Progression to late complete atrioventricular block following amplatzer device closure of atrial septal defect in a child

The Prevalence of and Predisposing Factors for Late Atrial Arrhythmias after Transcatheter Closure of Secundum Atrial Septal Defects in Children

BACKGROUND

A 24 h Holter study in children after transcatheter secundum ASD (ASD II) closure was conducted to detect the prevalence of defects and/or device-related late atrial arrhythmias (LAAs). ASD II closure with an Amplatzer septal occluder (ASO) is an established procedure. Little is known about LAAs after device implantation.

METHODS

The eligible participants were children who had undergone ASO implantation, with a follow-up of ≥5 years, as well as one pre- and at least one post-procedural Holter ECG.

RESULTS

In total, 161 patients (mean age: 6.2 ± 4.3 years), with a mean follow-up of 12.9 ± 3.1 years (range 5-19), were included. A median of four Holter ECGs per patient were available. LAAs occurred before intervention in four patients (2.5%), and it was peri-interventional in four patients (2.5%), sustained in three patients (1.9%), and developed in three patients (1.9%). In patients with pre- and peri-interventional LAAs, the Qp/Qs ratio was higher (6.4 ± 3.9 vs. non-AA: 2.0 ± 1.1 (p = 0.002)) and the IAS/ASO ratio was lower (1.18 ± 0.27 vs. non-AA: 1.7 ± 0.4 (p < 0.001)). The patients with LAAs differed from those without LAAs in their Qp/Qs (6.8 ± 3.5 vs. 2.0 ± 1.3; p < 0.0001) and IAS/ASO ratios (1.14 ± 0.19 vs. 1.73 ± 0.45; p < 0.001). The patients with LAAs had a Qp/Qs ratio ≥2.94:1, and those who developed LAAs had an IAS/ASO ratio <1.15.

CONCLUSIONS

LAAs occurred in 1.9% of patients and were sustained in another 1.9% of patients but persisted in those with large shunt defects and large occluders in relation to the atrial septal length. The predisposing factors for LAAs after ASD closure were a high Qp/Qs ratio, pre-existing atrial arrhythmias, and a low IAS/ASO ratio.

Current practice in atrial septal defect occlusion in children and adults

INTRODUCTION

Atrial septal defect (ASD) is one of the most common congenital heart diseases (CHD) in children and adults. This group of malformations includes several types of atrial communications allowing shunting of blood between the systemic and the pulmonary circulations. Early diagnosis and treatment carries favorable outcomes. Patients diagnosed during adulthood often present with complications related to longstanding volume overload such as pulmonary artery hypertension (PAH), atrial dysrhythmias, and right (RV) and left (LV) ventricular dysfunction.

AREA COVERED

This article intended to review all aspects of ASD; anatomy, pathophysiology, clinical presentation, natural history, and indication for treatment. Also, we covered the transcatheter therapy in detail, including the procedural aspect, available devices, and outcomes.

EXPERT OPINION

There has been a remarkable improvement in the treatment strategy of ASD over the last few decades. Transcatheter closure of ASD is currently accepted as the treatment of choice in most patients with appropriately selected secundum ASDs. This review will focus on the most recent advances in diagnosis and treatment strategy of secundum ASD.

Case report: Atrioventricular block after transcatheter atrial septal closure using the Figulla® Flex II ASD occluder

We report a 7-year-old male patient who developed severe atrioventricular block after transcatheter closure of the atrial septal defect with an Occlutech Figulla® Flex II ASD occluder (FSO). He had a small aortic rim and the defect measuring 22.3 mm by balloon sizing. When a 24 mm FSO was deployed, he developed Wenckebach second-degree heart block; however, it recovered to sinus rhythm. Hence, the device was implanted. The rhythm deteriorated to a fixed 2:1 heart block within 7 hr. He underwent surgical retrieval of the device and closure of the defect. Intraoperative findings demonstrated the right atrium disk compressing the triangle of Koch, resulting in a small hematoma. The rhythm recovered completely by 7 days after the surgery. Care must be taken when a relatively large device is deployed in a patient with small rims as even "soft and flexible" device like the FSO can injure the endocardium.

