Ventricular septal rupture masquerading as coronary perforation during intervention for acute myocardial infarction

Ventricular septal rupture is a serious complication of acute myocardial infarction. We experienced a case of septal rupture immediately after primary angioplasty with thrombolysis, whose angiographic findings were similar to those of coronary perforation. The progression of septal rupture was delineated by the serial angiograms. Catheter Cardiovasc Interv 2004;62:466–470. © 2004 Wiley‐Liss, Inc.     

A comparative study of Cardi‐O‐Fix septal occluder versus Amplatzer septal occluder in percutaneous closure of secundum atrial septal defects

Aim: We sought to investigate the safety and efficacy of Cardio‐O‐Fix septal occluder (CSO) in percutaneous closure of atrial septal defects (ASD) as compared to the Amplatzer septal occluder (ASO). Methods: A consecutive of 351 patients received transcatheter ASD closure with CSO or ASO from July 2004 to October 2010 were studied. The ASDs were divided into simple‐ (isolated defects <26 mm) or complex‐types (isolated defect ≥26 mm, double or multifenestrated defects). The procedures were guided by fluoroscopy and transthoracic or transesophageal echocardiography. Clinical and echocardiographic follow‐ups were arranged before discharge, at 1 month and then every 6‐month after implantation. Results: During the study period, 185 (125 males, aged 18.5 ± 15.6 years) and 166 (103 males, aged 21.0 ± 15.7 years) patients attempted CSO and ASO implants, respectively. The CSO group had similar ASD and device sizes, prevalence of complex lesions (17 vs. 16%, P = 0.796), procedural times and success rates (97% vs. 96%, P = 0.635) as compared to the ASO group. Acute residual shunts were less prevalent in CSO than ASO group and most shunts closed spontaneously at 6‐month follow‐ups. The average equipment cost per patient was lower in CSO group (US$ 4,100 vs. US$ 5,900, P < 0.001). The prevalence of device embolization and atrial arrhythmia (all <2%) were similar in both patient groups. Conclusion: Transcatheter ASD occlusion with CSO is safe and effective and it appeared to be an attractive alternative to ASO in closing simple‐type ASD because of its relatively low cost. © 2013 Wiley Periodicals, Inc.     

Long-term outcome of transcatheter secundum-type atrial septal defect closure using Amplatzer septal occluders

OBJECTIVES: The aim of this study was to assess long-term results of percutaneous closure of secundum-type atrial septal defect (ASD II) using Amplatzer septal occluders (ASO). BACKGROUND: Only immediate-, short-, and intermediate-term results of ASO implantation are known so far. METHODS: Between September 1995 and January 2000, 151 patients underwent a successful percutaneous closure of ASD II in our institution. All were included in the present study and were followed up until September 2004. RESULTS: This group of patients was followed up from 56 to 108 months (median 78 months). The mean stretched defect diameter was 15.9 +/- 4.8 mm. There were no deaths or significant complications during the study. At three years of follow-up, all defects were completely closed and remained closed thereafter. CONCLUSIONS: Since the first human implantations in September 1995, the Amplatzer septal occluder proved as a safe and effective device for percutaneous closure of ASD II.     

Echocardiographic predictors of cardiac erosion after amplatzer septal occluder placement

The risk of erosion after Amplatzer septal occluder (ASO) device placement in atrial septal defects is well described. Aortic rim deficiency and use of over‐sized device increase the risk of erosion. This study attempts to describe device characteristics, anatomical features and echocardiographic predictors that increase the risk of erosion. Methods : From 2005 through 2012, 12 new cases, with nine confirmed and three suspected device erosions where pre‐procedural, intra‐procedural, and/or post‐procedural echocardiograms were available and, were reviewed. Following parameters were evaluated: ASD location (high or low), rims deficiency and consistency, septal mal‐alignment, dynamic nature of the defect; device edge relationship toward the transverse sinus (TS), atrial free wall tenting and the size of the defect compared with the size of the device used for closure. Results : We found poor posterior rim consistency, aortic rim absence (in multiple views) and absent aortic rim at O degree in 100% of the patients. Septal mal‐alignment and dynamic ASD was present in nearly 50% of the cases. The device was over‐sized in three patients only. A 26‐mm device was the most common device that resulted in erosion. In cases, where patient had experienced bloody pericardial effusion and the device was in place, device tenting in the TS was observed. Surgical explantation of the device confirmed presence of erosion in all cases. Conclusion : Aortic rim absence in multiple views, poor posterior rim consistency, septal mal‐alignment, and dynamic ASD appear to be factors where erosion risk increases significantly. A thorough assessment of the device edge by echocardiography in short‐axis may show device tenting of the atrial free wall into the TS. This finding should be a strong indictor to recommend surgical removal of device after occurrence of pericardial effusion. © 2013 Wiley Periodicals, Inc.     

