Comparison of results of closure of secundum atrial septal defect by surgery versus Amplatzer septal occluder

A comparison of intracardiac echocardiography and transesophageal echocardiography for guiding device closure of ostium secundum atrial septal defect: A 15-year experience

BACKGROUND AND AIM

Our aim was to evaluate the fluoroscopy time (FT), procedure time (PT) safety and efficacy when using intracardiac echocardiography (ICE) in comparison to transesophageal echocardiography (TEE) guidance for transcatheter closure of Ostium Secundum Atrial Septal Defect (OS-ASD).

METHOD

Ninety patients (n = 90) diagnosed with OS-ASD underwent transcatheter closure between March 2006 and October 2021. Fifty-seven patients were treated under ICE guidance, while 33 patients were treated under TEE guidance.

RESULTS

Mean age was 43 ± 15 years and 42 ± 10 years in the ICE and TEE groups, respectively. The majority of patients had a centrally placed defect. Median FT was 8.40 min versus 11.70 min (p < .001) in the ICE group compared to the TEE group, respectively. Median PT was 43 min versus 94 min (p < .001) in the ICE group compared to the TEE group, respectively. Both ICE and TEE provided high quality images. All interventions were completed successfully, except for one patient in the ICE group who experienced a device migration, the development of atrial tachycardia in one patient and atrial fibrillation in two patients in the ICE group which spontaneously cardioverted. There were no other complications.

CONCLUSION

This study on a consistent cohort of patients with OS-ASD undergoing percutaneous closure suggests that use of ICE is safe and efficacious. Compared to TEE, ICE demonstrated significantly shorter FT and PT, decreasing the entire duration of the procedure and x-ray exposure. No relevant differences were observed in terms of success rate and complications.

GORE® Cardioform ASD Occluder experience in transcatheter closure of "complex" atrial septal defects

OBJECTIVE

To evaluate the GORE® Cardioform ASD Occluder (GCO) (WL Gore & Associates, Flagstaff, AZ) device for "complex" atrial septal defects (ASD) closure.

BACKGROUND

Transcatheter ASD closure is still challenging in "complex" clinical/anatomic settings. This study evaluated the results of GCO in closure of "complex" ASD in a tertiary referral center.

METHODS

Between January 2020 and March 2021, 72 patients with significant ASD were submitted to transcatheter closure with GCO at our Institution. Based on clinical/anatomic characteristics, they were classified as "complex" (n = 36, Group I) or "simple" (n = 36, Group II). We considered as "complex", defects with rim deficiency (< 5 mm) other than antero-superior, relatively large (diameter/patient weight > 1.2 or diameter/patient BSA > 20 mm/m² ) or within a multifenestrated septum. Procedure results and early outcome were compared between the groups.

RESULTS

Absolute and relative ASD size (20 ± 4 vs. 15 ± 3 mm, p < 0.0001; 0.9 ± 0.3 vs. 0.4 ± 0.2 mm/kg, p < 0.0001; 23 ± 7 vs. 12 ± 5 mm/m² , p < 0.0001), QP/QS (2.0 ± 0.8 vs. 1.4 ± 0.3, p < 0.001), procedure and fluoroscopy times (73 ± 36 vs. 43 ± 21 min, p < 0.0001; 16 ± 9 vs. 9 ± 4 min, p < 0.0001, procedure feasibility (94.4 vs. 100%, p < 0.0001) and overall complication rate (13.9 vs. 0%, p < 0.0001) were significantly different between the groups. Successful closure of "surgical" ASDs was achieved in 92% of cases. Complete closure at last follow-up evaluation did not significantly differ between the groups (97.1 vs. 100%, p = NS), as was wireframe fractures rate (49.1% in the overall population), without clinical, EKG and echocardiographic consequences.

CONCLUSIONS

Percutaneous treatment with GCO device is effective and safe in high percentage of "complex" ASDs.

Catheter-based closure of a large atrial septal defect with inferior rim deficiency using pulmonary vein slide-out assisted implantation technique: a case report

Background

Transcatheter approach for large and complex atrial septal defects may represent a therapeutic challenge, particularly when the postero-inferior rim is deficient and floppy.

Case summary

Here, we describe a successful catheter-based closure of a large (>30 mm) secundum atrial septal defect associated with postero-inferior rim deficiency in a 35-year-old female with congestive heart failure using pulmonary vein slide-out assisted implantation technique.

Discussion

Inferior–posterior rim deficiency is a well-known risk factor for device instability or embolization. Transcatheter closure may represent a safe and effective alternative to the traditional surgical approach provided that modified implantation techniques are employed.

Transcatheter closure of a residual shunt with posteroinferior deficient rim after surgical closure of an ASD: a case report

BACKGROUND

There are few reports in the literature of device closure of residual shunts following initial surgical closure of an atrial septal defect (ASD). This case study reports one such case. We describe here a case of secundum type ASD that was initially closed surgically, followed by device closure of a residual shunt with a posteroinferior deficient rim.