Recent review of transcatheter closure of atrial septal defect

Atrial septal defect (ASD) is one of the two most common congenital heart diseases in children and adult. After the application of catheter intervention for ASD, this became an alternative treatment other than surgery from late 1990. In 2001, the procedure was further approved by the US Food and Drug Administration (FDA), and become the first choice for most cases of secundum type of ASD worldwide. The success rate is more than 98% in literature reviews, with low complication rates in percutaneous ASD closure. Major complications are around 1%, including device embolization, cardiac erosions, new-onset atrial arrhythmia, and other comorbidities. We reviewed indications for percutaneous secundum type ASD closure, technique, successful rate and major complications in this article. To complete the catheter intervention with difficult ASD conditions, various procedural techniques have been developed recently. We also report a challenging case by a current balloon-assisted technique for huge ASD closure.

Surgical perspective of percutaneous device closure of atrial septal defect

Background Percutaneous device closure of an ostium secundum atrial septal defect is associated with excellent outcomes and cosmetic results but at the cost of occasional serious and sometimes fatal complications as well as lifelong follow-up. Surgical intervention is required in cases of device-related complications, which carries a slightly higher risk compared to primary closure of an atrial septal defect. We present a surgical perspective of device closure of atrial septal defect. Methods Our database was searched over 4 years for complications related to percutaneous device closure of atrial septal defect, which required surgical retrieval of the device and closure of the defect. We identified 14 cases that required surgical intervention. Results The median age of the 14 patients was 18 years (range 4-58 years). The size of the defect ranged from 15 to 40 mm (median 30 mm). Device embolization into any part of the cardiovascular system ( n = 8) was the most common complication, followed by malalignment of the device ( n = 5). One patient had left atrial appendage perforation causing pericardial effusion and cardiac tamponade, and underwent surgical repair. The other 13 patients underwent removal of the device and atrial septal defect closure. One patient developed severe mitral regurgitation requiring mitral valve replacement. There was no mortality. Conclusion Although the incidence of device-related complications may be small, they carry a high risk of death or long-term morbidity, even with a small atrial septal defect, unlike primary surgical closure of isolated atrial septal defect.

Transcatheter closure of ventricular septal defects using the Amplatzer Duct Occluder II device: a single-center experience

Introduction

Off-label use of different devices has been described for percutaneous closure of ventricular septal defects (VSD) because of the unacceptable rate of post-procedure heart block associated with special VSD devices.

Aim

To describe the early single-center clinical experience with closure of a VSD using the Amplatzer Duct Occluder II (ADO II) device in children.

Material and methods

Between May 2013 and June 2015, 26 patients between 13 days and 16 years of age underwent percutaneous closure of a VSD with an ADO II device at our institute. The decision to use the ADO II device was based primarily on lower risk of total atrioventricular block (TAVB) after VSD closure reported in the literature, reduction of the cost of the procedure and the need to close symptomatic VSDs in young patients.

Results

The location of the VSD was perimembranous in 21 patients, postsurgical residual in 2, midmuscular in 2 and apical muscular in 1. Complex procedures including newborn, combined procedures and postsurgical residual VSD were performed in 5 (19%) patients. The median duration of follow-up was 12 months. The complete VSD closure rate was 81% immediately after the procedure, 85% at 24 h, and 93% at the last follow-up. There was no device embolization. During the entire follow-up period, TAVB did not develop.

Conclusions

The ADO II constitutes a safe and effective therapeutic alternative for morphologically varied VSDs in all pediatric age groups. A larger range of sizes and configurations of this occluder may be required to successfully occlude a wider range of VSDs.

Comparison of Transcatheter Atrial Septal Defect Closure in Children, Adolescents and adults: Differences, Challenges and Short-, Mid- and Long-Term Results

Background and Objectives

This study aims to compare the characteristics, effectiveness and results of transcatheter closure of atrial septal defect between children, adolescents, and adults.

