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

Expanding role of absolute zero fluoroscopy atrial septal defect closure: a single-center experience

Introduction

Zero-fluoroscopy, exclusively ultrasound-guided atrial septal defect (ASD) catheter closure has been reported. However, data on the effectiveness of this technique in complex cases remains limited.

Objectives

This study aims to evaluate the safety, efficacy, and outcomes of ASD catheter closure using exclusive ultrasound guidance, with a particular focus on complex cases.

Methods

We conducted a retrospective review of clinical data from patients who underwent attempted ASD catheter closure with exclusive ultrasound guidance at our institution between July 2018 and April 2024. Patients were categorized into two groups based on the complexity of their cases (simple vs. complex ASD cases). Complex cases included patients with large defects (≥25 mm), multiple or fenestrated ASDs, deficient posterior-inferior rim <3 mm, deficient retro-aortic rim <5 mm, pulmonary hypertension, septal malalignment, and pregnancy. We analyzed and compared demographic information, procedural data, and outcomes between the two groups.

Results

We identified 339 patients (18.2% males, 53.6% adults) with a median age of 21 years (IQR, 9-38) and median weight of 46.5 Kg (IQR, 22-59). Overall, median defect size was 20 mm (IQR, 16-25) and device size was 26 mm (IQR, 20-32). 248 (73.1%) patients were classified as complex including 98 (28.9%) with large defects (≥25 mm), 33 (9.7%) with multiple or fenestrated ASDs, 53 (15.6%) with pulmonary hypertension, 171 (50.4%) with rim deficiency, 50 (14.7%) with septal malalignment, and 6 (1.7%) with pregnancy. Two procedures (0.5%) were guided using transthoracic ultrasound and 337 (99.4%) using both transthoracic and transoesophageal ultrasound. The implantation success rate was 98.9% in simple cases and 97.1% in complex cases (p < 0.001). The rate of conversion to fluoroscopy guidance was 0 (0%) in simple cases and 7 (2.8%) in complex cases (p < 0.001). The median procedural time was 41 min (IQR, 30-47) in simple cases and 45 min (IQR, 36-62) in complex cases (p = 0.008). Sixteen patients (4.7%) underwent balloon-assisted procedures, and 12 (3.5%) required redeployment. There were 6 (1.7%) serious procedural complications (0 in simple cases, 6 in complex cases). The median follow-up was 187 days (IQR, 21-428.7). There were no residual shunt at latest follow-up for both simple and complex cases.

Conclusions

Zero-fluoroscopy exclusively echocardiography-guided ASD closure is effective in both simple and complex cases. However, the rate of conversion to fluoroscopy and implantation failure are significantly higher in complex ASD cases.

Device-assisted transcatheter closure of large secundum atrial septal defects: a novel approach

BACKGROUND

Transcatheter closure of large and complex atrial septal defect can pose challenges and complications during device placement. To improve stability, several assistive techniques have been developed.

METHODS

This retrospective study evaluated the efficacy of the device-assisted device closure technique for large secundum atrial septal defects. Patients who underwent device-assisted device closure of atrial septal defect between December 2023 and August 2024 were analysed.

RESULTS

Twenty patients (mean age 38.69 years) underwent device closure of large secundum atrial septal defect with device-assisted device closure technique. The mean atrial septal defect diameter was 31.9 mm. The average thick-to-thick measurement was 38.3 mm, which determined the device size. The majority (18 cases) had thin, floppy margins and two had deficient inferior rim. Successful closure was achieved in 18 patients (90%), while two patients (10%) required other methods of assistance. Based on fluoroscopic guidance, patients were divided into two groups: Group A (8 patients) used anteroposterior projection, and Group B (12 patients) used left anterior oblique-cranial view. After initial two failures with anteroposterior view, all cases were successfully closed using left anterior oblique-cranial projection. Device sizes ranged from 36 to 50 mm (median 40 mm). Cocoon devices were used for sizes up to 42 mm, and Occlunix for larger devices. No significant procedural complications occurred, although two patients had minor post-procedural events.

