Echocardiographic follow-up of atrial septal defect after catheter closure by double-umbrella device

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Comparison of perventricular and percutaneous ultrasound-guided device closure of perimembranous ventricular septal defects

Background

Ultrasound-guided percutaneous device closure of perimembranous ventricular septal defects (PmVSD) is a minimally invasive recent treatment approach. Perventricular PmVSD device closure is an emerging radiation-free intervention, yet it comes with certain limitations. No studies compared both of these treatment approaches.

Methods

We performed a retrospective institutional data comparison of percutaneous (PCP Group, n = 138) and perventricular (PVP Group, n = 67) ultrasound-guided device closure procedures in 205 patients with PmVSD between March 2017 and December 2022.

Results

Patients of the PCP and PVP groups had a median age of 4.9 years (IQR, 3.1-14.0) and 5.3 years (IQR, 3.4-13.1) respectively. The median PmVSD diameter in the PCP Group was 4.0 mm (IQR, 3.3-5.3) and 5.2 mm (IQR, 4.0-7.0) in the PVP Group (p = 0.001). There was no significant difference in success rates between the PCP and PVP Groups (intention-to-treat population, 88.4% vs. 92.5%, p = 0.36; as-treated population, 88.4% vs. 89.3%, p = 0.84). 5/8 failed percutaneous cases that were shifted to the perventricular approach were successful. Compared to the PVP Group, patients of the PCP group experienced a significant decrease in ventilation time, drainage volume, and postoperative hospital stay (p < 0.001). The median follow-up period was 24 months (IQR, 6-42) for the PCP group and 61 months (IQR, 53-65) for the PVP group. The overall severe adverse event rate was 0% in the PCP group and 3.0% in the PVP group.

Conclusions

Perventricular and percutaneous ultrasound-guided device closure of PmVSD are both effective and safe treatment options. The percutaneous approach offers less trauma and faster recovery and may be the preferred approach in selected patients.

Transcatheter closure of post-myocardial infarction ventricular septal defect: A systematic review and single-arm meta-analysis

Background

Ventricular septal defects (VSDs) are one of the mechanical complications of acute myocardial infarction (AMI). Because of the high risks of mortality and postoperative complications, a new alternative method is needed. With the development of interventional medicine, transcatheter closure has been increasingly performed for postmyocardial infarction ventricular septal defects (PMIVSDs). The aim of this study is to explore the feasibility and safety of transcatheter closure of PMIVSDs by meta-analysis.

Methods

The included studies were mainly single-arm studies of transcatheter closure of PMIVSDs. We compared VSD size, device size, preoperative risk factors and interventions among PMIVSD patients. We analysed the transcatheter closure success rate, the 30-day mortality rate, and the incidence of residual shunts.

Results

A total of 12 single-arm articles (284 patients) were included. The combined incidences of preoperative hypertension, hyperlipidaemia, and diabetes were 66% [95% CI 0.56-0.75], 54% [95% CI 0.40-0.68], and 33% [95% CI] 0.21-0.46], respectively. Multiple studies reported the combined incidences of preoperative PCI, IABP, and CABG, which were 46% [95% CI 0.15-0.80], 60% [95% CI 0.44-0.75], and 8% [95% CI 0.02-0.18]. Eleven studies reported the number of successful closures and the 30-day mortality rate; the success rate was 90% [95% CI 0.86-0.94], and the 30-day mortality rate reached 27% [95% CI 0.86-0.94].

Conclusion

For patients with PMIVSD, transcatheter closure in the acute phase can be used as a rescue measure, while in the chronic phase, it is more effective and has a lower mortality rate, but the effect of selection bias should be considered. Residual shunts are a long-term complication that have a high incidence and long-lasting effects on patients. More large, multicentre, randomized controlled trials are needed in the future to confirm the safety and reliability of transcatheter closure of PMIVSDs.

Comparative effectiveness of devices for transcatheter closure of atrial septal defects: Systematic review and network meta-analysis

Atrial septal defect is a common congenital heart disease, producing a left-to-right shunt in the atrial septum; the current preferred treatment is transcatheter device closure. The aim is to conduct a systematic review to synthesize information on the comparative effectiveness and safety of atrial septal defect closure devices. The methods used: a comprehensive search of Ovid MEDLINE®, Embase, and Cochrane Central databases was conducted. Studies comparing procedural and follow-up outcomes of atrial septal defect devices were included. Network meta-analyses were conducted to generate direct and indirect evidence for comparative effectiveness and safety outcomes between devices. The results are as follows: Twelve studies met our inclusion criteria and were compared in network meta-analyses. The meta-analyses evaluated contemporary devices: the AMPLATZER Septal Occluder; the GORE CARDIOFORM Septal Occluder; the Figulla Flexible II Occluder; the CeraFlex Septal Occluder; and the HELEX Septal Occluder. These studies represented 3998 patients. The primary safety and efficacy outcomes were device embolization and follow-up residual shunt, respectively. Secondary clinical outcomes included procedural success and major and minor complications. No differences were found between devices in terms of device embolization and secondary clinical outcomes. Follow-up residual shunt was higher with the HELEX Septal Occluder compared with the AMPLATZER Septal Occluder (odds ratio 2.92, 95% confidence interval 1.12-7.61). To conclude: although most outcomes were similar between devices, evidence was largely based on observational low-quality studies. There were inconsistencies in outcome reporting and definitions; this merits future studies, with head-to-head device comparisons and standardization of outcomes.

Antithrombotic Therapy Duration after Patent Foramen Ovale Closure for Stroke Prevention: Impact on Long-Term Outcome

Background

The optimal duration of antithrombotic therapy (ATT) after patent foramen ovale (PFO) closure remains under debate. This study sought to compare the clinical outcome of patients receiving antithrombotic agents for a short (6 months) versus extended (>6 months) period after the procedure.

Methods

This was a retrospective cohort study using a propensity score matching analysis on 259 consecutive patients (131 males, 43 ± 10 years) undergoing PFO closure due to cryptogenic stroke, with complete follow-up (median duration of 10 [4–13] years). The outcome was compared between patients receiving short-term (Group short, N = 88) versus extended ATT (Group long, N = 171).