CASE PRESENTATION

A 7-month-old boy was admitted to our hospital for elective surgery to surgically correct a secundum type ASD. Unfortunately, a residual shunt 3.5 mm in diameter appeared before discharge and was enlarged at1-year follow-up. The cause of this residual shunt was dehiscence at the posteroinferior aspect, and the posteroinferior rim was 3.7 mm. After careful discussion and preparation, we proceeded with an interventional procedure. A 16 mm ASD occluder (AGA Medical Corp, Plymouth, Minnesota) was deployed successfully with no residual shunt. In some cases of ASD, interventional therapy is not considered due to the size and position of the defect, but we show here, a successful case of interventional therapy for a residual shunt with a deficient rim.

CONCLUSION

We have presented a case in which a postoperative residual shunt with a deficient rim was successfully closed with interventional therapy.

P wave dispersion in assessment of dysrhythmia risk in patients with secundum type atrial septal defect and the effect of transcatheter or surgical closure

Atrial dysrhythmia is an important cause of mortality and morbidity in patients with atrial septal defect. Increased P wave duration can predict the risk of atrial dysrhythmia. The aim of this study is to evaluate the risk of atrial dysrhythmia by measuring P wave dispersion, and to observe the effect of surgical and transcatheter closure. Sixty-one patients and 30 controls were investigated. In patient group, before and after closure and in control group at the time of presentation, 12-lead electrocardiography records were evaluated. P wave duration and amplitude, P wave axis, PR interval, P wave dispersion, QRS axis, corrected QT interval, and QT dispersion were calculated. The measurements in patient and control groups, measurements before and after closure, and measurements of surgical and transcatheter group were compared. There were 27 patients in surgical group and 34 patients in transcatheter group. In patient group, signs of right heart volume overload were apparent but there was no significant difference in terms of P wave dispersion between two groups. We compared patient group in itself and found that while the use of medication, cardiothoracic index, ratio of right ventricular dilation, and paradoxical movement in interventricular septum were increased, mean age of closure was younger in surgical group. While P wave dispersion decreased in transcatheter group after closure, it increased in surgical group (p = 0.021). In conclusion, atrial septal defects may cause atrial repolarisation abnormalities and this effect persists even after surgical closure. Transcatheter closure in childhood may decrease dysrhythmia risk in long-term follow-up.

The efficacy and safety of using amplatzer for transcatheter closure of atrial septal defect in small children with less than 10 kg

BACKGROUND

Atrial septal defect (ASD) accounts for about 10% of congenital heart diseases (CHDs). Self-closure of these defects in patients with defects less than 8 mm has been reported in several studies. In children, transcatheter closure of the ASD is suggested for asymptomatic patients older than two years and with weight > 15 kg. The purpose of this study was to show that transcatheter closure of ASD in small children with body weight less than 10 kg is an effective and safe method.

METHODS

Between July 2016 and September 2018, 35 children with body weight less than 10 kg underwent percutaneous closure of ASD using amplatzer. All patients had minimum defect size of 6 mm, pulmonary blood flow (Qp) to systemic blood flow (Qs) ratio above 1.5, right atrial and ventricular dilation, symptoms of delayed growth, and recurrent respiratory infections in their evaluation and had acceptable rims for intervention. Follow-up evaluations were done 1 day, 1 week, 1 month, 6 months, and yearly after discharge with transthoracic echocardiography (TTE) and electrocardiography (ECG).

RESULTS

The mean age of patients at procedure was 12.06 ± 4.47 months (range: 6 to 14 months), mean weight was 8.32 ± 0.72 kg (range: 7.5 to 9.8 kg). The mean defect size was 10.00 ± 2.32 mm (range: 6-13 mm). The mean device size used was 10.57 ± 2.57 mm (range: 7.5 to 15 mm). Mean duration of follow-up was 16.66 ± 6.93 months (range: 1-29 months). Respiratory rate, heart rate, pulmonary stenosis (PS), and Qp to Qs ratio had significant difference before and after procedure during the follow up (P < 0.001).

CONCLUSION

Transcatheter closure of ASD with amplatzer in symptomatic small children and infants is a safe and effective treatment associated with excellent success, but long-term follow-up in a large number of patients would be warranted.

Safety and effectiveness of transcatheter closure of atrial septal defects: Initial results in Fukushima Prefecture

BACKGROUND

Atrial septal defect is the third most common type of congenital heart disease. Surgical closure was the standard treatment for atrial septal defects before transcatheter closure was approved as minimally invasive treatment in Japan in 2006. In our hospital, this procedure has been performed since 2015.

OBJECTIVE

To evaluate the safety and effectiveness of transcatheter closure of atrial septal defects in our hospital.

METHODS

Thirty patients (mean age 57.0 ± 19.7 years, 11 males), who underwent transcatheter closure of atrial septal defect between September 2015 and February 2018 at the Fukushima Medical University Hospital, were enrolled. All procedures were performed under general anesthesia with angiographic and transesophageal echocardiographic guidance. Safety and effectiveness were evaluated by the procedural results and complications.

RESULTS

All 30 patients successfully underwent transcatheter closure of atrial septal defects and no patient developed complications. New York Heart Association functional class was improved, and the right ventricular area and right atrium area were decreased, postoperatively.

CONCLUSION

Transcatheter closure is a safe and effective treatment for atrial septal defects, and thus could be an alternative option to open heart surgery.