CONCLUSIONS

Device-assisted device closure technique offers a promising and safe dynamic assistance approach for transcatheter closure of large and challenging atrial septal defects. The left anterior oblique-cranial view showed promising results, though without statistical significance. While results are encouraging, larger prospective studies are needed to validate its effectiveness.

Purse string suture for rapid access hemostasis after removal of large-caliber femoral venous delivery sheaths in children with atrial septal defects

OBJECTIVES

To evaluate the efficacy and safety of purse-string sutures (PSS) compared with manual compression for access hemostasis in children with atrial septal defects (ASDs) after large-caliber venous delivery sheaths removal.

METHODS

We conducted a retrospective clinical data review of 271 children with ASDs who underwent transcatheter device closure through large-caliber venous delivery sheaths (≥ 8 Fr) at our institution from January 2018 to January 2023. The PSS group (n = 144) was compared to the control group (n = 127), which underwent manual compression for femoral venous hemostasis after sheath removal, focusing on hemostatic time, limb braking time, bed rest time, hospital stay, and vascular access complications. Two days post-catheterization, the sutures were taken out and a vascular ultrasound found the evidence of thrombosis, embolism, or venous narrowing.

RESULTS

Compared to the control group, the PSS group had significantly shorter average hemostatic time (4.63 ± 1.95 min vs. 19.69 ± 5.64 min), limb braking time (6.83 ± 2.25 h vs. 13.45 ± 2.87 h), and bed rest time (8.69 ± 1.43 h vs. 22.93 ± 2.24 h) (all, p < 0.001). There were no statistically significant differences in hospital stay and complications between the two groups.

CONCLUSIONS

The PSS is a simple, effective, and safe procedure that may play a valuable role in achieving rapid hemostasis after the removal of the large-caliber venous delivery sheaths in children. It allows earlier mobilization, reduces bed rest time, and alleviates discomfort compared to manual compression.

Device closure of an atrial septal defect from the upper caval vein: simplified technique

Interruption of the inferior caval vein complicates device closure of atrial septal defects. We present a case where a simplified technique was used: from right jugular access the delivery system was directly engaged into the left atrium, where the entire septal occluder was deployed. Both discs were aligned with the interatrial septum, after which the right disc was recaptured and re-deployed in the right atrium under tension. This technique will allow device closure of atrial septal defects from the upper caval vein in selected cases.

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.

Delivery systems for transcatheter therapies of congenital heart disease

INTRODUCTION

Delivery systems are crucially important for the implantation of medical devices in patients with congenital heart disease. However, very little data is available comparing the advantages and disadvantages of the various delivery systems.

AREAS COVERED

This article describes the delivery systems and methods used for delivery of atrial septal occluder devices, ventricular septal occluder devices, devices to occlude patent arterial ducts, and transcatheter pulmonary valves. Delivery systems are compared relating to prepping and loading, positioning of the delivery sheath/catheter, deployment, ability to recapture and reposition, as well as device release.

EXPERT OPINION

For most ASD/VSD/PDA occluder devices, the basic delivery mechanism has changed very little over the preceding 20 years. Future modifications may focus on meaningful modifications to the cable systems that reduce stiffness and improve angulation at the connection to the device. Over the next 5-10 years, it is expected to see significant changes to delivery systems used for transcatheter pulmonary valve implantation, that result in improvements in the ability to recapture and reposition self-expandable transcatheter valves during the deployment process, combined with kink resistant sheaths that facilitate easy tracking across often complex right ventricular outflow tracts.

Safety and efficacy of the Amplatzer™ Trevisio™ intravascular delivery system: Post-approval study results

BACKGROUND

The Amplatzer™ Trevisio™ Intravascular Delivery System (Trevisio DS; Abbott Laboratories, Chicago, IL, USA) facilitates the delivery of Amplatzer™ Occluders and features an ultraflexible tip, which improves assessment of occluder position before release.