Results

The PFO closure device was successfully implanted in all cases, with 3% of minor complications. After propensity score matching, there were no differences between Groups short and long in the rate of stroke (0.3 vs. 0.4% patient-year, p=1.00), bleeding (2 vs. 2% patient-year, p=0.17), and device thrombosis (0.3 vs. 0.1% patient-year; p=0.60). Univariate analysis showed that short-term ATT was not associated with an increased risk of recurrent stroke (HR: 1.271 [95% CI: 0.247–6.551], p=0.775) or prosthesis thrombus (HR: 0.50 [95% CI: 0.070–3.548], p=0.72). Kaplan–Meier analysis revealed similar overall survival in Group short and long (100 vs. 99 ± 1%, respectively; p=0.25).

Conclusions

Short-term (6 months) ATT after PFO closure did not impair the clinical outcome, with a preserved low rate of recurrent stroke (0.3% patient-year) and device thrombosis (0.2% patient-year) at 10-year follow-up.

Transcatheter closure of fenestrated atrial septal aneurysm in children: Feasibility and long-term results

BACKGROUND

To date, extensive experience in transcatheter closure of fenestrated atrial septal aneurysm (ASA) in the pediatric population is limited.

METHODS

To report on procedural feasibility, efficacy, and long-term outcome, we enrolled all children submitted to an attempt of transcatheter closure of fenestrated ASA at two, large volume, pediatric cardiology units (Naples and Massa, Italy) between April 2000 to May 2020.

RESULTS

This retrospective study included 139 patients (median age 9 years [range 2-18] and weight 36 kg [range 10-102]); 19 (13.7%) children were ≤20 kg (range 10-20) and 14 (10.1%) were ≤5 years old. Single perforation was observed in 28 patients (20.1%), while 111 patients (79.9%) had multifenestrated ASA. The median size of the main defect was 15 mm (range 6-34) and 25 patients (18%) had a defect ≥20 mm. The procedural success rate was 99% (95% confidence interval [CI]: 94.9-99.8) using a single device in 75 (69%), two devices in 31 (28%), and three devices in 3 (3%) cases. Early minor adverse events (AEs) occurred in four patients (2.8%). Late minor AEs were recorded in one patient (0.7%) over a median follow-up of 5 years ([range 0-18 years; total 890.2 person-years, and with 30 patients (22%) followed ≥10 years). Neither mortality nor major AEs were recorded. Freedom from AEs was 99.1% at 10-15 years (95% CI: 93.5-99.8%), without any difference according to atrial septum anatomy or patient age and weight.

CONCLUSION

Transcatheter closure of fenestrated ASA is technically feasible and effective in children with excellent long-term outcomes.

Transcatheter closure of atrial septal defect with deficient posterior-inferior or inferior vena cava rim under echocardiography only: a feasibility and safety analysis

BACKGROUND

The safe closure of atrial septal defect with deficient posterior-inferior or inferior vena cava rim is a controversial issue. Few studies have been conducted on the closure of atrial septal defect with deficient posterior-inferior or inferior vena cava rim without fluoroscopy. This study evaluated the feasibility and safety of echocardiography-guided transcatheter closure of atrial septal defect with deficient posterior-inferior or inferior vena cava rim.

METHODS

The data of 136 patients who underwent transcatheter atrial septal defect closure without fluoroscopy from March 2017 to March 2020 were retrospectively analysed. The patients were classified into the deficient (n = 45) and sufficient (n = 91) posterior-inferior or inferior vena cava rim groups. Procedure and the follow-up results were compared between the two groups.

RESULTS

Atrial septal defect indexed diameter and the device indexed diameter in the deficient rim group were both larger than that in the sufficient rim group (22.12 versus 17.38 mm/m2, p < 0.001; 24.77 versus 21.21 mm/m2, p = 0.003, respectively). There was no significant difference in the success rate of occlusion between two groups (97.78% in the deficient rim group versus 98.90% in the sufficient rim group, p = 1.000). During follow-up, the incidence of severe adverse cardiac events was not statistically significant (p = 0.551).

CONCLUSIONS

Atrial septal defect with deficient posterior-inferior or inferior vena cava rim can safely undergo transcatheter closure under echocardiography alone if precisely evaluated with transesophageal or transthoracic echocardiography and the size of the occluder is appropriate. The mid-term results after closure are similar to that for an atrial septal defect with sufficient rim.

Effectiveness and Safety of Transcatheter Atrial Septal Defect Closure in Adults with Systemic Essential Hypertension

Concomitant systemic essential hypertension (HTN) in adults with a secundum atrial septal defect (ASD) can unfavorably affect the hemodynamics and transcatheter ASD closure (ASDC) effects. This study aims to assess the effectiveness and safety of ASDC in adults with HTN in real-world clinical practice. Right ventricular (RV) reverse remodeling (RVR) and the lack of a left-to-right interatrial residual shunt (NoRS) in echocardiography 24 h and 6 months (6 M) post-ASDC, and ASDC-related complications within 6 M were evaluated in 184 adults: 79 with HTN (HTN+) and 105 without HTN (HTN−). Compared to HTN−, HTN+ patients were older and had a greater RV size and the prevalence of atrial arrhythmias, chronic heart failure, nonobstructive coronary artery disease, diabetes, hyperlipidemia, and left ventricular diastolic dysfunction. ASDC was successful and resulted in RVR, NoRS, and a lack of ASDC-related complications in the majority of HTN+ patients both at 24 h and 6 M. HTN+ and HTN− did not differ in ASD size, a successful implantation rate (98.7% vs. 99%), RVR 24 h (46.8% vs. 46.7%) and 6 M (59.4% vs. 67.9%) post-ASDC, NoRS 24 h (79% vs. 81.5%) and 6 M (76.6% vs. 86.9%) post-ASDC, and the composite of RVR and NoRS at 6 M (43.8% vs. 57.1%). Most ASDC-related complications in HTN+ occurred within 24 h and were minor; however, major complications such as device embolization within 24 h and mitral regurgitation within 6 M were observed. No differences between HTN+ and HTN− were observed in the total (12.7% vs. 9.5%) and major (5.1% vs. 4.8%) complications. Transcatheter ASDC is effective and safe in adults with secundum ASD and concomitant HTN in real-world clinical practice; however, proper preprocedural management and regular long-term follow-up post-ASDC are required.

