Current outcomes of surgical closure of secundum atrial septal defect

Echocardiographic Screening for Postoperative Pericardial Effusion in Children

Pericardial effusion (PE) after cardiac surgery can be life threatening without timely detection, and the optimal screening method is unknown. We sought to evaluate the role of a surveillance echocardiogram on postoperative day 10 (± 2), determine the incidence of postoperative PE, and identify risk factors. We conducted a retrospective cohort study including all pediatric patients who underwent open heart surgery at a single institution over a 7-month period. To identify risk factors for PE, medical records of patients with PE detected within 6 weeks after surgery (cases) were compared with patients without PE (controls). Of 203 patients, 52 (26%) had PE within 6 weeks; 42 (81%) were trivial-small and 10 (19%) were moderate-large. Twenty-nine (56%) were first detected within 7 days post-operatively, including all cases developing cardiac tamponade (n = 3). An echocardiogram was done 10 (± 2) days post-operatively in 41/52 cases, of which 12/41 (29%) did not have a PE at this time, 24/41 (59%) had a trivial-small PE, and 5/41(12%) had a moderate-large PE; 2 of the latter had no prior detected PE. Closure of an atrial septal defect had the highest incidence of PE (42%). PE cases were associated with postoperative nasopharyngeal detection of a respiratory virus (OR 3.8, p = 0.03). In conclusion, the majority of PE cases were detected within 7 days post-operatively, including all cases subsequently developing cardiac tamponade. Day 10 echocardiography infrequently detected a moderate or large effusion that had previously gone undiagnosed. A positive perioperative nasopharyngeal aspirate for a respiratory virus was associated with postoperative PE.

Remifentanil-based fast-track cardiac anesthesia combined with the postoperative serratus anterior plane block for transthoracic device closure of atrial septal defect in pediatric patients

BACKGROUND

To evaluate the safety and effectiveness of remifentanil-based fast-track cardiac anesthesia (FTCA) combined with the postoperative serratus anterior plane block (SAPB) for transthoracic device closure of atrial septal defect (ASD) in pediatric patients.

METHODS

A total of 70 children who underwent transthoracic device closure of ASDs from January 2018 to June 2020 were divided into two groups according to different anesthesia strategies administered, namely group F (fast-track anesthesia, n = 38) and group R (routine anesthesia, n = 32), and relevant clinical data were collected and analyzed.

RESULTS

There was no statistically significant difference between the two groups in general preoperative data, intraoperative hemodynamics, and FLACC score 1 h after extubation (p > .05). FLACC score of Group F was significantly lower than that of group R at 4, 8, 12, and 24 h after extubation (p < .05). The number of postoperative PCA press and the dose of PCA infusion in group F were lower than those in group R (p < .05). The mechanical ventilation duration, the length of intensive care unit stay in group F were statistically significantly lower than those in group R (p < .05).

CONCLUSION

Remifentanil-based FTCA combined with the postoperative SAPB for transthoracic device closure of ASD in pediatric patients could effectively reduce postoperative pain of the children.

Outcomes of Device Closure of Atrial Septal Defects

Several devices have been designed and tried over the years to percutaneously close atrial septal defects (ASDs). Most of the devices were first experimented in animal models with subsequent clinical testing in human subjects. Some devices were discontinued or withdrawn from further clinical use for varied reasons and other devices received Food and Drug Administration (FDA) approval with consequent continued usage. The outcomes of both discontinued and currently used devices was presented in some detail. The results of device implantation are generally good when appropriate care and precautions are undertaken. At this time, Amplatzer Septal Occluder is most frequently utilized device for occlusion of secundum ASD around the world.

Comparison of Remifentanil-Based Fast-Track and Fentanyl-Based Routine Cardiac Anesthesia for Intraoperative Device Closure of Atrial Septal Defect (ASD) in Pediatric Patients

Background

The aim of this study was to evaluate the effectiveness and safety of remifentanil-based fast-track anesthesia for intraoperative device closure of atrial septal defects (ASDs).

Material/Methods

The clinical data of 152 pediatric patients who received intraoperative device closure of ASD in our hospital from January 2015 to December 2017 were retrospectively analyzed. Patients were divided into 2 groups: group F (remifentanil-based fast-track anesthesia group, n=72) and group C (fentanyl-based routine anesthesia group, n=80). The relevant data from 2 groups were collected and analyzed.

Results

No significant differences were found in the preoperative data or intraoperative hemodynamic index between these 2 groups. Group C was significantly inferior to group F regarding the duration of mechanical ventilation, length of intensive care unit (ICU) stay, length of hospital stay, and hospitalization expenses (P<0.05). In terms of postoperative complications, no death, third-degree atrioventricular block, occluder detachment, or residual leakage was reported in either group. The incidence of lung infections and bronchospasm was significantly higher in group C than in group F. There were no anesthetic-related complications.

Conclusions

The application of remifentanil-based fast-track anesthesia for intraoperative device closure of ASD is as effective and safe as fentanyl-based routine anesthesia. Moreover, remifentanil-based fast-track anesthesia has the advantages of shorter duration of mechanical ventilation, shorter length of hospital and ICU stay, fewer postoperative complications, and lower hospitalization expenses, and is therefore worthy of promotion in clinical practice.

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.

Minimally invasive endoscopic surgery versus catheter-based device occlusion for atrial septal defects in adults: reconsideration of the standard of care

Objectives

Percutaneous ostium secundum atrial septal defect (ASD II) closure has become the standard of care for treatment of congenital ASD II in adults. Nevertheless, patients are frequently ineligible for this technique due to challenging morphology. In such cases, closure via minimally invasive cardiac surgery (MICS) is an appropriate treatment option. The aim of this study is to compare outcomes of MICS and use of a percutaneous Amplatzer septal occluder (ASO) device for treatment of ASD II in adults.

Methods

From July 2002 to June 2014, 95 patients underwent MICS for congenital ASD II closure. During the same period, 169 patients underwent ASO procedure. Outcomes in terms of remaining ASD II, new onset atrial fibrillation (AF), post-interventional stroke, myocardial infarction and the post procedural implementation of anticoagulation were compared.

Results

Apart from age (38.3 ± 12.7 vs 49.6 ± 15.7 years, P  < 0.0001) the groups did not differ in baseline characteristics. A significantly higher rate of residual ASD II was found in the ASO group at 3 months (0% vs 30.8%, P  < 0.0001), 6 months (0% vs 15.9%, P  < 0.0001) and 12 months follow-up (0% vs 7.1%, P  = 0.005). A significantly higher rate of new-onset AF was seen in the ASO group (0% vs 9.5%, P  = 0.0008).

