Catheter Closure of Secundum ASD Using “Other” Devices

[Very late erosion of the right atrium with Amplatzer(®) device]

Late atrial wall and aorta erosion is a rare cause of potential fatallity in patients who have undergone percutaneous closure of an atrial septal defect, especially when a high ratio device to defect is chosen, and an insufficient aortic rim is present. We report the case of a 70 year old male with an episode of hemodinamic collapse secondary to cardiac tamponade due to a late erosion of a 4 years ago implanted Amplatzer(®) used to close an atrial septal defect.

CONCLUSION

Very late wall erosion of an atrial septal closure device, although uncommon, should be suspected in patients presenting with hemodynamic collapse.

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.

Transcatheter closure of multiple interatrial communications

OBJECTIVES

We sought to examine acute and midterm results of closure of multiple interatrial communications with staged device deployment and to review the relevant literature.

BACKGROUND

Information about percutaneous methods of closure for multiple defects is limited.

METHODS

We treated 148 patients with multiple defects. Of these, 88 had a relevant left to right shunt ("LRS"), 52 had a presumed paradoxical embolism ("PPE"), five had both (LRS and PPE), and one patient, respectively, had migraine, decompression sickness, and a right to left shunt. After implantation of the first device, closure of additional septal defects was attempted only if indicated clinically.

RESULTS

Ninety-four patients received a single device and 53 more than one. In four patients, surgical defect closure followed. At the end of follow-up (FU; mean 4.5 ± 3.4 years), complete closure of all defects occurred in 67.6% (62.1% for LRS, 76.5% for PPE). Clinical success (small or trivial residual shunt) was achieved in 86.9% (83.9% for LRS, 90.2% for PPE). Complications included pericardial effusions in 2.7%, recurrent thromboembolic events in 4.8%, and new onset of atrial fibrillation in 10.1%. In a significant number of patients with multiple defects, after single device implantation, the likelihood of complete closure increased with FU time (26% complete closure at 1 month vs. 78% at 24 months).

CONCLUSION

Percutaneous closure of multiple interatrial communications is feasible and safe. Importantly, many residual defects close without further intervention at FU. Therefore, staged device delivery is an alternative to simultaneous device implantation, possibly requiring fewer and smaller second devices.

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

OBJECTIVES

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Atrial Septal Defect Treatment Options

Atrial septal defects have traditionally been repaired by surgical closure. Recently, transcatheter device closure has increasingly been used with excellent results. Although there is limited comparative research evaluating long-term outcomes of the transcatheter technique, preliminary data reveal significantly fewer complications and shorter hospital stays than those reported for surgical repair. This article reviews relevant literature comparing efficacy, cost, and complications of the transcatheter device procedures with the surgical closure of ASDs.