Various techniques for transcatheter retrieval of the atrial septal defect or patent foramen ovale closure devices: a systematic review

Atrial septal abnormalities are common congenital lesions that remain asymptomatic in many patients until adulthood. Adults with atrial septal defects (ASD) most commonly have ostium secundum ASD. Transcatheter closure has become increasingly popular in recent years as a successful alternative method to surgery for treating ASD and patent foramen ovale (PFO). The overall rate of ASD transcatheter closure device embolization has been reported to be less than 1%; however, retrieving the device via surgery or by trans-catheter route can be necessary. The current manuscript describes a systematic review of the techniques used to retrieve ASD closure devices, as well as their success rates, complications, and limitations. A comprehensive search was performed covering various databases including PubMed, MEDLINE, SCOPUS, Google Scholar, and Cochrane Library from inception until April 2022 for English-published case reports, case series, and experimental studies investigating the indications, safety, and limitations of ASD closure and ASD device retrieval by trans-catheter approaches. Finally, 20 studies were included in our review. Our findings showed that most of the studies used a single snare technique; of these, all but one reported 100% success. Double tool retrieval methods (snare plus snare, snare plus bioptome, or snare plus forceps) and the gooseneck snare technique yielded 100% success. One study that used the lasso technique reported unsuccessful retrieval and the need for surgical intervention. More recently, the novel "coronary wire trap technique" was introduced, which provides a simpler method for embolized device removal by trapping the device for retrieval using coronary wire.

[Case report: ablation of atrial fibrillation in patient with an interatrial septal oclussion device]

Interatrial septal occlusion devices hinder the transseptal approach for atrial fibrillation ablation, making it necessary to have imaging methods that safely guide transseptal puncture, such as intracardiac echocardiography (ICE). We describe the case of a 49-year-old patient with symptomatic paroxysmal atrial fibrillation, refractory to antiarrhythmic drugs, wearing an interatrial septal occlusion device, with a previous unsuccessful ablation attempt. Atrial fibrillation ablation was performed using the Carto V7 3D mapping system, the transseptal puncture was guided by ICE, and the procedure was successful. This case report highlights the importance of multimodality imaging to achieve successful and effective transseptal puncture for atrial fibrillation ablation in patients with interatrial septal occlusion devices.

Balloon Interrogation of Intervening Tissue: A Novel Method to Decide Strategy for Closing Multiple Atrial Septal Defects

BACKGROUND

Two separate ostium secundum atrial septal defects are a challenging substrate for device closure due to lack of a well-described strategy or an adequately evaluated protocol.

METHODS

This is a prospective study comprising 20 patients with 2 atrial septal defects who underwent device closure. All of them underwent balloon interrogation (BI) of the intervening tissue to decide 1- versus 2-device strategy. During BI, if the flow through both the defects could be stopped completely implying adequate mobility of the separating tissue, a single device strategy was used. The size of the device in this subset was determined by BI diameter. In case the flow persisted, 2 devices were used to close the defects separately.

RESULTS

The mean age was 24±17 years. The main defect size was (mean 14.5 mm±SD 2.69 mm), whereas the second defect measured (mean 8.5±SD 3.02 mm). The tissue separating the 2 defects was measured (mean 6.1±SD 2.6 mm). In 15 of them, based on the BI results, a single device was used successfully to close both the defects without a residual shunt. In the remaining 5 patients, 2 devices were used. There were no complications during the procedure or at follow-up period of 41.9±16.9 months.

CONCLUSIONS

BI in patients with 2 atrial septal defects is helpful in defining 1- versus 2-device strategies and in choosing the size of the device to be used. Nearly 3/4 of the patients may get away with a single device for closing both the defects successfully thereby decreasing the cost and complexity of the procedure.

Presence of a Septal Occluder Is No Longer an Obstacle for Pulmonary Vein Isolation by Cryoablation

Cryoablation for pulmonary vein isolation in atrial fibrillation has been considered a relative contraindication in the presence of a septal occluder device. We describe the successful conduct of this technique with a multimodality imaging approach.

Closure of a Prosthetic Mitral Valve Paravalvular Leak Using a Ventricular Septal Defect (VSD) Amplatzer Occluder Device

BACKGROUND Paravalvular leaks (PVL) are becoming more commonly experienced in clinical practice due to the increasing number of mitral valve replacements performed. There are about 182 000 valve replacements performed annually, with a 5-15% prevalence rate of paravalvular leaks. Due to increased mortality associated with surgical repair, percutaneous transcatheter closure procedures are increasingly being performed as an alternative to repeat surgery. CASE REPORT We present the case of a 52-year-old woman with past medical history of mitral valve endocarditis who developed worsening acute heart failure 1 month after surgical bioprosthetic mitral valve replacement. Transesophageal echocardiography at the time revealed dehiscence of the bioprosthetic mitral valve and severe mitral regurgitation. She subsequently had emergent surgical bioprosthetic mitral valve replacement and annular reconstruction. The post-operative course was complicated by increasing dyspnea and lower-extremity edema, with recurrent pericardial tamponade requiring placement of a pericardial window. Based on her multiple comorbidities, most notably the concomitant right ventricular failure with severe pulmonary hypertension and prior pericardial patch repair with compromise of her mitral valve annulus, she was deemed inoperable for re-do surgery and eventually underwent a successful percutaneous closure of the mitral paravalvular leak with a ventricular septal defect (VSD) Amplatzer occluder device. The patient made good recovery and was discharged home a few days after the procedure. CONCLUSIONS Although use of the Amplatzer VSD occluder device for this indication currently remains off-label, our report supports the use of the VSD occluder device in this subset of patients considering the high mortality rates associated with repeat surgical procedure.