Conclusions

MICS for ASD II is a safe and reproducible procedure with 0% mortality in our cohort. More complete closure of ASD, decreased rates of new onset AF and decreased need for oral anticoagulation are the advantages of the MICS procedure. Compared with the current standard of care, the MICS approach is feasible regardless of ASD morphology.

Comparative study of the transcatheter and transthoracic device closure treatments for atrial septal defect: A Chinese single-institution experience

The purpose of this study was to compare patient populations, safety, feasibility, complications, and total costs of the transcatheter and transthoracic device closure treatments for secundum atrial septal defect.From January 2014 to December 2014, we enrolled 155 patients with secundum atrial septal defects in our hospital. The patients were divided into 2 groups: the 70 patients in group A underwent transcatheter device closure, and the 85 patients in group B underwent transthoracic intraoperative device closure with a right lateral mini-thoracotomy.In group A, the total occlusion rate was 94.3% immediately after the operation, 100% at 3 months, and 100% at 12 months of follow-up; the group A results were not statistically different from the group B results (94.1%, 98.8%, 98.8%, respectively). There was a statistically significant difference in the minor complication rate (P < 0.05), and there were no reported deaths. There was a greater indicated scope using the transthoracic closure device to treat atrial septal defects. In our comparative study, the patients in group B had longer intensive care unit stays and hospital stays than group A (P < 0.05).Both of the device closure treatment options for secundum atrial septal defect are safe and feasible. The transcatheter device closure approach has the advantages of more cosmetic results, less trauma, and a shorter hospital stay than the transthoracic approach. On the contrary, the transthoracic closure device is an economical alternative choice, particularly for patients who are not eligible for the transcatheter closure device.

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

Background:

Transcatheter closure of atrial septal defects (ASD) has been accepted world-wide as an alternative to surgical closure with excellent results. This interventional, non-surgical technique plays an important role in the treatment of ASD mostly in the developing world where resources are limited.

Objectives:

To report the outcomes and short term follow-up of transcatheter closure of ASD over a 12-year period at our institution with limited resources.

Patients and Methods:

This retrospective study included all patients with the diagnosis of secundum ASD and significant shunting (Qp/Qs > 1.5:1) as well as dilated right atrium and right ventricle who had transcatheter closure at Integrated Cardiovascular Center (PJT), Dr. Cipto Mangunkusumo Hospital between October 2002 and October 2014. One hundred fifty-two patients enrolled in this study were candidates for device closure. Right and left heart cardiac catheterization was performed before the procedure. All patients underwent physical examination, ECG, chest X-ray and transthoracal echocardiography (TTE) prior to device implantation.

Results:

A total of 152 patients with significant ASD underwent device implantation. Subjects’ age ranged from 0.63 to 69.6 years, with median 9.36 years and mean 16.30 years. They consisted of 33 (21.7%) males and 119 (78.3%) females, with mean body weight of 29.9 kg (range 8 to 75; SD 18.2). The device was successfully implanted in 150 patients where the majority of cases received the Amplatzer septal occluder (147/150; 98%) and the others received the Heart Lifetech ASD occluder (3/150, 2%), whereas two other cases were not suitable for device closure and we decided for surgical closure. The mean ASD size was 19.75 (range 14 - 25) mm. During the procedure, 5 (4.9%) patients had bradycardia and 3 (2.9%) patients had supraventricular tachycardia (SVT), all of which resolved.

Conclusions:

In our center with limited facilities and manpower, transcatheter closure of atrial septal defect was effective and safe as an alternative treatment to surgery. The outcome and short-term follow-up revealed excellent results, but long-term follow-up is needed.

Transcatheter Closure of Large Atrial Septal Defects

Background—

Data are needed on the safety and efficacy of device closure of large atrial septal defects.

Methods and Results—

Between 1998 and 2013, 336 patients (161 children <15 years) with large, isolated, secundum atrial septal defects (balloon-stretched diameter ≥34 mm in adults or echocardiographic diameter >15 mm/m 2 in children) were managed using the Amplatzer device, at the Marie Lannelongue Hospital. Transthoracic echocardiographic guidance was used starting in 2005 (n=219; 65.2%). Balloon-stretched diameter was >40 mm in 36 adults; mean values were 37.6±3.3 mm in other adults and 26.3±6.3 mm/m 2 in children. Amplatzer closure was successful in 311 (92.6%; 95% confidence interval, 89%–95%) patients. Superior and posterior rim deficiencies were more common in failed than in successful procedures (superior, 24.0% versus 4.8%; P =0.002; and posterior, 32.0% versus 4.2%; P <0.001). Device migration occurred in 4 adults (2 cases each of surgical and transcatheter retrieval); in the 21 remaining failures, the device was unreleased and withdrawn. After a median follow-up of 10.0 years (2.5–17 years), all patients were alive with no history of late complications.

Conclusions—

Closure of large atrial septal defects using the Amplatzer device is safe and effective in both adults and children. Superior and posterior rim deficiencies are associated with procedural failure. Closure can be performed under transthoracic echocardiographic guidance in experienced centers. Early device migration is rare and can be safely managed by device extraction. Long-term follow-up showed no deaths or major late complications in our population of 311 patients.

Enlarged right ventricular size at 11 years' follow-up after closure of secundum-type atrial septal defect in children

BACKGROUND

The fate of right ventricular dimensions after surgical closure of secundum-type atrial septal defects remains unclear. The objectives of this study were to assess ventricular dimensions, exercise capability, and arrhythmias of patients operated for secundum-type atrial septal defect and compare the results with those in healthy references.

METHODS

A total of 78 consecutive patients underwent surgical closure for a secundum-type atrial septal defect between 1990 and 1995. In all, 42 patients were included and underwent a cross-sectional evaluation including echocardiography, magnetic resonance imaging, exercise testing, and 24-hour ambulatory electrocardiography. Patients were matched with healthy controls for gender, body surface area, and age.

