Transesophageal echocardiographic predictors for successful transcatheter closure of defects within the oval fossa using the CardioSEAL septal occlusion device

OBJECTIVES: To define the utility of transesophageal echocardiography in predicting the likelihood of a successful procedure and residual shunting in patients undergoing transcatheter closure of defects within the oval fossa using the CardioSEAL device. BACKGROUND: Transesophageal echocardiography is used to monitor transcatheter closure of interatrial defects within the the oval fossa, but predictors of successful closure and residual shunting have yet to be determined. METHODS: We reviewed transesophageal echocardiograms obtained from 26 consecutive patients undergoing attempted transcatheter closure of interatrial defects within the oval fossa between January, 1997 and May, 1998. Assessment of the atrial septum, the septal defect, and the rims of the oval fossa bordering the defect was performed in 3 planes: longitudinal, 4-chamber, and basal short-axis. RESULTS: Closure proved successful in 24 patients (92%). The defect was significantly larger, and the anterosuperior rim of the defect smaller, in the 2 patients in whom occlusion was not successful. Residual shunting 24 hrs after closure was detected in 14 patients. Significant predictors of leakage included smaller posterior and superior rims, a larger shunt prior to closure, and herniation of a one left atrial arm of the device into the right atrium. In all cases, the sites of leakage were the superior rim of the defect at the superior cavo-atrial junction, and the anterosuperior rim behind the aortic root. Herniation of a left atrial arm into the right atrium was seen in 7 patients (29%). In all, it was the anterosuperior arm which herniated Doppler color flow was suboptimal in detecting residual leaks, and was enhanced substantially with the use of contrast echocardiography. CONCLUSIONS: Transesophageal echocardiography allows excellent assessment of the oval fossa and deficiencies of its floor in all of their dimensions. It is an important tool for guiding the deployment of the occlusion device in patients undergoing attempted transcatheter closure of defects within the fossa. Contrast echocardiography should be used for optimal detection of residual shunting.     

Influence of atrial septal defect anatomy in patient selection and assessment of closure with the Cardioseal device; a three-dimensional transoesophageal echocardiographic reconstruction.

BACKGROUND: The maximal diameter of the defect and the dimensions of the septal rims are essential parameters for the selection of optimal cases for device closure. Neither two-dimensional echocardiography nor balloon catheter sizing provide optimal data. Unique three-dimensional echocardiography might help to improve patient selection and assessment of results. Our aim was to optimize transcatheter closure of secundum type atrial septal defects using three-dimensional echocardiography. METHODS: Sixteen patients enrolled in a protocol for atrial septal defect transcatheter closure with the Cardioseal device underwent transoesophageal two- and three-dimensional echocardiography. Maximal diameter and tissue rim of the atrial septal defect were measured and compared by both methods. In the 12 patients selected for closure, the balloon stretched diameter was compared to three-dimensional echocardiography measurements. Device placement was assessed by two- and three-dimensional echocardiography. RESULTS: The shape of the atrial septal defect appeared variable on three-dimensional views: round in nine patients but complex (oval, raquet-shaped, multiple) in seven patients. The surface area of the atrial septal defect varied by 68+/-15% during the cardiac cycle. The correlation between atrial septal defect maximal diameters measured by two-dimensional transoesophageal echocardiography and three-dimensional echocardiography was better in round defects (y=1 x +1.6, r=0.99) than in complex defects (y=0.7 x -0.5, r=0.88). The antero-superior rim could only be properly assessed by three-dimensional echocardiography. In 12 patients the correlation between stretched diameter and three-dimensional echocardiography maximal diameter was poor (y=0.3 x +13, r=0.41). After placement of the device, three-dimensional echocardiography enabled the mechanism of residual shunting to be understood in three patients. CONCLUSIONS: Dynamic three-dimensional echocardiography enhances the understanding of the anatomy and physiology of atrial septal defect and should be an important process in future initiatives for device closures.     

