Atrial septal defect occlusion with the buttoned device (a multi-institutional U.S. trial)

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.

Outcomes of Three Different Minimal Invasive Approaches for Secundum Atrial Septal Defect Closure: A Single Institute Experience

OBJECTIVE

The aims of this retrospective study were to investigate and evaluate the safety and efficacy of three approaches for closure of secundum atrial septal defect (ASD).

METHODS

In this study, we reviewed clinical data for transcatheter occlusion (TCO, n=63), transthoracic occlusion (TTO, n=55), and right anterolateral minithoracotomy (RALT, n=60) techniques used for ASD closure. We compared the safety and efficacy of the three approaches.

RESULTS

ASD size in the TTO group was similar to that in the RALT group (P=0.645) and significantly larger than that in the TCO group (P<0.001). The RALT group had more non-central types of ASD than the TTO and TCO groups (P=0.019 and P<0.001). The operative time in the TTO group was shorter than that in the TCO and RALT groups (P<0.001 and P<0.001). The ventilation time and intensive care unit duration were shorter in the TTO group than in the RALT group (P<0.001 and P<0.001). Hospital duration in the TCO group was shorter than that in the TTO and RALT groups (P<0.001 and P<0.001). There were no residual shunt and mortality in any group in hospital or during follow-up. There was no significant difference in the incidence of total complications among the three groups (P=0.738).

CONCLUSION

TCO, TTO, and RALT can be performed with favorable cosmetic and clinical results for closing ASD. Appropriate patient selection is an important factor for successful closure. These techniques are promising alternatives to standard median sternotomy and merit additional study.

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.

The Journey of an Indian Pediatric Cardiologist : Dr. K. C. Chaudhuri Lifetime Achievement Award/Oration at AIIMS, New Delhi, September 2017

The life journey of an Indian pediatric cardiologist, who bestowed considerable attention to the development of new knowledge and train/teach physicians around the world while providing care of patients with heart disease over a 45-y period, is reviewed. This appraisal focuses particular attention on the scientific contributions to the literature. These include spontaneous closure of physiologically advantageous ventricular septal defects, various issues related to a congenital heart defect namely, tricuspid atresia and transcatheter and, interventional pediatric cardiac procedures.

[Percutaneous closure of atrial septal defects with the Amplatzer® device: 15 years of experience]

INTRODUCTION

Percutaneous closure of atrial septal defects is an alternative to surgical treatment.

OBJECTIVES

We report the results of percutaneous closure of atrial septal defects with the Amplatzer(®) device.

METHOD

We include patients taken to the catheterization laboratory from September 1997 to December 2011.

RESULTS

We proceeded with defect closure in 721 patients and in 85 the defect was considered not suitable for closure. The stretched diameter of the defect was 23±6.7mm (limits, 5-42). All devices were positioned successfully. In 15 cases (2.1%) the device was changed due to instability and in 6 (0.8%) the device embolized within the first 24h, 4 were retrieved and repositioned (final success with intention to treat 719/806-89.2%). Immediate control showed complete closure in 247 patients (34.3%), leak through the device in 395 (54.9%), mild residual leak in 75 (10.4%) and moderate in 2 (0.3%). We have follow-up in 626 patients (87.1%) for 33±27.5 months, with headache in 54 (8.6%), new supraventricular arrhythmia in 10 (1.6%), puncture site complications in 4 (0.6%), and stroke in one (0.1%).

CONCLUSION

The design of the Amplatzer(®) device allows effective closure of atrial septal defects with a simple technique and patient safety.

Migration of an AMPLATZER atrial septal occluder to the abdominal aorta

Percutaneous closure of an atrial septal defect has been increasingly used, and complications have been rare. We report the case of a 63-year-old man who had undergone endovascular closure of a secundum atrial septal defect months earlier. The occluder was later found in the abdominal aorta.

Cor triatriatum dextro iatrogenica: an unusual complication of atrial septal defect closure device

We present a case of a rare complication of atrial septal defect (ASD) device closure causing cor triatriatum dextro iatrogenica. A 29-year-old female presented with sudden onset dysarthria and ataxia and was found to have basilar and thalamic infarcts. Further evaluation using transthoracic echocardiography revealed an ASD which was repaired using the Gore HELEX septal occluder. Transesophageal echocardiography done after 2 months of ASD closure revealed an interesting finding termed cor triatriatum dextro iatrogenica. We briefly describe the case and discuss the relevant literature.

Late migration of a Sideris septal occluder device for closure of atrial septal defect into the left atrium with mitral valve obstruction

The transcatheter closure of atrial septal defects provides an alternative to surgery, and various devices, such as the Sideris buttoned device, have been prescribed. Late complications have been rare and have not yet been reported within 2 years of implantation. This report presents a case of delayed migration of a Sideris buttoned device occurring 6 years after successful implantation. In conclusion, this report provides a reminder of the need for careful long-term follow-up of patients receiving transcatheter closure of atrial septal defects, particularly in cases involving the implantation of early-generated devices.

Late migration of a Sideris buttoned device for occlusion of atrial septal defect

We describe a 17-year-old patient with an atrial septal defect who underwent device closure with a second generation Sideris buttoned device at 4 years of age. She presented 13 years after the procedure with the acute onset of chest discomfort, at which time a chest radiograph showed migration of the wire of the right atrial counter-occluder to the lateral aspect of the right atrial wall, with an associated right atrial perforation. The patient underwent uneventful surgical device retrieval and atrial septal defect closure. Late migration of a portion of the Sideris buttoned device can occur, suggesting the need for continued follow up, and a high index of suspicion for device failure should a patient become symptomatic.