RESULTS

The mean age at surgery was 4.6 plus or minus 2.8 years, and the mean age at follow-up was 16 plus or minus 3 years. There were no residual intracardiac lesions. The mean right ventricular endsystolic volume was significantly larger in patients (142 ± 26 millilitres) than in references (137 ± 28 millilitres; p = 0.04). In 25% of the patients, right ventricular end-systolic volume was larger than the 95th percentile for references. No relevant arrhythmias were detected. Exercise testing did not reveal differences with healthy references: maximal power (169 ± 43 Watt patients versus 172 ± 53 controls; p = 0.8), maximal oxygen uptake (38 ± 8 versus 41 ± 13 millilitres per minute per kilogram; p = 0.1).

COMMENT

After surgical closure of secundum-type atrial septal defect, right ventricular end-systolic volume is increased. These findings have no impact on rhythm status or exercise capacity at this stage of follow-up, but may have implications for the timing of surgery or the technique of closure if confirmed in longer follow-up.

The effect of short-term prophylactic acetylsalicylic acid on the incidence of postpericardiotomy syndrome after surgical closure of atrial septal defects

Postpericardiotomy syndrome (PPS), a potential complication of open heart surgery, has a variable clinical course and severity. This study evaluated the effectiveness of acetylsalicylic acid (ASA) prophylaxis in preventing PPS after surgical closure of atrial septal defects (ASDs) in pediatric patients. A retrospective review was performed for 177 patients who underwent uncomplicated ASD closure from 1986 to 2006. The study group received prophylactic ASA 20 to 50 mg/kg/day for 1 to 6 weeks after surgery, whereas the control group did not. The primary outcome was a diagnosis of PPS based on the presence of two or more of the following symptoms or signs occurring at least 72 h postoperatively: fever (temperature >38 degrees C), pericardial or pleural rub, and worsening or recurring anterior pleuritic chest pain. Consequently, PPS developed in 5 (2.8%) of the 177 children: 2.8% (3/106) in the control group and 2.8% (2/71) in the study group (p = 1.00). The secondary outcomes were frequency of other postoperative complications. Postoperative pericardial effusions experienced by 26.7% of the patients were identified more frequently in the treatment group (p < 0.001). Postoperative prophylaxis ASA at a dose of 20 to 50 mg/kg/day for 1 to 6 weeks after surgical closure of ASD does not decrease the incidence of PPS in pediatric patients.

Closure of atrial septal defect with the Amplatzer septal occluder in adults

Transcatheter closure of atrial septal defects (ASDs) was performed mainly in children and adolescents. Information about outcome and complications in adults was limited. From November 1997 to November 2005, percutaneous closure of ASDs using the Amplatzer septal occluder was attempted in 650 consecutive adult patients. Median patient age was 45.8 +/- 16.2 years (range 18 to 90), mean systolic artery pressure was 33.3 +/- 10.6 mm Hg (range 11 to 85), and mean pulmonary and systemic blood flow (Qp/Qs) ratio was 1.9 +/- 0.7 (range 0.8 to 6.6). Mean stretched diameter of the ASD was 21.2 +/- 5.1 mm (range 3.1 to 43). Seventy-eight patients (12%) had multiple defects. Of 572 patients with a single ASD, device implantation was successful in 563 patients (98%). During follow-up, complete closure could be achieved in 96% of patients with a single ASD and 71% of patients with multiple defects. Mean systolic artery pressure decreased to 28.3 +/- 10.1 mm Hg and mean Qp/Qs ratio decreased to 1 +/- 0.3. The 3 complications that occurred during the procedure were device embolization (2 patients; 0.3%) and transient ST depression (1 patient; 0.2%). The most common complication immediately after the procedure and during follow-up was new-onset atrial fibrillation (28 patients; 4.3%). Electrical cardioversion was successfully in most. Complications requiring emergency or elective surgery occurred in 6 patients (0.9%; hemopericardium, 2 patients, 0.3%; device embolization, 3 patients, 0.5%, and pericardial tamponade, 1 patient, 0.2%). In conclusion, closure of ASDs using the Amplatzer septal occluder in adults was efficient and safe, with excellent long-term success rates. Serious complications were rare.

Surgical atrial septal defect closure after interventional occluder placement: Incidence and outcome

OBJECTIVE

Closure of ostium secundum atrial septal defects is generally performed by using an interventional approach. We evaluated the outcome of patients requiring secondary surgical therapy.

METHODS

From September 1996 until December, 2005, 418 patients received interventional and 297 patients underwent surgical closure of an ostium secundum atrial septal defect at our center. Another 15 patients (local, 5; regional, 5; and national, 5 referrals) had complications after occluder placement, and they form the study population.

RESULTS

Indications for surgical repair in these 15 patients were dislocation of the occluder in 5, neurologic events after occluder placement in 5, residual defects in 4, and sepsis with questionable occluder infection in 1 patient. A total of 7 patients had neurologic events, 5 of embolic origin. The interval between interventional occluder placement and definitive surgical repair was 319 +/- 416 days (median 123 days; range 0-1395 days). Patient age at operation was 34.9 +/- 18.6 years. Nine patients were operated on via an anterolateral minithoracotomy, and 6 received a conventional sternotomy. One patient with sepsis underwent abdominal surgery on postoperative day 1 and subsequently died of multiorgan failure; there was no proof of occluder endocarditis. At 2.2 +/- 1.9 years of follow-up, all other patients had returned to full-time work without residual neurologic impairment.

CONCLUSIONS

Complications may arise after interventional ostium secundum atrial septal defect closure. This must be evaluated against the extremely low risk of a standard surgical closure. The functional outcome after secondary surgical ostium secundum atrial septal defect closure with removal of an occluder system is excellent.

Transcatheter versus surgical closure of secundum atrial septal defect in adults: impact of age at intervention. A concurrent matched comparative study

OBJECTIVES

To compare the short- and mid-term outcomes of surgical (SUR) vs. transcatheter closure of secundum atrial septal defect (ASD) using Amplatzer septal occluder (ASO) in adults with a very similar spectrum of the disease; and to identify predictors for the primary end point.

DESIGN

Single-center, concurrent comparative study. Surgically treated patients were randomly matched (2:1) by age, sex, date of procedure, ASD size, and hemodynamic profile.

SETTING

Tertiary referral center.

PATIENTS

One hundred sixty-two concurrent patients with ASD submitted to ASO (n = 54) or SUR closure (n = 108) according with their preferences.

MAIN OUTCOME MEASURES

Primary end point was a composite index of major events including failure of the procedure, important bleeding, critical arrhythmias, serious infections, embolism, or any major cardiovascular intervention-related complication. Predictors of these major events were investigated.