Transcatheter closure of fenestrated atrial septal aneurysm: feasibility and long-term results

AIM

To report on the feasibility, efficacy and long-term outcome of transcatheter closure of fenestrated Atrial Septal Aneurysm (ASA).

METHODS

Between April 2000 and May 2020, 568 patients with fenestrated ASA underwent transcatheter closure at two large-volume Pediatric Cardiology and GUCH Units (Naples and Massa, Italy). Procedural indications were cardiac volume overload in 223 patients (39%) or prophylaxis of paradoxical embolization in 345 patients (61%). Patients' median age and weight were 42 years (range 19-52) and 66 kg (range 54-79), respectively. One-hundred and thirty-nine patients (25%) were younger than 18 years.

RESULTS

Single fenestration was found in 311 patients (55%) (Group 1), whereas 257 patients (45%) had multifenestrated ASA (Group 2). The procedure was successful in all but seven patients (1.2%). In Group 1, closure was achieved with a single device. In Group 2, one device was used in 168 patients (67%), two devices in 74 patients (28%), three devices in 12 patients (5%), and four devices in 1 patient (0.3%). The early complication rate was 3%, without any difference according to anatomy or patient's age. At discharge, complete shunt closure was higher in Group 1 (92% vs. 72%, P < 0.0001), without any difference between groups at the last follow-up evaluation (100% vs. 99%, P = 0.12). Procedural safety was persistent during the long-term follow-up (mean 7.2 ± 5.4, range 0-19 years): freedom from adverse events was 97% at 10-15 years. Seventeen patients (3%) were submitted to reintervention, mostly as prophylaxis of paradoxical embolization.

CONCLUSION

Transcatheter closure of perforated ASA is technically feasible in a high percentage of cases, with excellent long-term outcomes.

Perimembranous ventricular septal defect closure via ultra-minimal trans intercostal incision in children

AIMS

This study aimed to investigate the safety, feasibility and, availability of perimembranous ventricular septal defect (PmVSD) closure via a left parasternal ultra-minimal trans intercostal incision in children.

METHODS AND RESULTS

From January 2015 to January 2019, 131 children with restrictive PmVSDs were enrolled in this study and successfully done in 126 patients (96.18%). PmVSDs were occluded via an ultra-minimal trans intercostal incision (≤1 cm), and the entire occlusive process was guided and monitored by TEE. A pericardium hanging technique was employed without sternal incision. PmVSDs were closed through a short delivery sheath assembled using a concentric occluder device. All patients were followed up for a period ranging from18 months to 24 months. Thirteen patients with PmVSD had aneurysm of membranous septum (AMS). Multistream (≥2) PmVSDs with AMS were found in 11 cases. After the operation, mild residual shunt beside the amplatzer occluder in one patient was found and had self-healing result during the 5-month follow-up period. Five patients transferred to ventricular septal defect repair operation under direct visualization with a cardiopulmonary bypass. One reason was ventricular fibrillation when guidewire passed the PmVSD, another was device dislocation, and others were the guidewire cannot pass through the PmVSD.

CONCLUSIONS

PmVSDs closure using a concentric occluder via a left parasternal ultra-minimal trans intercostal incision under TEE guidance is feasible, safe, and effective in children. This approach can be considered as an alternative treatment to open-heart surgery for restrictive PmVSDs.

Feasibility of Transcatheter Closure of Secundum Atrial Septal Defect in Low Weight Infants Under 2-Year-Old from a 3-year Retrospective Cohort Study

We aimed to evaluate the feasibility of interventional treatment of atrial septal defect (ASD) in low weight infants under 2-year-old. Seven hundred and ninety-three secundum ASD patients were divided into 2 groups: 665 were above 2-year-old and 128 were under 2-year-old. The basic conditions before the operation, postoperative complications within 24 hours, and adverse outcomes during a three-year follow-up were compared between the 2 groups using multivariate analysis. There were significant differences in age, weight, and the diameter of the ASD between the 2 groups (p <0.001). The immediate success rate of the procedure was 96.7%. There were no significant differences in the success rate of the procedure, the incidence of residual shunt, arrhythmia, procedure-related arrhythmia, and occluder shedding between 2 groups (p >0.05). Similarly, we found no association between age ≤2-year-old and any adverse outcomes postprocedure within 24 hours, including procedure failure (OR = 0.35; 95%CI: 0.04 to 2.93), residual shunt (OR = 1.07; 95%CI: 0.54 to 2.14), arrhythmia (OR = 0.68; 95%CI: 0.32 to 1.43), or procedure-related arrhythmia (OR = 0.34; 95%CI: 0.04 to 2.87). In the follow-up data, we found no association between age ≤2-year-old and arrhythmia (HR = 0.95; 95%CI: 0.50 to 1.80) and procedure-related arrhythmia (HR = 0.96;95%CI:0.25 to 3.64). Kaplan-Meier survival curves indicated no significant difference in the occurrence of arrhythmia between the 2 groups (log-rank test: p = 0.776). In conclusion, percutaneous ASD closure in young and low weight infants has a high success and low complication rate, along with reliable effects.

Long-Term Follow-Up of Transthoracic Echocardiography-Guided Transcatheter Closure of Large Atrial Septal Defects (≥ 30 mm) Using the SHSMA Occluder

Transcatheter closure of large atrial septal defects (ASDs) remains controversial. The aim of this study was to evaluate the feasibility and safety of transthoracic echocardiography (TTE)-guided transcatheter closure of large ASDs. Patients with large secundum ASDs (≥ 30 mm) who underwent device closure were retrospectively reviewed. TTE was performed to guide ASD occluder positioning and assess the immediate and long-term outcomes. A total of 60 patients (median age 43.5 years, range 15-78 years) were enrolled in the study. The median ASD size was 35 mm (range 30-42 mm). Mild to moderate pulmonary hypertension was observed in 36 patients (60%). Thirty-one patients (51.7%) had one short rim, and 18 patients (30.0%) had two deficient rims. Placement of the device was successful in 57 patients (95%), and the median device size was 42 mm (range 40-50 mm). Dislodgement of the device occurred in three patients with two deficient rims: a larger device was redeployed in one case, and two patients required surgical repair. During a median follow-up of 37 months (range 6-83 months), no residual shunts, erosion, or embolization were noted, and pulmonary hypertension resolved in 75% of the patients. Thus t vast majority (95%) of large ASDs can be successfully closed percutaneously using the Chinese-made Shanghai Shape Memory Alloy (SHSMA) occluder under TTE guidance. Long-term follow-up showed that transcatheter closure could become a safe and effective alternative to surgery in select large ASDs.

