Risk Factors of Long-Term Sequelae After Transcatheter Closure of Perimembranous Ventricular Septal Defect in Young Children

BACKGROUND

Complications arising from transcatheter closure of perimembranous ventricular septal defects (pmVSD) in children, such as residual shunts and aortic regurgitation (AR), have been observed. However, the associated risk factors remain unclear. This study identified risk factors linked with residual shunts and AR following transcatheter closure of pmVSD in children aged 2-12 years.Methods and Results: The medical records of 63 children with pmVSD and a pulmonary-to-systemic blood flow ratio <2.0 who underwent transcatheter closure between 2011 and 2018 were analyzed with a minimum 3-year follow-up. The success rate of transcatheter closure was 98.4%, with no emergency surgery, permanent high-degree atrioventricular block, or mortality. Defects ≥4.5 mm had significantly higher odds of persistent residual shunt (odds ratio [OR] 6.85; P=0.03). The use of an oversize device (≥1.5 mm) showed a trend towards reducing residual shunts (OR 0.23; P=0.06). Age <4 years (OR 27.38; 95% confidence interval [CI] 2.33-321.68) and perimembranous outlet-type VSD (OR 11.94, 95% CI 1.10-129.81) were independent risk factors for AR progression after closure.

CONCLUSIONS

Careful attention is crucial for pmVSDs ≥4.5 mm to prevent persistent residual shunts in transcatheter closure. Assessing AR risk, particularly in children aged <4 years, is essential while considering the benefits of pmVSD closure.

Relationship between patent foramen ovale anatomical features and residual shunt after patent foramen ovale closure

Transcatheter closure of patent foramen ovale (PFO) is an effective strategy for preventing recurrence of paradoxical embolism. However, PFO closure is often associated with residual shunt, which is a risk of recurrent stroke. This study aimed to evaluate the relationship between the anatomical features of PFO and residual shunt. The degree of residual shunt and its relationship with the anatomical features of PFO were evaluated in 106 patients who underwent PFO closure at our institution between March 2011 and January 2022 and in whom contrast transthoracic echocardiography was performed 1 year later. The mean PFO tunnel length was 9.3 ± 3.6 mm and the mean PFO height was 3.2 ± 2.2 mm. Atrial septal aneurysm (ASA) was found in 37 patients. After PFO closure, residual shunt was observed in 28 patients (grade 1, n = 8; grade 2, n = 16; grade 3, n = 3; grade 4, n = 1). Univariate logistic analysis identified ASA to be associated with residual shunt (odds ratio 2.78, 95% confidence interval 1.14 to 6.79; p = 0.024). There was no association of residual shunt with the size of the PFO, the length of PFO tunnel, or the size of the device used for closure. Two of four patients with a large residual shunt of grade 3 or grade 4 were found to have device size mismatch. Residual shunt after PFO closure was observed in a quarter of patients and was related to the presence of ASA. A few patients had a large residual shunt due to the device size mismatch.

A Systematic Review and Meta-Analysis of the Association between Residual Shunts after Patent Foramen Ovale Closure and Long-Term Cerebrovascular Events

BACKGROUND

The association between a patent foramen ovale (PFO) and cryptogenic stroke (CS) is well established, and the benefits of PFO closure are clearly recognized. This study aimed to investigate the presence of a residual shunt in patients who have experienced cryptogenic cerebrovascular events following a PFO closure.

METHODS

Two researchers systematically searched the PubMed and Embase online database for pertinent clinical studies published between January 2000 and July 2021 concerning the recurrence of cerebrovascular events after PFO closures.

RESULTS

Upon screening an initial list of 2,342 articles, six studies were identified, involving 2,083 patients. Overall, the analysis indicated a marked difference in the recurrence of cerebrovascular events in 8.89% of residual shunt (RS) cases compared to only 2.90% of non-RS cases. The summary odds ratio was 3.484 (95% confidence interval, 2.169-5.596), which suggested that RS may be a risk factor for recurrent cerebrovascular events in patients that experienced PFO-related cerebrovascular events within 6 months after PFO closure surgery.

CONCLUSIONS

The presence of RS significantly increases the risk of recurrent cerebrovascular events in patients with clinical PFO closure.

A severe right-to-left intracardiac shunt after NobleStitch failure: when a device is needed

BACKGROUND

Transcatheter closure of patent foramen ovale (PFO) has been demonstrated to be superior to medical therapy in stroke prevention in selected patients. Beyond traditional permanent metallic devices, NobleStitch EL, a suture-based system, has been developed as a potential alternative.

CASE SUMMARY

A 50-year-old man underwent transcatheter closure of PFO with mild interatrial septal bulging and tunnel-like morphology with a NobleStitch device. A transthoracic echocardiography performed immediately after PFO closure showed residual shunt (RS), which persisted unchanged at staged controls, due to the inability of the delivery system to capture both the septum primum and the septum secundum. A second procedure was performed with the implantation of a Figulla Flex II 27/30 mm device, with no RS detectable at control echocardiography.