Intracardiac echocardiography: an ideal guiding tool for device closure of interatrial communications.

BACKGROUND: This study sought to evaluate safety and radiation exposure when using intracardiac echocardiography (ICE) in comparison to transesophageal echocardiography (TEE) in order to guide transcatheter closure of interatrial communications. METHODS: Eighty patients (44 males, 36 females, mean age 46, SD 13 years) undergoing device closure of atrial septal defect (n=12) or patent foramen ovale (n=68) had the procedure guided by ICE (n=50, group 1) or TEE (n=30, group 2). In group 1, all procedural stages were completely guided by ICE, including imaging of the interatrial communication during balloon sizing, device unfolding and release, and during the final check for adequate positioning. In group 2, exclusive implantation of devices was guided by use of TEE. RESULTS: Especially, the spatial relationship between device and cardiac structures (e.g. the ascending aorta, the interatrial septum and the superior vena cava) was accurately demonstrated in group 1. Image resolution provided by ICE was superior to that of TEE. No severe complications, including any related to ICE, were seen. Fluoroscopy time (FT) and procedure time (PT) were shorter in group 1 than in group 2 (FT: 5.5+/-1.5 min vs. 9.3+/-1.6 min, P<0.0001; PT: 31.9+/-4.6 min vs. 38.8+/-5.8 min, P<0.01). Neither sedation nor anesthesia was required in group 1. CONCLUSIONS: ICE is a safe tool to guide device closure of interatrial communications. For the patient, procedural stress and radiation exposure are negligible. ICE can be considered the guiding tool of choice for device closure, particularly when long or repeated echocardiographic viewing is required.     

Three-dimensional reconstruction by transesophageal echocardiography of Amplatzer and CardioSEAL prosthetic devices after percutaneous closure and atrial septal defects

OBJECTIVE: The Amplatzer and cardioSEAL devices are currently used for percutaneous closure of atrial septal defects. The in vivo morphology of these devices is unknown and this is why we sought to describe their geometric profile by three-dimensional echocardiography. METHODS: Thirteen patients, aged 6 to 18, underwent transcatheter closure of a secundum type atrial septal defect with either the CardioSEAL (n = 8) or the Amplatzer (n = 5) device. Three-dimensional reconstructions of the defect were obtained from transoesophageal bidimensional echocardiographic views. RESULTS: In the Amplatzer group, the stretched diameter of the defect was larger than in the CardioSEAL group (22 +/- 2 vs 18 +/- 1 mm, p = 0.003), but ehocardiographic surfaces were the same (3.3 +/- 1 vs 3.6 +/- 1 cm2, p = 0.3). The surface of the CardioSEAL device was measured at 4.8 +/- 2 cm2 whereas the Amplatzer's surface was 6.8 +/- 2 cm2 (p = 0.03). The Amplatzer device had a volume of 9 +/- 1 cm3 while the CardioSeal's volume was 3.1 +/- 1 cm3 (p < 0.0001). CONCLUSIONS: The CardioSEAL device occupies a small volume but it covers less of the septal defect and this may result in a higher incidence of residual shunting. The Amplatzer device almost always occludes the septum, but it tends to bulge into the atria and may cause mechanical complications.     

Retrograde use of the Cardioseal/Starflex occluder device.

The Cardioseal/Starflex septal occluder is usually deployed through a long transvenous sheath for closure of atrial septal defects, persistent foramen ovale, and, less commonly, ventricular septal defects. We describe two patients with residual left-to-right shunting after surgical palliation of congenital heart defects and illustrate the successful use of the double-umbrella device in these situations using a retrograde transarterial approach. This is exemplified by two previously not described interventions: retrograde closure of a large muscular ventricular septal defect in a patient after a palliative Mustard operation and a transcatheter closure of a Waterston-Cooley anastomosis. Effective and safe closure of left-to-right shunting can be achieved by retrograde use of the Cardioseal/Starflex device in selected adolescents and grown-ups with congenital heart disease.     

