Atrial Septal Occluder Device Embolization to an Iliac Artery: A Case Highlighting the Utility of Three‐Dimensional Transesophageal Echocardiography during Percutaneous Closure

Percutaneous closure of secundum atrial defects has become an accepted treatment in part because it is minimally invasive and relatively low risk. Despite recent advances in implantation technique and device improvements, complications occur. Here, we report a case of device embolization during percutaneous repair of an atrial septal defect (ASD) with multiple fenestrations. We highlight the value of using live/real time three‐dimensional transesophageal echocardiography to help plan the percutaneous procedure and detect complications.     

Immediate Change in Pulmonary Venous Flow Pattern after Deployment of Occluder Device for Atrial Septal Defect

Transcatheter closure of a secundum defect using a septal occluder is a safe and effective procedure based on long-term follow-up, but no clinical studies have examined immediate hemodynamic changes. We evaluated pulmonary venous flow velocity pattern before and immediately after deployment of the Amplatzer septal occluder for closure of atrial septal defect. From May 2003 to January 2005, 48 patients with secundum atrial septal defect received transcatheter closure with complete occlusion. Patients were divided into two groups according to age: pediatric group, under 16 years (n = 30, age 7.3 ± 3.2 years), and adult group, 16 years or older (n = 18, age 30.1 ± 11.4 years). Pulmonary venous flow pattern was recorded by transesophageal echocardiography before and immediately after occluder deployment. Immediately after deployment in both patient groups, pulmonary vein systolic (S) and diastolic (D) wave velocity decreased, but atrial reversal (AR) wave velocity increased. In the pediatric group, S-wave was 56.1 ± 17.1 versus 35.5 ± 11.3 cm/sec (P < 0.001); D-wave was 57.6 ± 12.5 versus 42.9 ± 11.8 cm/sec (P < 0.001); and AR wave velocity was 12.2 ± 3.8 versus 15.5 ± 4.1 cm/sec (P < 0.001). In the adult group, S-wave was 48.4 ± 13.7 versus 32.7 ± 10.3 cm/sec (P < 0.001); D-wave was 51.9 ± 11.7 versus 38.0 ± 8.5 m/sec (P < 0.001); and AR wave velocity was 12.1 ± 4.1 versus 16.2 ± 4.9 cm/sec (P < 0.001). Comparison of pulmonary venous flow before and immediately after deployment of the Amplatzer septal occluder provides an excellent model to evaluate the influence of an atrial communication on pulmonary venous flow. Pulmonary venous forward flow decreases following atrial septal defect (ASD) closure.     

Large Esophageal Hematoma Following Transesophageal Echocardiography‐Guided Device Closure of Atrial Septal Defect

A 47‐year‐old woman with a large ostium secundum atrial septal defect (ASD) and severe pulmonary artery hypertension underwent device closure of ASD under transesophageal echocardiography guidance. She developed a massive esophageal hematoma which was diagnosed 4 days after the procedure. The use of dual antiplatelets after the device closure further aggravated the hematoma. As the patient remained stable and the site of leak could not be identified by contrast studies, she was managed conservatively with nil per mouth, broad‐spectrum antibiotics, and continuous nasogastric aspiration. We were faced with the risk of thromboembolism after stopping antiplatelets versus the risk of increasing peri‐esophageal hematoma if they were continued. With careful monitoring for thrombus formation on the device, the antiplatelets were stopped and the hematoma resolved. The hematoma resolved by 10 days, and the antiplatelets were restarted gradually. Iatrogenic esophageal injury is an important cause of esophageal perforation, which is a condition with high mortality and morbidity. Esophageal perforation following device closure of ASD is particularly challenging as the scenario is worsened by the use of antiplatelets and they have to be discontinued with the attendant risk of thromboembolism.     

Embolization of Atrial Septal Occluder Device into the Pulmonary Artery: A Rare Complication and Usefulness of Live/Real Time Three-Dimensional Transthoracic Echocardiography

Percutaneous closure of atrial septal defects (ASD) in adults has emerged as an alternative to surgery. We report a rare complication of an atrial septal occluder device embolization into the pulmonary artery which was detected by fluoroscopy and echocardiography. The potential usefulness of live/real time three-dimensional transthoracic echocardiography in the management of patients undergoing percutaneous ASD occlusion is described.     

