Transesophageal echocardiography-guided percutaneous closure of multiple muscular ventricular septal defects with pulmonary hypertension using single device: A case report

Echocardiography-guided percutaneous closure of oval-shaped secundum atrial septal defects

BACKGROUND

An atrial septal defect (ASD) is considered oval-shaped when its shortest diameter is less than 75% of the longest diameter. Research on percutaneous closure of oval-shaped ASDs is limited, with no known reports of non-fluoroscopic closure for this population.

OBJECTIVE

To assess the effectiveness of non-fluoroscopic percutaneous closure for oval-shaped ASDs.

METHODS

This single-center retrospective study evaluates patients undergoing non-fluoroscopic percutaneous closure of oval-shaped ASDs, defined by the shortest to longest diameter ratio < 0.75, a circular index of 1.33, or ultrasound visualization of an oval shape. Device size was chosen to be 0-4 mm larger than the defect's longest diameter, based on transthoracic and transesophageal ultrasound measurements.

RESULTS

We identified 78 patients (33.3% children, 20.5% males) with a mean age of 27.4 ± 16.3 years and a mean weight of 46.8 ± 19.8 kg. The mean longest diameter and mean shortest diameter of ASDs were 23.3 ± 6.8 mm and 15.8 ± 5 mm, respectively. The mean ratio of the shortest to longest diameter was 0.7 ± 0.1. Percutaneous closure was not attempted in 7/78 (9%) patients. Three out of 71 (4.2%) procedures were fluoroscopy-guided upfront due to technical difficulties, and 5/71 (7%) were converted to fluoroscopy-guided closure. Overall procedural success rate was 98.6% (70/71) including 63/71 (88.7%) performed with zero fluoroscopy. Mean device size was 26.5 ± 7.1 mm. Mean procedural time was 45.3 ± 22.6 min. Eleven intraprocedural complications occurred including 6 arrhythmias, 3 pericardial effusions, and 2 device dislodgements.

CONCLUSION

Transcatheter closure of oval-shaped ASD is safe and feasible. Echocardiography is adequate for adequate operative guidance.

Resolution of Migraine with Aura Post-PFO Closure in a Young Female: A Case Report

BACKGROUND Migraine, a prevalent primary headache disorder, often disrupts daily life, particularly when accompanied by visual auras. While the etiology of migraines remains elusive, emerging evidence suggests a correlation with cardiovascular anomalies. CASE REPORT This case involves a 35-year-old woman experiencing migraine with aura. Imaging studies, including MRI/A, revealed small-vessel ischemic damage in the right frontal region and historical microbleeds in the right occipital area. The patient's RoPE score was a high 9 out of 10, and a grade 4 (severe) PFO was diagnosed following a TEE+bubble test. A transfemoral PFO closure was successfully performed using a 25-mm Amplatzer PFO occluder device via an antegrade transvenous approach without fluoroscopy. The patient was discharged in stable condition, with no migraine episodes reported at 5-month follow-up. The detection of PFO in young migraineurs, particularly those with aura, is crucial and warrants thorough investigation during their assessment and treatment. CONCLUSIONS This case underscores the importance of incorporating cardiac evaluations in the diagnostic regimen for young individuals presenting with migraine and aura to uncover and rectify potential contributory structural heart defects like PFO. After PFO closure, this patient's significant improvement, evidenced by the absence of migraine recurrence, highlights the potential therapeutic benefit of addressing cardiac anomalies in such patients. It is important to note that current evidence does not support PFO closure as a treatment for migraines unless there are findings suggestive of ischemic stroke.

Transoesophageal echocardiography-guided balloon-assisted percutaneous closure of a large secundum atrial septal defect in a pregnant woman: a case report

Background

According to the 2018 European Society of Cardiology guidelines, atrial septal defect (ASD) closure can be performed during pregnancy but is rarely indicated. In this case, we demonstrate the viability of percutaneous balloon-assisted ASD closure without fluoroscopy in a pregnant woman.

Case summary

A 23-year-old G3P2A0 woman who was 20 weeks pregnant had primary complaints of breathlessness [New York Heart Association functional class (NYHA fc) III and IV] for 1 week prior to admission. A transthoracic echocardiography showed a dilatation of the right atrium (RA), a dilated right ventricle, a dilated main pulmonary artery (28.1 mm), and an oval-shaped 22 × 33 mm-sized secundum ASD with a left-to-right shunt. Despite optimal pharmacological treatment, the NYHA fc persisted. Under transoesophageal echocardiography monitoring, we introduced a 40 mm Cera™ ASD Occluder (Lifetech, China) via the delivery sheath. The device was deployed in the usual position; however, despite numerous placement adjustments, the left atrium disc kept getting dislodged to the RA and could not engage correctly. Therefore, we decided to use a balloon-assisted approach using a sizing balloon of No. 34 mm. The device was successfully positioned, and a wiggle test was conducted to make sure that the device remained stable. The patient was able to give birth to the child normally several months later.

Discussion

Despite the fact that pregnant women with ASD receive a very low dose of radiation, it is nevertheless recommended to avoid radiation because this demographic is particularly vulnerable to it. It is possible to treat a large ASD in pregnant women with a successful balloon-assisted approach.