Transcatheter closure of atrial septal defect: principles and available devices

There has been a remarkable improvement in the treatment strategy of secundum atrial septal defect (ASD) over the last few decades. Indebted to the improvement in device technology and procedural techniques, transcatheter closure of ASD is currently accepted as the treatment of choice in most patients with secundum ASD. Recent generation devices enable easy and safe deployment of device with the properties of adequate flexibility, re-capturability and repositioning. Use of biocompatible materials with improved device design and refined equipment finish may promote re-endothelialization and reduce potential damage to nearby structures. Most of currently available devices show excellent efficacy and comparable outcome with its own advantages and disadvantages. In addition to improvement of device properties and performance, there has been distinct improvement in procedural technique from numerous experiences of device closure of ASD. Nowadays there are well established principles regarding patient selection, pre-procedural evaluation, step-by-step details of procedure as well as post-procedural follow-up. However, an operator may encounter pitfalls in closing complex lesions such as large defect, rim deficiencies and multiple defects, so every operator has to be familiar with each available device, general principle as well as special issues for complex lesions.

Lower Hospital Charges and Societal Costs for Catheter Device Closure of Atrial Septal Defects

Atrial septal defects (ASD) are among the most common congenital heart defects. As more ASDs are corrected by interventional catheterization instead of surgery, it is critical to understand the associated clinical and societal costs. The goal of this study was to use a national U.S. database to describe hospital charges and societal costs for surgical and catheter-based (ASD) closure. Retrospective review of hospital discharge data from the Kids' Inpatient Database from January 2010 to December 2012. The database was queried for admissions for <21 years old with ICD-9 procedure codes for surgical (35.51 or 35.61) or catheter (35.52) ASD closure; those with other cardiac conditions and/or additional cardiac procedures were excluded. Age, length of stay (LOS), and hospital charges and lost parental wages (societal costs) were compared between groups using t test or Mann-Whitney U test, as appropriate. Four hundred and eighty-six surgical and 305 catheter ASD closures were identified. LOS, hospital charges, and total societal costs were higher in surgical ASD compared to catheter ASD admissions (3.6 vs. 1.3 days, p < 0.001, $87,465 vs. $64,109, p < 0.001, and $90,000 vs. $64,966, p < 0.001, respectively). In this review of a large national inpatient database, we found that hospital and societal costs for surgical ASD closure are significantly higher than catheter ASD closure in the United States in the current era. Factors that likely contribute to this include longer LOS and longer post-operative recovery. Using "real-world" data, this study demonstrates a substantial cost advantage for catheter ASD closure compared to surgical.

Transcatheter Versus Surgical Closure of Atrial Septal Defects in Children: A Value Comparison

OBJECTIVES

The purpose of this study was to determine whether a transcatheter procedure or surgical closure offers a better value proposition for atrial septal defect (ASD) closure.

BACKGROUND

Secundum ASDs are common congenital heart defects with both transcatheter and surgical treatment options. Although both options have been shown to have excellent results in children, the relative value of the 2 procedures is unclear.

METHODS

Using data from the Pediatric Hospital Information System for 2004 to 2012, we compared the value of transcatheter versus surgical ASD closure for children ages 1 to 17 years, with value being defined as outcomes relative to costs. Total charges for procedure-related encounters were converted to costs using hospital-specific cost-to-charge ratios, and all costs were adjusted for inflation to reflect 2012 dollars.

RESULTS

There were 4,606 transcatheter procedures and 3,159 surgeries at 35 children's hospitals. Those undergoing transcatheter closure were more likely to be older (5.6 years vs. 4.5 years, p < 0.0001). There was no mortality in either group. Children with a surgical procedure had a longer length of stay (4.0 days vs. 1.5 days, p < 0.0001), were more likely to have an infection (odds ratio: 3.73, p < 0.0001) or procedural complication (odds ratio: 6.66, p < 0.0001). Costs for transcatheter procedure encounters were lower than costs for surgical encounters (mean of $19,128 vs. $25,359, p < 0.0001).

CONCLUSIONS

Both transcatheter and surgical ASD closure had excellent short-term outcomes, but transcatheter procedures had lower lengths of stay, rates of infection, and complications, resulting in lower overall costs. For children who are eligible, transcatheter ASD closure provides better short-term value than surgery.

Contributors to and impact of residual shunting after device closure of atrial septal defects

BACKGROUND

The prevalence of residual shunt in patients after device closure of atrial septal defect and its impact on long-term outcome has not been previously defined.

METHODS

From a prospective, single-institution registry of 408 patients, we selected individuals with agitated saline studies performed 1 year after closure. Baseline echocardiographic, invasive hemodynamic, and comorbidity data were compared to identify contributors to residual shunt. Survival was determined by review of the medical records and the Social Security Death Index. Survival analysis according to shunt included construction of Kaplan-Meier curves and Cox proportional hazards modeling.