Light anti-thrombotic regimen for prevention of device thrombosis and/or thrombotic complications after interatrial shunts device-based closure

AIMS

The optimal antiplatelet therapy after atrial septal defect (ASD) or patent foramen ovale device closure (PFO) remain to be established. We evaluated the safety and effectiveness of 6-month 100 mg Aspirin (ASA) regimen in the very long-term follow up after intracardiac echocardiography (ICE) -aided interatrial shunt closure in a large retrospective cohort.

METHODS

Single-center retrospective analysis which included medical and instrumental data of 789 consecutive patients referred to our institution over a 15 years period due interatrial shunt catheter-based closure.

RESULTS

Finally, 734 patients were included in the analysis (mean age 46.1 ± 14.6 years, 398 females): ASD and PFO closure were successfully performed in 281 and 453 patients, respectively. Over the follow-up period, no major bleeding events were observed while the rate of minor bleeding events was 0.9%. Tolerance problems were detected in 3.4% of cases (n==28). In 11 patients (1.5%) an abnormal complete blood count was detected and monitored up to normalization. On a mean follow -up of 10.3 ± 3.0 years (range 1-15), 10 patients (1.36%) had a persistent moderate shunt 12 months after closure and maintained Aspirin 100 mg life-long, whereas the remaining 724 suspended the treatment after 6 months. Device thrombosis in ASD and PFO groups were 0% and 0.2%, respectively. A cerebral ischemic event occurred in 0.4% of the entire cohort.

CONCLUSIONS

A regimen of 100 mg of ASA for six months after ASD/PFO closure appeared to be both safe and effective in preventing device thrombosis and major bleedings.

Percutaneous Device Closure of Patent Ductus Arteriosus in Adult Patients with 10-Year Follow-up

Objectives:

We report our 10-year experience with transcatheter closure of patent ductus arteriosus (PDA) in adult using different closure devices.

Background:

Transcatheter closure of PDA in adults can be challenging because of frequently associated comorbidities. Reports on immediate and intermediate-term results of PDA closure are excellent. This study aimed to provide the outcomes of PDA closure using different devices on long and very long term follow-up in adults.

Materials and Methods:

Between September 2009 and December 2018, data were retrospectively reviewed from 27 patients who underwent transcatheter closure of PDA. Outcome parameters were procedural success, procedure-related complications, evidence of residual shunt, and improvement in the signs/symptoms for which the procedure was performed. The mean follow-up interval was 72 months.

Results:

A device was successfully implanted in 27 of 27 patients (15 females). Median age and weight were 24 years (range: 18–57 years) and 69 kg (range: 53–102 kg), respectively. The mean PDA diameter was 4.1 ± 2.1 mm. Devices used were Amplatzer Duct Occluder (19/27), Occlutech Duct Occluder (6/27), and PFM Nit-Occlud (2/27). Doppler transthoracic echocardiography (TTE) demonstrated 92.6% of full occlusion at day 1, rising to 96.3% at 1 month. Three procedure-related complications occurred with no death. Among symptomatic 26 patients (96.3%), there was marked improvement in symptoms. Among 22 patients (81.5%) for whom the procedure was performed to address left ventricular (LV) enlargement, there was reduction or stabilization in LV size on serial TTEs.

Conclusions:

Transcatheter closure of PDA in the adult patient appears to be safe and effective.

Midterm Follow-up Results of Transcatheter Interatrial Septal Defect Closure

Objectives

We studied immediate and midterm results of transcatheter closure of atrial septal defects (ASDs) using the Amplatzer septal device closure.

Methods

The study included one hundred and thirty-seven patients (31 men, 106 women; mean age 8 ± 7.3 years; range 1-65 years) who underwent transcatheter closure of secundum ASD between October 2014 and October 2016 in our center. All the patients were evaluated by transthoracic echocardiography before and during the procedure and in adult patients; transesophageal echocardiography was performed before the procedure. Closure of ASDs was performed under general anesthesia with transthoracic echocardiographic guidance. Follow-up controls were done on the day after procedure, 1 week, 1, 3, 6, and 12 months, and annually thereafter. The median follow-up periods of ASD was 15 months.

Results

The mean ASD and device size were 13.5 ± 2.3 and 14.3 ± 3.2 mm, respectively. The mean procedural and fluoroscopy times were 21.3 ± 4.7 and 5.1 ± 1.9 min. Immediate complications such as mortality, bleeding, fatal arrhythmia, and device embolization did not occur in any patient during and after the procedure. Cardiac arrhythmias were seen in 4 patients during the 1^st month after the procedure. Late device embolization did not occur during the follow-up. No residual shunts were seen after the procedure. Transient ischemic attack was seen in one patient during the procedure and in one patient 2 days after the procedure without long-term complication.

Conclusion

Transcatheter closure of ASDs using the Amplatzer devices is an efficacious and safe therapeutic option.

Simultaneous Transcatheter Closure of Multiple Atrial Septal Defects Using Dual Amplatzer Septal Occluder Devices

BACKGROUND

Transcatheter closure has been a recognised treatment strategy for multiple atrial septal defects (mASDs). This study aimed to examine the feasibility, effectiveness, and safety of transcatheter closure of mASDs using dual Amplatzer septal occluder (ASO) devices.

METHODS

We retrospectively reviewed 34 patients who underwent transcatheter closure of mASDs using dual ASO devices from April 2005 to December 2014.