Subjects and Methods

In this study, 683 patients who underwent atrial septal defect closure in the last 10 years were divided into three groups: children (age <12), adolescents (age 12 to 16), and adults (age >16) as group 1, group 2 and group 3, respectively.

Results

The average defect size and incidence of complex atrial septal defect were higher in group 3 (p=0.0001 and 0.03 respectively). While the average size of the devic was higher in adults (22.6±6.4 mm vs. 18.5±4.9 mm; p=0.0001), the ratio of the device size/total septum was higher in both children and adolescents (Group 1 and 2). In the child and adolescent groups and patients with only complex atrial septal defect, the use of techniques, other than standard deployment, was similar in all three groups (p=0.86 and 0.41, respectively). The ratio of the residual shunt was similar in all three groups. Major complications were seen in 5 cases (4 cases with migration, and 1 case with dislocation) in group 3 and 1 case (migration) in group 1.

Conclusion

Depending on the complexity of the defect and age of the patient, transcatheter closure of atrial septal defect might have certain difficulties and complications. Patients must be evaluated in detail to avoid major complications and possible problems during the procedure.

Atrioventricular block after ASD closure

OBJECTIVE

Secundum atrial septal defect (ASD) is a common congenital heart defect. There is limited data on both early and late atrioventricular (AV) block post ASD closure. The aim of this study was to determine the incidence and risk factors of AV block associated with ASD closure.

METHODS

A retrospective analysis of all patients who underwent ASD closure either with a device or surgical method at the Royal Children's Hospital Melbourne between 1996 and 2010 was performed. Baseline demographics, procedural details and follow-up data were collected from medical records.

RESULTS

A total of 378 patients were identified; 242 in the device group and 136 in the surgical group. Fourteen patients (3.7%) had AV block (1 with second degree and 13 with first degree) at a median follow-up of 28 months; 11/242 (4.5%) in the device group and 3/135 (2.2%) in the surgical group (p=0.39). Six patients had new-onset AV block after ASD closure. In the device subgroup, patients with AV block at follow-up had a larger indexed device size compared with those without (22 (15-31) vs 18(7-38), p=0.02). Multivariate analysis revealed the presence of AV block either pre procedure or post procedure to be the only variables associated with late AV block.

CONCLUSIONS

Late AV block in patients with repaired ASD is rare and most likely independent of the technique used. In the device subgroup, the only risk factor identified to be associated with late AV block was the presence of either preprocedural or postprocedural AV block, so long-term follow-up for these patients should be provided.

Late complete atrioventricular block after closure of an atrial septal defect with a gore septal occluder (GSO™)

Temporary intermittent complete heart block (CHB) occurred the day after interventional closure of an ASD with a 30 mm Gore Septal Occluder (GSO™) in a 2 years and 11‐month‐old female. CHB disappeared without further treatment and stable sinus rhythm recovered within 3 days. Only short episodes of 2nd degree AV‐block (Wenckebach periodicity) at rare intervals were documented in Holter‐monitors the following 2 months. Eleven months after device implantation the patient suffered from long lasting episodes of CHB. Surgical removal of the device resulted in incomplete recovery of AV‐conduction. Histopathological work‐up of the explanted GSO showed complete endothelialization of the device and regular scar formation. One year after surgery, the child had sinus rhythm during daytime but needed VVI‐pacing while sleeping. Young age, inferior localization of the defect, and use of a large device have been individual risk factors for CHB in this patient. Clinical course and histologic findings indicate that mechanical compression was the only cause for CHB. The cumulative number of reports of CHB after use of different ASD‐devices supports the recommendation to postpone the intervention in asymptomatic patients to preschool‐age. Early removal of a pushing device may increase the chance of complete recovery from CHB. © 2015 Wiley Periodicals, Inc.