RESULTS

Among 213 analyzed patients, 27% were men and age at repair was 47 ± 17 years. Thirty patients (14%) had residual shunt at 1 year. Residual shunt was more common with Helex (22%) and CardioSEAL/STARFlex (40%) occluder devices than Amplatzer devices (9%; P = .005). Residual shunts were more common in whites (79% vs 46%, P = .004). At 7.3 ± 3.3 years of follow-up, 13 (6%) of patients had died, including 8 (5%) with Amplatzer, 5 (25%) with CardioSEAL/STARFlex, and 0 with Helex devices. Patients with residual shunting had a higher hazard of death (20% vs 4%, P = .001; hazard ratio 4.95 [1.59-14.90]). In an exploratory multivariable analysis, residual shunting, age, hypertension, coronary artery disease, and diastolic dysfunction were associated with death.

CONCLUSIONS

Residual shunt after atrial septal defect device closure is common and adversely impacts long-term survival.

In-Hospital and 4-Year Clinical Outcomes Following Transcatheter Versus Surgical Closure for Secundum Atrial Septal Defect in Adults: A National Cohort Propensity Score Analysis

Atrial septal defect (ASD) closure is major therapy for patients with secundum ASD. Although surgical closure (SC) and transcatheter closure (TC) are usually performed in such patients, data on the long-term outcomes comparing TC and SC in adults are limited. Data on the participants of this cohort study were retrieved from Taiwan's National Health Insurance Research Database from 2004 to 2011. Secundum ASD patients > 18 years of age who underwent TC or SC were initially enrolled, and those with associated comorbidities were excluded. After propensity score matching, the clinical outcomes between the TC and SC groups were analyzed. There were 595 patients recruited in the TC group and 308 patients in the SC group. The SC group had a higher incidence of systemic thromboembolism (P < 0.001), ischemic stroke (P = 0.002), and all-cause mortality (P = 0.013) when compared with those of the TC group at the index hospitalization, and similar phenomena could also be seen in a around 4-year follow-up period after the procedures (systemic thromboembolism (P < 0.001, HR = 11.48, 95% CI: 3.29-40.05), ischemic stroke (P = 0.005, HR = 9.28, 95% CI: 1.94-44.39), and all-cause mortality (P = 0.035, HR = 2.28, 95% CI: 1.06-4.89). In addition, atrial fibrillation (P = 0.005) and atrial flutter (P = 0.049) more frequently developed in the SC group than in the TC group at the index hospitalization. The adult secundum ASD patients had lower incidence rates of systemic thromboembolism, ischemic stroke, and all-cause mortality after TC than those after SC in the 4-year follow-up after procedures. Transcatheter ASD closure should therefore be given priority.

Transcatheter closure of atrial septal defects

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

Cupping of the left atrial disc: a new echocardiographic pointer towards atrial septal defect-device mismatch

We report a case of percutaneous atrial septal defect closure (ASD) in which, despite careful device selection and successful shunt closure, a number of adverse echocardiographic features developed, necessitating surgical extraction of the device and patch closure of the defect. Lessons regarding case selection, device choice, appropriate follow-up and recognition of adverse echocardiographic features can be learned from this experience.

Transcatheter closure of multiple atrial septal defects with the amplatzer device

Percutaneous device occlusion of secundum atrial septal defect (ASD) has become an accepted alternative to surgical repair. A variety of devices have been used successfully. However, all of them have limitations. We report our experience with two devices used to close multiple ASDs.

Comparison of Clinical Outcomes and Cost Between Surgical and Transcatheter Device Closure of Atrial Septal Defects in Singapore Children

Introduction: With advances in interventional catheterisation, transcatheter device closure of atrial septal defect (ASD) is now a feasible option to open heart surgery, especially in patients with isolated ASD. We aim to compare the outcomes, benefits and costs between device closure versus standard open-heart surgery for ASD in Singapore. Materials and Methods: This is a comparative study between 2 cohorts with isolated secundum ASDs who underwent closure of ASD either by surgery or device, at the Department of Paediatrics, National University Hospital (NUH). The clinical outcomes, complications, length of stay and total costs incurred were compared. Results: Surgical patients were at slightly greater risk of developing complications (RR=1.33; 95% CI, 0.30 to 5.95) than the device group. The median length of inpatient stay for the surgical group was significantly longer than that for the device group. Seventy percent of the patients in the device group did not need to be in ICU while 40% of patients in the surgery group stayed 2 or at least 3 days in ICU (P <0.001). The mean cost per successful procedure was $1511 (95% CI, -352 to 3375) higher for the device group patients despite a shorter length of stay in hospital. Conclusions: We concluded that transcatheter device closure is an effective and safe alternative to surgery in the treatment of suitable ASDs. Despite the high cost of the device, direct and indirect benefits for the patients and their families, who undergo device occlusion include less morbidity, better cosmesis, shorter length of stay in hospital, faster recovery and shorter time taken to resume normal activities. Key words: Amplatzer, ASD, Cost, Device occlusion, Interventional cardiology

Intermediate-term effects of transcatheter secundum atrial septal defect closure on cardiac remodeling in children and adults