RESULTS

Atrial septal defects were successfully closed in all patients, and there was no mortality. The primary event rate was 13.2% in ASO vs. 25.0% in SUR (P = .001). Multivariate analysis showed that higher rate of events was significantly associated with age >40 years; systemic/pulmonary output ratio <2.1; and systolic pulmonary arterial pressure >50 mm Hg; while in the ASO group the event rate was only associated with the ASD size (>15 cm(2)/m(2); relative risk = 1.75, 95% confidence interval 1.01-8.8). There were no differences in the event-free survival curves in adults with ages <40 years.

CONCLUSIONS

The efficacy for closure ASD was similar in both groups. The higher morbidity observed in SUR group was observed only in the patients submitted to the procedure with age >40 years. The length of hospital stay was shorter in the ASO group. Surgical closure is a safe and effective treatment, especially in young adults. There is certainly nothing wrong with continuing to do surgery in countries where the resources are limited.

Device closure rates of simple atrial septal defects optimized by the STARFlex device

OBJECTIVES

This study sought to review the outcomes of 3 generations of closure devices for secundum atrial septal defects (ASDs) at a single institution.

BACKGROUND

Transcatheter closure of ASDs is now increasingly performed with devices that have been modified over time to improve performance.

METHODS

A review of prospective clinical trials of Clamshell (C.R. Bard Inc., Murray Hill, New Jersey), CardioSEAL (NMT Medical Inc., Boston, Massachusetts), and STARFlex (NMT Medical Inc.) closure devices for simple ASDs was performed. The entry criteria for these trials were age > or =2 years, isolated secundum ASD, evidence of right ventricular volume overload, and maximum stretched diameter varying from 20 to 25 mm. Successful outcomes were defined as no more than small residual leak (< or =2 mm) with absence of a severe complication or the need for an additional device or surgery.

RESULTS

A total of 72 Clamshell, 30 CardioSEAL, and 42 STARFlex devices were placed in uncomplicated ASDs. Each device modification resulted in improved closure rates, with the STARFlex device achieving a 93% complete closure rate with a device/stretched diameter ratio significantly smaller than with the other devices (p = 0.001). Severe complications occurred in 5 Clamshell, 1 CardioSEAL, and 0 STARFlex cases. Successful outcomes increased for each generation of device (79%, 93%, and 98% respectively, p = 0.009). There have been no long-term complications for either the CardioSEAL or the STARFlex devices.

CONCLUSIONS

Modifications in 3 generations of devices have resulted in improved results for percutaneous ASD closure.

Closure of atrial and ventricular septal defects should be performed by the surgeon

Surgeons look back on 57 years of experience in the closure of atrial septal defects (ASDs) and 46 years in the closure of ventricular septal defects (VSDs). The transcatheter approaches to repair ASDs started first in the 1980s and for VSDs 8 years later. This study sought to reveal the surgical features only given by the surgical therapy and the limitation of interventional ASD and VSD closure. A variety of surgical techniques including the minimal invasive techniques for ASD or VSD closure are well described in recent publication with good results. The surgical trend is to improve the cosmetic outcome by minimizing the size of skin incision. The latest robotically assisted technique requires only four stab wound incisions. New techniques and devices have revolutionized the transcatheter technique but could not achieve the surgical ability to close all types of ASD or VSD, control arrhythmias, and correct additional valve disease or malformation. The mortality for interventional and surgical procedures approaches zero in recent publication. The residual shunting after surgical closure of ASD varies from 2% to 7.8% versus 5% to 33% after interventional closure. General complications caused by the surgical procedure are negligible; however, the shortness of hospital stay and the cosmetic appeal is an advantage of interventional ASD closure. There is no scientific comparison of surgical vs. interventional VSD closure yet.

Surgical Versus Percutaneous Occlusion of Ostium Secundum Atrial Septal Defects

OBJECTIVES

We compared the effectiveness and cost of percutaneous occlusion using an Amplatzer septal occluder (ASO) (AGA Medical Corp., Golden Valley, Minnesota) device compared with surgical closure of an ostium secundum atrial septal defect (ASD II) in Guatemala.

BACKGROUND

The percutaneous occlusion of ASD II in first-world nations seems to offer better clinical results and lower cost compared with surgical closure.

METHODS

We reviewed the clinical course of 111 patients referred to our institution for closure of isolated ASD II. Successful closure was assessed immediately after the procedures and at 12 months. Actual hospital costs were calculated for every patient who underwent either of the two procedures.

RESULTS

Eighty-three patients with ASD II (75%) were selected for percutaneous occlusion with the ASO device, and the remaining 28 patients (25%) underwent surgical closure. In the device group, in 72 patients (86.7%) devices were successfully deployed. At immediate and 12-month follow-up, the complete closure rate was 87.5% (63 of 72 patients) and 97.2% (70 of 71 patients), respectively. In the surgical group, all patients had successful closure immediately after the procedure and at 12 months. Surgical closure offered a 27% cost savings in comparison with percutaneous occlusion (U.S. 3,329.50 dollars +/- 411.30 dollars and U.S. 4,521.03 dollars +/- 429.71 dollars; p < 0.001, respectively). Cost of the device (U.S. 2,930.00 dollars) proved to be the main cause for this difference.

CONCLUSIONS

We confirmed the clinical advantages of percutaneous occlusion over surgical closure of ASD II. However, percutaneous occlusion costs were higher compared with surgical closure. In Guatemala, where health care resources are limited, ASD II closure with the ASO device did not prove to be cost-effective.

Long-term outcome after surgical closure of atrial septal defect in childhood with extensive assessment including MRI measurement of the ventricles

Surgical closure of the secundum type of atrial septal defect (ASD) in childhood leads to excellent survival. However, relevant morbidity has been reported. Transcatheter closure of these defects has now become an alternative approach. To compare the results of the two different interventions, reliable data are needed on the long-term morbidity after defect closure with both methods. Patients were evaluated after a minimum of 10 years after surgical closure of an ASD in childhood. Assessment included analysis of perioperative data, interview, clinical examination, electrocardiogram, (ECG), 24-hour ECG, ergometry, chest radiograph, echocardiography, and MRI. A total of 66 patients underwent operation between 1971 and 1986 at our institution. Forty-eight of them (73%) were interviewed and 38 (58%) participated fully in the study program. Eighteen (27%) either refused to participate or were lost to follow-up. There were no substantial residual disorders, such as arrhythmias, right-sided heart dilatation, pulmonary hypertension, or reduced work capacity. Surgical closure of an ASD in childhood has an excellent long-term outcome. Surgical closure is thus the standard against which transcatheter closure needs to be measured.