Reversible complete atrioventricular block after percutaneous ASD device closure in a child <15 kg

Transcatheter device closure of atrial septal defect (ASD) in small children less than 15 kg may be associated with increased complications. Complete atrioventricular heart block (CHB) is a rare complication of ASD device closure in such a setting. We report the case of a 2-year-old girl, less than 15 kg, who underwent device closure of ASD with Amplatzer Septal Occluder and subsequently developed CHB 12 h after the procedure which resolved completely with steroid treatment on fifth day. Case report of a similar kind is rarely reported in the literature. Despite adequate postero-inferior margin CHB may still occur in small children as in our case.

Risk factors and prognosis of atrioventricular block after atrial septum defect closure using the Amplatzer device

Amplatzer septal occluder (ASO)-induced complications have been observed. However, little attention is paid to the atrioventricular block (AVB) induced by atrial septum defect (ASD) closure using the Amplatzer device. This study aimed to analyze the risk factors and prognosis of AVB after catheter closure and to reduce the incidence of adverse events. In this study, 706 ASD patients who received closure in our division were investigated retrospectively for the relationship between AVB and factors such as age, size of the ASD (D(d)), diameter of the occluder (D(o)), diameter of the septum (D(s)), D(o)/D(d) ratio, and D(o)/D(s) ratio. Data distribution was evaluated with the Kolmogorov-Smirnov normality test. The Wilcoxon rank sum test was used to compare non-normal distribution data. A p value lower than 0.05 was considered significant. Of the 706 patients, six had experienced the development of AVB, giving an incidence of 0.85%. The risk factors included younger age, larger size of the ASD, larger size of the device, and the D(o)/D(s) ratio (≥0.45). The milder AVB is, the better the prognosis. An AVB of III° and an unchanged electrocardiogram (ECG) within 3 days after the procedure are poor prognostic indicators. More attention should be paid to AVB induced by ASD closure. Younger age, size of the ASD, size of the device, and a D(o)/D(s) ratio of 0.45 or higher are the risk factors associated with AVB after closure. A timely retrieval of the device should be considered for a good prognosis.

[Atrioventricular block after transcatheter atrial septal defect closure using the Amplatzer septal occluder(®)]

Transcatheter closure of atrial septal defect (ASD) in children is now an accepted treatment as an alternative to surgery. We report a case of complete atrioventricular block (AVB) observed over several days after closure of an ASD with an Amplatzer Septal Occluder(®) in a 13-year-old child. The spontaneous outcome was good with regression of the complete AVB, but 1 year later, a first-degree AVB was still present. The use of large devices in young children and a small postero-inferior rim seem to be risk factors of AVB. Transcatheter closure of ASD requires close monitoring of cardiac rhythm.

Holter electrocardiography findings and P-wave dispersion in pediatric patients with transcatheter closure of atrial septal defects

BACKGROUND

This study aimed to determine the frequency of postintervention arrhythmia and factors associated with the development of arrhythmia, including the correlation between arrhythmia and P-wave dispersion, and the effects of the latter on transcatheter closure of atrial septal defects (ASDs).

METHODS

Holter ECG recordings were performed before and after the intervention and 6 and 12 months later in 47 of the 59 patients who had undergone transcatheter ASD closure and once in the healthy control subjects.

RESULTS

A statistically significant correlation was identified between the patients' arrhythmia grade according to Lown's system and each of the following: the number of defects, the size of the atrioventricular valve rim, the presence of an atrial septal aneurysm.

CONCLUSION

The frequency of arrhythmia increases after transcatheter ASD closure, gradually decreases within the next year, and is most frequently of a benign nature. Lown's arrhythmia grading of patients occluded with either the Amplatzer septal occluder (ASO) or the Cardio-O-Fix septal occluder (CSO) were compared, and the arrhythmia frequency was higher with the latter. One day after the intervention, the P maximum (Pmax ) and the P dispersion(Pdis ) values were not increased but in fact slightly reduced in patients occluded with either ASO or CSO. An improvement in the electrical system resulting from early anatomical and mechanical healing following transcatheter ASD occlusion may explain the reduction in the Pmax and Pdis values.