Assessment of atrial septal defect size with 3D-transesophageal echocardiography: comparison with balloon method

BACKGROUND

Transcatheter closure of atrial septal defect (ASD) is an alternative approach to surgery in selected patients. Balloon stretched diameter (BSD) is considered as the standard way of measuring ASD size. Three-dimensional transesophageal echocardiography (3D-TEE) provides views of the ASD allowing its measurement and identifying its spatial relation with neighboring structures. Our aim was to compare the BSD and 3D-TEE methods to measure the ASD size before transcatheter closure.

METHODS AND RESULTS

Seventy-six consecutive patients were enrolled for ASD device closure. Three-dimensional transesophageal echocardiography and balloon sizing were adequately performed in 70 patients before the defect closure. The mean maximal diameter measured by 3D-TEE was 20 +/- 15 mm (range 10-28) while the mean BSD was 22 +/- 4.8 mm (range 9-31). When comparing the 3D-TEE and transcatheter measurements, there was a good correlation between the two methods (y = 3.15 + 0.77x; r = 0.8). The defect as viewed by 3D-TEE was unique in 54 patients and multiple in 16 patients. In patients with a single defect, the correlation between the two methods was high (y = 1.74 + 0.84x; r = 0.85) while patients with multiple ASDs, the correlation was poor (y = 12.4 + 0.4x; r = 0.45). Transcatheter closure was performed successfully in 86%. The mean size of the Amplatzer device was 23 +/- 4.8 mm (range 4-32). The reference to choose the size of the device was the BSD in single defects and the 3D-TEE maximal diameter in multiple defects.

CONCLUSION

Three-dimensional transesophageal echocardiography and transcatheter methods are two complementary techniques for the success of transcatheter ASDs closure.

Diverse experience with the CardioSEAL and STARFlex septal occluders

Apart from closure of atrial septal defects, there is little information concerning the use of the CardioSEAL family of occluders in congenitally malformed hearts. We review here our initial experience using the CardioSEAL and STARFlex occluders in 12 patients aged 17.3 +/- 11.2 years, with a range from 4 to 34 years. Of the patients, 5 had fenestrated extracardiac Fontan procedures, 5 had persistent patency of the arterial duct, 1 had a leak across a Mustard baffle, and the final patient had a huge pulmonary arteriovenous malformation. We implanted successfully 9 CardioSEAL, and 3 STARFlex occluders, with sizes from 17 to 40 mm. In one patient, the occluder embolized to the right pulmonary artery, from where it was retrieved through the catheter. In two patients, there was a trivial residual leak immediately after implantation, but no patient had a residual leak after 6 months of follow-up. We noted improved ventricular dimensions, without any fractures of the arms of the occluders, perforations, or disturbances of flow after 2.4 +/- 0.9 years of follow-up. We have demonstrated, therefore, the versatility of the CardioSEAL and STARFlex occluders, which have been used safely and effectively to close a variety of intra and extracardiac communications other than atrial septal defects.

Beating atrial septal defect closure monitored by epicardial real-time three-dimensional echocardiography without cardiopulmonary bypass

BACKGROUND

We assessed the feasibility of beating atrial septal defect (ASD) closure monitored by real-time 3D echocardiography (RT3DE).

METHODS AND RESULTS

RT3DE was developed with prototype ultrasound equipment consisting of a high-speed 3D rendering unit with a frame rate of 5 to 10 frames/s. We also developed a prototype semiautomatic suture device and suture cutting system. In the experiment, 12 mongrel dogs were anesthetized, and after median sternotomy, the echo probe was applied directly to the surface of the right atrium. Three surgical maneuvers (balloon atrial septectomy, enlargement of the ASD, and ASD closure) were performed through the atrial port inserted into the right atrial appendage. The heart was then excised, and the area of the ASD measured by RT3DE was compared with its area measured directly. The ASD was successfully closed in all experimental animals except the first 2. Examination of the excised heart showed that none of the sutures were loose. The mean area of the ASD was 82.5+/-38.6 mm(2) when measured by RT3DE and 81.6+/-38.2 mm(2) when measured directly, and there was a significant correlation between the areas measured by RT3DE and those measured directly (echo measurements=1.007xdirect measurements+0.337; P<0.0001). A Bland-Altman analysis revealed close agreement between the results obtained by the 2 methods (7.807 mm(2) upper and -6.024 mm(2) lower limit of agreement).

CONCLUSIONS

Introduction of RT3DE, a semiautomatic suture device, and a suture cutting system made beating ASD closure without cardiopulmonary bypass possible.

Minimal access closure of patent foramen ovale: is it also recommended for patients with paradoxical emboli?

BACKGROUND

To investigate the outcome of the port-access approach for patent foramen ovale (PFO) closure and to identify the long-term risk of recurrent thromboembolic events in the paradoxical embolus subgroup after closure.

METHODS

Between 1997 and 2001, 31 patients underwent PFO closure using the port-access approach. Twelve of the 31 patients underwent PFO closure secondary to at least one paradoxical embolic event leading to either transient ischemic attack or cerebral infarction. All patients were followed longitudinally with office visits and telephone interviews.

RESULTS

The mean age was 47 years (range 18 to 85 years). All procedures were completed successfully without conversion to median sternotomy. The mean duration of aortic occlusion and cardiopulmonary bypass for all patients (n = 31) was 32 minutes (range 17 to 55 minutes) and 72 minutes (range 40 to 124 minutes), respectively. Postoperative complications included pneumonia/pulmonary embolus (n = 1), transient atrial fibrillation (n = 3, 9.7%), and exploration for bleeding (n = 3, 9.7%). No deaths were recorded. All patients were assessed using transesophageal echocardiography, and the closure of the PFO was documented. The average length of hospital stay was 3.8 days (range 2 to 10 days) for patients with paradoxical emboli. The mean follow-up period for the paradoxical embolus subgroup was 23 months (range 4 to 45 months). One patient was lost to follow-up. Neither transient ischemic attack nor cerebral infarction recurred during follow-up.