Transcatheter closure of interatrial communications for secondary prevention of paradoxical embolism: single-center experience

BACKGROUND: Patients with a patent foramen ovale (PFO) after cerebral, coronary, or systemic embolic events of presumed paradoxical origin are at risk for recurrent thromboembolism. We report our single-center experience of interventional closure of interatrial communications for secondary prevention of presumed paradoxical embolism. Methods and Results- Since 1997, percutaneous closure of interatrial communications was performed at our institution in 66 patients (mean age 47.8+/-12.7 years; 31 males) with a PFO or an atrial septal defect and at least 1 documented presumed paradoxical thromboembolic event. Fifty-eight patients had cerebral embolism, 10 had coronary embolism, and 3 had peripheral embolism. Several patients experienced multilocal arterial embolism. Fifty-four patients had a PFO, 33 of them with an atrial septal aneurysm, and 12 had an atrial septal defect. The implantation procedure was successful and without complication in all patients. After 3 months, only 2 patients showed a residual shunt, which disappeared in both cases after 12 months. In 112.2 patient-years of follow-up (range, 5 weeks to 3.5 years), we have not seen any recurrent thromboembolic event. CONCLUSIONS: Interventional closure of interatrial communications is a safe and effective therapeutic option for the secondary prevention of presumed paradoxical embolism. To further evaluate this strategy, randomized trials comparing interventional closure with anticoagulation have been initiated by us and others.     

Association of interatrial shunts and migraine headaches: impact of transcatheter closure

OBJECTIVES: To examine the relationship between patent foramen ovale (PFO) or atrial septal defect (ASD) with the incidence of migraine headache (MHA) and assess whether closure of the interatrial shunt in patients with MHA would result in improvement of MHA. BACKGROUND: Migraine headache is present in 12% of adults and has been associated with interatrial communications. This study examined the relationship between PFO or ASD with the incidence of MHA and assessed whether closure of the interatrial shunt in patients with MHA would result in improvement of MHA. METHODS: A sample of 89 (66 PFO/23 ASD) adult patients underwent transcatheter closure of an interatrial communication using the CardioSEAL (n = 22), Amplatzer PFO (n = 43), or the Amplatzer ASD (n = 24) device. RESULTS: Before the procedure, MHA was present in 42% of patients (45% of patients with PFO and 30% of patients with ASD). At three months after the procedure, MHA disappeared completely in 75% of patients with MHA and aura and in 31% of patients with MHA without aura. Of the remaining patients, 40% had significant improvement (>or=2 grades by the Migraine Disability Assessment Questionnaire) of MHA. CONCLUSIONS: Transcatheter closure of PFO or ASD results in complete resolution of MHA in 60% of patients (75% of patients with migraine and aura) and improvement in symptoms in 40% of the remaining patients. Interatrial communications may play a role in the etiology of MHA either through paradoxic embolism or humoral factors that escape degradation in bypassing the pulmonary circulation. A randomized trial is needed to determine whether transcatheter closure of interatrial shunts is an effective treatment for MHA.     

Catheter closure of atrial septal defects and patent foramen ovale in patients with an atrial septal aneurysm using different devices

BACKGROUND: Atrial septal aneurysm is frequently associated with patent foramen ovale (PFO) and atrial septal defects (ASD). Moreover, a relationship between atrial septal aneurysm and embolic cerebrovascular events has been suggested. The aims of this study were to analyze morphological and functional characteristics of atrial septal aneurysm in PFO and ASD patients and to assess the feasibility and efficacy of different devices for transcatheter closure and the influence of atrial septal aneurysm. METHODS: Between March 1997 and May 2000 transcatheter ASD or PFO closure was attempted in 63 patients (mean age 47 +/- 13 years) with an atrial septal aneurysm using one of the following devices: Angelwings (n = 3), Cardioseal (n = 5), Cardioseal-Starflex (n = 7), Amplatzer (n = 11), Amplatzer-PFO (n = 5), PFO-Star (n = 25), or Helex (n = 7). RESULTS: Implantation was primarily successful (after the first or second attempt) in all patients. One PFO-Star device embolized 12 hours after the procedure. During follow-up (0.6-37 months, mean 10.4 +/- 9.2) a residual shunt could be detected by transesophageal echocardiography after 2 weeks in four patients and after 6 months in one patient. Three PFO patients had cerebrovascular events after implantation. Two patients had a transient ischemic attack (TIA) and one patient a stroke. A thrombus formation on the device detected in three patients disappeared after antithrombotic therapy. CONCLUSION: We conclude that ASDs and PFOs with an associated atrial septal aneurysm can be closed with different available devices. There seem to be no additional risks compared with patients without atrial septal aneurysm.     