Atrioventricular block subsequent to intraoperative device closure atrial septal defect with transthoracic minimal invasion; a rare and serious complication

OBJECTIVES

Atrioventricular block (AVB) is a infrequent and serious complication after percutaneous ASD closure. In this study, we report on the incidence of AVB associated with intraoperative device closure of the ASD with transthoracic minimal invasion, and the outcomes of this complication in our center.

METHODS

Between May 2006 and January 2011, a total of 213 secundum-type ASD patients were accepted in our hospital for intraoperative and transthoracic device closure with a domestic occluder. All patients were assessed by real-time transthoracic echocardiography (TTE) and electrocardiograph (ECG).

RESULTS

All patients were occluded successfully under this approach. Immediate postprocedure third-degree AVB was observed in two patients. Since heart rates were in the range of about 50 to 55 beats per minute, no intervention was needed except for close observation for one patient. Another patient who recovered sinus rhythm intermittently during the operation was fitted with a temporary pacemaker. Approximately one week following glucocorticoid treatment, the AVB resolved spontaneously in these two patients. Mobitz type II AVB occurred in three patients during the procedure. Two patients developed post-operative cardiac arrest and were rescued successfully with cardiopulmonary resuscitation. One other patient changed to Mobitz type I AVB after three days. During the follow-up period, which ranged from six months to five years, no further occurrence of AVB was found.

CONCLUSIONS

Intraoperative and transthoracic device closure of secundum ASDs with domestic occluder resulted in excellent closure rate. AVB is an infrequent but serious complication during and after device closure of a secundum ASD. AVB is a complication that warrants greater attention and long-term follow-up.

Device closure of atrial septal defect: medium-term outcome with special reference to complications

BACKGROUND

There are concerns over the outcome of device closure of secundum atrial septal defect with special reference to erosions and aortic regurgitation.

AIM

To assess the medium-term outcome of device closure of atrial septal defects with special reference to complications.

METHODS

A total of 205 patients with secundum atrial septal defects underwent transcatheter closure from October, 1999 to April, 2009. The median age was 18 (1.4-55) years. Amplatzer Septal Occluder was used in all the patients. Medium-term follow-up was available in 176 of 200 (88%) patients.

RESULTS

Device closure was successful in 200 out of 205 (98%) patients. The device embolised in four patients and was associated with short inferior caval vein margin (p = 0.003). Balloon sizing in 71 patients (35%) resulted in implantation of a larger device (p = 0.002). Early complications included pericardial effusion, 2:1 heart block, and infective endocarditis (1 patient each). There were eight patients who reported migraine (3.9%). At median follow-up of 5.8 (0.6-10.3) years, complete closure occurred in 197 out of 200 patients. Short superior caval vein margin was associated with a residual shunt (p < 0.001). There were two patients who developed mild aortic regurgitation (1%), which correlated with a device-to-defect ratio of >1.3:1 (p = 0.001). There were no erosions, late embolisation, or thromboembolism. Atrial fibrillation occurred in three adults (1.5%).

CONCLUSIONS

Device closure of secundum atrial septal defects using Amplatzer Septal Occluder is safe and effective in the medium term. Short inferior caval vein margin correlates with increased risk of embolisation and short superior caval vein margin with a residual shunt. The risk of developing aortic regurgitation is low and correlates with increased device-to-defect ratio.

Resolution of heart block after surgical removal of an amplatzer device

A large secundum atrial septal defect in a 4-year-old child was closed by percutaneous placement of an Amplatzer septal occluder (AGA Medical Corporation, Plymouth, MN). After device placement, complete heart block developed that did not resolve after 3 days of medical management. The patient subsequently underwent surgical removal of the device and suture closure of the atrial septal defect. The patient recovered conduction after the operation. We report the successful treatment of device-induced heart block with surgical removal of the device.