Transcatheter Closure of Atrial Septal Defects in a Center With Limited Resources: Outcomes and Short Term Follow-Up

Percutaneous atrial septal defect closure using transesophageal echocardiography without fluoroscopy in a pregnant woman: a case report

Transcatheter closure is the treatment of choice for atrial septal defect (ASD); it has good efficacy and minimal complications. However, this approach in a pregnant woman is limited due to the risk of radiation exposure. A novel fluoroscopy-free technique has been introduced to reduce x-ray exposure. This case reported the experience of an ASD transcatheter closure in a pregnant woman without fluoroscopy guidance. To the best of our knowledge, this is the first successful fluoroscopy-free technique for transcatheter closure in Indonesia. The case is a 26-year-old primigravida at 26 weeks’ gestational age with secundum ASD and pulmonary hypertension. Transcatheter closure was successfully performed with a Cera ASD occluder (Lifetech Scientific Corporation) no. 28 mm guided by transesophageal echocardiography. During the procedure, transient supraventricular tachycardia was developed. There were no other major or minor periprocedural complications. ASD transcatheter closure in a pregnant woman without fluoroscopy is feasible, safe, and effective. 

Transcatheter Closure of Atrial Septal Defects: Comparable Experience and Outcomes Between Developing and Developed Countries

Atrial septal defect (ASD) is one of the most common congenital heart defects. Transcatheter device closure of ASDs is safe and effective with most of the reported data being described from developed countries. To evaluate the short and mid-term results and experience of device closure of ASDs at a tertiary center in a developing country and compare it to that from developed countries. Retrospective study based on data collection from all patients who have undergone transcatheter percutaneous device closure for ASD from January 2005 until December 2017 at the Children's Heart Center at the American University of Beirut, Medical Center, Lebanon. During the study period, a total of 254 cardiac catheterizations were performed for device closure of ASDs. The mean age of the patients was 18 ± 17.9 years with 37% being less than 6 years of age. Females were 54%. Defect size ranged from 7 to 37 mm and device size ranged from 8 to 40 mm. The procedure was executed with a success rate of 96%. Five patients had device embolization (2%); in one patient the device was snared and for the remainder the devices were removed surgically. None of the study patients had thrombus formation, neurological complications, bacterial endocarditis, or cardiac erosions. There was no mortality. Device closure of ASDs at our tertiary center in a developing country has an effective and safe profile with excellent results and low complications rates, which compare favorably to those reported from centers in developed countries.

Impact of Congenital Cardiac Catheterization Project on Outcomes-Quality Improvement (C3PO-QI) in LMICs

Background

The importance of registries for collaborative quality improvement has been overlooked in low/middle-income countries (LMIC). Aga Khan University Hospital (AKUH) in Pakistan joined the Congenital Cardiac Catheterization Project on Outcomes-Quality Improvement (C3PO-QI) in March 2017 with the goal of leveraging international collaboration to improve patient care and institutional standards.

Methods

The C3PO-QI key driver-based approach was used, with certain modifications, for process re-engineering in AKUH's congenital cardiac catheterisation laboratory (CCL) to reduce radiation exposure during cardiac catheterisation procedures (the primary outcome of C3PO- QI). Educating staff and standardising procedural documentation were the principal goals of the process re-engineering. Data survey was used to assess staff knowledge, attitude and practice before and after the initiative. Additionally, case demographics and outcomes were compared between AKUH and C3PO-QI centres.

Results

There was an increase in appropriate recording of radiation surrogates (0%-100%, p=0.00) and in the percentage of cases that met the established benchmark of 'Ideal documentation' (35% vs 95%, p=0.001). There was also an increase in self-reported staff interest during the case (25% vs 75%, p=0.001). AKUH versus C3PO-QI data showed similar demographic characteristics. There was a slight over-representation of diagnostic cases (42% vs 32%) as compared with interventional (58% vs 68%) at AKUH. Furthermore, interventional procedures were predominately PDA and ASD device closures (n=19 and 15, respectively). The frequency of adverse events were the same between AKUH and collaborative sites.