The study aimed to investigate the intermediate-term effects of transcatheter atrial septal defect (ASD) closure on cardiac remodeling in children and adult patients. Between December 2003 and February 2009, 117 patients (48 males, 50 adults) underwent transcatheter ASD closure with the Amplatzer septal occluder (ASO). The mean age of the patients was 15 years, and the mean follow-up period was 25.9 +/- 12.4 months. New York Heart Association (NYHA) class, electrocardiographic parameters, and transthoracic echocardiographic (TTE) examination were evaluated before the ASD closure, then 1 day, 1 month, 6 months, 12 months, and yearly afterward. Transcatheter ASD closure was successfully performed for 112 (96%) of the 117 patients. The mean ASD diameter measured by transesophageal echocardiography (TEE) was 14.0 +/- 4.2 mm, and the mean diameter stretched with a sizing balloon was 16.6 +/- 4.8 mm. The mean size of the implanted device was 18.6 +/- 4.9 mm. The Qp/Qs ratio was 2.2 +/- 0.8. The mean systolic pulmonary artery pressure was 40 +/- 10 mmHg. At the end of the mean follow-up period of 2 years, the indexed right ventricular (RV) end-diastolic diameter had decreased from 36 +/- 5 to 30 +/- 5 mm/m(2) (p = 0.005), and the indexed left ventricular (LV) end-diastolic diameter had increased from 33 +/- 5 to 37 +/- 6 mm/m(2) (p = 0.001), resulting in an RV/LV ratio decreased from 1.1 +/- 0.2 to 0.8 +/- 0.2 (p = 0.001). The New York Heart Association (NYHA) functional capacity of the patients was improved significantly 24 months after ASD closure (1.9 +/- 0.5 to 1.3 +/- 0.5; p = 0.001). At the 2-year follow up electrocardiographic examination, the P maximum had decreased from 128 +/- 15 to 102 +/- 12 ms (p = 0.001), the P dispersion had decreased from 48 +/- 11 to 36 +/- 9 ms (p = 0.001), and the QT dispersion had decreased from 66 +/- 11 to 54 +/- 8 ms (p = 0.001). Five of six patients experienced resolution of their preclosure arrhythmias, whereas the remaining patient continued to have paroxysmal atrial fibrillation. A new arrhythmia (supraventricular tachycardia) developed in one patient and was well controlled medically. Transcatheter ASD closure leads to a significant improvement in clinical status and heart cavity dimensions in adults and children, as shown by intermediate-term follow-up evaluation. Transcatheter ASD closure can reverse electrical and mechanical changes in atrial myocardium, resulting in a subsequent reduction in P maximum and P dispersion times.

[Transcatheter versus surgical closure of atrial septal defect and patent ductus arteriosus in adults]

We present the results of two studies that compared surgical treatment and percutaneous intervention in two groups of adult patients: one with atrial septal defects and the other with patent ductus arteriosus. In both groups, percutaneous intervention was superior to surgery in terms of patient safety, with fewer immediate and long-term complications.

Transcatheter closure of atrial septal defects with multiple devices in adults: procedural and clinical outcomes

OBJECTIVE

This study reports the procedural, short and medium term outcomes in patients receiving multiple implants for device closure of secundum atrial septal defects (ASD).

DESIGN AND SETTING

From the database of the Toronto Congenital Cardiac Centre, 36 consecutive patients (mean age 46+/-15 years; 23 females) received >1 implant for closure of an interatrial communication. Short term (mean 97+/-77 days) and medium term (mean 2.5+/-1.4 years) follow-up data were analyzed. Procedures were performed under intracardiac echo (ICE) and fluoroscopic guidance.

RESULTS

The Amplatzer Septal Occluder (ASO) was implanted in all except one. Thirty-one patients had 2, and 4 patients, 3 ASO devices. There were no major adverse events at implantation or on follow-up. Patients with >NYHA class I symptoms fell from 44% to 6% (p<0.05) at 3 months. Right ventricular (RV) systolic pressure fell from 39+/-7 to 32+/-4 mm Hg in the short term (p<0.05), and to 30+/-4 mm Hg in the medium term (p<0.05, compared to baseline) and RV diameters fell from 48+/-5 to 40+/-5 (p<0.05) in the short term and to 38+/-8 mm (p=ns) in the medium term. Small residual leaks were present in 22% at 3 months and 12% (p<0.05) at 1 year.

CONCLUSION

Multiple ASD device implants can be safely employed with excellent outcomes. Significant reductions in RV pressure and diameter occur in the short term with a continued trend to benefit.

Cribriform amplatzer device closure of fenestrated atrial septal defects: feasibility and technical aspects

Fenestrated atrial septal defects (F-ASDs) may pose a challenge to device closure; recently, a cribriform device with a minimal connecting intrawaist diameter and large, equal left- and right-sided discs has been designed to cover more than one adjacent defect. This study demonstrates the feasibility and technical aspects of closing F-ASDs using this new device. Sixteen patients between August 2003 and January 2006 were included in this study. The inclusion criterion was the presence of a F-ASD diagnosed by transesophageal echocardiography. One of the three available cribriform ASD device sizes (18, 25, or 35 mm) was implanted. Patients were followed for at least 1 year after the procedure. Thirteen patients had successful cribriform ASD device implantation (median age and weight, 12.5 years and 36 kg, respectively). Ten patients (62%) had an associated atrial septal aneurysm. The mean procedure time was 75.6 +/- 28.5 min and the mean fluoroscopy time 14.8 +/- 6.3 min. The RVEDD was significantly reduced, from a mean of 24.2 mm to 21.0 (p < 0.05). One patient developed atrial tachycardia requiring cardioversion during the procedure. There were no embolic events, heart block, or mortality. Complete closure was 10 of 13 (77 %) the next day and 12 of 13 (92%) at 6 and 12 months. We conclude that the cribriform Amplatzer device can be successfully and safely used in patients with F-ASDs. Complete closure may take up to 6 months.

