Percutaneous removal of unraveled HELEX® septal occluder 4 months post deployment

The GORE® HELEX® Septal Occluder (HSO: W.L. Gore & Associates; Flagstaff, AZ) is preferentially used at our institution for percutaneous closure of the patent foramen ovale (PFO). Adequate deployment of the device requires capture of three sequential eyelets by the locking loop. At times, the right atrial eyelet is not caught, particularly when a long tunnel PFO causes too much separation between the discs. Although rarely, unlocked devices have been left in the atrial septum with no untoward events provided they appear stable in the catheterization laboratory and the shunt has been eliminated. We report a patient in whom an unlocked, but otherwise well positioned, HSO subsequently unraveled with the right atrial disc migrating through the tricuspid valve while the left atrial disc remained well apposed to the left side of the atrial septum. The PFO was closed prior to liver transplantation to prevent an embolic event during the transplant. The patient required placement of several internal jugular central lines prior to transplant, and this instrumentation in the right atrium may have caused unraveling of the device. The HSO was removed percutaneously 15 weeks after implantation despite a well‐seated and likely partially endothelialized left atrial disc. © 2015 Wiley Periodicals, Inc.     

Initial experience with the novel patent foramen ovale occlusion device Nit‐Occlud® in patients with stroke or transient ischemic attack

• Percutaneous approach rather than surgical cutdown is the procedure of choice for TAVR patients to minimize morbidity and procedure time.
• ProGlide has been shown to have noninferior outcomes versus surgical cutdown with shorter procedure time and less pain; noninferiority was not demonstrated by single Prostar XL in a randomized trial of “preclosure” for endovascular aortic aneurysm repair. The current study did not include a ProGlide arm.
• As the size of Transcatheter Aortic Valve Replacement devices continues to decrease, the need for large bulky 4‐needle devices like the Prostar XL is likely to become obsolete.

     

Effective percutaneous “edge‐to‐edge” mitral valve repair with mitraclip in a patient with acute post‐MI regurgitation not related to papillary muscle rupture

A 65‐year‐old woman was admitted to our institution for rest dyspnea and hypotension. EKG showed sinus tachycardia with signs of infero‐posterior STEMI. 2D‐echocardiogram showed severe left ventricular systolic dysfunction with a‐ diskynesia of the inferior and posterior walls and severe functional mitral regurgitation (MR). The patient underwent urgent coronary angiography that showed 3‐vessels disease with total occlusion of both first obtuse marginal (OM) branch of the left circumflex artery and right coronary artery (RCA) and critical stenosis of left anterior descending (LAD). Because of extremely high surgical risk, we performed a staged totally percoutaneous approach. First, we reopened the presumed culprit vessels (RCA and OM) and then, after 48 hr, we performed angioplasty of the LAD. Since revascularization provided no significant improvement in respiratory and hemodynamic parameters we performed a percutaneous mitral repair with Mitraclip. MR grade was reduced from severe to trivial with rapid improvement of the respiratory and hemodynamic parameters. The post‐procedural course was uneventful and the patient was discharged 7 days later. At the 30‐day and 6‐month follow‐up the patient remained asymptomatic in NYHA I functional class with no recurrence of MR. Acute MR due to post‐AMI mechanical complications is generally considered a contraindication to MitraClip implantation for several reasons. However, the present report shows that, in selected cases, the Mitraclip system may be successfully used to reduce the severity of acute MR secondary to AMI and may allow to reverse cardiogenic shock and/or refractory pulmonary congestion related to the acute regurgitation. © 2016 Wiley Periodicals, Inc.     

Technique of temporary subcutaneous “Figure‐of‐eight” sutures to achieve hemostasis after removal of large‐caliber femoral venous sheaths

Over the last decade, significant advances have been made in percutaneous treatment of structural heart diseases. Many of these interventions require insertion of large caliber sheaths in the femoral veins. Manual compression, compression devices, and various closure devices have been used for removal of large‐sized venous sheaths. Here, we describe the use of a temporary subcutaneous “Figure‐of‐Eight” suture technique for venous access site closure after removal of large‐caliber sheaths. © 2011 Wiley‐Liss, Inc.     

Two cases of pericardial tamponade due to nitinol wire fracture of a gore septal occluder

Percutaneous patent foramen ovale (PFO) closure is recommended for secondary prevention of paradoxical embolism through a PFO. In the United States, two Food and Drug Administration‐approved PFO closure devices are currently available, and the choice depends on operator preference and PFO anatomy. Although these devices are easy to implant, there are several potential complications. As opposed to the Amplatzer PFO Occluder, there has been no published case of atrial erosion with Gore closure devices. This report describes two cases of pericardial tamponade due to perforation of the atrial wall induced by a wire frame fracture of the Gore Helex and Cardioform devices.     

Self‐repositioning of an embolized patent ductus arteriosus device—a nightmare turned into sweet dreams

A 7‐month‐old boy was admitted for the device closure of symptomatic patent ductus arteriosus (PDA) with moderate pulmonary hypertension. The PDA measured 4.2 mm with adequate ampulla. It was closed with an 8–6 mm Heart R device from pulmonary artery (PA) end. Post extubation, the device embolized to proximal descending thoracic aorta just distal to PDA ampulla. While attempting to snare from the venous side, the device self‐repositioned to PDA. It was stable thereafter and patient was discharged after 2 days. We report a complication, which got self‐corrected. © 2014 Wiley Periodicals, Inc.     