AIMS

To assess the safety and efficacy of the Trevisio DS for transcatheter closure of patent foramen ovale and atrial septal defect.

METHODS

The Amplatzer™ Trevisio™ Intravascular Delivery System Post-Approval Study was a prospective, postmarket, single-arm, multicentre, observational study of the Trevisio DS. Enrolled patients were indicated for transcatheter closure of patent foramen ovale or atrial septal defect. In all procedures, the Trevisio DS was used to deliver Amplatzer™ Occluders. Technical success was defined as successful deployment and release of at least one occluder. Device- or procedure-related serious adverse events were tracked until discharge or day 7, whichever occurred earlier.

RESULTS

The study enrolled 144 patients with patent foramen ovale and 107 patients with atrial septal defect at 22 European sites; 53 patients with atrial septal defect (49.6%) were aged<18years. The rate of technical success was 98.4% (97.2% for atrial septal defect, 99.3% for patent foramen ovale). There was one serious adverse event (0.4%), an acute periprocedural device embolization that occurred after occluder release in a patient with atrial septal defect; the device was retrieved percutaneously. This was determined by the implanter to be unrelated to the performance of the Trevisio DS.

CONCLUSIONS

The Trevisio DS exhibited a high rate of technical success and an excellent safety profile during transcatheter closure of patent foramen ovale and atrial septal defect.

Update on Transcatheter Device Closure of Congenital Septal Defects

PURPOSE OF REVIEW

The goal of this paper is to review currently available devices for closure of atrial septal defects (ASDs) and ventricular septal defects (VSDs).

RECENT FINDINGS

Favorable results from the ASSURED trial resulted in FDA approval for the most recently developed device for transcatheter ASD closure in the United States. Further studies are required to assist in the development or approval of safe devices for transcatheter perimembranous VSD closure in pediatric patients. Device closure is the less invasive and preferred management option for many ASDs, with multiple studies demonstrating lower complication rates, shorter hospital stays, and lower mortality than surgical repair. Complex ASDs that make device closure more difficult include large defects, rim deficiencies, fenestrated defects, multiple defects, and the presence of pulmonary arterial hypertension. Device closure has also become an accepted alternative to surgery for some types of ventricular septal defects VSDs, though challenges and limitations remain. Future innovations including novel devices and techniques are needed to further expand on the types of defects that can be safely closed via transcatheter approach.

FAST technique: fast atrial sheath traction technique for device closure of atrial septal defects

BACKGROUND

Transcatheter closure of atrial septal defects (ASDs) is well-established. However, this procedure can be challenging, requiring multiple attempts and advanced implantation maneuvers.

MATERIALS AND METHODS

From July 2019 to July 2022, patients to whom the fast atrial sheath traction (FAST) technique was applied for ASD device closure were prospectively followed up. The device was rapidly unsheathed in the middle of the left atrium (LA) to let it clamp the ASD from both sides simultaneously. This novel technique was directly applied in patients with absent aortic rims and/or ASD size-to-body weight ratio higher than 0.9 or after failed attempts of standard implantation.

RESULTS

Seventeen patients (64.7% males) were involved with a median age of 9.8 years [interquartile range (IQR), 7.6-15.1] and a median weight of 34 kg (IQR, 22-44). The median ASD size on ultrasound was 19 mm (IQR, 16-22). Five (29.4%) patients had absent aortic rims, and three (17.6%) patients had an ASD size-to-body weight ratio higher than 0.9. The median device size was 22 mm (IQR, 17-24). The median difference between device size and ASD two-dimensional static diameter was 3 mm (IQR, 1-3). All interventions were straightforward without any complications using three different occluder devices. One device was removed before release and upsized to the next size. The median fluoroscopy time was 4.1 min (IQR, 3.6-4.6). All patients were discharged the next postoperative day. On a median follow-up of 13 months (IQR, 8-13), no complications were detected. All patients achieved full clinical recovery with complete shunt closure.