Closure of an iatrogenic ventricular septal defect using a hybrid approach and echocardiographic guidance

Treatment of postsurgical iatrogenic ventricular septal defects (VSDs) remains a challenge. Surgical closure is associated with significant morbidity and mortality. A peripheral accessed percutaneous approach is faced with difficulties of gaining adequate access and complex positioning in a beating heart. We report a case of using a hybrid approach to treat iatrogenic VSD with surgical right atriotomy and delivery of an Amplatzer system under direct visualization and transesophageal echocardiography guidance.

Risk factors for adverse events within one year after atrial septal closure in children: a retrospective follow-up study

INTRODUCTION

Secundum atrial septal defect is one of the most common congenital heart defects. Previous paediatric studies have mainly addressed echocardiographic and few clinical factors among children associated with adverse events. The aim of this study was to identify neonatal and other clinical risk factors associated with adverse events up to one year after closure of atrial septal defect.

METHODS

This retrospective case-control study includes children born in Sweden between 2000 and 2014 that were treated surgically or percutaneously for an atrial septal defect. Conditional logistic regression was used to evaluate the association between major and minor adverse events and potential risk factors, adjusting for confounding factors including prematurity, neonatal sepsis, neonatal general ventilatory support, symptomatic atrial septal defects, and pulmonary hypertension.

RESULTS

Overall, 396 children with 400 atrial septal defect closures were included. The median body weight at closure was 14.5 (3.5-110) kg, and the median age was 3.0 (0.1-17.8) years. Overall, 110 minor adverse events and 68 major events were recorded in 87 and 49 children, respectively. Only symptomatic atrial septal defects were associated with both minor (odds ratio (OR) = 2.18, confidence interval (CI) 95% 1.05-8.06) and major (OR = 2.80 CI 95% 1.23-6.37) adverse events.

CONCLUSION

There was no association between the investigated neonatal comorbidities and major or minor events after atrial septal defect closure. Patients with symptomatic atrial septal defects had a two to four times increased risk of having a major event, suggesting careful management and follow-up of these children prior to and after closure.

Malposition of left atrial disc and feasibility of recapturing Figulla-II Occlutech septal occluder

We report a case of Figulla-II Occlutech septal occluder malposition with residual shunt at posteriosuperior margin of an atrial septal defect. Improvising its bioptome type delivery cable, same system was used to recapture the device and redeploy it successfully. This report highlights a potential malfunction of Figulla-II Occlutech disc and the advantage of its delivery system for retrieval of the device.

Transcatheter Closure of Ruptured Sinus of Valsalva Aneurysm with Double-Disc Perimembranous VSD Occluder in Man with Mechanical Aortic Valve

Sinus of Valsalva aneurysm, a rare cardiac anomaly, can be life-threatening if it ruptures. Transcatheter closure has emerged as an effective alternative to surgical management; however, it has rarely been reported in patients with previous mechanical aortic valve replacements. We describe the case of a 45-year-old man who presented with a ruptured aneurysm of the noncoronary sinus of Valsalva 14 years after the implantation of a mechanical aortic valve. The ruptured aneurysm was closed by transcatheter means with use of a double-disc perimembranous ventricular septal defect occluder. The patient remained asymptomatic one year after the procedure. Our case suggests that transcatheter closure with use of this type of occluder is a viable method for successfully repairing ruptured sinus of Valsalva aneurysms in patients who have mechanical aortic valves.

[Late onset endocarditis in Amplatzer carrier. Conservative management in a pediatric patient]

Since their introduction, percutaneous techniques have been replacing conventional surgery as a first-line treatment for septal defects. Amplatzer devices were the first to be approved by the Food and Drug Administration, and their placement has become a standard procedure in pediatric cardiology. Bacterial endocarditis of intracardiac devices such as the Amplatzer septal occluder is very infrequent. We report a case of bacterial endocarditis in a pediatric patient with an Amplatzer device, who developed an infectious endocarditis six years after its placement and received conservative management with intravenous antibiotics, with satisfactory evolution.

Right main bronchus para-occluder fistula closure with a septal defect occluder

We present a case of successful closure of a para-occluder fistula. The bronchopleural fistula occurred after a right-sided pneumonectomy performed for multidrug-resistant tuberculosis. Initial closure of the bronchopleural fistula with the use of an atrial septal defect occluder 3 years later led to relapse of the fistula after 2 years. To manage the relapsing bronchopleural fistula, we partially destroyed the former nonfunctioning occluder, measured the size of the bronchial defect with a sizing balloon, and installed an atrial septal defect occluder of a larger size.

Spontaneous Resolution of Residual Shunting in 2 Compromised Patients after Amplatzer Occlusion of Postinfarction Ventricular Septal Defects

Ventricular septal defect (VSD) is a rare, potentially fatal complication of acute myocardial infarction. When surgical closure is contraindicated, transcatheter closure may be an alternative. Residual shunting after transcatheter closure of postinfarction VSDs has been reported; however, we found few cases of this in patients who also had severe heart failure or hemolysis. We report 2 closures of postinfarction VSDs with use of the Amplatzer Septal Occluder. Both elderly patients-one with severe heart failure, one with persistent hemolysis, and neither a surgical candidate-had high-velocity residual shunting through the occluders. We intensively managed the patients' conditions and used angiography and transthoracic echocardiography to record the gradual disappearance of each shunt over 4 months-the first such serial monitoring of which we are aware. We think that even substantial shunting in the presence of severe heart failure or hemolysis can eventually resolve spontaneously, assuming effective management of the concomitant medical conditions.