Transcatheter closure of atrial septal defect with Amplatzer device in children aged less than 10 years old: immediate and late follow-up

AIMS

To analyze the efficacy and follow-up results of percutaneous closure of Atrial septal defect (ASD) with the Amplatzer septal occluder in children aged <10 years old.

METHODS

Between November 1998 and September 2005, 27 patients diagnosed with ASD were treated percutaneously with an Amplatzer septal occluder. The procedure was carried out in the cathlab, under general anesthesia and with both fluoroscopy and transesophageal echocardiography guidance. Basal physical examinations and echocardiograms were performed prior to the procedure and at 30 days, 6, and 12 months of follow-up. Survival free of symptom was estimated by Kaplan-Meier.

RESULTS

The mean age, weight, height, body mass index, and corporal surface was: 5.35 +/- 2.11 years, 23.07 +/- 9.43 kg, 110.55 +/- 17.6 cm, 16.77 +/- 2.42 kg/m(2), and 1.24 +/- 2.44 m(2). The prevalence of septal aneurysm was 3.7% and all patients presented single secundum ASD. The mean stretched diameter by fluoroscopy and transesophageal echocardiography were 17.18 +/- 6.75 mm and 16.77 +/- 5.99 mm, and the prostheses sizes were 18.83 +/- 6.98 mm, ranging from 10 to 30 mm. The systolic and diastolic pulmonary pressures were 25.26 +/- 5.97 mm Hg and 13.38 +/- 3.40 mm Hg, respectively. The procedure time was 82.92 +/- 29.14 min and the hospital stay was 2.20 +/- 0.26 days. Clinical and echocardiography follow-ups were performed within 11.59 +/- 4.42 months and all devices were in the correct position with no residual shunt. Right ventricular diameter decreased from 19.38 +/- 5.23mm to 11.38 +/- 11.92 (P 0.001). No major complications or deaths occurred; two patients had a hematoma at the vascular access.

CONCLUSION

Secundum atrial septal defect closure can be safely and successfully performed with the Amplatzer septal occluder in children younger than 10 years old.

Helex septal occluder: feasibility study of closure of atrial septal defect

BACKGROUND

A variety of transcatheter atrial septal defect (ASD) occluders are currently in use, the most commonly used device is the Amplatzer Septal Occluder (ASO) yet there is no perfect device. The Helex Septal Occluder is a new device (by W.L. Gore & Associates, Inc.) designed to improve the results of transcatheter ASD closure. We report our first experience in closing secundum ASDs with this new device after its recent modifications.

METHODS

Thirteen patients were selected for Helex device closure with median age of 8 years (2.5-44 years) and median weight 30 Kg (12-96 Kg). Inclusion criteria were: small to moderate Secundum ASDs with sufficient rims by transthoracic echo (TTE) and confirmed by transoesophageal echo (TEE). Two cardiologists carried out the decision of device size. One of the five available Helex ASD device sizes was used (15-35 mm). Follow up TTE was performed the next day, one month, six months and one year later.

RESULTS

Twelve patients had successful Helex septal occluder implantation. One patient was switched to Cribriform ASD device during the procedure because of failure of the locking mechanism. Two patients had trivial residual left to right shunt which disappeared at one month follow up in one patient. No embolic event, AV block or mortality was observed.

CONCLUSION

This feasibility study of the novel Helex septal occluder after its recent modification showed that it can successfully and safely close well selected secundum ASDs. There are several advantages over the currently available devices.

Transcatheter versus surgical closure of secundum atrial septal defect in adults: impact of age at intervention. A concurrent matched comparative study

OBJECTIVES

To compare the short- and mid-term outcomes of surgical (SUR) vs. transcatheter closure of secundum atrial septal defect (ASD) using Amplatzer septal occluder (ASO) in adults with a very similar spectrum of the disease; and to identify predictors for the primary end point.

DESIGN

Single-center, concurrent comparative study. Surgically treated patients were randomly matched (2:1) by age, sex, date of procedure, ASD size, and hemodynamic profile.

SETTING

Tertiary referral center.

PATIENTS

One hundred sixty-two concurrent patients with ASD submitted to ASO (n = 54) or SUR closure (n = 108) according with their preferences.

MAIN OUTCOME MEASURES

Primary end point was a composite index of major events including failure of the procedure, important bleeding, critical arrhythmias, serious infections, embolism, or any major cardiovascular intervention-related complication. Predictors of these major events were investigated.

RESULTS

Atrial septal defects were successfully closed in all patients, and there was no mortality. The primary event rate was 13.2% in ASO vs. 25.0% in SUR (P = .001). Multivariate analysis showed that higher rate of events was significantly associated with age >40 years; systemic/pulmonary output ratio <2.1; and systolic pulmonary arterial pressure >50 mm Hg; while in the ASO group the event rate was only associated with the ASD size (>15 cm(2)/m(2); relative risk = 1.75, 95% confidence interval 1.01-8.8). There were no differences in the event-free survival curves in adults with ages <40 years.