Thoracoscopic ASD closure is a reliable supplement for percutaneous treatment

OBJECTIVE

To determine the feasibility and effectiveness of endoscopic atrial septal defect (ASD) closure when percutaneous ASD closure is impossible or has failed.

PATIENTS

Between March 1997 and February 2003, 74 patients (63% female, mean (SD) age 44 (16) years) underwent an endoscopic ASD closure. Median preoperative New York Heart Association functional class was I. Clinical and echocardiographic follow up was obtained for all patients (mean (SD) 38 (19) months). Patients were assessed for scar aesthetics, procedure related pain, functional recovery, and overall patient satisfaction.

RESULTS

ASD closure was successful in all patients (two primum ASD, 68 secundum ASD, four sinus venosus type). Patch repair was performed in 42%. Mean aortic cross clamp and cardiopulmonary bypass times were 54 (24) minutes and 98 (35) minutes, respectively. There were no in-hospital deaths and no conversions to sternotomy. Complications included one iliac vein stenting, one femoral arterioplasty, two revisions for suspected bleeding, and seven cases of atrial fibrillation. Two patients required late reoperation: one for atrial thrombus and another for tricuspid regurgitation. Echocardiographic control confirmed complete ASD closure in 71 patients and a small residual shunt in three patients. Ninety three per cent of the patients were highly satisfied with very low procedure related pain and 97% felt they had an aesthetically pleasing scar.

CONCLUSION

Endoscopic ASD closure can be safely done with a high degree of patient satisfaction. It is now the authors' exclusive surgical approach whenever percutaneous treatment is not indicated or has failed.

[Percutaneous closure of the inter-auricular communications, well defined indications]

POSSIBLITIES FOR PROGNOSTIC IMPROVEMENT: The inter-auricular communication (IAC) is the most frequent of congential malformations in adults and is responsible for enhanced morbidity and rduction in life expectancy. The closure of an IAC with volumic overload eradicates such morbidity and mortality. The technical progress in the conception of prosthesises that obstrue the interauricular communications via the percutaneous route make this technique a reliable alternative to surgery that, itself, leads to a certain degree of discomfort and considerable morbidity. DEPENDING ON THE ECHOCARDIOGRAPHICAL DATA: The selection of patients is crucial and relies on trans-thoracic echocardiography. It is indicated in isolated ostium secundum-type inter-auricular communications with a border of at least 4 mm separating it from the adjacent structures of the heart; the size on the echocardiography must not exceed 30 mm. FROM A TECHNICAL POINT OF VIEW: The closure is made under fluoroscopic and echocardiographic control via the trans-oesophageal route. It is rapid, simple, and induces a low rate of morbidity. With Amplatz's prosthesis, the percentage of complete closure is equivalent to that obtained with surgery but with less morbidity with regard to arrhythmia. Today the reliable percutaneous closure of an IAC will probably permit the extension of the indications for the closure of this congenital abnormality in adults.

Management of patients with stroke and a patent foramen ovale

Observational studies have established a strong association between the presence of patent foramen ovale (PFO) and increased risk of ischemic stroke. The mechanism involved is presumed to be a paradoxical embolism from a venous thrombus that travels via the PFO to the systemic circulation. The best treatment modality to prevent recurrent stroke in patients with PFO remains undefined. There are four major choices: 1) medical therapy with anticoagulants, 2) medical therapy with antiplatelet agents, 3) surgical closure, and 4) percutaneous device closure. The Patent Foramen Ovale in Cryptogenic Stroke Study has demonstrated that antiplatelet and anticoagulant therapies are of equal benefit in preventing recurrent neurologic events in stroke patients with a PFO. Medical therapy should remain as the initial choice of secondary prophylactic therapy. PFO closure, either surgical or percutaneous, may further reduce event rates; however, this remains to be demonstrated because no randomized trial to date has compared PFO closure with medical therapy.

Management of patients with stroke and a patent foramen ovale

Observational studies have established a strong association between the presence of patent foramen ovale (PFO) and increased risk of ischemic stroke. The mechanism involved is presumed to be a paradoxical embolism from a venous thrombus that travels via the PFO to the systemic circulation. The best treatment modality to prevent recurrent stroke in patients with PFO remains undefined. There are four major choices: 1) medical therapy with anticoagulants, 2) medical therapy with antiplatelet agents, 3) surgical closure, and 4) percutaneous device closure. The Patent Foramen Ovale in Cryptogenic Stroke Study has demonstrated that antiplatelet and anticoagulant therapies are of equal benefit in preventing recurrent neurologic events in stroke patients with a PFO. Medical therapy should remain as the initial choice of secondary prophylactic therapy. PFO closure, either surgical or percutaneous, may further reduce event rates; however, this remains to be demonstrated because no randomized trial to date has compared PFO closure with medical therapy.

ASD Closure with the Amplatzer Device

We report the safety and efficacy of the Amplatzer device for transcatheter closure of ASD and fenestrated Fontan in children and adults. One hundred and two patients underwent transcatheter occlusion of the defect. The median age of the patients was 18.2 years, the median size of the ASDs by TEE was 17.6 mm, the median balloon-stretched diameter was 19.9 mm, and the median size of the device implanted was 20 mm. Immediately after the release of the device, color Doppler echocardiography revealed no residual shunt in 92 (90.19%) of 102 patients. At 24 hours all the patients 101/101 (100%) had complete closure. The minor complications encountered after the procedure were atrial arrhythmias in 4 patients. The only major complication we had was a baby who died. In conclusion, the ASO device is a safe and effective device for catheter closure of most secundum ASDs and fenestrated Fontan.