Transcatheter closure of residual atrial septal defect following implantation of buttoned device

We report a case in which residual shunting after a buttoned device occlusion of atrial septal defect (ASD) was eliminated by transcatheter retrieval of a portion of the device, followed by implantation of a second device. This method may be helpful for those patients with residual ASDs who decline surgical device retrieval and defect closure. © 1995 Wiley-Liss, Inc.     

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

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

Transcatheter closure of a residual postmyocardial infarction ventricular septal defect with the Amplatzer septal occluder

Acute ventricular septal rupture following myocardial infarction carries a high mortality. Early surgery improves survival but long term outcome depends on residual shunting and left ventricular function. Residual shunting is common despite apparently successful closure and may require reoperation. Transcatheter closure is an established method of treating selected congenital defects but clinical experience of transcatheter closure in postinfarction ventricular septal rupture is minimal. Transcatheter closure of a residual ventricular septal defect was successfully done using a new device, the Amplatzer septal occluder, in a 50 year old Indian man who had previously undergone emergency surgical repair for postinfarction acute ventricular septal rupture. The technique is described and its potential as a treatment in postinfarction ventricular septal rupture, its possible complications, and the important aspects of case selection and device design are discussed.

Keywords: ventricular septal defect; transcatheter closure; Amplazter septal occluder     

Transcatheter device closure of interatrial septal defects in patients with hypoxia

BACKGROUND: There has been growing interest in transcatheter closure of interatrial septal defects (IASDs) for a variety of indications, but reports are limited in patients with hypoxia from right-to-left shunting. METHODS: Between August 2000 and October 2004, 181 patients were referred to our institution for elective closure of a patent foramen ovale (PFO) or atrial septal defect (ASD). Among these patients, 10 (5.5%) underwent closure for hypoxia due to persistent or intermittent right-to-left shunting. Clinical evaluation, including echocardiography with color Doppler and agitated saline, was performed in all patients to determine the degree of right-to-left shunting. Defects were closed with Amplatzer (n = 4) or Cardioseal (n = 6) devices, under transesophageal (TEE) or intracardiac echocardiography (ICE) guidance. RESULTS: Mean age was 62.7 years (range: 31-88 years) with 70% female. Characteristics for closure included four patients with persistent hypoxia and six with intermittent hypoxia, including two with platypnea-orthodeoxia syndrome. All patients had echocardiography showing moderate (n = 6) or severe (n = 4) shunting. Patients had significant comorbidities, including chronic lung disease requiring supplemental oxygen (n = 5) and congestive heart failure (n = 2). TEE guidance was used in three patients, and ICE was performed in the remainder. Mean closure device diameter was 27 mm. Mean preprocedural arterial oxygen saturation of 86.7% improved to 95.9% immediately after closure, with color Doppler and agitated saline revealing the absence of (n = 5) or mild (n = 5) shunting. In-hospital major complications were limited to one patient with a transient ischemic attack after an initially unsuccessful closure attempt. CONCLUSIONS: Percutaneous closure of IASDs in a heterogeneous group of patients with hypoxia can be safely and effectively performed. The procedure results in immediate arterial saturation improvement and reduced right-to-left shunting.     