Clinics in diagnostic imaging (186). Atrial septal defect with pulmonary arterial hypertension

We report a case of a 61-year-old woman with a large atrial septal defect (ASD) that was detected incidentally on chest radiography and computed tomography when she presented with sepsis. Echocardiography confirmed a large secundum ASD with left-to-right shunt flow, right heart dilatation and severe pulmonary hypertension. The patient had a poor clinical outcome despite intensive care and eventually passed away. Haemodynamically significant ASDs have a known association with increased morbidity and mortality, and their early detection and closure cannot be understated. This article aimed to highlight the imaging features of ASD, with special emphasis on the routine chest radiograph. The pathophysiology and clinical manifestations of ASD are also briefly discussed.

Transesophageal echocardiography and fluoroscopy for percutaneous closure of atrial septal defects: A comparative study

The aim of the study was to compare transesophageal echocardiography (TEE) and fluoroscopy for percutaneous atrial septal defect (ASD) closure.This was a retrospective analysis of children who underwent percutaneous ASD closure. The procedure was guided by TEE without fluoroscopy in 130 patients (TEE group) and by fluoroscopy in 163 patients (fluoroscopy group). Baseline demographic/clinical characteristics were recorded. Patients were followed until hospital discharge. Outcomes were procedure duration, peri/postoperative complications, hospital stay, and costs.The TEE and fluoroscopy groups showed no significant differences in age (71.7 ± 40.7 vs 62.5 ± 38.8 months), male/female ratio (54/76 vs 66/97), weight (22.0 ± 12.0 vs 20.1 ± 9.0 kg), ASD diameter (9.9 ± 4.2 vs 9.3 ± 3.9 cm), distances to the superior vena cava (13.4 ± 4.6 vs 13.3 ± 4.2 cm), inferior vena cava (13.4 ± 4.3 vs 13.9 ± 4.1 cm) and atrial septal roof (12.1 ± 4.0 vs 12.3 ± 3.2 cm), or atrial septal size (38.2 ± 6.2 vs 39.4 ± 26.6 cm); distance to the mitral valve was greater in the TEE group (13.2 ± 4.4 vs 11.3 ± 3.9 cm; P < .001). The TEE and fluoroscopy groups showed no significant differences in occlusion device size (14.3 ± 4.6 vs 13.8 ± 4.0 cm) or sheath size (8.7 ± 1.8 vs 8.7 ± 0.9 cm), but procedure duration was shorter in the TEE group (21.5 ± 14.6 vs 28.6 ± 10.9 minutes; P < .001). Postoperative fever (>38°C) occurred less frequently in the TEE group than in the fluoroscopy group (0.8% vs 9.2%; P < .001); there were no significant differences for the other complications. No patient had postoperative residual shunt, occlusion device shedding/displacement, or pericardial effusion. The TEE group had longer hospital stay (3.2 ± 0.6 vs 2.9 ± 0.6 days; P < .001) and higher procedure cost (29,687 ± 4218 vs 28,530 ± 1668 CNY (China Yuan); P = .002) than the fluoroscopy group.TEE-guided percutaneous ASD closure can be used as an alternative to fluoroscopy-guided procedures and avoids the use of radiation or contrast agents.

Transcatheter closure of atrial septal defect: principles and available devices

There has been a remarkable improvement in the treatment strategy of secundum atrial septal defect (ASD) over the last few decades. Indebted to the improvement in device technology and procedural techniques, transcatheter closure of ASD is currently accepted as the treatment of choice in most patients with secundum ASD. Recent generation devices enable easy and safe deployment of device with the properties of adequate flexibility, re-capturability and repositioning. Use of biocompatible materials with improved device design and refined equipment finish may promote re-endothelialization and reduce potential damage to nearby structures. Most of currently available devices show excellent efficacy and comparable outcome with its own advantages and disadvantages. In addition to improvement of device properties and performance, there has been distinct improvement in procedural technique from numerous experiences of device closure of ASD. Nowadays there are well established principles regarding patient selection, pre-procedural evaluation, step-by-step details of procedure as well as post-procedural follow-up. However, an operator may encounter pitfalls in closing complex lesions such as large defect, rim deficiencies and multiple defects, so every operator has to be familiar with each available device, general principle as well as special issues for complex lesions.

Transcatheter retrieval of an Amplatzer Vascular Plug

Introduction

An Amplatzer Vascular Plug (AVP), which was designed as a permanent occluding device derived from the Amplatzer Septal Occluder and Amplatzer Duct Occluder, is a useful embolic device that can be precisely deployed in medium to large vessels with high resistance to migration. However, migration of these Amplatzer devices has been reported as a relatively rare but major complication.

Case report

A 59-year-old woman was referred for the treatment of advanced pancreatic body cancer; after systemic chemotherapy, distal pancreatectomy with en bloc celiac axis resection (DP-CAR) was planned as curative treatment. Therefore, preoperative embolisation of the common hepatic artery (CHA) for arterial redistribution was performed. Although a 6-mm AVP II was deployed at the mid-portion of the CHA, the AVP migrated to the proper hepatic artery. Although migrated AVP retrieval using a goose neck snare was attempted, it was impossible to retrieve it into the 5-F guiding sheath. Therefore, the AVP was delivered to the splenic artery, which was planned to be resected in DP-CAR. Finally, a 10-mm AVP II was redeployed at the proximal portion of the CHA, and complete occlusion was achieved.