CONCLUSION

We present a new implantation technique to efficiently close simple and complex ASDs. The FAST technique can be of benefit in overcoming left disc malalignment to the septum in defects with absent aortic rims and in avoiding complex implantation maneuvers and the risks of injuring the pulmonary veins.

The Ceraflex and Figulla atrial septal occluders: early and intermediate-term safety and efficacy study

BACKGROUND

Ceraflex septal occluder and the Figulla atrial septal defect occluder have the advantage of a pivoting mechanism and softer device architecture. This study sought to examine the safety and efficacy of these occluders compared to the Amplatzer septal occluder.

METHODS

This was a retrospective study. Between January, 2013 and April, 2020, patients with at least 6 months of follow-up were included. Early and late-onset outcomes were examined.

RESULTS

Four hundred seven patients (range: 0.17-70.72 years; 53.1% >18 years; male: 29.2%) underwent atrial septal defect occlusion using Amplatzer septal occluder (n = 313), Ceraflex septal occluder (n = 36) and FSO (n = 58). A longer procedure time was observed in the Amplatzer septal occluder group. Early-onset complication rates in Amplatzer septal occluder, Ceraflex septal occluder and Figulla atrial septal defect occluder were 3.83%, 5.56% and 0%. Ten (2.46%) patients developed delayed complications (2.56%, 0% and 1.72% in the Amplatzer septal occluder, Ceraflex septal occluder and Figulla atrial septal defect occluder groups). Device erosion rate was not different between groups. The occlusion rates were comparable among all the devices.

CONCLUSION

There is no significant difference in safety and efficacies between the novel atrial septal defect occluding devices compared to Amplatzer septal occluder.

An Up-to-Date Narrative Review on Congenital Heart Disease Percutaneous Treatment in Children Using Contemporary Devices

Background: Congenital heart pathology has a significant burden regarding morbidity and mortality in the pediatric population. Several transcatheter interventions and devices have been designed as an alternative to surgical repair. Percutaneous interventions have been proven to yield good results in most cases but with less stress and trauma than that attributed to surgical treatment, especially in frail pediatric patients. We aimed to review the literature and to investigate the feasibility and efficacy of transcatheter interventions and implantable devices for congenital heart disease management in children. Methods: We performed a search in Scopus and MEDLINE databases using prespecified keywords to retrieve clinical studies published between 2000 and 2021. Results: This article provides an up-to-date review regarding the applicability of interventional techniques in simple inter-atrial or inter-ventricular defects, and in challenging congenital defects, such as hypoplastic left heart syndrome, tetralogy of Fallot, or coronary artery fistula. Furthermore, we reviewed recent indications for defibrillator and cardiac resynchronization therapy, and new and promising devices currently being tested. Conclusion: Transcatheter treatment represents a feasible and efficient alternative to surgical repair of congenital heart defects. Novel devices could extend the indications and possibilities of percutaneous interventions in pediatric patients with congenital heart diseases.

3D model-guided transcatheter closure of ascending aorta pseudoaneurysm with the novel Amplatzer Trevisio intravascular delivery system

Ascending aorta pseudoaneurysm (AAP) is a rare but life-threatening complication of atherosclerosis, endocarditis, chest trauma, transcatheter or cardio-thoracic procedures. Since surgical repair is burdened by high morbidity and mortality, percutaneous closure is nowadays considered a valuable cost-effective therapeutic alternative. Due to unpredictability and complexity of local anatomy, no standardized technique and device are advised. In this setting, 3D printing technology could significantly help in planning trans-catheter approach. This article reports on a 3D printed model-guided percutaneous closure of a huge AAP using an Amplatzer Septal Occluder (Abbott, Plymouth MN) implanted by the recently commercialized Amplatzer Trevisio Intravascular Delivery System.