Left Atrial Thrombus on Atrial Septal Defect Closure Device as a Source of Cerebral Emboli 3 Years After Implantation

Cardiac myxoma following transcatheter closure of an atrial septal defect

To date, no significant association has been reported between atrial septal defects (ASD) and cardiac myxomas. This study reports a 56-year-old woman with cardiac myxoma following transcatheter closure of ASD. She presented with a 3-month history of recurrent dizziness, vertigo, palpitations, and generalized weakness after undergoing ASD occlusion a year earlier. Echocardiography and cardiac computed tomography scans identified a large, mobile mass (7.2 cm × 2.8 cm) in the left atrium, protruding through the mitral valve. The patient underwent median sternotomy and pericardiotomy, and the histopathological examination confirmed the diagnosis of atrial myxoma. The current case illustrates the challenges in determining whether an atrial mass is a benign myxoma or a dangerous thrombus. While there is no definitive link between the implantation of an ASD closure device and the formation of a myxoma, the emergence of this tumor is a potential occurrence.

Performance, safety, and biocompatibility of a novel PFO closure device in a long-term porcine model

BACKGROUND

As the catheter-based device closure of the patent foramen ovale (PFO) is expanding, novel devices aim to address the limitations of first-generation occluders (e.g. bulk, erosion, dislodgment). The second-generation device from Encore Medical (Eagan, MN, USA) features an articulating frame structure which allows the device to better conform to atrial anatomies, has lower disc thickness and metal mass/surface area, and is fully retrievable at any point in the procedure. The aim of the study was to evaluate the feasibility and safety of a novel low-profile, fully retrievable, Encore PFO closure device in the animal model.

METHODS

Six swine underwent implantation of the novel PFO occluder under fluoroscopic and intra-cardiac echocardiography guidance and survived for 140 days. Interim transthoracic echocardiography (TTE) was conducted on Day 29. Following terminal angiography and TTE at 140 days, the hearts were subjected to gross and histopathologic analysis.

RESULTS

All animals were successfully implanted and survived for 140 days. Interim TTE revealed proper device retention with no blood flow across the septum or thrombus in any of the animals. X-ray and pathology results showed preserved implant integrity with no fractures, and complete integration of the devices into the septum with complete re-endothelialization and nearly complete coverage by a mature, relatively thin neoendocardium. No surface fibrin deposition or thrombosis was reported.

CONCLUSIONS

In the standard porcine model, device retention and biocompatibility remained favorable following structural and functional device modifications exemplified by the second-generation PFO occluder from Encore Medical, including marked reduction of metal mass.

Atrial Myxoma on Atrial Septal Defect Occlusion Device: A Rare but True Occurrence

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Device occlusion is the method of choice to treat atrial septal defects.

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Atrial myxoma on an atrial septal defect occlusion device is rare but does occur.

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Echocardiography plays an essential role in confirming an atrial myxoma.

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Echocardiography helps to exclude a left atrial thrombus.

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Echocardiography contributes to surgical planning.

Recurrent Stroke due to Patent Foramen Ovale Closure Device Thrombus Eight Years after Implantation

Patent foramen ovale (PFO) is a common heart defect and is found in about 25% of the general population. Although randomized trials have failed to show the superiority of percutaneous closure of PFO over medical management, the number of patients with closure device placement has grown over the years. Delayed complications from PFO closure are rare. We present a case of cardioembolic stroke secondary to a mobile thrombus on a PFO closure device 8 years after implantation.

Intra-arterial thrombolysis of central retinal artery occlusion following percutaneous atrial septal defect closure

Use of percutaneous devices for atrial septal defect (ASD) closure is growing, given the minimally invasive nature and the long-term durability of this approach. The reported rate of thrombus formation after catheter closure is 1.2%. Thrombotic risk varies according to closure device and Dacron-covered nitinol Amplatzer devices carry a 0-0.3% rate of thrombus formation; but central retinal artery occlusion (CRAO) is rarely implicated as an adverse event. Herein, we report the first successful intra-arterial thrombolytic treatment of CRAO developing after ASD closure via Amplatzer device. © 2015 Wiley Periodicals, Inc.

PFO closuRE and CryptogenIc StrokE (PRECISE) registry: a multi-center, international registry

BACKGROUND

The Premere™ PFO closure device has a special design for closure of patent foramen ovale (PFO) including a flexible distance and angulation between the right and left disc providing minimal septal distortion. The primary objective of the study was to determine the degree of risk for stroke or transient ischemic attack (TIA) in patients after Premere™ PFO closure device implantation.

METHODS

In this multicenter, prospective observational registry, patients with a clinical indication for PFO closure were included. Patients had a history of stroke or TIA with right to left shunt. Follow-up visits were scheduled according to routine clinical practice.

RESULTS

In 23 centers from 10 countries, 267 patients with successful device implantation were included. Assessment of right to left shunt after device implantation revealed no residual shunt in 71 %, small shunts in 16.8 %, and moderate or large residual shunts in 5.6 and 6.5 %. With common clinical practice, use of Coumadin or heparin decreased from 27 % pre- to 3 % post-implantation, while use of acetylsalicylic acid or thienopyridines increased from 64 to 95 % and 27 to 80 %, respectively; 18 % of patients were discharged with anti-platelet monotherapy. Mean follow-up was 11 ± 9 months (range 1-24 months). There was no stroke or TIA. During follow-up, there was one sudden death. Atrial fibrillation occurred in five (1.9 %) patients. One (0.4 %) patient with a thrombophilic diathesis developed a thrombus.