CONCLUSIONS

The port-access approach to PFO closure is a safe and effective procedure, with acceptable initial experience outcome and excellent low-risk rate of recurrent thromboembolic events.

Transcatheter closure of atrial septal defects with the Amplatzer septal occluder--a Japanese clinical trial

This study reports the results of a Japanese clinical trial of transcatheter closure of atrial septal defects (ASD) using the Amplatzer septal occluder (ASO). Thirty-five patients with secundum ASD underwent transcatheter closure using the ASO at a median age of 12.9 years (range, 3.2-29.2 years) and a median weight of 39.2kg (range, 11.6-65.1 kg). The ASO was successfully implanted in 34 patients. The mean ASD diameter of the 34 patients measured by transesophageal echocardiography was 11.7 +/- 4.2mm (range, 5.0-20.8mm) and the mean balloon stretched diameter was 16.8 +/- 4.2 mm (range, 9-25 mm). The mean ASO size was 16.9 +/- 4.3 mm (range, 9-26mm). Complete closure rate at 1 day and 1 year after closure was 91% and 97%, respectively. One patient developed a transient second-degree atrioventricular block during the implantation procedure. No other complications occurred. Transcatheter closure of ASD using the ASO is effective and safe.

Non-surgical closure of atrial septal defect

BACKGROUND

Recently many devices for the transcatheter closure of atrial septal defect (ASD) were developed in the world. Several ASD closing devices, such as Clamshell device, buttoned device, ASD occluder system (ASDOS), Angel Wings, are not fully acceptable from a practical point of view. We reported the clinical trials of transcatheter closure of ASD for Clamshell double umbrella device and Amplatzer septal occluder (ASO) in Japan.

METHODS

Clamshell devices were implanted in 11 patients. Clinical trials for ASO device were carried out in 34 patients in Japan. We reported the results of 17 patients in National Children's Hospital.

RESULTS

Clamshell devices were implanted in all of the patients successfully. Minimal residual shunt was present in four patients (36%), 1 year after the procedure by Doppler color flow imaging. Nine of 11 umbrellas demonstrated fracture of the stainless steel arm. Arm fracture occurred between 1 week and 12 months after implantation. The implantations of ASO device were successful in all of the 17 patients. Sixteen out of 17 (94.1%) had complete closure in the average observation period of 5.5 months. Complications were minimal and transient.

CONCLUSIONS

With respect to complete closure rate, easy manipulation, and complication rate, ASO is the best transcatheter ASD closure device among all the devices at the present time.

Percutaneous closure with Amplatzer device is a safe and efficient alternative to surgery in adults with large atrial septal defects

BACKGROUND

In adults with atrial septal defect (ASD) and large right-to-left shunt, closure of the defect is recommended. Percutaneous closure is still rarely used in this population. This study presents the results of transcatheter closure with the Amplatzer occluder in such patients.

METHODS AND RESULTS

We studied 44 consecutive adult patients with a secundum ASD and 2 of the 3 following criteria: QP/QS >/=2 by oximetry, echocardiographic right ventricle overload, and ASD size >20 mm. Forty-two patients had a successful implantation. In 1 patient an unstable device was withdrawn; in another one, the device embolized in the pulmonary artery. At 6-month median follow-up, 95% had a complete closure; 2 patients with an additional defect had a small residual shunt. Major complications were the aforementioned embolization and a cerebrovascular accident in a patient with atrial fibrillation treated with aspirin. Others were minor and transitory: premature atrial beats in 3 patients, and paroxysmal atrial fibrillation and pulmonary edema in 1 patient each.

CONCLUSIONS

Transcatheter closure of large ASDs with the Amplatzer device is efficient with less morbidity than surgical closure.

Platypnea-orthodeoxia: management by transcatheter buttoned device implantation

Dyspnea and arterial desaturation on upright position in elderly subjects is described as platypnea-orthodeoxia syndrome (POS) and in some patients it is due to right-to-left shunt across the atrial septal defect (ASD)/patent foramen ovale (PFO). Surgical closure of ASD/PFO has been the only available treatment option. Buttoned device has been used for occlusion of ostium secundum ASD, PFO associated with presumed paradoxical embolism and cerebrovascular accidents and ASD/PFO in association with other congenital heart defects causing right-to-left shunt. The objective of this article is to describe the use of buttoned device in effectively occluding ASD/PFO to relieve hypoxemia of POS. During a 4-year period ending January 2000, 10 patients, ages 71 +/- 9 (range 60-83) years with POS underwent buttoned device closure of their ASD/PFO. Echocardiographic and balloon-stretched atrial defect sizes were 8 +/- 3 mm and 12 +/- 3 mm, respectively. The ASD/PFO were occluded with devices ranging in size from 25 to 40 mm delivered via 9 French, long, blue Cook sheaths; eight had an additional 25- or 35-mm occluder placed on the right atrial side. The oxygen saturation increased (P < 0.001) from 76 +/- 7% (range 69-86%) to 95 +/- 2% (range 92-98%). No complications were encountered. Relief of symptoms was seen in all patients. Follow-up of 1-36 months (median 12 months) revealed persistent improvement of symptoms. Buttoned device occlusion of ASD/PFO to relieve hypoxemia of POS is feasible, safe, and effective and is an excellent alternative to surgery. Cathet Cardiovasc Intervent 2001;54:77-82.