CONCLUSIONS

The efficacy for closure ASD was similar in both groups. The higher morbidity observed in SUR group was observed only in the patients submitted to the procedure with age >40 years. The length of hospital stay was shorter in the ASO group. Surgical closure is a safe and effective treatment, especially in young adults. There is certainly nothing wrong with continuing to do surgery in countries where the resources are limited.

The anaesthetist and the cardiac catheterisation laboratory

Interventional cardiology is an innovative and expanding field. Anaesthetists are increasingly involved in managing complex congenital and acquired heart lesions in the cardiac catheterisation laboratory. This article provides an overview of common lesions encountered in the cardiac catheterisation laboratory, the anaesthetic management of patients with congenital and acquired heart lesions, the procedures performed and the complications encountered during such procedures.

Predictors of spontaneous closure of isolated secundum atrial septal defect in children: a longitudinal study

OBJECTIVES

The goals were to assess the frequency of spontaneous closure of isolated secundum atrial septal defect in children and to identify predictors of spontaneous atrial septal defect closure.

METHODS

A retrospective cohort study was performed in a tertiary care pediatric cardiology center. Consecutive patients (n = 200) diagnosed as having isolated atrial septal defects (no multiple or fenestrated atrial septal defects, no additional congenital heart disease, and no syndromes) were monitored for > 6 months with serial 2-dimensional echocardiography, according to a standardized protocol.

RESULTS

The median age at diagnosis was 5 months (minimum: 0 months; maximum: 13.9 years). The atrial septal defect diameter at diagnosis was 4 to 5 mm in 40% of cases, 6 to 7 mm in 28% of cases, 8 to 10 mm in 21% of cases, and > 10 mm in 11% of cases. The median age at the final follow-up evaluation was 4.5 years (range: 6.8 months to 16.2 years). Thirty-four percent of atrial septal defects showed spontaneous closure, and 28% decreased to a diameter of < or = 3 mm. Logistic regression analysis revealed atrial septal defect diameter and age at diagnosis as independent predictors of spontaneous closure or regression to < or = 3-mm defect size. Of atrial septal defects with a diameter of 4 to 5 mm at diagnosis, 56% showed spontaneous closure, 30% regressed to a diameter of < or = 3 mm, and none required surgical closure. Of atrial septal defects with a diameter of > 10 mm at diagnosis, none closed spontaneously, whereas 77% required surgical or device closure. Gender and observation time were not associated with spontaneous atrial septal defect closure or regression to < or = 3 mm.

CONCLUSIONS

In the present study population of children with atrial septal defects, 62% showed spontaneous closure (34%) or regression to < or = 3 mm (28%). Initial atrial septal defect diameter was the main predictor of spontaneous closure.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Surgical Versus Percutaneous Occlusion of Ostium Secundum Atrial Septal Defects

OBJECTIVES

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Use of a percutaneous atrial septal occluder device for complete acute occlusion of an intrahepatic portosystemic shunt in a dog

A 3-month-old sexually intact male German Shepherd Dog was evaluated because of signs of depression, ataxia, and collapse. Clinicopathologic abnormalities included low serum BUN and albumin concentrations and high serum liver enzyme activities and plasma ammonia and serum bile acids concentrations. Abdominal ultrasonography revealed an intrahepatic portosystemic shunt (PSS). The dog was anesthetized; via a transjugular approach, guidewires and catheters were directed with fluoroscopic guidance to locate the shunt and determine its anatomic features. Minimal changes in portal vein pressure during temporary shunt balloon occlusion enabled complete shunt attenuation, which was performed by use of a self-expanding septal occlusion device that is typically used for treatment of atrial septal defects in humans. Following initial misplacement of the device, the procedure was repeated successfully 2 months later and resulted in complete shunt occlusion. One year after this second procedure, the dog was clinically normal and serum bile acids concentration was within reference limits. In certain dogs with intrahepatic PSSs, treatment with minimally invasive interventional techniques involving fluoroscopy may reduce the morbidity and mortality rates associated with more invasive surgical procedures.

Thoracoscopic ASD closure is a reliable supplement for percutaneous treatment

OBJECTIVE

To determine the feasibility and effectiveness of endoscopic atrial septal defect (ASD) closure when percutaneous ASD closure is impossible or has failed.

PATIENTS

Between March 1997 and February 2003, 74 patients (63% female, mean (SD) age 44 (16) years) underwent an endoscopic ASD closure. Median preoperative New York Heart Association functional class was I. Clinical and echocardiographic follow up was obtained for all patients (mean (SD) 38 (19) months). Patients were assessed for scar aesthetics, procedure related pain, functional recovery, and overall patient satisfaction.

RESULTS

ASD closure was successful in all patients (two primum ASD, 68 secundum ASD, four sinus venosus type). Patch repair was performed in 42%. Mean aortic cross clamp and cardiopulmonary bypass times were 54 (24) minutes and 98 (35) minutes, respectively. There were no in-hospital deaths and no conversions to sternotomy. Complications included one iliac vein stenting, one femoral arterioplasty, two revisions for suspected bleeding, and seven cases of atrial fibrillation. Two patients required late reoperation: one for atrial thrombus and another for tricuspid regurgitation. Echocardiographic control confirmed complete ASD closure in 71 patients and a small residual shunt in three patients. Ninety three per cent of the patients were highly satisfied with very low procedure related pain and 97% felt they had an aesthetically pleasing scar.