Conclusions

When AVP retrieval is not possible, delivery to the other arteries having lesser influence might be an alternate technique.

The Role of Heart Team Approach in Penetrating Cardiac Trauma: Case Report and Review of the Literature

Penetrating cardiac trauma has been increasing in clinical experience and is joined to important morbidity and mortality. A case of a 38-year-old female with history of postpartum depression was reported, admitted to our department for cardiac tamponade due to penetrating self-inflicted multiple stab wound of the chest complicated by rupture of anterior left ventricular wall and traumatic ventricular septal defect. Following the unstable hemodynamic instability, a combined therapeutic strategy was chosen: surgery and transcatheter implantation to correct free wall ventricle damage and traumatic ventricular septal defect, respectively.

Novel delivery technique for atrial septal defect closure in young children utilizing the GORE® CARDIOFORM® septal occluder

OBJECTIVES

To develop a novel delivery technique to overcome vascular size limitations for device closure of a secundum ASD in the young patient.

BACKGROUND

The efficacy, clinical utility, and safety of transcatheter closure in comparison to surgical closure are well established; however, access vessel size remains a potential limitation to device selection in the young patient.

METHODS

A retrospective medical record review of all cases of secundum ASD closure between April 2015 and April 2016 utilizing a novel delivery method described herein at two separate academic institutions. The device is disassembled allowing the delivery sheath to serve as the introducer. It is advanced to the RA with re-introduction of the device allowing for deployment in the standard fashion.

RESULTS

Overall, 10 patients underwent secundum ASD closure via this novel delivery technique. There were six females (60%) and the average age at time of the procedure was 4.2 years ± 1.6 years (range 2-6 years). The majority of patients had an isolated secundum ASD (70%) with the primary indication for closure being right ventricular volume overload (90%). All patients had successful placement of a GORE^® CARDIOFORM^® Septal Occluder (GCSO) with no or trivial residual shunt. No patients had vascular complications related to the procedure.

CONCLUSIONS

We describe a novel technique for ASD closure using the GCSO delivery sheath as the access sheath, which reduces the vascular access size requirement by 25%, thus addressing one common limitation for percutaneous device closure of a secundum ASD in young patients. © 2016 Wiley Periodicals, Inc.

Transcatheter Closure of Iatrogenic VSDs after Aortic Valve Replacement Surgery: 2 Case Reports and a Literature Review

We report 2 new cases of transcatheter closure of iatrogenic ventricular septal defects after aortic valve replacement surgery, together with our finding, in a literature review, of 9 additional patients who had undergone this procedure from 2004 through 2013. In all 11 cases, transcatheter device closure was indicated for a substantial intracardiac shunt with symptomatic heart failure, and such a device was successfully deployed across the iatrogenic ventricular septal defect, with clinical improvement. Our review suggests that transcatheter closure of iatrogenic ventricular septal defects in patients with previous aortic valve replacement surgery is a safe and effective treatment option, providing anatomic defect closure and relief of symptoms in the short-to-medium term.

Successful device closure of a post-infarction ventricular septal defect

Ventricular septal defect (VSD) is a lethal complication of myocardial infarction. The event occurs 2-8 days after an infarction and patients should undergo emergency surgical treatment. We report on successful device closure of post-infarction VSD. A previously healthy 66-year-old male was admitted with aggravated dyspnea. Echocardiography showed moderate left ventricular (LV) systolic dysfunction with akinesia of the left anterior descending (LAD) territory and muscular VSD size approximately 2 cm. Coronary angiography showed mid-LAD total occlusion without collaterals. Without percutaneous coronary intervention due to time delay, VSD repair was performed. However, a murmur was heard again and pulmonary edema was not controlled 3 days after the operation. Echocardiography showed remnant VSD, and medical treatment failed. Percutaneous treatment using a septal occluder device was decided on. After the procedure, heart failure was controlled and the patient was discharged without complications. This is the first report on device closure of post-infarction VSD in Korea.

Two Cases of Transcatheter Closure of Central Aortopulmonary Shunts: One with an Amplatzer Duct Occluder II and One with an Amplatzer Vascular Plug I

When total correction is not possible in infants who have a cyanotic congenital heart disease, creation of a palliative aortopulmonary shunt is essential. A central aortopulmonary shunt is preferable, because of its technical and hemodynamic advantages. Overcirculation, thrombosis, and stenosis of the shunt are the main postoperative sequelae that necessitate urgent reintervention. Percutaneous transcatheter closure of aortopulmonary shunts can eliminate the need for reoperation and substantially decrease postoperative morbidity and mortality rates. We report our successful transcatheter closures of central aortopulmonary shunts in a 3-month-old infant and a 15-year-old girl, with use of an Amplatzer Duct Occluder II and an Amplatzer Vascular Plug I, respectively. To our knowledge, this is the first report of the transcatheter closure of central aortopulmonary shunts with these 2 devices.

Successful retrieval of a Figulla Occlutech septal occluder - embolized device stability and potential solutions

Go to: We report a case of an atrial septal defect where a Figulla Occlutech device embolized into the right ventricle. As this device has no left atrial hub, we brought the bare device into the inferior vena cava and used a novel two-snare technique to slenderize the device into the sheath. This report highlights additional tips in transcatheter device retrieval.