Experience using the new GORE® septal occluder at the margins

Complex atrial anatomy continues to challenge transcatheter device closure of septal defects. Devices and technology continue to evolve. We report three cases from our institution where the new Gore^® Septal Occluder was utilized for the closure of a lateral tunnel fenestration, a moderate‐sized secundum atrial septal defect and a long tunnel patent foramen ovale. Each case highlights the successful use of this new generation device in challenging circumstances. © 2013 Wiley Periodicals, Inc.     

Added value of three‐dimensional transthoracic echocardiography in assessment of an adult patient with atrioventricular septal defect

Transthoracic echocardiography is the principal imaging modality for assessment of patients with atrioventricular septal defects. Three‐dimensional echocardiography streamlines and simplifies data acquisition offering a unique realistic en‐face display of heart valves and septal defects and enables accurate evaluation of the cardiac anatomy, dynamic, and function. We demonstrated an added value of three‐dimensional echocardiography in assessment of an adult patient with atrioventricular septal defect and its advantages over conventional echocardiography.     

Failure of the GORE HELEX atrial septal defect occluder to treat membranous VSDs in swine

Objective: We tested the suitability of the GORE HELEX septal occluder for closure of membranous ventricular septal defect in three Yucatan minipigs that had naturally‐occurring membranous ventricular septal defects. Methods: The animals were studied in the Gore Science Center Laboratory in Flagstaff, Arizona. In all of the device implantations, seating of the right disk along the right ventricular septum was problematic with resultant entanglement of one device in the chordae tendinae during attempted removal, implantation of one device onto the tricuspid valve papillary muscle and unlocking of one device occurring after implantation. Conclusions: A new occluder design appears to be needed to minimize the risk of disk entanglement with cardiac structures, particularly within the right ventricle. These studies did establish that the Yucatan mini swine are an acceptable and appropriate model for evaluating occluders intended for closure of membranous ventricular septal defects. © 2010 Wiley‐Liss, Inc.     

Two cases of late embolization of Amplatzer septal occluder devices to the pulmonary artery following closure of secundum atrial septal defects

The Amplatzer septal occluder (ASO; AGA Medical Corporation) is a self‐expanding nitinol double‐disk device that is being used for atrial septal defect closure with increasing frequency. The morbidity of the procedure is thought to be low, but complications are possible. We describe two cases of delayed embolization of the device to the right heart. Our patients both required surgical retrieval of the devices, which had migrated to the pulmonary artery. © 2005 Wiley‐Liss, Inc.     

Percutaneous ventricular septal defect closure with amplatzer devices resulting in severe tricuspid regurgitation

While percutaneous intervention is an alternative for patients who are not surgical candidates, the rate of morbidity and mortality is comparable to open repair. Appending the reported complications associated with percutaneous intervention (device mal‐positioning, dislodgement, and entrapment in the sub‐valvular apparatus), we report mechanical damage to the tricuspid valve (TV). Percutaneous closure with an Amplatzer septal occluder device was attempted on three patients who developed a ventricular septal defects (VSD) after myocardial infarction. In all three cases, damage to the tricuspid leaflet was noted post‐procedure. The accompanying severe tricuspid regurgitation led to right ventricular failure, even in the patients where the VSD was considered successfully occluded. Despite successful deployment of the Amplatzer device, complications with catheter manipulation may still arise. Damage to the TV can occur during percutaneous VSD closure with Amplatzer device. Periprocedure TEE monitoring can detect damage to the tricuspid leaflets. © 2013 Wiley Periodicals, Inc.     

Transcatheter closure of atrial septal communication during pregnancy in women with Ebstein's anomaly of the tricuspid valve and cyanosis

Transcatheter atrial septal defect occlusion is described in three pregnant patients with Ebstein's anomaly and exercise‐induced cyanosis. Procedures took place in the second and third trimester. Careful hemodynamic testing was performed prior to permanent atrial septal occlusion to confirm the capacity of the right ventricle to accept the entirety of systemic venous return in the volume‐expanded state of pregnancy. Outcomes for mother and fetus were favorable in all patients with significant reduction in maternal symptoms and resolution of cyanosis. © 2014 Wiley Periodicals, Inc.     