RESULTS

Eight men and 26 women who successfully underwent transcatheter closure of mASDs were included. Ten (29.4%) patients had 3 defects or more. The mean diameters of the larger and smaller defects were 14.0±3.9 mm (8-20 mm) and 9.1±2.6 mm (4-15 mm), respectively. The mean diameters of the larger and smaller devices were 22.2±4.8 mm (13-30 mm) and 17.3±4.1 mm (10-26 mm), respectively. Devices were deployed by the "sandwiches" technique or an interleaved pattern. Immediately after the procedure, 23 (67.6%) patients had complete closure and 11 patients had a residual shunt (6 trivial, 3 small, 1 moderate, 1 large). During the 6 months of follow-up, 30 (88.2%) patients had complete closure of the shunt and 4 patients had a residual shunt (1 large, 3 small). Complications included 2 cases of pericardial effusion, which disappeared at 3 months.

CONCLUSIONS

Simultaneous device implantation in transcatheter closure of mASDs is feasible and effective. The incidence rate of residual shunts is slightly high in the short term, but tends to decrease during mid-term follow-up.

Historical developments of atrial septal defect closure devices: what we learn from the past

INTRODUCTION

Since King and Mills' pioneering work in percutaneous closure devices of secundum atrial septal defects (ASD) four decades ago, developments in device shape, material and implantation technique led to adoption of percutaneous ASD closure as current treatment of choice. Not only was the feasibility of such a percutaneous procedure tested altogether, but pursuing the ideal device in terms of safety and efficacy became priority.

AREAS COVERED

In this review we present the historical development of ASD devices in design, material and technique with clinical data, and provide the future perspectives in percutaneous ASD closures.

EXPERT OPINION

An 'ideal device' requires complete defect closure with negligible risk of complications using a safe, straightforward delivery technique with repositioning and retrieving properties. Some of the devices currently at hand come close to fulfilling these criteria, however none seem to provide those prerequisites completely. By understanding how challenges in device development were overcome in the past, new insights into future improvements are given.

Feasibility, Safety and Long-Term Follow-Up of Transcatheter Closure of Secundum Atrial Septal Defects with Deficient Rims

Objective: The aim of this work was to evaluate the feasibility and safety of transcatheter closure procedures for the treatment of atrial septal defects (ASDs) with insufficient rims. Methods: A total of 507 secondary ASDs were divided into two groups based on whether they had deficient rims or not (152 vs. 355 cases, respectively). Any complications, including residual shunt, heart arrhythmia, occluder translocation, etc., were followed up for 1-3 years. Results: There were no differences in gender, weight, exposure time, ECG states, pulmonary pressure, the intervention success rate, occurrence of residual shunt, the operation time and occurrence of residual shunt during follow-up between the two groups (p > 0.05). However, the occurrence of rhythm disorders was significantly different between the two groups; ASDs with deficient rims were at an elevated risk (p < 0.05). Specifically, there was a significantly higher incidence in the occurrence of arrhythmia in the deficient rims group at 24 h postoperation, but no differences in arrhythmia incidence at any of the other follow-up time points (1, 3, 6, 12 and 36 months; p > 0.05). Conclusions: Patients with deficient rims experience a high success rate of ASD intervention and low rate of complications when the procedures are performed by experienced operators.

Perventricular device closure of a doubly committed juxtaarterial ventricular septal defect through a left parasternal approach: midterm follow-up results

Background

It is infeasible to occlude a doubly committed juxtaarterial ventricular septal defect (DCVSD) percutaneously. The previous perventricular device closure technique was performed through an inferior median sternotomy approach. The purpose of this study is to evaluate the feasibility, safety and efficacy of perventricular device closure of DCVSDs through a left parasternal approach.

Methods

Sixty-two patients, with the DCVSD of less than 6 mm in diameter, were enrolled in this study. The pericardial space was approached through a left parasternal mini-incision without entering into the pleural space. Two parallel pursestring sutures were placed on the right ventricular outflow tract for puncture. Under transesophageal echocardiographic guidance, a new delivery sheath loaded with the device was inserted into the right ventricle and advanced through the defect into the left ventricle. The device, connected with a device stay suture, was deployed subsequently.

Results

Successful device closure of the defects was achieved in 58/62 patients (94 %). The DCVSD failed to close in 4 (6 %) patients due to device-related aortic regurgitation and device migration. The mean DCVSD diameter was 3.4 ± 1.0 mm (range, 2.0 to 6.0 mm). The implanted device size was 5.2 ± 1.3 mm (range, 4 to 8 mm). Forty-four out of 58 patients (76 %) was implanted with an eccentric occluder. The mean intracardiac manipulation time was 14 ± 13 min (range, 2 to 60 min). The procedure time was 66 ± 15 min (range, 42 to 98 min). During the follow-up period of 180 to 1860 (median 880) days, new mild pulmonary regurgitation occurred in 2 patients. No other device-related complications were found. The complete closure rate was 95 % at discharge, 98 % at 1-, 6- and 12-month, 96 % at 2-year, and 100 % at 3-year follow-up.

Conclusions

Perventricular device closure of a DCVSD through a left parasternal approach is feasible, safe, and efficacious in selected patients. This minimally invasive technique permits easy defect crossing and accurate device positioning.

Current perspectives in percutaneous atrial septal defect closure devices

In the last decade, percutaneous atrial septal defect (ASD) closure has become the treatment of choice in most clinical presentations of ASD. Percutaneous ASD closure has established procedural safety through operator experience and improved device structure and deliverability. There have also been advances in diagnostic capabilities. Devices have evolved from large bulky meshes to repositionable, minimal residual mesh content that easily endothelializes and conforms well to surrounding structures. Biodegradable technology has been introduced and will be closely watched as a future option. The evolution of ASD closure device usage in the last four decades incorporates development that minimizes a wide range of serious side effects that have been reported over the years. Complications reported in the literature include thrombus formation, air embolization, device embolization, erosions, residual shunts, and nickel hypersensitivity. Modern devices have intermediate to long term data with outcomes that have been favorable. Devices are available in multiple sizes with improved delivery mechanisms to recapture, reposition, and safely close simple and complex ASDs amenable to percutaneous closure. In this review, commonly used devices and deployment procedures are discussed together with a look at devices that show promise for the future.

Percutaneous Closure of Atrial Septal Defects Under Transthoracic Echocardiography Guidance Without Fluoroscopy or Intubation in Children

OBJECTIVE

Demonstrate the benefits of percutaneous atrial septal defect (ASD) closure under guidance of transthoracic echocardiography (TTE) without fluoroscopy.