An Atrial Septal Ridge Diagnosed by Transesophageal Echocardiography

A left atrial ridge is an anomaly of irregular fusion between the septum primum and septum secundum.1 Aberrant fusion of the septa results in thickened and fibrotic tissue along the region of the fossa ovalis that will occasionally protrude into the left atrium.2 The presence of a left atrial ridge has multiple clinical implications due to its close proximity to the fossa ovalis. The location of this uncommon incongruence may make transseptal catheter-based approaches more challenging, underscoring the importance of imaging guidance to determine the ideal transseptal puncture site.Figure 1 shows cardiac images of a 64-year-old female with a history of severe mitral regurgitation, atrial fibrillation, sick sinus syndrome status post pacemaker implantation, pulmonary hypertension, systemic lupus erythematosus, and chronic kidney disease. She was seen by the valve team and underwent a transesophageal echocardiogram (TEE) to determine candidacy for transcatheter edge-to-edge repair of the mitral valve. Two-dimensional biplane imaging of the interatrial septum (IAS) shows a linear structure on the left atrial side of the fossa ovalis. Three-dimensional imaging of the IAS revealed that the structure was consistent with an atrial septal ridge.Open in a separate windowFigure 1(A) Transesophageal echocardiogram (TEE) 2-dimensional (2D) imaging of the interatrial septum with the atrial septal ridge shown by the yellow arrows. (B) 3D TEE rotated view of the interatrial septum with the fossa ovalis shown in plane with the ridge (yellow arrow). (C) Cardiac magnetic resonance cine SSFP 4-chamber image demonstrating the atrial septal ridge (yellow arrow). (D) The MitraClip transcatheter mitral valve delivery system safely traversed across the interatrial septum (red arrow) with the yellow arrow pointing towards the atrial septal ridge. RA: right atrium; LA: left atrium; AV: aortic valve; IAS: interatrial septum; FO: fossa ovalis; MV: mitral valve     

Multiplane Transesophageal Echocardiographic Detection of Sinus Venosus Atrial Septal Defect

We present two case reports of diagnosis and evaluation of sinus venosus atrial septal defects by multiplane transesophageal echocardiography.     

Transesophageal Three-Dimensional Echo Assessment of Sinus Venosus Atrial Septal Defect

The incremental value of three-dimensional echocardiography over transesophageal multiplane two-dimensional imaging in the assessment of sinus venosus atrial septal defect is demonstrated in the present study.     

Complex Atrial Septal Defect: Percutaneous Repair Guided by Three‐Dimensional Echocardiography

Three‐dimensional transesophageal echocardiography (3D TEE) has been used to guide the percutaneous repair of simple atrial septal defects (ASDs). There has been limited experience in using this imaging modality to guide complex ASD repair. In this report, we describe how 3D TEE was used to guide the repair of a complex, multifenestrated ASD. In a single view, 3D TEE provides a superior anatomic definition when compared to the traditional two‐dimensional echocardiography. We believe that this emerging technology will play a critical role as the number and complexity of percutaneous techniques treating structural heart disease continue to rise. (Echocardiography 2010;27:590‐593)     

Transesophageal Echocardiographic Identification of Atrial Septal Aneurysm

This case illustrates the usefulness of biplane transesophageal echocardiography in the diagnosis of an atrial septal aneurysm, which in some views, mimicked a mass lesion in the left atrium. (ECHOCARDIOGRAPHY, Volume 8, July 1991)     

Left Ventricular to Right Atrial Septal Defect Secondary to Blunt Thoracic Trauma Diagnosed by Transesophageal Echocardiography

A case report is presented of a 58-year-old man who developed a new holosystolic murmur 4 months after a high-speed motor vehicle accident. Cardiac catheterization demonstrated a left-to-right shunt at the right atrial level. Intraoperative transesophageal echocardiography (TEE) identified and localized a discrete atrioventricular septal defect associated with a shunt from the left ventricle to the right atrium without tricuspid regurgitation, findings that were confirmed after surgical exploration. TEE is recommended for patients with a heart murmur and a history of blunt cardiac trauma, may permit early diagnosis, and may allow surgical repair in selected patients without pre-operative catheterization. (ECHOCARDIOGRAPHY, Volume 8, May 1991)     

Real Time Three‐Dimensional Transesophageal Echocardiographic Evaluation of a Sinus Venosus Atrial Septal Defect