Stepwise Progression of Right-to-Left Atrial Shunting through a Combination of Patent Foramen Ovale and Tricuspid Regurgitation

Patent foramen ovale is a common clinical finding that generally becomes a concern in the presence of transient ischemic attack or stroke. Rarely, patent foramen ovale is associated with hypoxemia in the presence of substantial right-to-left atrial shunting. We present the case of an 86-year-old woman with a pacemaker, who was initially asymptomatic notwithstanding a patent foramen ovale. Over 1.5 years, her symptoms progressed in a stepwise fashion, in the setting of progressive pacemaker-associated tricuspid regurgitation. Ultimately, the patient's symptoms and her hypoxemia resolved after percutaneous closure of her patent foramen ovale with use of a 25-mm "Cribriform" occluder device. This case highlights the fact that clinically significant right-to-left shunting requires an anatomic lesion, such as patent foramen ovale, together with elevated right atrial pressure, which in this case was contributed by severe tricuspid regurgitation.

A heart team and multi-modality imaging approach to percutaneous closure of a post-myocardial infarction ventricular septal defect

Post-infarction ventricular septal defect (PI-VSD) is a devastating complication that carries a high mortality with or without surgical repair. Percutaneous closure is an attractive alternative in select patients though requires appropriate characterization of the PI-VSD as well as careful device and patient selection. We describe a multidisciplinary and multi-modality imaging approach to successful percutaneous closure of a PI-VSD.

Platypnea-Orthodeoxia Syndrome: Diagnostic Challenge and the Importance of Heightened Clinical Suspicion

Platypnea-orthodeoxia syndrome is an uncommon condition of positional dyspnea and hypoxemia; symptoms occur when the patient is upright and resolve with recumbency. Causes can be broadly categorized into 4 groups: intracardiac shunting, pulmonary shunting, ventilation-perfusion mismatch, or a combination of these. Platypnea-orthodeoxia syndrome should be suspected when normal arterial oxygen saturations are recorded while an individual is supine, followed by abrupt declines in those saturations when upright. Further investigations with use of imaging and cardiac catheterization aid in the evaluation. When platypnea-orthodeoxia syndrome is due to intracardiac shunting without pulmonary hypertension, intracardiac shunt closure can be curative. In this article, we report a case of platypnea-orthodeoxia syndrome in an 83-year-old woman who was successfully treated by means of percutaneous transcatheter closure of an atrial septal defect.

Direct Percutaneous Repair of Left Ventricular Pseudoaneurysm via Transthoracic Deployment of a Ventricular Septal Defect Closure Device

In this case report, we describe direct percutaneous delivery of a muscular-ventricular-septal-defect occluder device to close a left ventricular pseudoaneurysm. The occluder was positioned and deployed with the aid of concurrent transthoracic ultrasonography, transesophageal echocardiography, and fluoroscopy. In contrast with previously published reports, we describe and illustrate a direct transthoracic route across the pseudoaneurysmal sac, which obviated the need for indirect transfemoral or transapical approaches.

Percutaneous repair of post-myocardial infarction ventricular septal defect: current approaches and future perspectives

Post-myocardial infarction ventricular septal defect is a devastating complication of ST-elevation myocardial infarction. Although surgical intervention is considered the gold standard for treatment, it carries high morbidity and mortality rates. We present 2 cases that illustrate the application of percutaneous closure of a post-myocardial infarction ventricular septal defect: the first in a patient who had undergone prior surgical closure and then developed a new shunt, and the second as a bridge to definitive surgery in a critically ill patient.

Prevalence of deficient retro-aortic rim and its effects on outcomes in device closure of atrial septal defects

Deficient retro-aortic rim is of concern as a risk factor for aortic erosion after device closure of atrial septal defects (ASD). However, its prevalence and contribution to technical failure and adverse outcomes have not been delineated. A single-center retrospective cohort study of children and adults undergoing cardiac catheterization for device occlusion of ASD from 1 January 1999 to 1 April 2012 was performed. Risk factors for technical failure and early adverse outcome were assessed using multivariate logistic regression. During the study period, 445 consecutive subjects with a median age of 5.9 years (range, 0.8-80 years) underwent catheterization. Of the subjects with reviewable echocardiograms, 60 % had deficient retro-aortic rim. No attempt at device closure was made for 3.6 % of the subjects. Of the remaining 429 subjects, 96 % underwent successful device occlusion. Major early adverse events occurred in 1.2 % (95 % confidence interval 0.4-2.7 %) of the cases, all of them either device embolization or malposition. Deficient retro-aortic rim was not a risk factor for composite outcome of technical failure or early major adverse event. No deaths, late reinterventions, or erosion events occurred during 2,395 total person-years (median, 5.8 years) of follow-up evaluation. Deficient retro-aortic rim was associated with increased risk of device impingement on the aorta, but no association was seen between device impingement or deficient retro-aortic rim and the development of new/progressive aortic insufficiency. Deficient retro-aortic rim is highly prevalent but did not increase the risk of adverse outcomes. Its contribution to the risk of aortic erosion could not be addressed by this study.

Left ventricular to right atrial shunt (Gerbode defect): congenital versus acquired

Introduction

Congenital left ventricular to right atrial (LV-RA) shunt (Gerbode defect) is rare, while acquired LV-RA shunt has been increasingly reported. As yet, systematically incorporated data of the LV-RA shunt have not been presented.

Aim

To present the clinical features, diagnostic challenge and management strategies of congenital and acquired LV-RA shunts.

Material and methods

The data source was based on a comprehensive literature retrieval of the LV-RA shunt in the period 1990–2013.