METHODS

From February 2013 to April 2014, 127 consecutive patients with an isolated type II ASD were recruited to undergo percutaneous closure under either TTE (n = 60, TTE group) or TEE (n = 67, TEE group) guidance. The TTE group received local anesthesia or sedation with propofol, and the TEE group received general anesthesia with endotracheal intubation. Follow-up examinations were performed for both groups at 1 month, 3 months, 6 months, and 1 year after discharge and annually thereafter.

RESULTS

The TTE group had a significantly shorter procedure time and respirator ventilation duration than the TEE group. The dose of propofol required, the cost, and the pharyngeal complication rate were significantly lower in the TTE group than in the TEE group. The median follow-up of 11.6 months was uneventful in all patients.

CONCLUSIONS

Percutaneous ASD closure with TTE guidance as the only imaging tool avoids fluoroscopy, endotracheal intubation, and probe insertion and is associated with a satisfactory procedural success rate and lower costs. This procedure is a safe and reliable treatment for ASD.

Clinical, hemodynamic, and intracardiac echocardiographic characteristics of secundum atrial septal defects-related paradoxical embolism in adulthood

BACKGROUND

Paradoxical embolism associated with secundum atrial septal defect (sASD) is a relatively rare but well-known occurrence. The purpose of our study is to report the clinical, hemodynamic, and anatomical features assessed by intracardiac echocardiography (ICE) of sASD as related to paradoxical embolism.

METHODS

Five hundred thirty-seven patients (mean age 48 ± 19.0 years) admitted for transcatheter repair of interatrial shunts were enrolled in a prospective registry over a 10-year period (September 2003-September 2013). All patients underwent transesophageal echocardiography, complete right and left catheterization, prior to the device-based procedure. ICE was performed in all patients in order to investigate the interatrial septum anatomy and to monitor device implantation. These results were compared with the data of patients with patent foramen ovale (PFO) patients and nonemboligenous sASD admitted at the same time period.

RESULTS

Twenty-four patients (6.2%) out of 386 who underwent transcatheter repair for paradoxical embolism had a secundum ASD. The defects were cribrosus in 41.6% (10/24). All single sASD (58.3%) had a peculiar anatomical feature a so-called flat elliptical shape with a major axis of 7.6 ± 2.4 and minimal axis of 2.5 ± 1.6 mm. Patients with sASD-related paradoxical embolism had a higher frequency of deep venous thrombosis compared to PFO patients. In comparison to nonemboligenous sASD, such patients had lower mean pulmonary pressure and smaller defects.

CONCLUSION

sASD related to paradoxical embolism had peculiar clinical, hemodynamic, and anatomical characteristics, which classified such defects in the middle of the spectrum between nonemboligenous secundum ASD and PFO.

Usefulness of intracardiac echocardiography with a mechanical probe for catheter-based interventions: a 10-year prospective registry

BACKGROUND

The clinical outcome benefit of intracardiac echocardiography (ICE) with a mechanical probe during congenital heart disease interventions has not been fully investigated. We reported the long-term results of a prospective registry of interatrial shunt closure guided by mechanical ICE.

METHODS

We enrolled 537 patients (mean age 48 ± 19.0 years, 378 females) submitted to ICE-aided procedures in a prospective registry over a 10-year period (September 2003-September 2013). All patients underwent transesophageal echocardiography (TEE) before the planned procedure. We evaluated (1) structure identification capability, (2) fossa ovale and interatrial septum component measurement, (3) procedure monitoring capability, (4) procedural and fluoroscopy times, and radiograph dose, (5) probe-related complications.

RESULTS

ICE was successfully performed and was able to correctly identify the structures previously assessed by TEE in all patients. In 24 patients (4.5%), ICE allowed better anatomy definition than TEE. In 35 other patients (6.5%), ICE identified structures not observed by TEE, which led to change indications to interventions or the operative technique to be used. In 131 patients (24.4%), ICE evaluation led to change the planned device to be implanted. There was only one probe-related complication (0.2%).

CONCLUSIONS

Mechanical ICE may offer a valid alternative to conventional TEE in guiding congenital heart disease interventional procedures.

Device closure of secundum atrial septal defects in infants weighing less than 8 kg

This study aimed to assess the technical aspects of atrial septal defect (ASD) closure using the Amplatzer septal occluder (ASO) and the Gore Helex septal occluder (GHSO) for infants weighing less than 8 kg and to determine the safety, effectiveness, and near-to-intermediate-term outcome of the closure. The Mid-Atlantic Group of Interventional Cardiology Registry of percutaneous, transcatheter ASD closure procedures was reviewed for this analysis. Patients from 10 hospitals in the United States were included. The cohort for this report consisted of 68 patients weighing less than 8 kg (range, 2.3-7.8 kg; mean, 5.5 ± 1.6 kg) and ranging in age from 1 to 24 months (mean, 8.6 ± 4.7 months). The indications for ASD closure were failure to thrive, significant right heart enlargement, shunts otherwise thought to be hemodynamically significant, and poor overall clinical status. Devices were successfully implanted in 66 of the 68 infants (97.1 % procedural success rate). Five minor procedure-related complications occurred. At follow-up assessment, clinical status had improved significantly as measured by improved weight gain and decreased ventilator or oxygen dependence. All residual shunts spontaneously closed during the follow-up period. Six late deaths occurred, none of which were clearly device related. The ASO and GHSO can be safely and effectively implanted for ASD closure in infants weighing less than 8 kg. These procedures usually are successful and seldom complicated, resulting in significant clinical improvement.

Percutaneous closure of ruptured sinus of Valsalva aneurysm: results from a multicentre experience

AIMS

To evaluate the safety and efficacy of percutaneous closure (PC) using modified double-disc ventricular septal defect (VSD) occluders in patients with ruptured sinus of Valsalva aneurysm (RSVA).