Healing response to the Clamshell device for closure of intracardiac defects in humans

The healing response to intracardiac devices in humans is largely unknown. During regulatory trials using the Clamshell device in over 800 patients, attempts were made to perform histopathological evaluation of all explanted devices. We reviewed all those with complete histopathological examination (n = 12) from Fontan baffles (n = 4), ventricular septal defects (n = 2), and atrial septal defects (ASD; n = 6), explanted at 2.7 months to 3.6 years (median, 1.6 years), at autopsy (n = 1) or surgery (n = 11), performed for residual defects (n = 5), atrial masses (n = 3), or Fontan revision (n = 3). All but one were nearly (n = 3) or completely (n = 8) covered by pseudointima, composed of fibroelastic tissue, predominantly collagen, with focal foreign body reaction in contact with fabric, without acute inflammation or infection. Atrial masses of granulation tissue were present in three cases (ASD), opposite to protruding fractured arms. No associations were identified between coverage and closure status, position, arm fractures, or implant period. In conclusion, the healing response to transcatheter Clamshell implantation in humans is characterized by a relatively rapid development of a nonthrombotic pseudointima composed of fibroelastic tissue with minimal foreign body reaction. Cathet Cardiovasc Intervent 2001;54:101-111.

Centering-on-demand buttoned device: its role in transcatheter occlusion of atrial septal defects

Since the initial design and description of the buttoned device, it has undergone a number of design changes. Introduction of radiopacity in the knot (button) made it easier to visualize and document that buttoning has indeed occurred. Introduction of two buttons has markedly decreased the unbuttoning rate with potential for eliminating it. A centering mechanism was then incorporated into the device, which allowed closure of larger defects and use of smaller-sized devices. For some unknown reason, unbuttoning rate no longer occurs since the introduction of this device. The centering-on-demand (COD) device also appears to have increased the effective occlusion rates. At the present time, however, no long-term follow-up data are available to assess the long-term efficacy of the new device. Experience in a larger number of patients and evaluation of follow-up data are necessary to confirm the safety and efficacy observed in the small cohort reported in this review.

Unique echocardiographic features associated with deployment of the Amplatzer atrial septal defect device

The purpose of this study was to describe the unique echocardiographic findings associated with deployment of the Amplatzer atrial septal defect (ASD) device. Thirty-five patients (2 to 40 years old; 23 female and 12 male patients) underwent echocardiography during attempted ASD closure with the Amplatzer device. Transesophageal and transthoracic echocardiograms were performed during the placement and follow-up of the device, respectively. In 5 patients, the device was not deployed because of transesophageal echocardiography (TEE) findings (an exceedingly large defect in 3 patients, partial obstruction of the upper right pulmonary vein by the device in 1, and complex atrial septal anatomy in 1). In the remaining 30 patients, after deployment but before release, the device distorted the atrial septum from the normal vertical orientation to an oblique transverse orientation. Excessive septal distortion (i.e., > or =90 degrees in 1 patient) was associated with device embolization upon release. In other patients, TEE also identified mild splaying of the device on the aortic wall, mild abutment of the device upon the mitral valve, and temporary partial obstruction of pulmonary vein flow. Color Doppler revealed residual shunts in 21 of 29 patients immediately after release, but in none of 15 patients at 1-year follow-up. Transesophageal echocardiography is essential to ensure proper Amplatzer device placement. Distortion of the atrial septum and Amplatzer device orientation occur before release but resolve on release from the delivery cable. Small residual shunts are common early, but they resolve in 6 to 12 months.

One-year follow-up of the amplatzer device to close atrial septal defects

The early and 1-year follow-up of a single United States center using the Amplatzer atrial septal defect closure device is reported. Complete closure was documented in all patients by 1 year after device implantation.

Surgical management of complications after transcatheter closure of an atrial septal defect or patent foramen ovale

OBJECTIVE

During recent years, transcatheter closure has become an alternative to operations for the treatment of atrial septal defects and patent foramen ovale. However, this procedure may be unsuccessful or complicated and requires surgical treatment.

METHODS

We retrospectively analyzed the outcomes of patients who needed surgical treatment after failed or complicated transcatheter closure of an atrial septal defect or a patent foramen ovale.

RESULTS

Between April 1994 and March 1999, 124 patients were treated with transcatheter closure of an atrial septal defect or a patent foramen ovale at our institution. We report the results of 10 (8%) patients of this series who required operations after transcatheter closure attempts. In 8 of these 10 patients a significant shunt caused by malposition or dislocation of the device persisted, leading to surgical closure of the defect. In 2 patients injury of the femoral artery at the puncture site required surgical repair. In one patient the device had to be removed surgically from the iliac vein after retraction. One patient died of left ventricular perforation after dislocation of the device and several surgical attempts to close the left ventricular rupture. All other patients recovered well.

CONCLUSION

An operation was required after transcatheter closure of an atrial septal defect or a patent foramen ovale in 8% of patients. After device complications, the atrial septal defect and the patent foramen ovale can still successfully be closed surgically with good results and low morbidity. However, serious complications like cardiac perforation may have a fatal outcome. Residual shunt, dislocation, or vascular complications are the most frequent problems that require surgical interventions.