Results

In comparison with the acquired Gerbode defect, the congenital Gerbode defect group of patients were younger and were associated more often with additional congenital disorders. Previous cardiac surgery and infective endocarditis were the two major aetiologies of the occurrence of the acquired shunts. Paravalvular abscess was associated in 10.2% and atrioventricular block in 13.6% of the acquired group patients. Transoesophageal echocardiography showed a higher diagnostic accuracy, lower missed diagnosis and lower inclusive diagnosis rates, in comparison to transthoracic echocardiography, but the misdiagnosis rates of the two modalities did not differ from each other. Four (4.5%) of the acquired group patients were complicated by atrioventricular block following surgical or interventional closure of the shunt. Eight (9.1%) patients died in the acquired group, but no patient died in the congenital group.

Conclusions

The diagnosis of an LV-RA shunt is quite challenging, especially in the context of coexisting abnormalities including an additional intracardiac shunt, tricuspid regurgitation, pulmonary artery hypertension and infective endocarditis, which have to be carefully differentiated from the shunt by further investigations. A better control of infective complications and careful manoeuvres during surgery may help to keep the LV-RA-sensitive septum intact.

Percutaneous closure versus medical therapy alone for cryptogenic stroke patients with a patent foramen ovale: meta-analysis of randomized controlled trials

Of cryptogenic stroke patients younger than 55 years of age, up to 61% have had a patent foramen ovale (PFO). Observational studies have revealed reductions in recurrent neurologic events through PFO closure versus medical therapy, and randomized controlled trials have shown nonsignificant trends toward benefit. We systematically searched for randomized controlled trials of percutaneous PFO closure with medical therapy versus medical therapy alone in patients with cryptogenic stroke and performed a meta-analysis of treatment outcomes. The primary endpoint was combined death, stroke, and transient ischemic attack. We included 3 trials. Of 2,303 total patients, 1,150 underwent PFO closure and 1,153 received medical therapy (median follow-up period, 2.6 yr). The pooled incidence of the primary endpoint was 1.2 events per 100 patient-years in the closure group (95% confidence interval [CI], 0.2-2.3) and 1.8 in the therapy group (95% CI, 0.7-2.9) (P=0.32); the number needed to treat was 167 (range, 100-500). The corresponding pooled hazard ratio was 0.67 (95% CI, 0.44-1.01; P=0.054) in favor of closure. Closure was associated with an increased risk of atrial fibrillation: relative risk=3.51 (95% CI, 1.44-8.55; P=0.006). When stratified by device, use of the Amplatzer™ PFO Occluder resulted in significant stroke-prevention benefit over medical therapy alone: hazard ratio=0.44 (95% CI, 0.21-0.95; P=0.037). When compared with medical therapy alone, PFO closure with medical therapy showed a trend toward a decreased hazard of combined events, although the absolute event reduction was small and the number needed to treat was high.

Percutaneous retrograde transfemoral closure of mitral paravalvular leak in 3 patients without construction of an arteriovenous wire loop

Percutaneous closure of paravalvular leaks has emerged as an alternative to repeated surgeries. Different percutaneous techniques and various devices have been used, off-label, for paravalvular leak closure. For mitral leaks, antegrade transseptal, retrograde transfemoral, and retrograde transapical techniques have been developed. In the antegrade transseptal approach, an arteriovenous guidewire loop is often created to advance the delivery sheath. In retrograde transfemoral closure, the wire in the left atrium is usually snared after transseptal puncture, to pull it from the femoral vein. The delivery sheath and closure device will subsequently be deployed from the left atrium. Each of these procedures takes time, is costly, and increases the risk of complications. We present the cases of 3 patients in whom we closed mitral paravalvular leaks by means of a retrograde transfemoral approach, with use of an Amplatzer™ Duct Occluder II device and without the construction of an arteriovenous wire loop. We think that this approach can be very useful in a specific group of patients-reducing costs, fluoroscopy times, and complications related to transseptal puncture and construction of an arteriovenous wire loop. In our institution, this reported technique is routinely used for mitral paravalvular leak closure.

Systematic review of interventions to repair ascending aortic pseudoaneurysms

BACKGROUND

The safety and efficacy of endovascular therapies for ascending aortic pseudoaneurysms (AAPs) are still controversial.

METHODS

We report an endovascular correction of an AAP in a high-risk surgical patient and present the results of a literature review focusing on AAP treatment strategies. A multilingual search of AAP therapy was performed with limiting dates of January 1980 to May 2014. The studies were classified by intervention.

RESULTS

A 79-year-old male with a 9 × 10 × 7 cm AAP in the anterior mediastinum was considered too high risk for surgery. An endovascular closure with a 12 mm Amplatzer septal occluder device (St. Jude Medical) was performed, and computed tomography angiography at 3-month follow-up exhibited a thrombosed AAP with minimal residual shunt. In our literature search, we identified 355 cases of AAPs, mostly case reports (91.5%) and a few patient series (8.5%). Surgical correction accounted for 73.8% of the cases, 5% of the patients were conservatively treated or considered too critically ill for any intervention, and 21.2% were treated with endovascular techniques. The most commonly reported endovascular techniques were stent grafts (9.8%) and septal occluder devices (9.8%).

CONCLUSION

Although endovascular closure of AAPs with off-label devices is a reliable option for controlling the expansion and symptoms in high-risk surgical patients, solid data on survival are lacking. Efforts to promote discussion within the heart team to expand the application of endovascular techniques can provide groundbreaking evidence to support the use of endovascular techniques as guideline therapy when facing these complicated cases.