CONCLUSIONS

In this prospective, international, multicenter PRECISE registry, the use of the Premere™ PFO closure device for closure of PFO after stroke or TIA resulted in good clinical results with no recurrent event.

Stroke due to late device thrombosis following successful percutaneous patent foramen ovale closure

We report a case of stroke due to device thrombosis occurring three years following percutaneous patent foramen ovale (patent foramen ovale) closure with an Amplatzer atrial septal occluder device. We discuss risk factors that may have contributed to device thrombosis and raise concerns regarding the lack of a dedicated PFO closure device for clinical use in the United States.

A suture not always the ideal solution: problems encountered in developing a suture-based PFO closure technique

OBJECTIVES

To summarize our experiences with the first-in-man suture-based patent foramen ovale (PFO) closure technique.

BACKGROUND

PFO is often present with the occurrence of cryptogenic stroke and migraine with aura. Successful PFO closure can be performed percutaneously using catheter techniques with many different closure devices. The described novel closure system is intended to deliver, via endovascular access, a suture into the atrial septal wall tissue for closure of PFO.

METHODS

Eleven patients, between 22 and 58 years of age (mean 46.6 +/- 9.6), who had a cryptogenic ischemic stroke, TIA, or a peripheral embolism and a PFO were considered for percutaneous closure with this technique.

RESULTS

The mean stretched diameter of the defect evaluated during balloon sizing was 8.8 +/- 0.4 mm (range 7-12.5). Delivery of the suture was successful in all patients. No intraprocedural complications occurred. During the follow up, complete closure could be achieved in one patient. Six patients with significant residual shunting during follow-up had successful closure using a conventional device. One patient was lost for follow-up after the 3-month visit. The residual shunt in the remaining three patients was very small and they declined to be treated with a conventional device. No complications occurred during the follow up.

CONCLUSIONS

Transcatheter application of a suture for closure of PFO is technically feasible and safe. However, despite successful suturing of the septum primum to the septum secundum, the PFO did not close in most of the patients.

Pulmonary embolism: a late complication of a correctly positioned occluder device for patent foramen ovale

We describe a patient with pulmonary embolism originating from right atrial thrombosis that developed at least 18 months after patent foramen ovale (PFO) device implantation. On surgical inspection, the PFO device was found to be correctly positioned, stable and well endothelialized. We then hypothesize that current smoker status, double antiplatelet regimen discontinuation and mild hyperhomocysteinaemia may have had a role in determining this severe, unexpected and late complication in this patient.

Atrial Septal Defect and Atrial Fibrillation: The Known and Unknown

Atrial fibrillation (AF) is a common complication in patients with atrial septal defects (ASDs). The link between AF and ASD is fairly complex and entails modifications in electrophysiologic, contractile and structural properties, at the cellular and tissue level, of both atria, mainly due to chronic atrial stretch and dilation. Surgical repair or percutaneous closure of ASDs are equally effective in reducing mortality and symptoms but limited in preventing or curbing AF, unless combined with an arrhythmia-specific procedure. Transesophageal echocardiography (TEE) and intracardiac echocardiography (ICE) have improved the safety and success of the above procedures. Finally, clearer understanding of the pathophysiology of AF in patients with ASD (and CHF, in general) has led to target-specific advances in medical management.

Patent Foramen Ovale Using the Premere Device: The Results of the CLOSEUP Trial

OBJECTIVES

The CLOSEUP trial was conducted to determine the safety and effectiveness of the Premere closure device in closure of patent foramen ovale (PFO).

BACKGROUND

PFO is a relatively common congenital condition, associated with cryptogenic stroke and migraine with aura. The Premere device is specifically designed to close PFO of variable size and length, with right and left anchor arms connected by a flexible tether. The device has an open architecture, a low profile, and a small surface area on the left atrial side which may discourage thrombus formation.

METHODS

Patients between 18 and 65 years of age who had a cryptogenic ischemic stroke or a transient ischemic attack and a PFO underwent percutaneous PFO closure using the Premere device.

RESULTS

Of the 73 enrolled patients, six patients had atrial anatomy not appropriate for the Premere; 27 patients received the 15 mm and 40 patients received the 20 mm device. Implantation was successful in all patients. At 6 months of follow-up, 86% of patients had no shunt that could be provoked with Valsalva as assessed during contrast echocardiography. Closure rates were better with the 20 mm versus the 15 mm device, and three patients with residual shunt had atrial septal aneurysms at baseline. One patient had transient atrial fibrillation which resolved by 3 months. There were no instances of thrombus, death, or stroke.

CONCLUSIONS

These data demonstrate that the Premere device can safely and effectively close PFO. Additional studies should be undertaken to demonstrate the effectiveness of PFO closure in reducing thrombo-embolic events such as stroke.