METHODS AND RESULTS

Between 2005 and 2012, 25 patients were enrolled in our study for attempted PC. There were five patients (20%) with RSVA combined with VSD and two (8%) with aortic regurgitation (AR). The median age was 45 years (24-74 years). The QP/QS was 2.4±0.6 (1.6-4.0). The median diameter of lesions was 6 mm (4-8 mm) while the median size of occluders was 8 mm (6-12 mm). Twenty-three patients (92%) underwent PC successfully. Occluders were retrieved in two patients within one week. Trivial residual shunts developed in three and mild occluder-related AR occurred in five at discharge. During a median follow-up of 19 months (6-96 months) all trivial residual shunts vanished and mild occluder-related AR disappeared in four out of five patients. The proportion of patients in NYHA Class III/IV was reduced from 72% at baseline to 12% at the time of last follow-up (p<0.001).

CONCLUSIONS

In selected patients with RSVA, PC using modified double-disc occluders may become a valuable alternative to surgery with encouraging immediate outcomes and midterm results.

Transcatheter closure of secundum atrial septal defect in patients over 60 years old

BACKGROUND AND OBJECTIVES

Atrial septal defect (ASD) is the one of most common congenital heart diseases detected in adults. Along with remarkable development of device technology, the first treatment strategy of secundum ASD has been transcatheter closure in feasible cases. However, there are only a few publications regarding the results of transcatheter closure of ASD in elderly patients, especially those over 60 years of age. We report our results of transcatheter closure of ASD in patients over 60 years old.

SUBJECTS AND METHODS

Between May 2006 and December 2011, 31 patients over 60 years old (25 female and 6 male; mean 66.7±5.25 years old, range 61-78 years old) were referred to our center.

RESULTS

A total of 23 patients underwent therapeutic catheterization to close secundum ASD, and the closure was successful in 22 patients (95.7%). All patients who underwent the procedure survived except for one patient who expired because of left ventricular dysfunction. A small residual shunt was observed in two (9%) of 21 patients before discharge but disappeared at follow-up. All patients eventually had complete closure. There were five patients who had coronary problems. One patient underwent percutaneous coronary intervention using a stent at the same time as transcatheter closure of ASD. Atrial arrhythmias were detected in 6 of 23 patients (26.1%) before the procedure. One patient was successfully treated by radiofrequency ablation before the procedure. No patients displayed new onset arrhythmia during the follow-up period. Follow-up echocardiographic evaluation showed a significantly improved right ventricular geometry.

CONCLUSION

We conclude that transcatheter closure of ASD is a safe and an effective treatment method for patients over 60 years old if the procedure is performed under a thorough evaluation of comorbidities and risk factors.

Feasibility and safety of transthoracic echocardiography-guided transcatheter closure of atrial septal defects with deficient superior-anterior rims

Although previous studies showed that transthoracic echocardiography (TTE) can be used to guide transcatheter closure of atrial septal defect (ASD), whether TTE can be used to guide transcatheter closure of secundum ASD with a deficient superior-anterior rim is unknown and this critical issue was addressed in the present study. A total of 280 patients with secundum ASD who underwent transcatheter ASD closure were recruited and divided into groups A and B depending on ASD superior-anterior rim>4 mm (n = 118) or ≤4 mm (n = 162). TTE was used to guide Amplatzer-type septal occluder (ASO) positioning and assess residual shunt. Procedure success was defined as no, trivial and small residual shunt immediately after the procedure as assessed by color Doppler flow imaging. Group A and group B did not differ in complication rate (8.55% vs.7.55%), procedure success rate (98.3% vs. 95.0%) or complete closure rate immediately after the procedure (89.7% vs. 89.3%) or at 6-month follow-up (98.3% vs. 96.8%). The mean procedure and fluoroscopy time in group B were much longer than those in group A. In conclusion, the absence of a sufficient superior-anterior rim in patients undergoing percutaneous closure of secundum-type ASDs using fluoroscopic and TTE guidance is associated with slightly greater device malposition and migration as well as increased procedural and fluoroscopic times, but the overall complication rate did not differ with TTE guidance when compared to historical controls that used TEE guidance.

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.

Permanent right-to-left shunt is the key factor in managing patent foramen ovale

OBJECTIVES

We sought to prospectively evaluate risk of stroke and impact of transcatheter patent foramen ovale (PFO) closure in patients with permanent right-to left shunt compared with those with Valsalva maneuver-induced right-to-left shunt.

BACKGROUND

Pathophysiology and properly management of PFO still remain far from being fully clarified: in particular, the contribution of permanent right-to-left shunt remains unknown.

METHODS

Between March 2006 and October 2010, we enrolled 180 (mean age 44 ± 10.9 years, 98 women) of 320 consecutive patients referred to our center for transcatheter PFO closure, who had spontaneous permanent right-to-left shunt on transcranial Doppler and transthoracic/transesophageal echocardiography. All patients fulfilled the standard current indications for transcatheter closure and underwent preoperative transesophageal echocardiography and brain magnetic resonance imaging, with subsequent intracardiac echocardiographic-guided transcatheter PFO closure. We compared the clinical echocardiographic characteristics of these patients (Permanent Group) with the rest of 140 patients with right-to-left shunt only during Valsalva maneuver (Valsalva Group).

RESULTS

Compared with the Valsalva Group patients, patients of the Permanent Group had increased frequency of multiple ischemic brain lesions on magnetic resonance imaging, previous recurrent stroke, previous peripheral arteries embolism, migraine with aura, and-more frequently-atrial septal aneurysm and prominent Eustachian valve. The presence of permanent shunt confers the highest risk of recurrent stroke (odds ratio: 5.9, 95% confidence interval: 2.0 to 12, p < 0.001). No differences were recorded between the 2 groups with regard to recurrence of ischemic events after the closure procedure.

CONCLUSIONS

Despite its small-sample nature, our study suggests that patients with permanent right-to-left shunt have potentially a higher risk of paradoxical embolism compared with those without.

Five-year follow-up of transcatheter intracardiac echocardiography-assisted closure of interatrial shunts

OBJECTIVE

We sought to prospectively evaluate long-term follow-up results of intracardiac echocardiography-aided transcatheter closure of interatrial shunts in adults.

BACKGROUND

Intracardiac echocardiography improves the safety and effectiveness of transcatheter device-based closure of interatrial shunts, but its impact on long-term follow-up is unknown.