Recommendations of the British Paediatric Cardiac Association for therapeutic cardiac catheterisation in congenital cardiac disease

The aims of these recommendations are to improve the outcome for patients after, and to provide acceptable standards of practice of therapeutic cardiac catheterisation performed to treat congenital cardiac disease. The scope of the recommendations includes all interventional procedures, recognising that for some congenital malformations, surgical treatment is equally as effective as, or occasionally preferable to, interventional treatment. The limitations of the recommendations are that, at present, no data are available which compare the results of interventional treatment with surgery, and certainly none which evaluate the numbers and types of procedures that need to be performed for the maintenance of skills. Thus, there is a recognised need to collect comprehensive data with which these recommendations could be reviewed in the future, and re-written as evidence-based guidelines. Such a review will have to take into account the methods of collection of data, their effectiveness, and the latest developments in technology. The present recommendations should, therefore, be considered as consensus statements, and as describing accepted practice, which could be used as a basis for ensuring and improving the quality of future care.

Transesophageal echocardiography to evaluate success of transcatheter closure of large secundum atrial septal defects in adults using the buttoned device

OBJECTIVES

To determine the success rate of transcatheter closure of secundum atrial septal defects (ASDs) in adults and to characterize anatomical structures predisposing to unsatisfactory results.

PATIENTS AND METHODS

Preinterventional and follow-up transesophageal echocardiography of 17 consecutive patients treated with a Sideris buttoned device was reviewed. Residual jet size of 5 mm or smaller was considered an adequate result; jet size larger than 5 mm was inadequate. Maximal ASD diameter, ASD area, and anterior, posterior, superior, and inferior septal rims were measured.

RESULTS

The 7 patients with adequate results (41%) had smaller defects before implantation of a buttoned device (mean +/- SD maximal ASD diameter, 12 +/- 4 vs 19 +/- 5 mm; P<.005). Total rim length (mean +/- SD) was longer in patients with an adequate result (71 +/- 8 vs 46 +/- 11 mm; P<.001). The ASD size and length of the superior septal rim were independent predictors for an adequate result. Only 3 patients, all with ASD diameter less than 13 mm, had completely closed defects. All patients with ASD diameter greater than 20 mm had inadequate results and an unsatisfactory device position. The defect size (mean +/- SD) was similarly reduced in patients with adequate and inadequate results (9 +/- 3 vs 8 +/- 4 mm).

CONCLUSION

Adults with a small ASD are more likely to have an adequate result after treatment with the buttoned device. A sufficiently large superior septal rim is particularly important for an adequate result. Most patients with a large ASD have inadequate results, although their ASD size is reduced by a similar absolute area as in patients with an adequate result.

Transcatheter occlusion of complex atrial septal defects

Percutaneous device occlusion of secundum atrial septal defects (ASDs) is becoming an accepted alternative to surgical closure. This method allows us to evaluate patients with complex conditions for treatment. From a total of 70 patients with ASD evaluated for percutaneous closure, we selected for analysis 28 who had complex conditions. The mean age was 36+/-23 yr (range, 4-72). Six had heart failure, and of these six, three had atrial fibrillation. At cardiac catheterization, the pulmonary pressure was 47+/-24 mm Hg, and the QP/QS was 1.7+/-0.4; two patients had bidirectional shunt and systemic pulmonary pressure. Two patients received a buttoned device and 26 an Amplatzer septal occluder. The groups of patients with complex conditions were separated into the following groups. Group I (n = 4) underwent combined treatment of associated anomalies. Two patients had pulmonary stenosis, one had mitral stenosis, and one had an aortic root-left atrium fistula. They were treated in or during with the same procedure by combined transcatheter techniques (balloon valvuloplasty and fistula occlusion) before ASD occlusion. Group II (n = 9) had multiple defects (cribiform or two separate holes). They were treated with a single device in five instances and with two separate devices in four cases. Group III (n = 14) had large (32+/-3 mm) single defects. Nine of them underwent successful implantation using a device 33+/-3 mm in diameter; in the remaining five patients the device was removed because of instability. Group IV (n = 3) had residual defects after previous partial device occlusion. All three defects were successfully occluded with a second device. No movement or interference with the first device was observed. Group V (n = 6) had severe pulmonary hypertension (86+/-16 mm Hg). Immediately after ASD occlusion we observed significant relief in these patients (67+/-14 mm Hg; P<0.01). There were no major complications; all 23 patients with successful implants were discharged without symptoms 2-7 days later; one patient with atrial fibrillation recovered sinus rhythm. The follow-up (8+/-5 mo) Doppler echo study showed complete ASD occlusion in 22 patients and a peak pulmonary pressure of 30+/-14 mm Hg. We conclude that transcatheter occlusion of ASDs is an effective and safe treatment for patients with complex anatomic or physiopathologic conditions, as evaluated by short-term follow-up.

Results of transvenous occlusion of secundum atrial septal defects with the fourth generation buttoned device: comparison with first, second and third generation devices. International Buttoned Device Trial Group

OBJECTIVES

The purpose of this study was to assess safety and effectiveness of the fourth generation buttoned device in dosing atrial septal defects (ASDs) and to test the hypothesis that introduction of double button reduces unbuttoning rate without reducing effectiveness.

BACKGROUND

Because of the high unbuttoning rate (7.2%) with first, second and third generation buttoned devices, the device was modified (fourth generation) so that there were two radiopaque spring buttons 4 mm apart on the button loop attached to the occluder.

METHODS

During a four-year period ending in September 1997, 423 patients, ages 1.5 to 80 years (median 16 years), underwent closure of ASD at 40 medical centers around the world.

