Intra-operative device closure of multiple atrial septal defects facilitated by a unique atrial septum remodeling technique: initial results and experience in 11 patients

Inter-Defect Septal Puncture Technique For Single Device Closure of Wide-Spaced Multi-Hole Atrial Septal Defect

Closure of a wide-spaced multi-hole secundum atrial septal defect (MHASD) using a single occluder is difficult to accomplish. Multiple occluder implantation has risks such as incomplete endothelialisation, device embolisation, and residual shunt. Blade or balloon septotomy enables single device occlusion; however, the aforementioned may cause a short circumferential rim with subsequent device instability. This paper describes an inter-defect septal puncture technique for single device closure of different layouts of wide-spaced MHASDs via per-atrial or percutaneous approach under exclusive transoesophageal echocardiographic guidance. This technique combined with anti-tenting puncture equally befits a small caval atrial septal defect and MHASD with a floppy aneurysmal septum.

Device closure of diverse layout of multi-hole secundum atrial septal defect: different techniques and long-term follow-up

Background

There are no unanimous reports on different layouts and classifications of multi-hole secundum atrial septal defects (MHASD) and subsequent standardized occlusion techniques. The MHASD can be isolated or cribriform with variable inter-defects distance. In this retrospective study, experience-based classification and two approaches-based occlusion results are presented.

Methods

We retrospectively collected and analyzed data of 150 MHASD patients from 1320 patients who underwent atrial septal defect occlusion in our institute. The MHASD patients were categorized into 4 types; type A, B, C and D and occluded under exclusive transesophageal echocardiographic guidance. According to different types, 122 patients were occluded using peratrial approach and 28 patients via percutaneous approach. In type A, single device implantation is performed to occlude the large hole and squeeze the small one. For type B single or double-device deployment was performed depending on an inter-defects distance. In type C and D, a patent foramen-ovale (PF) device was selectively positioned to the central defect to occlude the central defect and cover the peripheral ones. In peratrial approach, 8 patients underwent inter-defects septal puncture technique to achieve single-device occlusion. The intracardiac manipulation time, procedural time, double device deployment, redeployment rate, residual shunt, and proportions were analyzed between (and within peratrial technique) two techniques.

Results

Successful occlusion was achieved in all 150 patients. Single device occlusion was applied in 78/84 type A and 22/37 type B patients (p < 0.05). Double device occlusion was more applicable to type B than A patients (p < 0.01). Sixteen of 21 type C and all type D patients used PF device for a satisfactory occlusion. Redeployment of the device occurred frequently in type B patients than A (p < 0.01). The intracardiac manipulation time and procedural time were shorter in type A than B (p < 0.05). The intracardiac manipulation time was also shortened in type A peratrial than type A percutaneous group (p < 0.05). Complete occlusion rate for all patients at discharge was 70% and rose to 82% at 1 year follow up.

Conclusions

The diverse layouts and classification of MHASDs can help to choose different techniques and proper devices of different kinds to achieve better occlusion results.

Strategy of treating secundum atrial septal defect not referred to percutaneous closure

OBJECTIVE

To evaluate safety and effectiveness of intraoperative device closure for secundum atrial septal defect (ASD) not referred to percutaneous closure.

DESIGN AND PATIENTS

From April 2010 to December 2018, 231 secundum ASD children (≤14 years) directly recommended to surgical repair were enrolled in this study. These patients were divided into two groups according to the parents' choice based on surgeons' recommendation. Follow-up evaluations were adopted at 2 weeks, 3 months, 6 months, and 12 months after the procedure and yearly thereafter. In Group A, 127 patients underwent an initial attempt at device closure. In Group B, 104 patients underwent a repair procedure under cardiopulmonary bypass.

RESULTS

All patients survived. Group A had lower values of operation time, mechanical ventilation time, cardiac intensive care unit duration and amount of blood transfusion. Nevertheless, postoperative hospitalization time between two groups showed no statistical difference. In group A, 109 (85.83%) patients were successfully occluded, whereas 18 (14.17%) patients were converted to open-heart surgery. No severe complications occurred in the follow-up period.

CONCLUSION

Intraoperative device closure is safe, effective procedure for selected cases with secundum ASDs which were not referred to percutaneous closure because of more suitable occluder selection, no "unbutton effect" and stitching enhancement.

A Novel Hybrid Approach for Balloon Dilation of Pulmonary Vein Stenosis Following Total Anomalous Pulmonary Venous Connection Repair with Atrial Septal Patching

Pulmonary venous obstruction after the repair of total anomalous pulmonary venous connection is a serious complication. Transcatheter interventional treatment is a palliative choice to defer the timing of surgery; however, penetrating through the patched atrial septum may be difficult. We report a technique for pulmonary venous obstruction after mixed-type total anomalous pulmonary venous connection repair using balloon dilatation of the pulmonary veins through a novel hybrid approach.