We present a case of a 65‐year‐old man who presented with atrial flutter and dilation of right heart was noted on transthoracic echocardiography. Transesophageal echocardiography revealed a large sinus venosus atrial septal defect close to superior vena cava and anomalous connection of right superior pulmonary vein. Additionally, real time three‐dimensional transesophageal echocardiography provided superior spatial details and demonstrated the size, location of the defect and its spatial relationship to the surrounding structures. Patient underwent successful surgical repair. (Echocardiography 2011;28:E82‐E84)     

Incidence and Predictors of Atrial Septal Defect after Percutaneous Transvenous Mitral Commissurotomy – A Transesophageal Echocardiographic Study of 209 Cases

Background: The incidence of atrial septal defect (ASD) after percutaneous transvenous mitral commissurotomy (PTMC) ranges from 15.2% to 92% in small studies. Aim: To estimate the incidence of atrial septal defect (ASD) following PTMC and to determine the factors contributing to its development. Methods: We studied 209 patients with mitral stenosis (MS) undergoing PTMC. Transesophageal echocardiography (TEE) with color Doppler examination was performed to detect ASD. Results: TEE demonstrated ASD in 139 (66.5%) of 209 patients. The mean diameter of the interatrial septal defect detected by TEE was 4.47 ± 1.7 mm. The most common site of septal puncture was the inferior vena caval side of the interatrial septum followed by fossa ovalis. Color flow imaging across the defect showed left to right shunting in all the patients (100%). We examined the relationship of age, Wilkins score, left atrial volumes, the mitral valve orifice area, mitral valve gradient, and the degree of mitral and tricuspid regurgitation between the group that developed ASD and the group without ASD and found that none of these factors predicted the development of ASD. A residual ASD was seen in 11 patients (8.7%) at 6‐month follow‐up. Conclusion: Incidence of residual atrial septal defect immediately following PTMC by TEE color flow Doppler imaging is 66.5%. Surrogate markers of elevated left atrial pressures do not determine the development of atrial septal defect after PTMC. The majority of the defects close spontaneously and a residual defect is observed in 8.7% patients at 6 months.     

超声心动图检查继发孔型房间隔缺损封堵术后并发症的诊断价值

目的:研究超声心动图检查继发孔型房间隔缺损封堵术后并发症的应用价值。方法:选取我院2009年7月至2018年7月确诊继发孔型房间隔缺损并行经导管或经胸封堵术的患者3910例,所有患者术前经胸超声心动图(TTE)或经食管超声心动图(TEE)诊断筛选适应证,术中经经胸超声心动图或经食管超声心动图监测,术后复查经胸超声心动图,观察评价封堵器形态位置,评估相关并发症。结果:3910例行房间隔封堵术的患者中,封堵器脱落8例(0.20%),均急诊转外科修补治疗。心脏穿孔/磨蚀事件共8例,其中主动脉窦-右心房瘘1例(0.03%),经皮封堵治疗成功;二尖瓣前叶穿孔2例(0.05%),予随诊观察7年未特殊处理;心脏穿孔或心房壁损伤5例(0.13%),其中1例死亡(0.03%),4例行心包穿刺引流后好转(0.10%)。术后心包积液102例(2.61%),其中8例为少中量-中量心包积液,术后随访无明显变化或有所增多,患者血流动力学稳定,予随诊观察;94例为微量-少量心包积液,随诊观察积液量未见增加。术后残余分流167例(4.27%),其中多发房间隔缺损共102例;另外残余分流束宽度大于等于5 mm共17例,残余分流束小于5 mm或少量分流共150例,复查后分流均减少或消失。结论:房间隔缺损封堵术相关严重并发症包括封堵器脱落、心脏穿孔/磨蚀,发生率极低但危害大,常见并发症包括心包积液和残余分流,发生率低且预后好,超声心动图在及时诊断并发症和随访观察方面起到了不可替代的作用。     

Three‐Dimensional Echocardiography Guided Closure of Complex Multiple Atrial Septal Defects

Transcatheter closure of complex multiple atrial septal defects (ASDs) remains a challenge. We describe our clinical experience with staged device deployment in a patient with multiple ASDs using four Amplatzer septal occluder devices. Three‐dimensional transesophageal echocardiography imaging contributed not only to the therapeutic guidance of successful device deployment but also to the decision making for the staged device delivery approach in a case of morphologically complex multiple ASDs.