Patent Foramen Ovale and Stroke

Observational data from prospective and retrospective trials indicate that a patent foramen ovale (PFO) is associated with the risk of ischemic stroke. The mechanism involved is presumed to be paradoxical embolism from a venous thrombus that travels via the PFO to the systemic circulation causing an ischemic stroke. Primary stroke prevention data for patients with a PFO are nonexistent. Given the substantial prevalence of PFO in the total population (~ 25% to 30%), a primary prevention study may not be feasible. However, whether targeted primary prevention for patients with PFOs of certain morphologic characteristics (eg, larger size, greater degree of shunt) would be possible remains undefined. Given the large number of asymptomatic subjects, no therapy is currently recommended. The best treatment modality to prevent recurrent stroke in patients with PFO has not been defined. There are four major treatment choices: surgical closure, percutaneous device closure, medical therapy with anticoagulants, and medical therapy with antiplatelet agents. Regarding medical therapy, the Patent Foramen Ovale in Cryptogenic Stroke Study has demonstrated that antiplatelet and anticoagulant therapies are of equal benefit in preventing recurrent adverse events. Although closure of the PFO, either surgical or percutaneous, may further reduce the event rates, this remains to be demonstrated because no randomized trial to date has compared PFO closure with medical therapy.

Secundum ASD closure using a right lateral minithoracotomy: five-year experience in 122 patients

BACKGROUND

Surgical closure of secundum atrial septal defect (ASD) is a standard procedure associated with very low mortality and morbidity. We evaluated outcomes in the era of catheter-based interventional closure and minimally invasive techniques.

METHODS

From May 1996, February 2002, 177 patients with a body weight of more than 30 kg underwent surgical ASD closure. A right lateral minithoracotomy (LMT) was used in 122 patients and a conventional approach, in 55. Diagnoses included secundum ASD in 106 patients in the LMT group and 40 in the conventional group, sinus venosus ASD in 13 patients in each group, and status post interventional closure in 3 and 2 patients, respectively. Mean age was 37 +/- 17 years in the LMT group and 43 +/- 20 years, in the conventional group and mean body weight was 66 +/- 17 kg and 70 +/- 16 kg, respectively. In the LMT group, femoral cannulation was performed for cardiopulmonary bypass.

RESULTS

Direct ASD closure was carried out in 67.2% of patients in the LMT group and 58.2% of those in the conventional group. The remaining patients had pericardial patch closure. There was one death: A patient in the conventional group who required explantation of an Amplatzer device because of infection died postoperatively. Average stay in the intensive care unit was 1.2 +/- 0.5 days. Two patients required reoperation for residual ASD after direct closure; 1 sustained a temporary neurological deficit that resolved completely. On postoperative echocardiography, a minimal residual shunt was seen in only 3 patients. All patients were in good clinical condition with improved functional status at discharge from the hospital.

CONCLUSIONS

Secundum ASD closure by LMT has become as standard and safe an operation as the conventional technique and achieves good perioperative results and satisfactory long-term outcomes. Thus LMT is an attractive option for patients who are not suitable for closure using catheter-based devices.

[Percutaneous catheter closure of atrial septal defect. Short-term and mid-term results]

INTRODUCTION

Percutaneous closure of atrial septal defects (ASD) is becoming more frequent.

PATIENTS AND METHOD

From October 1997 to October 2002, 209 patients, age 0.4-70 (mean 19.5) years, were catheterized to close an ASD or patent foramen ovale (PFO). Transesophageal echocardiography was performed simultaneously in all patients. Two hundred and six patients had ASD (25 multiple ASDs) and 3 had PFO. Three devices were used, the Amplatzer Atrial Septal Occluder (ASO), CardioSeal (CS), and Starflex (SF).

RESULTS

Device implantation was achieved in 181 patients (87%) but had to be abandoned in 28 patients, generally because the ASD was too large. One hundred and seventy-four ASOs were implanted in 172 patients with ASD (2 ASOs were implanted in 2 patients with double ASD) and CS/SF in 9 patients (3 patients with PFO and 6 with ASD). The procedure was effective in 166/172 (96%) ASO implantations and in 8/9 (89%) CS/SF implantations. The procedure was unsuccessful in 7 patients and the device had to be removed (6 ASO and 1 SF). The occlusion rate with ASO was 88% after 24 hours, 91% after 1 month, 95% after 1 year, 97% after 2 years, and 100% after 4 and 5 years. All defects treated with SF/CS were closed successfully after 24 hours. In one case the ASO device was embolized to the aorta. In the first month after ASO implantation, supraventricular tachycardia appeared in 2 patients and transient left ventricular failure in 2 patients. No late complications were observed.

CONCLUSION

Percutaneous catheter closure of selected types of ASD using the Amplatzer Atrial Septal Occluder, CardioSeal, or Starflex should be offered to patients as non-surgical alternative. The type of device used depends on the defect size and morphology as well as the surgeon's experience. The presence of multiple defects does not exclude the possibility of a successful percutaneous catheter closure.

Transcatheter patch occlusion of experimental atrial septal defects

The effectiveness and safety of transcatheter patch atrial septal defect (ASD) occlusion were studied in 20 piglets. Experimental atrial septal defects were created by foramen ovale dilation. ASDs were corrected by polyurethane patches of two types (flat and sleeve). Specially made balloon catheters supported the patches for periods varying from 1 to 6 days; after this period, the supporting catheters were withdrawn and the patches were released. All transcatheter patches were safely embedded in the atrial septum 48 hr or more after implantation. All defects were fully occluded. One patch became infected. The transcatheter patch experimental ASD occlusion method was found effective and safe, potentially applicable in the occlusion of human ASDs.

Transcatheter closure of atrial septal defects with the Amplatzer septal occluder--a Japanese clinical trial

This study reports the results of a Japanese clinical trial of transcatheter closure of atrial septal defects (ASD) using the Amplatzer septal occluder (ASO). Thirty-five patients with secundum ASD underwent transcatheter closure using the ASO at a median age of 12.9 years (range, 3.2-29.2 years) and a median weight of 39.2kg (range, 11.6-65.1 kg). The ASO was successfully implanted in 34 patients. The mean ASD diameter of the 34 patients measured by transesophageal echocardiography was 11.7 +/- 4.2mm (range, 5.0-20.8mm) and the mean balloon stretched diameter was 16.8 +/- 4.2 mm (range, 9-25 mm). The mean ASO size was 16.9 +/- 4.3 mm (range, 9-26mm). Complete closure rate at 1 day and 1 year after closure was 91% and 97%, respectively. One patient developed a transient second-degree atrioventricular block during the implantation procedure. No other complications occurred. Transcatheter closure of ASD using the ASO is effective and safe.

[Surgical closure of atrial septal defect before or after the age of 25 years. Comparison with the natural history of unoperated patients]

INTRODUCTION

Surgical closure of an atrial septal defect (ASD) before the age of 25 years has been demonstrated to reduce complications during adulthood. However, the outcome for patients operated after the age of 25 is still debated.

