic conditions.

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.

Percutaneous closure of atrial septal defects: echocardiographic and functional results in patients older than 60 years

BACKGROUND

Percutaneous closure of atrial septal defects is well established in children and adults and has been found to improve symptoms and positively influence right-heart remodeling. The aim of this study was to evaluate the efficacy and long-term outcome in adult patients older than 60 years.

METHODS AND RESULTS

The study population comprised 96 patients in the age group of 60 to 84 years. Percutaneous closure was performed effectively in all patients. Functional capacity according to New York Heart Association functional class and peak oxygen uptake (VO(2)max) in the cardiopulmonary exercise testing improved significantly after atrial septal defects closure, especially in patients with a pulmonary-to-systemic flow ratio >2. Echocardiographic measurements of the right ventricular end-diastolic diameter showed a significant decrease. No device-associated complications were observed, but in 16 patients, paroxysmal atrial fibrillation occurred after device implantation.

CONCLUSIONS

Percutaneous atrial septal defects closure can be performed safely and with minimal risk even in elderly patients. They profit in terms of symptom reduction, improvement of exercise capacity, and right-heart remodeling.

Closure of atrial septal defect with the Amplatzer septal occluder in adults

Transcatheter closure of atrial septal defects (ASDs) was performed mainly in children and adolescents. Information about outcome and complications in adults was limited. From November 1997 to November 2005, percutaneous closure of ASDs using the Amplatzer septal occluder was attempted in 650 consecutive adult patients. Median patient age was 45.8 +/- 16.2 years (range 18 to 90), mean systolic artery pressure was 33.3 +/- 10.6 mm Hg (range 11 to 85), and mean pulmonary and systemic blood flow (Qp/Qs) ratio was 1.9 +/- 0.7 (range 0.8 to 6.6). Mean stretched diameter of the ASD was 21.2 +/- 5.1 mm (range 3.1 to 43). Seventy-eight patients (12%) had multiple defects. Of 572 patients with a single ASD, device implantation was successful in 563 patients (98%). During follow-up, complete closure could be achieved in 96% of patients with a single ASD and 71% of patients with multiple defects. Mean systolic artery pressure decreased to 28.3 +/- 10.1 mm Hg and mean Qp/Qs ratio decreased to 1 +/- 0.3. The 3 complications that occurred during the procedure were device embolization (2 patients; 0.3%) and transient ST depression (1 patient; 0.2%). The most common complication immediately after the procedure and during follow-up was new-onset atrial fibrillation (28 patients; 4.3%). Electrical cardioversion was successfully in most. Complications requiring emergency or elective surgery occurred in 6 patients (0.9%; hemopericardium, 2 patients, 0.3%; device embolization, 3 patients, 0.5%, and pericardial tamponade, 1 patient, 0.2%). In conclusion, closure of ASDs using the Amplatzer septal occluder in adults was efficient and safe, with excellent long-term success rates. Serious complications were rare.

Incidence of atrial fibrillation following transcatheter closure of atrial septal defects in adults

Transcatheter closure of secundum atrial septal defect (ASD) and patent foramen ovale (PFO) has become a routine procedure. Little is known about the effect of atrial septal device implantation on the occurrence of atrial fibrillation (AF). We evaluated the frequency of AF occurring after transcatheter PFO and ASD closure in a large population. From 1994 until 2007 a total of 1,062 patients underwent transcatheter closure of an interatrial communication. New-onset AF was defined by 12-lead electrocardiogram or Holter monitoring in patients without a history of AF at baseline. Of the 1,062 patients, 822 had a PFO and 240 had an ASD. During a median follow up of 20 months, new-onset AF was documented in 8% of patients. New-onset AF occurred in 7% of patients after PFO closure and in 12% of patients with underlying ASD. The annual incidence of new-onset AF was 2.5% and 4.1% in patients with PFO and ASD, respectively. Generally, patients with new-onset AF were older than those without AF. Device type or size did not influence the occurrence of AF. In the group of patients with PFO, residual shunt was more common in patients with AF compared with the non-AF group. In conclusion, AF is more common after PFO and ASD closure compared with the general population; although device type or size did not impact the occurrence of AF, residual shunt may influence the occurrence of AF after intervention in patients with underlying PFO.

[Dislodged Amplatzer occluder in the aorta]

Percutaneous device closure of atrial septal defect (ASD) has merged as an alternative to traditional surgical closure. The authors are presenting the case of a 55-year-old female patient with chest complaints following Amplatzer occluder implantation for closure of secundum type ASD. She had been presented ambulatory at her cardiologist's office 3 days after the discharge from the hospital. Echocardiography revealed persisting ASD and displacement of the device. She had been referred to the Heart Institute of Pécs, where chest X-ray and CT examination were done. The dislocated occluder device was found wedged in the bifurcation of aorta and brachiocephalic trunk. Open heart surgery was indicated and the device was removed, after that the ASD was directly closed. The patient had been discharged in good health at the 5th postoperative day.