METHODS

Over a 5-year period, we prospectively enrolled 258 consecutive patients (mean age 48 ± 19.1 years, 169 females) who had been referred to our centre for catheter-based closure of interatrial shunts. All patients were screened with transesophageal echocardiography before the operation. Eligible patients underwent intracardiac echocardiography study and attempted closure.

RESULTS

After intracardiac echocardiography study and measurements, 18 patients did not proceed to transcatheter closure due to unsuitable rims, atrial myxoma not diagnosed by preoperative transesophageal echocardiography or inaccurate transesophageal echocardiography measurement of defects more than 40 mm. The remaining 240 patients underwent transcatheter closure: transesophageal echocardiography-planned device type and size were modified in 108 patients (45%). Rates of procedural success, predischarge occlusion and complication were 100%, 94.2% and 5%, respectively. On mean follow-up of 65 ± 15.3 months, the follow-up occlusion rate was 96.5%. There were no cases of aortic/atrial erosion, device thrombosis or atrioventricular valve inferences.

CONCLUSIONS

Intracardiac echocardiography-guided interatrial shunt transcatheter closure is safe and effective and appears to have excellent long-term results, potentially minimizing the complications resulting from incorrect device selection and sizing.

Percutaneous transcatheter closure of interatrial septal defect in adults: procedural outcome and long-term results

BACKGROUND

Percutaneous transcatheter closure of patent foramen ovale (PFO) and atrial septal defect (ASD) has been shown to be feasible.

AIM

The aim of this study was to evaluate the safety and efficacy of transcatheter interatrial septal shunt closure with prosthesis implantation in adults patients during long-term follow-up. In addition, the impact of thrombophilia and pulmonary hypertension on the outcome were investigated.

METHODS

Between June 1999 and November 2009, 287 patients (112 males, 43 ± 14 years) were treated in our institution by transcatheter closure of PFO (N = 175) or ASD (N = 112). Clinical and echocardiographic follow-up were prospectively performed at 1, 6 and 12 months followed by a 1 once a year evaluation.

RESULTS

All procedures were successful with eight procedural complications (2.7%): one stroke, two femoral pseudoaneurysms, three transient atrial fibrillation, two minors pericardial effusions. Among patients with presumed paradoxical embolism, thrombophilia was observed in 29 patients (17%); only one of them experienced a recurrent stroke. Among patients with ASD, pulmonary hypertension was observed in 32 cases (28%) and significantly reduced 6 months after shunt closure (from 47 ± 7 to 31 ± 11 mm Hg, P < 0.0001). 99% of patients achieved a complete follow-up. Clinical improvement was observed in 93%. Freedom from death, cardiac surgery or recurrent embolism was 98 ± 1% at 5 years.

CONCLUSION

Percutaneous transcatheter interatrial septal defect closure is a safe and effective treatment in adults patients, even in case of thrombophilia or pulmonary hypertension, during a long-term follow-up, up to 11 years.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Treatment of isolated ventricular septal defects in children: Amplatzer versus surgical closure

BACKGROUND

Isolated hemodynamically significant ventricular septal defects (VSD) were previously treated surgically. Since the introduction of percutaneous (PC) devices, the management of isolated VSD has evolved. In our center, Amplatzer devices have been implanted for selected isolated perimembranous VSD since 2002.

METHODS

The charts of all isolated PC perimembranous VSD closures and all surgical closures performed since 2002 were reviewed retrospectively. Clinical, electrocardiographic, and echocardiographic data were analyzed. The preclosure, immediate postclosure, and 1-month, 6-month, and 12-month postclosure results were assessed.

RESULTS

Thirty-seven patients underwent PC closure, and 34 had surgical treatment. Mean follow-up was 42.1 ± 26.0 months. The PC group was significantly older (p < 0.01) and larger in size (p < 0.001). Surgical patients had more severe congestive heart failure and a significantly lower VSD gradient (p < 0.004). At follow-up, there were no differences in the incidence of residual shunting between the two groups (p = 0.92). All valvular regurgitations improved over time, except for 3 aortic regurgitations (5.4%) in the PC group that got worse. Two permanent pacemakers were implanted for early complete heart block in the PC group, and one was implanted in the surgical group (p = 0.94).

CONCLUSIONS

The surgical results in our population were excellent. The selection of patients with perimembranous VSD remains a challenge to avoid post-PC intervention complications such as heart block and aortic insufficiency. For isolated VSD, PC closure, which avoids the morbidity of open heart surgery, should be considered as part of the therapeutic armamentarium.

Left atrial dysfunction in patients with patent foramen ovale and atrial septal aneurysm scheduled for transcatheter closure may play a role in aura genesis

BACKGROUND

It has been suggested that a left atrial (LA) dysfunction induced by large shunt and large atrial septal aneurysm (ASA) may act as a concurrent mechanism of arterial embolism in patients with patent foramen ovale (PFO) and prior stroke. We aimed to evaluate the potential contribution of this mechanism as trigger of migraine in patients with PFO.

METHODS

From January 2007 to September 2009, we prospectively enrolled subjects with migraine who underwent percutaneous PFO closure. Echocardiographic parameter of LA dysfunction was evaluated: pre- and postoperative values were compared to values of different sex and heart rate matched populations: 30 healthy patients, 21 migraine patients without PFO (MwoPFO), and a group of 25 PFO patients without migraine (PFOwoM). The Migraine Disability Assessment Score (MIDAS) was used to assess the incidence and severity of migraine.

RESULTS

Forty-five patients (38 females, mean age 38 +/- 6.7 years, mean MIDAS 35.8 +/- 4.7, and 28 patients with migraine with aura) fulfilled the inclusion criteria. After successful percutaneous closure (mean follow-up of 18.2 +/- 4.8 months), PFO closure remained complete in 95%; 35 of 45 patients reported resolution or amelioration of migraine (mean MIDAS score 12.3 +/- 8.8, P < 0.03). All patients with aura reported aura resolution. Preclosure values demonstrated significantly greater LA dysfunction, when compared with healthy and MwoPFO groups. Among patients in the study group, only patients with migraine with aura showed LA dysfunction comparable to PFOwoM patients.

CONCLUSION

This study suggests that LA dysfunction probably does not contribute to migraine itself but may play a role in the genesis of aura symptoms.