METHODS

In a retrospective study we examined the outcome of early and late surgical repair of ASD in adults, as compared with the natural evolution of unoperated patients. The study population was 280 patients (mean age 40 18 years) with non-restrictive ASD: 102 patients (group 1) underwent surgery before the age of 25 years, 90 patients (group 2) underwent surgery after the age of 25 years, and 88 unoperated patients were older than 25 years at the time of study (group 3). The variables analyzed were left ventricular systolic function, left atrial dimensions, systolic pulmonary pressure, right ventricular dimensions, the degree of mitral and tricuspid regurgitation, and the prevalence of late atrial fibrillation.

RESULTS

Left ventricular systolic function and the degree of mitral regurgitation were not statistically different between groups. Compared with the patients in group 2, the patients in group 1 had a significantly lower systolic pulmonary arterial pressure (p < 0.001) and less dilated right ventricle (p < 0.001) and left atrium (p < 0.001). The degree of tricuspid regurgitation (p < 0.001) and prevalence of atrial fibrillation (p < 0.001) were significantly higher in the patients of group 2. Compared with group 3, the patients in group 2 had a significantly lower systolic pulmonary arterial pressure (p < 0.001) and less dilated right ventricle (p < 0.001). However, the left atrial dimensions, degree of tricuspid regurgitation, and prevalence of atrial fibrillation did not differ in a statistically significant way between the two groups.

CONCLUSIONS

Surgical repair of an atrial septal defect in patients over 25 years of age does not fully prevent hemodynamic deterioration and the development of atrial arrhythmias. Therefore it seems that the surgical closure of ASD before adulthood should be strongly recommended.

Comparison between transcatheter and surgical closure of secundum atrial septal defect in children and adults: results of a multicenter nonrandomized trial

OBJECTIVES

This study sought to compare the safety, efficacy and clinical utility of the Amplatzer septal occluder (ASO) for closure of secundum atrial septal defect (ASD) with surgical closure.

BACKGROUND

The clinical utility of a device such as the ASO can only be judged against the results of contemporaneous surgery.

METHODS

A multicenter, nonrandomized concurrent study was performed in 29 pediatric cardiology centers from March 1998 to March 2000. The patients were assigned to either the device or surgical closure group according to the patients' option. Baseline physical exams and echocardiography were performed preprocedure and at follow-up (6 and 12 months for device group, 12 months for surgical group).

RESULTS

A total of 442 patients were in the group undergoing device closure, whereas 154 patients were in the surgical group. The median age was 9.8 years for the device group and 4.1 years for the surgical group (p < 0.001). In the device group, 395 (89.4%) patients had a single ASD; in the surgical group, 124 (80.5%) (p = 0.008) had a single ASD. The size of the primary ASD was 13.3 +/- 5.4 mm for the device group and 14.2 +/- 6.3 mm for the surgery group (p = 0.099). The procedural attempt success rate was 95.7% for the device group and 100% for the surgical group (p = 0.006).

CONCLUSIONS

The early, primary and secondary efficacy success rates were 94.8%, 98.5% and 91.6%, respectively, for the device group, and 96.1%, 100% and 89.0% for the surgical group (all p > 0.05). The complication rate was 7.2% for the device group and 24.0% for the surgical group (p < 0.001). The mean length of hospital stay was 1.0 +/- 0.3 day for the device group and 3.4 +/- 1.2 days for the surgical group (p < 0.001). Mortality was 0% for both groups. The early, primary and secondary efficacy success rates for surgical versus. device closure of ASD were not statistically different; however, the complication rate was lower and the length of hospital stay was shorter for device closure than for surgical repair. Appropriate patient selection is an important factor for successful device closure. Transcatheter closure of secundum ASD using the ASO is a safe and effective alternative to surgical repair.

Predisposing conditions for atrial fibrillation in atrial septal defect with and without operative closure

The aims of this study were to determine the prevalence and predisposing conditions for atrial fibrillation (AF) in adults with atrial septal defect (ASD) and to evaluate the influence of age at surgical repair. The study population consisted of 286 adults with ASD (mean age 39.5 +/- 19 years). All patients had >or = 1 follow-up visit and a Doppler echocardiographic study. One hundred ninety-two of the patients underwent surgical closure 1 to 34 years before the study. Analyzed variables were entered into univariate (Mann-Whitney U) and multivariate (stepwise logistic regression) models to assess independent predictors for AF. The prevalence of AF was similar in surgically treated patients (15.6%) and in the nonsurgical group (13.8%) (p = 0.69). Multivariate analysis showed that current age (RR 1.9 per each decade of age, 95% confidence interval [CI] 1.3 to 2.7, p = 0.001), mitral regurgitation (RR 3.0 per each degree of regurgitation, 95% CI 1.6 to 5.8, p = 0.001), left atrial enlargement (RR 2.8 per each 10 mm increase in size, 95% CI 1.5 to 5.2, p = 0.001), and tricuspid regurgitation (RR 1.9 per each degree of regurgitation, 95% CI 1.0 to 3.7, p = 0.04) were independent predictors of AF; however, gender, anatomic type, defect size, Qp:Qs, pulmonary artery pressure, right ventricular dimension, left ventricular shortening fraction, and prior surgical repair were not related to late AF development. In the surgical group, age >25 years at the time of surgery was the only predictor for AF independent of age at the time of the study (p = 0.02).

Percutaneous closure with Amplatzer device is a safe and efficient alternative to surgery in adults with large atrial septal defects

BACKGROUND

In adults with atrial septal defect (ASD) and large right-to-left shunt, closure of the defect is recommended. Percutaneous closure is still rarely used in this population. This study presents the results of transcatheter closure with the Amplatzer occluder in such patients.

METHODS AND RESULTS

We studied 44 consecutive adult patients with a secundum ASD and 2 of the 3 following criteria: QP/QS >/=2 by oximetry, echocardiographic right ventricle overload, and ASD size >20 mm. Forty-two patients had a successful implantation. In 1 patient an unstable device was withdrawn; in another one, the device embolized in the pulmonary artery. At 6-month median follow-up, 95% had a complete closure; 2 patients with an additional defect had a small residual shunt. Major complications were the aforementioned embolization and a cerebrovascular accident in a patient with atrial fibrillation treated with aspirin. Others were minor and transitory: premature atrial beats in 3 patients, and paroxysmal atrial fibrillation and pulmonary edema in 1 patient each.