RESULTS

The ASD size varied between 5 and 30 mm (median 17 mm). The device size varied between 25 and 60 mm. Unbuttoning occurred in 4 (0.9%) of 423 patients. Effective occlusion, defined as no (n = 343) or trivial (n = 34) residual shunt on echo-Doppler studies performed within 24 h of the procedure, was demonstrated in 377 patients (90%). Thus, the unbuttoning rate (0.9 vs. 7.2%) decreased (p<0.01) while effective occlusion rate (90 vs. 92%) remained unchanged (p>0.1) with this device, compared with earlier generation devices. During follow-up from one month to five years (23+/-15 months), 21 (5%) of 417 patients required surgical (n = 12) or transcatheter (n = 9) reintervention, mostly to treat significant residual shunt. In the remaining patients there was gradual reduction and disappearance of the residual shunt. No wire integrity problems were observed.

CONCLUSIONS

These data suggest that the fourth generation buttoned device is as effective as earlier generation devices, but without significant unbuttoning. Follow-up results remained good, with a reintervention-free rate of 89% at five years.

Transcatheter closure of atrial septal defect with a CardioSEAL device

Transcatheter closure of an interatrial septal defect (ASD) with a CardioSEAL device was successfully performed on 12 Taiwanese children. There were five boys and seven girls, aged from 3.6-13.9 (8.3+/-3.2) years and with body weight of 15-57 (33.7+/-14.7) kgs. After one year of follow-up studies, which included physical examination, ECG, chest X-ray and echocardiography, complete closure of ASD was achieved in nine (75%) patients. Two children with a trivial residual shunt were asymptomatic and without audible cardiac murmur. A girl had a small residual left to right atrial shunt by color Doppler echocardiography, but without audible cardiac murmur. There were no immediate or intermediate complications. Transcatheter implantation of the CardioSEAL device is a safe and proper treatment for children with non-complicated small to medium secundum ASD.

Surgical validation and implications for transcatheter closure of quantitative echocardiographic evaluation of atrial septal defect

Accurate evaluation of secundum atrial septal defect (ASD) is important for the success of transcatheter closure. The purpose of this study was (1) to describe a quantitative evaluation by transthoracic (TTE) and transesophageal (TEE) echocardiography of the various morphologic features of ASD that might be important for patient selection for transcatheter closure, and (2) to assess the reliability of these 2 methods by surgical findings. Preoperative TTE and TEE were used to evaluate the ASD of 27 children undergoing surgical closure. Measurements included the diameters of ASD and the atrial septal lengths in the transverse and longitudinal axis, and the width of the superior, inferior, anteroinferior, and posterior septal margins. The shape and location of the ASD and the adequacy of the septal margins for anchoring occluding devices were determined. Echocardiographic data were compared with corresponding surgical measurements. No significant difference occurred in the means of all the parameters measured with the 3 methods, except for the transverse ASD diameter (p <0.05). Good agreement occurred between TTE and TEE and surgical data, except for the transverse ASD diameter, transverse atrial septal length, and the posterior septal margin on TTE. Intraclass correlations between TTE and TEE and surgical measurements of all parameters were good, except for the transverse ASD diameter. The accuracy in determining shape and location of the ASD by TTE and TEE were 100%, whereas that for determining the adequacy of septal margins was 98% and 97%, respectively. In conclusion, TTE and TEE are reliable methods for quantitative evaluation of ASD.

Acute animal studies of the STARFlex system: a new self-centering cardioSEAL septal occluder

The STARFlex system is a modified CardioSEAL device with a flexible self-centering mechanism comprised of nitinol springs strung between opposing arms, a connecting ball (sleeve joint that allows the device to pivot prerelease), and a front-loading delivery system. It was designed to allow a smaller device/defect sizing ratio and delivery profile, provide centering capability, and improve closure rates. To test this system, 13 devices (23, 28, and 33 mm) were deployed in six sheep within created atrial septal defects (12- to 22-mm diameter; n = 10), in the left atrium (n = 2), and in inferior vena cava (n = 1). All implantations in atrial septal defects were successful, with device/defect ratio ranging from 1.3 to 1.9 (median, 1.3), with no residual leak by angiography or echocardiography in seven (3/10 had </= small immediate leaks). The STARFlex system was effective in closing created atrial septal defects using a 10 Fr delivery sheath and low device/defect sizing ratios, comparing favorably with the standard CardioSEAL. Cathet. Cardiovasc. Intervent. 49:225-233, 2000.

Transcatheter closure of atrial-septal defects and patent foramen ovale in adults: optimal anatomic adaptation of occlusion device

BACKGROUND

For transcatheter closure of atrial-septal defects, different occlusion systems are available. The purpose of this study was to examine the clinical feasibility of the ASD Occlusion System (ASDOS, Dr Osypka GmbH, Grenzach-Wyhlen, Germany) and to evaluate the short- and long-term results.

METHODS AND RESULTS

The study was composed of 20 consecutive patients with atrial-septal secundum defect (n = 13) or patent foramen ovale (n = 7). The device implantation was successful in all patients. For optimal closure of the defect, left atrial and right atrial umbrellas of different sizes were required in 10 of 20 patients. No major short- or long-term complications occurred. During the mean follow-up period of 13.9 +/- 5 months, 5 strut fractures without dislocation were observed, and in 8 (40%) of 20 patients transesophageal echocardiography revealed a small residual shunt.

CONCLUSION

The ASDOS double umbrella system is suitable for transcatheter closure of interatrial defects in selected patients. This system showed a high procedural safety and has the unique advantage of individual adaptation of the occluding device on the defect anatomy that results in high closure effectiveness.