Transcatheter treatment of coronary artery disease and atrial septal defect with sequential implantation of coronary stent and Amplatzer septal occluder: preliminary results.

Coronary stent implantation had been established as a highly effective revascularization technique in patients with occlusive coronary artery disease. Transcatheter closure of atrial septal defects is becoming a definite alternative to surgery in properly selected patients. During a 19-month period, 6 patients (50% women; mean age, 58 +/- 17 years; range, 32-73 years) of a consecutive series of 176 prospective multicenter registry patients undergoing transcatheter atrial septal defect closure were treated with sequential percutaneous coronary revascularization and Amplatzer septal occluder implantation. Indication for revascularization was stable angina in four patients and unstable angina in two. Indication for defect closure was significant left-to-right shunt with right ventricular enlargement. Defect diameter ranged from 13 to 20 mm by transesophageal echocardiography, and the stretched diameter measured 13 to 25 mm. Procedural success of both interventions was achieved in all cases without in-hospital complications. A total of seven stents were successfully implanted in five coronary vessels. No stent was used in one patient after successful PTCA. Immediate total closure of the defect was obtained in five patients. Trivial residual shunting, observed in one patient, disappeared at 24 hr. No adverse cardiac events, recurrence of anginal symptoms, or evidence of residual shunt were observed at clinical and echocardiographic follow-up, which ranged from 60 to 390 days (mean, 258 +/- 150 days). These results suggest that sequential transcatheter therapy of coronary artery disease and atrial septal defect is safe and efficacious in selected patients.     

Extending the limits of transcatheter closure of atrial septal defects with the double umbrella device (CardioSEAL)

Objective—To report initial findings from a selected group of patients with morphological variations of the atrial septal defect who underwent transcatheter closure with a second generation redesigned double umbrella device.
Patients—Two patients with abnormal location of the oval fossa and partial deficiency of the septal rim, three patients with multiple defects, and two patients with a multiperforated aneurysm of the interatrial septum (age range, 3.6-25.5 years).
Methods—Defects were closed with the double umbrella device (CardioSEAL) consisting of two sets of flexible arms (with central and two mid-arm hinges) covered with sewn Dacron patches. The implantation procedure was monitored by transoesophageal echocardiography.
Results—The diameter of the defect measured during transoesophageal echocardiography ranged from 7-18 mm and the balloon stretched diameter ranged from 13-21 mm. The size of the devices varied from 28-33 mm and the ratio of device size to defect size varied from 1.6-2.1. Two devices (23 and 28 mm) were chosen in a patient with two separated defects. No complications or serious arrhythmias were observed during implantation or follow up (median, 1.8 months). Residual shunting was trivial in three patients and mild in one patient (inferiorly located additional defect).
Conclusions—To extend the selection critera of an isolated central interatrial defect for transcatheter closure, some modifications of the implantation technique are needed. Using the redesigned double umbrella device, effective closure in patients with multiple or irregularly shaped atrial septal defects was achieved, indicating a broadening of the spectrum of transcatheter closure.

Keywords: atrial septal defects;  transcatheter closure;  congenital heart disorders;  double umbrella device;  CardioSEAL     

Interventional Closure of Atrial Septal Defects in Adult Patients with Ebstein's Anomaly

Ebstein's anomaly is frequently associated with interatrial communications. In patients with severe tricuspid regurgitation standard treatment is the surgical repair or replacement of the tricuspid valve and patch closure of the atrial septal defect. We sought to evaluate the feasibility and short‐term outcome of interventional device closure of interatrial communications in Ebstein patients with mild to moderate tricuspid regurgitation and various degrees of clinical symptoms. In this case series of 9 patients the device closure could be performed safely and 8 of 9 patients improved in their exercise capacity or clinical condition. However, the patients need to be selected carefully and appropriately for this palliative method. In those with predominant left‐to‐right shunting, ASD‐closure reduces the volume load of the right ventricle and can be performed according to routine procedures. In those patients with cyanosis and right‐to‐left shunting however, test occlusion of the interatrial communication with adequate balloon size followed by careful examination of the hemodynamics at rest and under catecholamine stimulation is compulsatory to evaluate the feasibility of device closure. The tricuspid regurgitation should not exceed moderate level, the right atrial and ventricular pressure should be within normal range for an adequate time during test occlusion and the systemic blood pressure and cardiac output maintained safely.     