An interatrial tunnel: a rare form of atrial septal defects

Atrial septal defects (ASDs) account for approximately 6%–10% of congenital heart defects. The well‐known types of atrial septal communications are the ostium secundum, ostium primum, sinus venosus types, and coronary sinus defects. A 50‐year‐old female was referred for TEE for better assessment of MR severity and mechanism. 2D/3D‐TEE showed a rare combination of different abnormalities; bi‐leaflet mitral valve prolapse, cleft P2, cor triatriatum sinister, and a tunnel‐shaped IAS communication. To the best of our knowledge, this is a very rare case with a rare form of atrial septal defect that was not described before. We named this defect an interatrial tunnel.     

Atrial septal interventions in patients with hypoplastic left heart syndrome

Objectives: To report an institutional experience performing percutaneous atrial septal interventions in patients with hypoplastic left heart syndrome (HLHS). Background: The success of the Hybrid approach in palliating patients with HLHS is crucially dependant on relieving any significant interatrial restriction. Data on transcatheter interventions to relieve atrial septal restrictions in patients with HLHS are limited. Methods: We retrospectively reviewed 67 transcatheter atrial septal interventions that were performed between July 2002 and September 2007 in 56 patients with HLHS. The median weight was 3.35 kg. About 10.7% of patients had an intact atrial septum. Balloon atrial septostomy (BAS) was used in 77.6% of procedures, additional techniques in 35.8% of procedures. Patients were divided into those with standard atrial septal anatomy (group A, n = 33) and those with complex atrial septal anatomy (group B, n = 23). Results: The mean trans‐septal gradient was reduced significantly from 7 mm Hg to 1 mm Hg with the median time to discharge being 3.5 days. Major adverse events were seen in 8.9% of procedures, whereas minor adverse events occurred in 26.8% of procedures. Adverse events were significantly less common in patients with standard atrial septal anatomy, compared to those with complex atrial septal anatomy (25.6% versus 50.0%). About 19.6% patients required repeated atrial septal interventions. Survival up to and including Comprehensive stage II palliation was 73% group A, and 57% in group B. Conclusions: With utilization of appropriate techniques and equipment, atrial septal interventions in HLHS can be performed successfully in virtually all patients. Complex atrial septal anatomy is technically challenging and has a higher incidence of procedural adverse events. In the majority of patients, standard BAS can be performed safely, and is usually the only intervention required to achieve adequate relief of atrial septal restriction until Comprehensive stage II palliation. © 2008 Wiley‐Liss, Inc.     

Successful embolization of a left ventricular pseudoaneurysm after perventricular ventricular septal defect device closure

Perventricular device closure has become an important management adjunct for ventricular septal defects deemed inoperable and difficult to address in the catheterization laboratory. Complications directly related to the procedure are rarely reported, and all have been manifest in the periprocedural period. We present the case of a 6‐week‐old boy who underwent perventricular closure of a muscular ventricular septal defect and had a left ventricle pseudoaneurysm identified 10 months later during catheterization to close residual septal defects. We describe the subsequent percutaneous coil embolization of the pseudoaneurysm and clinical follow‐up. © 2009 Wiley‐Liss, Inc.     

Rare complication of ventricular septal defect in three patients following transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) is a highly‐effective but technically challenging procedure. Despite improvement in device technology and operator techniques, complications are common and previously unknown procedural‐related complications continue to arise. In this report, we present a case series of three patients with acquired perimembranous ventricular septal defects following transfemoral TAVR with an Edwards SAPIEN prosthesis. © 2013 Wiley Periodicals, Inc.     

Percutaneous closure of a complex posttraumatic muscular ventricular septal defect

We report the percutaneous closure of a complex traumatic ventricular septal defect resulting from a stab wound to the anterior chest. The patient presented with heart failure 3 months after the initial trauma. Evaluation revealed a new large ventricular septal defect with diminished cardiac function. Closure was accomplished with a combination of an Amplatzer muscular ventricular septal defect occluder and two Amplatzer vascular plugs. © 2008 Wiley‐Liss, Inc.     

Percutaneous closure of an iatrogenic atrial septal defect

The use of the Tandem Heart? percutaneous ventricular assist device (Tandem Heart pVAD, Cardiac Assist technologies, Pittsburgh, PA) as a bridge to recovery or to other cardiopulmonary support systems has been rising. One requirement for placement of this device is an intraatrial septostomy which is usually closed during the surgical insertion of more permanent ventricular assist devices. We present a case of a 62‐year‐old man with a residual acquired atrial septal defect (ASD) from Tandem Heart? placement, which could not be closed surgically during insertion of left and right ventricular assist devices. The patient remained intubated and hypoxemic after removal of his right ventricular assist device due to the presence of persistent right to left shunting. With closure of the ASD using an 8‐mm Amplatzer® septal occluder (ASO; AGA Medical Corp., Golden Valley, MN) the patient stabilized and was successfully extubated. © 2009 Wiley‐Liss, Inc.     