Transcatheter closure as standard treatment for most interatrial defects: experience in 200 patients treated with the Amplatzer Septal Occluder

To judge whether an Amplatzer Septal Occluder can be used as standard therapy instead of surgery for closure of atrial septal defects we report our experiences in 200 patients. Of these patients, 127 had an atrial septal defect with haemodynamically significant left-to-right shunt, 68 patients a persistent oval foramen after presumed paradoxical embolism, and 5 had a fenestration after Fontan-repair. Mean age was 29.8 years (0.8 to 77.7 years). Body weight ranged from 6.9 to 120.0 kg (mean 51.5 kg). After diagnostic cardiac catheterization, and balloon-sizing of the defect, we implanted Amplatzer Septal Occluders with stents of 4 to 28 mm diameter. Follow-up studies were obtained after 48 hours, and one, six, and twelve months. Transcatheter closure of the atrial septal defect proved successful in all without any relevant residual shunts. In particular, complete closure was achieved in all patients after presumed paradoxical embolism. The mean period of follow-up is 9.5 months, with a range from 0.4 to 23.5 months, giving a total of 1898 patient months. The occlusion rate after three month was 98.1%. A trivial haemodynamically insignificant residual shunt remained in 1.9% of the patients. Fluoroscopy times ranged from 0 to 43.5 minutes, with a median of 8.7 minutes. The excellent results in the short and medium term in children and adults have resulted in using this device routinely at the present time for closure of central atrial septal defects up to a diameter of 28 mm. Final judgement, however, is only possible after long-term follow-up.

Thrombus formation after transcatheter closure of atrial septal defect

Thrombotic layers and/or atrial thrombi were detected by transesophageal echocardiography as a usual finding after transcatheter closure of atrial septal defects with the ASDOS device. The size of the thrombotic structures regularly decreased within 6 months without any clinical signs of embolization.

New self-expanding patent foramen ovale occlusion device

Our purpose was to evaluate a new self-expanding device for closure of the patent foramen ovale (PFO). A transeptal catheter passage through the flap of the fossa ovalis was performed with a transeptal needle inside a catheter, creating a PFO in two minipigs. In an additional five animals, a naturally occurring PFO was found. The device is made from 0.005 inch nitinol wire mesh with polyester fabric inside, similar in construction to the Amplatzer atrial septal occluder. However, the left atrial disc is smaller (18 mm) than the right atrial disc (26 mm). Both discs are connected by a very short flexible waist (3 mm) that allows free movement of both retention discs. Pulmonary and right atrial angiography were performed after placement, at 1 month, and at 3 months follow-up. Placement of the device was technically successful in six animals. One animal died from ventricular fibrillation during placement. Pulmonary angiography and echocardiography showed complete occlusion of the PFO in six animals. Two animals were sacrificed after 1 month and four animals after 3 months. In the animals sacrificed at 1 month, histopathological examination showed partial (n = 2) endothelialization, and in the 3 months follow-up group (n = 4) endothelialization was complete. The device appears to be highly effective for occlusion of PFOs. This procedure may be performed as an outpatient procedure due to the small 7 Fr delivery system sheath. Cathet. Cardiovasc. Intervent. 47:370-376, 1999.

Interventional procedures for congenital heart disease

Interventional techniques available for use in treating congenital heart disease include balloon dilation of valves and vessels, stent placement and coil embolization of collaterals, patent ducts and other arterial fistulae. In addition, a variety of devices for closure of atrial and ventricular septal defects and patent ducts currently are under investigation. Radiofrequency ablation of arrhythmias also is applicable to the pediatric population.

Closure of atrial septal defects via limited right anterolateral thoracotomy as a minimal invasive approach in female patients

OBJECTIVE

The closure of atrial septal defects via sternotomy is a low-risk and high-benefit procedure. Limited right anterolateral thoracotomy is an alternative approach with regard to cosmetic aspects. However, it is discussed that a lateral approach is not appropriate for more complex lesions and is associated with an increased incidence of phrenic nerve damage.

METHODS AND RESULTS

The perioperative and long-term outcomes (mean follow-up time: 73.2 months) of 87 female patients, mean age 20.4 years (range: 3-56 years), operated on for all types of atrial septal defects via limited right anterolateral thoracotomy between 1982 and 1993, were analysed retrospectively. Special features of the operation technique were a limited skin incision, protection of mammary gland tissue, prevention of phrenic nerve damage, and aortic cannulation in all patients. There were no intraoperative complications. Postoperative complications occurred in 12/87 patients including one rethoracotomy for postoperative bleeding and one late pericardial tamponade due to coumadine overdose. Follow-up was assessed by a survey obtained by the patients or their parents, and their family doctors in 79 patients (90.8%) Cardiac symptoms, mostly supraventricular arrhythmias, were observed in 13.9%. Echocardiography revealed mild tricuspid valve regurgitation (one patient) and mild mitral valve incompetence (one patient with ostium primum defect); there were no residual shunts. Cosmetic results were considered good and excellent in 87.3% and satisfactory in 8.9%. Three patients (3.8%) complained of a broad scar. Anaesthetic areas and optional scar pain were quite frequent (16.5%), whereas restriction of shoulder movement, breast asymmetry and scoliosis were rare. In summary, only one patient, suffering from intercostal neuralgia, would prefer sternotomy.

CONCLUSION

Limited right anterolateral thoracotomy has a high cosmetic acceptance and was proven to be safe and effective for closure of any kind of atrial septal defects. Therefore, it is recommended as standard approach for atrial septal defects especially in female patients. reserved.