SCAI expert consensus statement on operator and institutional requirements for PFO closure for secondary prevention of paradoxical embolic stroke

Until recently, evidence to support Patent Foramen Ovale (PFO) closure for secondary prevention of recurrent stroke has been controversial. Publication of high‐quality evidence from randomized clinical trials and the subsequent FDA approval of two devices for percutaneous PFO closure is expected to increase the volume of PFO closure procedures not only in the United States but worldwide. As this technology is disseminated broadly to the public, ensuring the safe and efficacious performance of PFO closure is essential to mitigate risk and avoid unnecessary procedures. This document, prepared by a multi‐disciplinary writing group convened by the Society for Cardiovascular Angiography and Interventions and including representatives from the American Academy of Neurology, makes recommendations for institutional infrastructure and individual skills necessary to initiate and maintain an active PFO/stroke program, with emphasis on shared decision making and patient‐centered care.     

Management of residual shunts after initial percutaneous patent foramen ovale closure: A single center experience with immediate and long‐term follow‐up

Background: Moderate‐to‐large residual shunts following percutaneous patent foramen ovale (PFO) closure are clinically important and associated with recurrent neuroembolic events. However, their management has not been clearly established in clinical practice. We report our experience in patients of these patients with a prior history of cryptogenic stroke and/or transient ischemic attack (TIA). Methods: All patients undergoing percutaneous PFO closure were routinely screened at six‐months for residual shunts using transthoracic 2D echocardiography with antecubital administration of agitated saline contrast and color flow Doppler. Patients with evidence of moderate‐to‐large residual shunts were selected to undergo reintervention with shunt closure. Postreintervention follow‐up was performed at 24‐hr, 30 days, and every six months thereafter. Clinical predictors of the moderate‐to‐large residual shunts, and the feasibility, safety and long‐term efficacy of percutaneous residual shunt closure using a second device implant were examined. Results: Between 1995 and 2007, a total of 424 patients underwent PFO closure. Of these, 5% (21/424) had moderate‐to‐large residual shunts. Baseline characteristics among patients with moderate‐to‐large residual shunts and those with only none or small defects (n = 403) were similar. Multivariate analysis identified the 24‐hr postprocedure shunt as the only independent predictor of residual shunting at six months. Of the 21 study patients with moderate‐to‐large residual shunt (mean age, 47 ± 14), one underwent successful elective surgical repair, while the remaining 20 underwent transcatheter closure using a second device. The technique was successful in 95% (19/20), and all but one patient had complete shunt closure at six months of their percutaneous reintervention. We report no deaths, recurrent strokes or TIAs during the long‐term mean follow‐up period of 2.9 years. Conclusions: Our study suggests that in patients with moderate‐to‐large residual PFO shunts, percutaneous reintervention using a second device implant is safe and effective. © 2010 Wiley‐Liss, Inc.     

Patent foramen ovale with right atrial septal pouch

A patent foramen ovale (PFO) is a communication across the inter‐atrial septum and a right atrial septal pouch (RASP) is an indentation of the atrial septum caused by an incomplete fusion of the septum primum and septum secundum with its base opening into the right atrium. A 63‐year‐old male who had a history of two strokes and episodes of transient neurological deficit was diagnosed to have a small right‐to‐left shunt. At the time of PFO closure, an angiogram of the atrial septum revealed a small PFO associated with a RASP. The small PFO was crossed with a straight‐tipped guide wire and was closed using a 25‐mm GORE CARDIOFORM Septal Occluder (W.L. Gore and Associates, AZ). It is hypothesized that stagnant blood in the RASP may generate a clot that can cross the PFO and cause an infarct. © 2015 Wiley Periodicals, Inc.     

Iatrogenic erosion of the septum primum resulting in an atrial septal defect with left‐to‐right shunt: A rare pitfall of patent foramen ovale percutaneous closure

Iatrogenic erosion of the septum primum after foramen ovale closure is an anecdotal event. We report the case of a 39‐year‐old woman admitted to our institution for multifocal cryptogenic cerebral ischemia and a patent foramen ovale (PFO) associated with an aneurysm of the septum primum. The patient underwent percutaneous closure of the PFO with an Amplatzer PFO Occluder device. At the 6‐months follow up, the device was in the right position, but a jagged defect of the septum primum and evidence of significant left‐to‐right shunting was detected. The atrial septal defect was then repaired by a surgical approach. Although this event is not life‐threatening, it should be considered as a therapeutic pitfall, resulting in a risk of paradoxical embolism recurrences and long‐term hemodynamic impairment. © 2013 Wiley Periodicals, Inc.     

Transcatheter embolization of a large aneurysm in a congenital coronary cameral fistula from the left coronary artery to the right ventricle

A congenital coronary cameral fistula (CCCF) is characterized by left ventricular dysfunction, electrocardiographic changes due to a reduced left coronary blood flow and impaired physical activity. CCCF's with a giant aneurysm are very rarely seen. The presence of a giant aneurysm imposes even greater health risks. We report a case of a CCCF from the left coronary artery to the right ventricle with a large distal aneurysm in a 20‐year‐old woman that we closed percutaneously with coils for the closure of ventricular septal defects (VSD) and persistent ductus arteriosus (PDA). © 2014 Wiley Periodicals, Inc.