CONCLUSIONS

Transcatheter closure of large ASDs with the Amplatzer device is efficient with less morbidity than surgical closure.

Surgical Closure of Secundum Atrial Septal Defects: The Cutting Edge?

Between January 1985 and November 1998, 270 patients (aged 2 to 220 months) underwent surgical closure of a secundum atrial septal defect. Cardiopulmonary bypass times ranged from 12 to 103 minutes, with aortic crossclamp times of 5 to 49 minutes. Use of blood products decreased from 2.7 units per patient in the first 5 years to 0.2 units in the last 4 years. Median intensive care unit and hospital stays were 2 days and 6 days, respectively. Complications included: bleeding in 6 patients (2%), which required reexploration in 3; air embolism in 1; and arrhythmias in 4. Postpericardiotomy syndrome occurred in 43 patients (16%), requiring drainage in 5. Follow-up (12 to 179 months) was available in 245 patients (91%). There were no early or late deaths. Most patients (94%) were in sinus rhythm, 8 had low atrial rhythm, 3 had first-degree atrioventricular block, and 1 had atrial flutter. Echocardiography in 207 patients (77%) demonstrated a residual shunt in 1 (0.5%), which was hemodynamically insignificant. Late reoperation was required in 4 patients for sternal nonunion. Surgical closure of secundum atrial septal defect remains the gold standard with which transcatheter closure should be compared, particularly with reference to morbidity and residual shunts.

Occlusion of interatrial communications with the Amplatzer device: experience in 48 consecutive patients

Both secundum atrial septal defect (ASD) and patent foramen ovale (PFO) have been closed interventionally using several different occluding devices. At a single institution we strived for interventional occlusion of interatrial communications using the Amplatzer device exclusively. During a study period of 22 months, we studied 48 patients ranging in age from 1 to 48 years with an ASD (n = 45) or a PFO (n = 3). Successful implantation of an Amplatzer device was possible in 92% of the patients, and 95% of these patients had a complete early closure of their defect. There were no complications related to the procedure. We conclude that interventional closure of interatrial communications with the Amplatzer device is feasible and safe for selected patients.

Transcatheter closure of atrial septal defects in children & adults using the Amplatzer Septal Occluder

We are reporting the worldwide experience in closing atrial septal defects (ASDs) in children and adults using the Amplatzer Septal Occluder (ASO) as of July 2000. The outcome measures were safety and efficacy with special emphasis on: (1) immediate success of the ASD closure as measured by transesophageal echocardiography (TEE), (2) short- and medium-term follow-up at 24 hours and 1 and 3 months and long-term follow-up at 1, 2, and 3 years as assessed by transthoracic echocardiography (TTE); and (3) the incidence of complications. In all, 3580 procedures were performed in 3535 patients. In 75 patients, the device was not implanted for variety of reasons; 3460 patients received a single ASO device and 45 received two devices for multiple ASDs. The median age of the patients was 12.1 year, (range, 10 days-88 years, the median weight was 41.0 kg (range, 2.4-137 kg) and the median Qp/Qs ratio was 2 (range, 0.3-10). The median size of ASD by TEE was 14 mm (range, 1-38 mm) and the median stretched diameter was 18 mm (range, 4-44 mm). The median size of device implanted was 18 mm (range, 4-40 mm). The median fluoroscopy time was 17.1 minutes (range, 0.0-194.0 minutes). The immediate success rate including those patients with complete closure, trivial residual shunt, or with small residual shunt was 97.4%. This increased to 99.2% and 100% at 3 months and 3 years, respectively. Minor complications were encountered in 2.8% of procedures, while serious complications occurred in less than 0.3% of the cases. There were no device related deaths. We conclude that the ASO is a safe and effective device for catheter closure of small to large ASDs up to a stretched diameter of 40 mm in children and adults with very high short-, medium, and long-term success rates.

Surgical management of complications after transcatheter closure of an atrial septal defect or patent foramen ovale

OBJECTIVE

During recent years, transcatheter closure has become an alternative to operations for the treatment of atrial septal defects and patent foramen ovale. However, this procedure may be unsuccessful or complicated and requires surgical treatment.

METHODS

We retrospectively analyzed the outcomes of patients who needed surgical treatment after failed or complicated transcatheter closure of an atrial septal defect or a patent foramen ovale.

RESULTS

Between April 1994 and March 1999, 124 patients were treated with transcatheter closure of an atrial septal defect or a patent foramen ovale at our institution. We report the results of 10 (8%) patients of this series who required operations after transcatheter closure attempts. In 8 of these 10 patients a significant shunt caused by malposition or dislocation of the device persisted, leading to surgical closure of the defect. In 2 patients injury of the femoral artery at the puncture site required surgical repair. In one patient the device had to be removed surgically from the iliac vein after retraction. One patient died of left ventricular perforation after dislocation of the device and several surgical attempts to close the left ventricular rupture. All other patients recovered well.

CONCLUSION

An operation was required after transcatheter closure of an atrial septal defect or a patent foramen ovale in 8% of patients. After device complications, the atrial septal defect and the patent foramen ovale can still successfully be closed surgically with good results and low morbidity. However, serious complications like cardiac perforation may have a fatal outcome. Residual shunt, dislocation, or vascular complications are the most frequent problems that require surgical interventions.

Recommendations of the British Paediatric Cardiac Association for therapeutic cardiac catheterisation in congenital cardiac disease

The aims of these recommendations are to improve the outcome for patients after, and to provide acceptable standards of practice of therapeutic cardiac catheterisation performed to treat congenital cardiac disease. The scope of the recommendations includes all interventional procedures, recognising that for some congenital malformations, surgical treatment is equally as effective as, or occasionally preferable to, interventional treatment. The limitations of the recommendations are that, at present, no data are available which compare the results of interventional treatment with surgery, and certainly none which evaluate the numbers and types of procedures that need to be performed for the maintenance of skills. Thus, there is a recognised need to collect comprehensive data with which these recommendations could be reviewed in the future, and re-written as evidence-based guidelines. Such a review will have to take into account the methods of collection of data, their effectiveness, and the latest developments in technology. The present recommendations should, therefore, be considered as consensus statements, and as describing accepted practice, which could be used as a basis for ensuring and improving the quality of future care.