Cyanoacrylate for septal ablation in hypertrophic cardiomyopathy

Objective: Alcohol septal ablation (ASA) has been shown to be an effective treatment in patients with hypertrophic obstructive cardiomyopathy (HOCM) who are refractory to medical treatment. We describe an alternative approach for septal ablation with glue (cyanoacrylate), which is particularly useful in patients with the collateral formation to the right coronary artery in whom ASA is contraindicated. Methods: In our method left coronary ostium was cannulated with 6–8F guiding catheter. Septal branch was cannulated with a 4F catheter and a microcatheter then cyanoacrylate mixture was instilled into the septal artery. Immediate polymerization prevents the leak into the left anterior descending coronary artery, and also into the right coronary artery (RCA) via septal collaterals. Results: Glue septal ablation (GSA) was performed in 18 patients (6 patients had collateral branches to RCA). Immediately after the procedure peak left ventricular outflow (LVOT) gradient reduced significantly both in cardiac catheterization (65.0 ± 13.8 vs. 14.2 ± 5.7 mmHg, P < 0.001) and Doppler echocardiographic measurements (75.8 ± 19.9 vs. 18.0 ± 9.1 mmHg, P < 0.001). LVOT tract gradient reduction persisted after 6 months follow‐up. Septal wall thickness (20.2 ± 3.7 mm vs. 16.5 ± 3.2 mm, P = 0.003) reduced and NYHA functional class (3.1 ± 0.4 vs. 2.2 ± 0.3, P < 0.001) improved. There was no significant complication during the procedure and within 6 months follow‐up period. Conclusions: GSA seems to be an efficient and safe approach to HOCM, especially in patients with the collateral formation. Further experience is needed in order to assess the long‐term efficacy and safety of this technique. (J Interven Cardiol 2011;24:77–84)     

Ventricular septal defect closure in a small children with the Amplatzer Duct Occluder II

Transcatheter technique for muscular ventricular septal defect closure remains challenging, particularly in small patients. We report the successful use of the low profile Amplatzer Duct Occluder II for multiple ventricular septal defect closure in an infant with D‐transposition of the great arteries, status postpulmonary artery banding. The multiple apical ventricular septal defects were successfully closed with two Amplatzer Duct Occluder II and one Amplatzer Muscular Ventricular Septal Defect Occluder during two interventional catheterizations. The patient subsequently underwent successful surgical repair. © 2011 Wiley‐Liss, Inc.     

New technique for device closure of large atrial septal defects.

The objective of this study was to describe a new technique for transcatheter device closure of large atrial septal defects (ASDs) using the Amplatzer septal occluder and our experience with this technique in 14 patients. Transcatheter closure of large (> 25 mm) ASDs is challenging. We have developed a balloon-assisted technique (BAT) to facilitate device closure of large ASDs. The BAT consists of using a balloon catheter to support the left atrial (LA) disk of the Amplatzer septal occluder during device deployment. The balloon support prevents prolapse of the LA disk into the right atrium. Between April 2003 and February 2004, 14 patients with large ASDs (mean age, 25.71 +/- 15.71 years; mean weight, 51.21 +/- 23.78 kg) underwent device closure with the Amplatzer septal occluder using the BAT. The median balloon-stretched diameter of the ASD was 32 (range, 26-40) mm. The median device size used was 33 mm (range, 26-40 mm). All 14 patients had successful deployment of the device using the BAT. The mean follow-up period was 16.5 +/- 11.95 weeks. No major complications were noted during the procedure or on short-term follow-up. The BAT enables predictably successful closure of large ASDs using the Amplatzer septal occluder.     

Peratrial closure of atrial septal defects without cardiopulmonary bypass

The objective of this study was to introduce a new technique for occlusion of an atrial septal defect without cardiopulmonary bypass, using a modified Amplatzer device. Between October 2004 and November 2005, 96 secundum atrial septal defects in 83 patients were occluded by this method. A 3-cm incision in the right 4(th) intercostal space and a minithoracotomy were performed. Via this incision, the right atrium was exposed and the septal closure device was deployed under transesophageal echocardiographic guidance. The sizes of the defects ranged from 10 to 39 mm. The mean device size was 34.1 +/- 9 mm (12-46 mm). There was no operative mortality and no major morbidity on follow-up of 3-15 months. This new minimally invasive method of secundum atrial septal defect closure is safe and cosmetically superior to conventional surgery. Avoidance of cardiopulmonary bypass can reduce recovery time and complications. The indications are more extensive than percutaneous transcatheter closure, and the results are encouraging.