Conclusion

Collaborative efforts between developed and LMIC CCL are significant in advancing system-level processes.

Short-term outcomes of transcatheter closure of secundum atrial septal defect in children and adolescents: An experience of two centers in Upper Egypt

Background

The aim of this study was to evaluate the acute and short-term outcomes of transcatheter closure of secundum atrial septal defect (ASD) in children and adolescents in the first 4-year experience in two institutional centers in Upper Egypt.

Methods

This was a retrospective cohort study including 135 children and adolescents who underwent ASD closure between April 2012 and May 2016. A review of the acute and short-term outcomes and adverse events was performed.

Results

The patients had a median age of 5 years (interquartile range: 3-9 years), 71% of patients were ≤5 years, and median weight was 17 kg (interquartile range: 13-30 kg). Single defects were observed in 113 patients (84%). The remainder had multiple or multifenestrated defects that were closed by a single device. The mean defect size of single defects and the mean interatrial septum length were 15.24 ± 5.16 mm and 38.13 ± 6.3 mm, respectively. The ratio of device to TEE (Transoesophageal echocardiography) size of ASD was 1.19 ± 0.12. The devices were implanted successfully in 98.5% of patients. Six cases had concordant PS (Pulmonary stenosis), patent ductus arteriosus or perimembranous ventricular septal defect and were treated with balloon dilation, or closure. No residual flow was seen after device placement except in one patient with multiple fenestrations. There were five high-severity adverse events (3.7%) with no mortality. Device erosion was confirmed in one of two patients with massive haemopericardium; embolization of the device with retrieval in one patient; and heart block was detected in two cases. No cardiac perforation, device erosion, embolization, thrombus formation, or clinical evidence of bacterial endocarditis was observed during follow-up.

Conclusions

Transcatheter closure of ASDs in children and adolescents was feasible and safe in the first 4 years experience in our centers, with good short-term outcome. Balloon sizing is not necessary for transcatheter closure of secundum ASD. Multiple defects can be safety closed by a single device.

Safety and efficacy of transthoracic versus transesophageal echocardiography in transcatheter closure of atrial septal defects. Reporting a single center experience from Saudi Arabia

Objectives:

To assess the safety and effectiveness of transthoracic echocardiography (TTE) in monitoring transcatheter closure of atrial septal defect (ASD), in comparison with conventional technique using transesophageal echocardiography (TEE).

Methods:

A retrospective review of all cases of transcatheter closure of isolated ostium secundum ASDs operated from 2005 to 2015, at the Pediatric Interventional Cardiology Department, King Abdulaziz University Hospital, Jeddah, Kingdom of Saudi Arabia. Exclusion criteria included age ≤3 years at the time of the procedure and rim size ≤3 mm. Patients were divided into 2 groups: TTE and TEE group. Demographic and clinical baseline data, procedure data, and outcomes were compared between the 2 groups.

Results:

We included 77 cases: 45 in TTE group and 28 in TEE (mean ± standard deviation age=8.18 ± 5.85 versus 17.68 ± 14.88), with no significant difference in ASD size, rim adequacy, or other anatomical difficulties. All (100%) patients in TEE group underwent general anesthesia, versus 8.9% in TTE group. Device deployment was comparably successful (97.8% versus 92.9%, p=0.554); while procedure time (76.27 ± 31.80 versus 119.85 ± 19.90 minutes, p<0.001) and fluoroscopy time (11.29 ± 9.04 versus 18.73 ± 11.54 minutes, p=0.003) were significantly reduced in TTE versus TEE. Prevalence of postprocedural complications was comparable in the 2 groups.

Conclusion:

Transthoracic echocardiography has non-inferior efficacy in device deployment with reference to TEE and superior safety features including significant reduction of procedure and fluoroscopy times and lesser use of general anesthesia.