Surgical off-pump closure of perimembranous ventricular septal defects

OBJECTIVE

To present our first experience in perventricular closure of ventricular septal defect, which is in our opinion, an important adjunct to current ventricular septal defect treatment options.

BACKGROUND

Surgical closure under cardiopulmonary bypass is the treatment of choice for a perimembranous ventricular septal defect. Percutaneous techniques have technical limitations. To date, an off-pump approach and device deployment through the wall of the right ventricle is not widespread and has only been reported from China and Germany. We think this approach is promising in selected patients.

METHODS

In July 2012, 7 pediatric patients with an isolated perimembranous ventricular septal defect (age range, 4 months to 8 years, mean 2.5 years, all female) with a body weight of 5 to 27 kg, mean 12.7 kg, underwent minimally invasive perventricular device closure.

RESULTS

In all patients, the ventricular septal defect was occluded successfully based on transesophageal echocardiographic confirmation. There were no cases of occluder dislocation noted in the operating room or in the postoperative period. No residual shunts were observed. There was no transient or persistent rhythm disorder in any of the patients. All patients were discharged 4-5 days postoperatively, in excellent physical condition.

CONCLUSIONS

The described off-pump approach showed excellent results. It offers such advantages as avoidance of the morbidity associated with cardiopulmonary bypass, significantly shorter hospital stay and therefore reduced costs, and a cosmetic advantage.

Intraoperative device closure of atrial septal defects with minimal transthoracic invasion: a single-center experience

Atrial septal defect is one of the most common congenital heart defects. Open-heart repair via midline sternotomy or right thoracotomy and cardiopulmonary bypass has been considered the standard treatment for the closure of atrial septal defects, but transcatheter closure with the Amplatzer septal occluder has recently become a viable option. We have adopted a 3rd alternative: intraoperative device closure with minimal transthoracic invasion. From May 2007 through June 2011, 250 patients with secundum atrial septal defect underwent cardiac surgery at our institution. Open-heart repair with cardiopulmonary bypass was performed in 72 patients, and intraoperative device closure was performed in 178 patients. This minimally invasive approach, which required a full evaluation of the atrial septal defect by transthoracic echocardiography, was performed by deploying the device through the delivery sheath to occlude the atrial septal defect. The approach was successful in 175 of the 178 patients. The size of the implanted occluder ranged from 12 to 46 mm in diameter. Minor complications included transient arrhythmias (n=7) and pleural effusion (n=25). After complete release, the intraoperative occluder device dislodged in the right atrium in 3 patients, who then underwent immediate surgical repair with cardiopulmonary bypass. All discharged patients were monitored for 2.3 years to 5 years. As monotherapy, intraoperative device closure of atrial septal defect with minimal transthoracic invasion is a safe and feasible technique. It is particularly beneficial for elderly patients or patients with pulmonary hypertension and is associated with better cosmetic results and less trauma than is surgical closure.

Retrograde percutaneous closure of a ventricular septal defect after myectomy for hypertrophic obstructive cardiomyopathy

In patients with hypertrophic obstructive cardiomyopathy, hemodynamically significant ventricular septal defect after septal myectomy is a rare sequela that warrants closure. Percutaneous closure provides a safer alternative to repeated sternotomy, which is associated with significant morbidity and mortality rates. We report a possibly unique case of successful retrograde percutaneous closure, with an AMPLATZER Muscular VSD Occluder, of an iatrogenic ventricular septal defect consequent to surgical therapy for hypertrophic obstructive cardiomyopathy.

Pan-nitinol occluder and special delivery device for closure of patent ductus arteriosus: a canine-model feasibility study

The aim of this study was to evaluate a new type of occluder for patent ductus arteriosus. Patent ductus arteriosus was established in a canine model by anastomosing a length of autologous jugular vein to the descending aorta and the left pulmonary artery in an end-to-side fashion. Transcatheter closure of each patent ductus arteriosus was performed on 10 dogs, which were then monitored for as long as 6 months with aortography, echocardiography, and histologic evaluation. Transcatheter closure with use of the novel pan-nitinol device was successful in all canine models. Postoperative echocardiography showed that the location and shape of the occluders were normal, without any residual shunting. Further histologic evaluation confirmed that the occluder surface was completely endothelialized 3 months after implantation. Transcatheter patent ductus arteriosus closure with the pan-nitinol occluder can be performed safely and successfully in a canine model and shows good biological compatibility and low mortality rates.

AMPLATZER Septal Occluder failure resulting in paradoxical cerebral embolism

Patent foramen ovale and atrial septal defect are risk factors for paradoxical embolism and subsequent cerebral ischemic events. The transseptal passage of emboli from the right to the left cardiac chambers appears to play an important role. The therapeutic options are medical therapy (anti-aggregation or anticoagulation), surgical closure, or transcatheter closure. Transcatheter closure of atrial septal defects affords the advantage of closing an atrial defect without the associated morbidity of open-heart surgery and the bleeding sequelae of oral anticoagulation. After closure, however, the presence of a residual shunt is independently associated with an increased risk of recurrent ischemic events. Newer devices, such as the AMPLATZER Septal Occluder, have decreased the risk of residual shunting and thromboembolic events. In addition, they have a very low risk of device dislodgement, migration, and embolization.We describe the case of a 60-year-old woman with Ebstein anomaly and recurrent ischemic strokes who presented with acute ischemic infarcts and paradoxical embolism 3 years after undergoing transcatheter closure of an atrial septal defect. A right-to-left shunt through a displaced AMPLATZER Septal Occluder was detected. Pulmonary hypertension and resultant right ventricular failure and right atrial dilation could have contributed to the persistent shunting and paradoxical embolism.To our knowledge, the delayed dysfunction of an AMPLATZER Septal Occluder has not been reported. In addition to describing the patient's case, we review the relevant medical literature.

