Transhepatic atrial septal defect closure: simple way to achieve haemostasis in a patient with important co-morbidities

Transhepatic Transcatheter Pulmonary Valve Replacement

Transcatheter pulmonary valve replacement (TPVR) is complicated in patients without adequate femoral or internal jugular vascular access. Transhepatic vascular access has been shown to be safe and effective across a spectrum of diagnostic and interventional procedures. Closure of the hepatic venous tract can be accomplished with a multitude of readily available vascular occlusion devices. The rates of major adverse events are low: 5% to 8% with hemoperitoneum and complete heart block are most significant. To our knowledge, this is the first report of using transhepatic access for TPVR; closure of the hepatic venous tract was achieved with an Amplatzer vascular plug type II.

Gelatin sponge to close a tract after large-bore transhepatic access: tips for success

Percutaneous transhepatic venous access has been utilised for numerous transcatheter cardiac procedures. Traditionally, a large transhepatic tract requires the placement of permanent occlusion devices or coils. We describe a successful closure using a simple technique (Surgifoam) without the need for metal hardware placement. Immediate hemostasis was achieved. No complications were encountered.

Preliminary Experience With the New Amplatzer™ Trevisio™ Delivery System in Transcatheter Atrial Septal Defect Closures in Children

Objectives: To evaluate safety, efficacy, and technical advantages of Amplatzer™ Trevisio™ intravascular delivery system (ATIDS) in percutaneous atrial septal defect (ASD) closure in children. Background: The Trevisio™ is a novel delivery system designed for accurate and facilitated implantation of Amplatzer™ devices. There are no published clinical reports so far. Methods: During September 2020, 9 children with anatomically challenging ASDs underwent attempted transcatheter closure using ATIDS to deliver Amplatzer™ Septal occluders (ASO). All interventions were performed under general anesthesia, trans-esophageal echocardiography (TOE), and fluoroscopic guidance. Standard safety, immediate, and 60-days outcomes were prospectively assessed. Results: The median age was 8.1 (5.1-16.9) years and the median bodyweight was 30 (18-63) kg. Six patients had isolated secundum-type ASDs with absent anterosuperior rims including one with an aneurysmal septum. Three patients had unclassical defects associated with complex congenital heart anomalies. Eight devices were delivered from the femoral vein and the jugular vein was accessed in one patient with interrupted inferior caval vein and azygos continuation. All implantations were successful. The shape, position, and orientation of the ASO were identical before and after release on TOE and fluoroscopy. There was no device embolization or serious complication following closure. Complete shunt closure was confirmed on follow-up. Conclusions: We report the first clinical experience with ATIDS in transcatheter ASD pediatric closures. Safety and efficacy were witnessed in our case-series. The major advantage of reduced-tension deployment and reliable precision in device positioning is highly beneficial in challenging anatomies and unusual access.

Secundum Atrial Septal Defect Closure via the Transhepatic Approach in a Patient With Situs Ambiguus and a Left-Sided Inferior Vena Cava

Secundum atrial septal defect (ASD) is the most common type of ASD. Symptoms including dyspnea on exertion usually manifest in the third and fourth decade of life. The transcatheter closure is the treatment of choice for secundum ASD. The transfemoral venous approach has been the mainstay. However, this approach can be challenging or impossible in patients with congenital absence or interruption of the inferior vena cava (IVC). The latter has been reported in patients with situs ambiguus and inversus. In this patient population, other forms of venous access such as the transjugular or transhepatic approach are used. We present a unique case of symptomatic secundum ASD in a patient who was incidentally found to have situs ambiguus with a left-sided intact IVC. An initial attempt at the ASD closure via the transfemoral approach was unsuccessful due to acute angulation. A repeat attempt was successful via the transhepatic approach with the guidance of real-time ultrasound, transesophageal echocardiogram, and the involvement of an interventional radiologist. The procedure was well tolerated without any complications. Repeat transthoracic echocardiogram with agitated saline the day after the procedure was negative for interatrial shunting.