A new technique for sizing of atrial septal defects

This article evaluates a new compliant balloon catheter for sizing of Atrial Septal Defects (ASDs) in vitro and in vivo using X-ray and echo measurements. A phantom consisting of a plastic plate with 17 circular holes varying from 8 to 30 mm was used to determine the accuracy of the measurements. The catheter has a 7 Fr shaft with a double lumen. The balloon is made from a 0.002" plastic membrane. Four platinum marker bands on the shaft of the catheter allow radiographic measurements. The balloon catheter was placed through various holes of the phantom and inflated with 38% contrast medium. X-ray measurement by video and cine recording were performed and compared with the true measurement of the model. The study was carried out in a double blind fashion. For echo measurements, the plastic model was immersed in a water bath. The balloon was inflated with water and measured in a long-axis view. The actual diameters were compared with the measurements obtained by video, cine, and echo recordings. One young pig with a surgically created ASD was used for in vivo measurement. The balloon catheter was passed through the ASD over an exchange wire, inflated with diluted contrast medium until a waist was observed, which was measured by video and cine techniques. The animal was euthanized, and the defect was measured by a tapered measuring probe. The difference between the actual size and measurements obtained by video recordings was 0.54 +/- 0.30 mm, by cine 0.62 +/- 0.20 mm, and by echo measurements 0.60 +/- 0.43 mm. All measurements were less than 1 mm in error except for four measurements (<1.5 mm). A strong correlation was present between each two groups (r = 0.99, P < 0.0001). In the in vivo study, the size of the video and cine recordings (14.2 and 13.9 mm, respectively) were very closer to the actual size (14 mm) as measured by a probe in the postmortem specimen. The new balloon catheter provides a more rapid and precise determination of the stretched diameter of atrial septal defects. It eliminates the error of pulling a catheter through the communication. This new technique should be of benefit to all investigators using septal occlusion devices and will facilitate the selection of the properly sized Amplatzer septal occluder.

Transcatheter closure of atrial septal defect and patent foramen ovale with ASDOS device (a multi-institutional European trial)

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

Early clinical experience with use of the 'Amplatzer Septal Occluder' device for atrial septal defect

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

Non surgical treatment in congenital heart disease

Dilation of blood vessels transluminally was demonstrated by Dr Andreas Gruntzig in 1978. In 1982, Kan demonstrated that congenitally stenosed valve can be dilated with the use of cylindrical balloon and opened up new vistas in the non-surgical treatment of congenital heart lesions. Rapid progress has been now made in (1) Understanding of mechanism of success or failure of balloon dilation (2) Development of newer hardwares like low profile balloon, high pressure balloons, extra support wires which have contributed to increase in success rate of the procedures (3) Understanding the unnatural history of various congenital heart lesions from the vast data bank of Registries of balloon dilation. As a consequence balloon dilation has become the first procedure of choice in the treatment of valvar pulmonary stenosis and post surgical recurrent coarctation. Although an essentially palliative procedure for the treatment of valvar aortic stenosis and native coarctation beyond the neonatal period, non-randomised studies have shown results similar to that of surgical correction. Balloon dilation of pulmonary artery, pulmonary vein, venous baffles stenosis have shown poor overall results. Balloon dilation for sub-pulmonary stenosis like tetralogy of Fallot is controversial. The development of stents to keep dilated vessel open has also found a place in treatment of congenital heart lesions. Thus pulmonary artery stenosis, recurrent coarctation in adults, venous baffle obstruction, conduit stenosis which respond poorly to balloon dilation alone have shown promising early and mid term results with stents. The use of stents to keep the ductus open, recurrent coarctation in children, in right ventricular outflow tract obstruction is controversial. Development of devices to achieve closure of cardiac defects is relatively new. Patent arterial duct was the first defect to be closed with the help of devices and has shown good results on long term follow up. Recently stainless steel coils have been used to close dose small ducti (up to 3 mm) with very promising medium term results. Its use has also been extended to larger ducti (up to 7 mm). Devices used for closing atrial septal defects, ventricular septal defects are undergoing rapid development. In atrial septal defects its use is restricted to small defects in the fossa ovalis area and in ventricular defects, to only those which are in the muscular septum. Most of the devices in use today for atrial septal closure are relatively new and await long term results. The results achieved by non surgical treatment for many congenital heart lesions are essentially palliative and may require repeat interventions at some point in the unnatural history which increases the cost of treatment substantially. The reuse of balloons, guide wires in developing countries helps reduce the overall cost of the procedure.

Intermediate-term results of Phase I Food and Drug Administration Trials of buttoned device occlusion of secundum atrial septal defects

OBJECTIVES

This study was conducted to evaluate the intermediate-term results of the multi-institutional U.S. trial of the buttoned device for transcatheter closure of atrial septal defects (ASDs).

BACKGROUND

The trial was conducted in three centers (University of Arizona, University of Michigan and University of Wisconsin) under a Food and Drug Administration (FDA)-approved clinical trial with investigational device exemption. Only short-term follow-up is known.

METHODS

All 46 patients who had successful implantation of the device were prospectively followed up. Patients were evaluated at 1, 6 and 12 months after device occlusion and yearly thereafter.

RESULTS

This cohort was followed up from 51 to 68 months (mean 60.8, median 62). Patient ages ranged from 1 to 62 years (median 4); weights ranged from 10 to 105 kg (median 18); and stretched ASD sizes were 14 +/- 4 mm (left to right shunts) and 10 +/- 3 mm (right to left shunts). Of the 46 patients, 45 (98%) had effective occlusion of their ASD, and 34 (74%) had complete ASD closure. The incidence of residual shunts decreased from 65% (30 of 46 patients) at 1 month after device placement to 27% (12 of 45 patients) at last follow-up. All residual shunts were quantitated as trivial. Only two patients (4%) required reintervention for significant residual defects. There were no cases of endocarditis or thromboembolism in 224 patient-years of follow-up.

CONCLUSIONS

In up to 5.5 years of follow-up, the buttoned device provided effective closure in 98% of patients in whom the device was successfully implanted. The incidence of residual shunts decreased during follow-up, and no instances of endocarditis or thromboembolism were observed.