Bioabsorbable atrial septal occluder for percutaneous closure of atrial septal defect in children

The BioSTAR bioabsorbable septal repair implant is a new transcatheter secundum atrial septal defect occlusion device that is absorbed and replaced by healthy native tissue. This retrospective analysis was designed to determine the most significant factors for its successful use in children. From October 2009 through December 2010, 33 children underwent catheterization to close secundum atrial septal defects by means of the BioSTAR. The mean age of the patients was 6.8 ± 3.4 years (range, 2.5-13 yr), and the mean body weight was 22.6 ± 11 kg (range, 11-55 kg). The device was successfully implanted in 91% of patients (30/33). In 2 patients, the attempt had to be abandoned because of deficient aortic rim. A 3rd patient had to be converted to surgery because the device embolized to the pulmonary artery. In 1 patient, 2 BioSTAR devices were used to occlude 2 separate holes. The mean maximum stretched diameter of the single-hole defects was 13.5 ± 2.5 mm (range, 8.5-18 mm). Twenty-five patients (76%) had a single-hole defect. The mean follow-up time was 7.7 ± 4.1 months (range, 0.8-15.6 mo). The occlusion rates were 77% after 24 hours and 97% at the end of follow-up. The BioSTAR septal occluder is best suited for small-to-moderate defects. Percutaneous closure of secundum atrial septal defects with the BioSTAR is safe and effective, yielding a high success rate at midterm outcome.

Percutaneous closure of a left ventricular pseudoaneurysm in a high-risk surgical candidate

Few cases of percutaneous device closure of a left ventricular pseudoaneurysm have been reported. We describe the case of a 67-year-old man with a history of coronary artery disease who presented with shortness of breath and chest pain. Computed tomographic angiography showed a left ventricular pseudoaneurysm that was filling from a small leak in the anterolateral aspect of the ventricle. The patient had undergone 3 previous sternotomies and was a high-risk candidate for surgical treatment of the pseudoaneurysm. Despite technical challenges, we closed the pseudoaneurysm percutaneously with use of a 6-mm AMPLATZER muscular ventricular septal defect occluder. The patient was released from the hospital the next day and was asymptomatic a year later.To our knowledge, this is the first report of the percutaneous closure of a left ventricular pseudoaneurysm via the femoral vein. We show that this manner of closure can be feasible in patients who have undergone multiple sternotomies and who are at high surgical risk.

Thrombus formation during percutaneous closure of an atrial septal defect with an Amplatzer septal occluder

Percutaneous closure of an ostium secundum-type atrial septal defect is typically a safe and effective therapeutic option in the presence of significant shunting or paradoxical embolism. Infrequently, however, periprocedural sequelae occur.Herein, we report the cases of 2 patients, each of whom underwent transcatheter closure of an atrial septal defect with the use of an Amplatzer Septal Occluder under transesophageal echocardiographic guidance. In both patients, acute thrombi formed periprocedurally, despite preprocedural anticoagulation. In patient 1, the infusion of unfractionated heparin for 24 hours prevented the recurrence of thrombus; in patient 2, the thrombus was isolated under the arm of the occluder, and unfractionated heparin was infused. Both patients were asymptomatic and without detectable thrombus after the procedure and at follow-up. These reports highlight a rare early sequela and the importance of transesophageal echocardiographic monitoring during the percutaneous closure of an atrial septal defect.

Combined percutaneous treatment of atrial septal defect and pulmonic or aortic stenosis in adult patients

Combined atrial septal defect and pulmonic or aortic stenosis are relatively uncommon conditions in adult patients, with few reported cases of percutaneous treatment. We present two patients with secundum type atrial septal defect and concomitant pulmonic or aortic stenosis and their treatment by transcatheter techniques.

Transcatheter closure with use of the SHSMA occluder in 180 patients with congenital heart defects: preliminary results

Transcatheter closure of congenital heart defects with the use of septal occluders has been widely accepted as a preferred treatment; however, the high cost of these devices limits their clinical application in some countries. Few clinical data are available regarding lower-cost products. Accordingly, we evaluated the efficacy and safety of the Chinese-made Shanghai Shape Memory Alloy (SHSMA) occluder in patients with congenital heart defects. From December 2001 through December 2008, a total of 180 patients with congenital heart defects (ages, 3-68 yr; mean age, 17.35 ± 13.22 yr) underwent transcatheter closure with use of the SHSMA occluder: 73 had atrial septal defects; 64, ventricular septal defects; 40, patent ductus arteriosus; and 3, complex congenital defects. The mean diameters of the defects were 20 ± 7.6 mm (atrial septal), 4.9 ± 2.1 mm (ventricular septal), and 5.6 ± 2.2 mm (patent ductus arteriosus). The procedural success rates were 98.6% for atrial defects, 98.4% for ventricular defects, and 100% for patent ductus arteriosus and for complex defects. The overall incidences of sequelae were 5.5%, 9.4%, 2.5%, and 0, respectively. Six months postprocedurally, complete occlusion was associated with a significant decrease in the right ventricular Tei index in atrial septal defect patients (P < 0.05) and with improvement of body mass index in 11 children. These results suggest that the SHSMA occluder is a safe, effective device for the transcatheter closure of congenital heart defects. For confirmation, a randomized controlled trial with more patients and a longer follow-up period is warranted.