DISCUSSION

The NobleStitch device is interesting in its concept, but several pitfalls may be encountered during its deployment. Opposite to permanent metallic devices, RSs after the procedure are not expected to decrease over time and should be managed with a different approach.

Why Follow-up Examinations After Left Atrial Appendage Closure Are Important: Detection of Complications During Follow-up and How to Deal with Them

PURPOSE OF REVIEW

Device-related thrombus (DRT) formation and incomplete left atrial appendage closure (LAAC) are the two major complications that can occur after LAAC and can potentially limit the success of such a procedure. This review discusses the incidence, clinical and/or prognostic significance, detection methods, treatment options, and potential strategies to prevent these complications.

RECENT FINDINGS

It has recently been proven that the presence of a DRT represents an independent predictor for ischemic stroke after LAAC. Continued need for anticoagulation due to incomplete LAAC is clinically relevant to the patient. The appearances of a DRT or an incompletely closed LAA after a LAAC procedure are not rare complications. Due to the clinical and/or prognostic significance of these complications, it is important to detect them in a timely manner during follow-up by using the appropriate diagnostic imaging techniques. Since a DRT is associated with an increased risk of stroke, the therapy should be aggressive. In the case of incomplete LAA closure, an additional closure device may be used to complete occlusion and avoid lifelong anticoagulation therapy.

Transcatheter closure of a residual shunt with posteroinferior deficient rim after surgical closure of an ASD: a case report

BACKGROUND

There are few reports in the literature of device closure of residual shunts following initial surgical closure of an atrial septal defect (ASD). This case study reports one such case. We describe here a case of secundum type ASD that was initially closed surgically, followed by device closure of a residual shunt with a posteroinferior deficient rim.

CASE PRESENTATION

A 7-month-old boy was admitted to our hospital for elective surgery to surgically correct a secundum type ASD. Unfortunately, a residual shunt 3.5 mm in diameter appeared before discharge and was enlarged at1-year follow-up. The cause of this residual shunt was dehiscence at the posteroinferior aspect, and the posteroinferior rim was 3.7 mm. After careful discussion and preparation, we proceeded with an interventional procedure. A 16 mm ASD occluder (AGA Medical Corp, Plymouth, Minnesota) was deployed successfully with no residual shunt. In some cases of ASD, interventional therapy is not considered due to the size and position of the defect, but we show here, a successful case of interventional therapy for a residual shunt with a deficient rim.

CONCLUSION

We have presented a case in which a postoperative residual shunt with a deficient rim was successfully closed with interventional therapy.

Contemporary outcomes of percutaneous closure of patent ductus arteriosus in adolescents and adults

Background

Catheter based treatment has gained wide acceptance for management of patent ductus arteriosus (PDA) ever since its introduction. Percutaneous closure in adults can be challenging because of anatomical factors including large sizes, associated pulmonary arterial hypertension (PAH) and co-morbidities. This study aimed to provide comprehensive contemporary data on the safety and efficacy of percutaneous device closure of PDA in adult and adolescent population at a large referral center.

Methods

This single-center retrospective analysis included 70 patients (33 adolescents and 37 adults) who underwent successful percutaneous device closure of PDA between January 2011 and February 2017.Baseline patient demographics, clinical characteristics, procedural and device related variables, and immediate outcomes during hospital stay were recorded. Patients were followed up for residual shunt and complications.

Results

Of 70 PDA device closure cases, 71.4% were females; the mean age was 23 years (range:10-58years). Devices used were 4-Cook’s detachable coils, 64-occluders (ADO-I and II, Lifetech, Cardi-O-Fix), 1-vascular plug and 1-ventricular septal occluder device. Device success was achieved in all including those with very large PDAs. At 24-h post-procedure, the success rate of transcatheter intervention was 95.7%. At 6-months follow up, complete closure was observed in all (mean follow up duration-531 days). In patients with severe PAH, significant immediate and sustained reduction of the mean pulmonary pressure was observed(77 mmHg to 33 mmHg;P = 0.014). No procedure-related complications including death, device embolization and stenosis of aorta or pulmonary artery occurred.

Conclusions

In contemporary practice, percutaneous device closure is an effective and safe treatment option for adolescent and adult PDA patients.

Successful percutaneous closure of a residual atrial septal defect due to device failure

A 39-year-old woman underwent uneventful percutaneous occlusion of an ostium secundum atrial septal defect (ASD) with a 22 mm Ultrasept ASD Occluder^®. Transesophageal echocardiography (TEE) performed two years after implantation revealed a de novo residual left-to-right shunt through the correctly implanted device. Three-dimensional transesophageal echocardiography (3D TEE) further clarified this finding by showing a perforation of the device membrane coating. The patient underwent transcatheter closure of the residual shunt with a 20 mm Ultrasept PFO^® device. The procedure was guided by fluoroscopy and real-time 3D TEE. At the end of the procedure 3D TEE documented correct device deployment with complete defect coverage and absence of residual shunt.