CONCLUSION

Endoscopic ASD closure can be safely done with a high degree of patient satisfaction. It is now the authors' exclusive surgical approach whenever percutaneous treatment is not indicated or has failed.

Amplatzer atrial septal defect occluder for pediatric patients: radiographic appearance

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Closure of defects of the atrial septum in adults using the Amplatzer device: 100 consecutive patients in a single center

BACKGROUND

Transcatheter device closure of atrial septal defects (ASD) is an alternative to surgery, but experience is limited in adults, especially in those with large (> 26 mm) defects.

HYPOTHESIS

We investigated the safety, efficacy, and learning curve for closure of ASD and patent foramen ovale (PFO) using the Amplatzer device.

METHODS

In all, 101 procedures were carried out in 100 consecutive adult patients in a single cardiac center between July 1998 and August 2002.

RESULTS

Preprocedure diagnosis was ASD and PFO in 50 patients each. A device was deployed in 94 of 101 attempts (93%) in 94 of 100 patients (94%). Atrial septal defect device sizes were 10-38 mm, median 24 mm, and 40% were > 26 mm. Major complications occurred in 2 of 100 patients (2%). One ASD device displaced requiring surgery within 24 h and one patient with PFO experienced pericardial tamponade; there were no deaths. Local vascular complications occurred in 4 of 100 (4%) and late complications in 4 of 100 (4%) patients. Patent foramen ovale closure was quicker (p<0.001), required less radiation (p=0.04), and was associated with fewer local vascular complications than ASD closure (p=0.04). Deployment of ASD devices > 26 mm was not associated with increased complications, length of procedure, or radiation compared with devices < or = 26 mm (all p>0.05). Complications in the first 35 patients were more frequent than in subsequent patients: 7 of 35 (20%) versus 3 of 65 (4.6%) (p=0.04); procedure and fluoroscopy times (both p<0.001) and radiation doses (p=0.001) were also higher.

CONCLUSION

The Amplatzer device is an effective method for transcatheter closure of interatrial defects in adults, including large ASDs up to 38 mm. Major complications are uncommon. A learning curve of approximately 35 cases was suggested by the decline of complications, procedure times, and radiation exposure.

Short- and intermediate-term results of transcatheter closure of atrial septal defect with the Amplatzer Septal Occluder

BACKGROUND

The Amplatzer Septal Occluder (ASO) (AGA Medical Corp, Golden Valley, Minn) has gained wide acceptance for transcatheter closure of atrial septal defect (ASD). We conducted this study to evaluate the short-and intermediate-term results of ASD closure with the ASO and to determine the impact of deficient rim on the results.

METHODS

Between March 1999 and February 2003, 197 patients underwent attempted transcatheter closure of ASD with the ASO. The size of the selected device either equaled or was 1 to 2 mm larger than the stretched diameter of the defect. Transesophageal echocardiography was used to monitor the implantation procedure. One hundred and fourteen patients (58%) with a deficiency in 1 rim (<5 mm) were included as group I, and the remaining 83 patients with adequate rims comprised group II.

RESULTS

The mean stretched diameter measured with the balloon catheter was 18.6 +/- 6.7 mm (range 7.1-37.2 mm). Deployment of the ASO was successful in 191 (97%) patients and failed in 6. There was no significant difference between the 2 groups in the success rate for ASD closure (110/114 vs 81/83). Repositioning of the device was required in 28 patients: 21 in group I and 7 in group II (21/114 vs 7/83, P >.05) The mean stretched diameter of the defect in these 28 patients was significantly larger than that in those who did not require repositioning of the device (27.3 +/- 5.7 vs 17.1 +/- 5.5 mm, P <.01). Three patients experienced severe complications: 1 had transient complete atrioventricular block, 1 had tamponade requiring drainage, and 1 had dislodgement of the device requiring emergent operation. One had a distal embolism to a fingertip. Echocardiography at 1 day, 3 months, 6 months, 12 months, and 24 months after the procedure showed residual shunts in 37/191 (19%), 15/189 (8%), 11/176 (6%), 7/131 (5%), and 3/72 (4%) patients, respectively.

CONCLUSIONS

The ASO is a safe and effective device for the transcatheter closure of ASD. Deficiency in 1 rim, particularly the superior anterior rim, does not influence the success rate of ASD closure.

Transthoracic echocardiographic guidance of transcatheter atrial septal defect closure

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

Radiologic findings of 2 commonly used cardiac septal occluders with clinical correlation

Transcatheter closure of an atrial septal defect, patent foramen ovale, or post-myocardial infarction ventricular septal defect has become a safe and effective alternative to medical and surgical therapy. Although the use of transcatheter closure of septal defects is becoming increasingly more popular, there are few reports of the radiographic appearance of the closure devices. We report the chest radiographic findings in 36 patients after transcatheter closure of septal defects with Amplatzer or CardioSEAL occluders in an effort to aid radiologists in recognizing the appearances of these devices and enable them to confirm proper positioning.