Transcatheter closure of a multiperforated atrial septal defect extending from the oval fossa to the mouth of the inferior caval vein

We report a novel technique using an Amplatzer atrial septal occluder to close a defect located in the inferior-posterior portion of the interatrial septum that extended into the mouth of the inferior caval vein. Because of the close relation of the defect to the inferior caval vein, the right atrial disc was opened into the inferior caval vein and pushed toward the right atrium by use of the delivery cable. There was no residual shunting immediately and 3 months after the intervention. We conclude that even defects located infero-posteriorly within the oval fossa may be successfully closed by transcatheter techniques using the Amplatzer device.     

Transcatheter closure of atrial septal defects

The first transcatheter closure of an atrial septal defect (ASD) was performed by King and Mills in 1976. The Lock Clamshell occluder and the buttoned device are the latest devices to undergo clinical trials. Successful transcatheter closure has been possible with minimal morbidity and mortality. Small residual shunts may remain, however, in up to 20% of patients 1 year after the procedure. The clinical significance and natural history of these small residual atrial communications remains to be determined. This article reviews the history and development of the current ASD closure techniques, with emphasis on the experience with the Lock Clamshell occluder and the buttoned device.     

Efficacy and long-term patency of fenestrated amplatzer devices in children.

INTRODUCTION: Novel transcatheter techniques to control interatrial communications exist. Devices with restrictive fenestrations can be implanted to maintain patency of an atrial septostomy, or reduce an interatrial communication. Experience with these devices in children is limited. PATIENTS AND METHODS: Fenestrated atrial septal devices were implanted into 10 children (5 male, age 1.5-15.5 years). Devices were modified by the manufacturer (MM, n = 6), or by a modification of an atrial septal occlusion device by the operator (OM, n = 4). Seven devices were implanted after atrial septal puncture and septostomy for severe symptomatic pulmonary hypertension (PHT) [4 heart failure, 3 syncope], according to World Health Organisation Guidelines. Two devices were implanted to reduce left to right shunting through large atrial septal defects with associated PHT. One device was implanted acutely to offload the left atrium during extracorporal circulatory support prior to heart transplantation. Warfarin (n = 5), aspirin (n = 4), or heparin (n = 1) were used for prevention of fenestration thrombosis. RESULTS: Symptoms in all patients with PHT improved after implantation; syncope recurred with fenestration occlusion in one patient. Nine patients were followed up to a mean of 26 months. Five devices (all MM; warfarin n = 4, aspirin n = 1) remained patent on echocardiography. Fenestrations occluded in 4 children after median follow-up of 10 months (MM n = 1, OM n = 3, warfarin n = 1, aspirin n = 3). CONCLUSIONS: Implantation of fenestrated atrial devices is feasible and effective; but the occlusion rate is high. Further research on fenestrated atrial septal devices with better long-term patency, and effective antithrombotic drug treatment is necessary.     

Transcatheter closure of multiple atrial septal defects. Initial results and value of two- and three-dimensional transoesophageal echocardiography.

AIMS: To examine the feasibility of transcatheter closure of multiple atrial septal defects using two Amplatzer devices simultaneously and to describe the importance and the role of two- and three-dimensional transoesophageal echocardiography in the selection and closure of such defects. METHODS: Twenty-two patients with more than one atrial septal defect underwent an attempt at transcatheter closure of their atrial septal defects at a mean+/-SD age of 30. 8+/-18.6 years (range 3.7-65.9 years) and mean weight of 56.6+/-25.5 kg (range 12.9-99 kg) using two Amplatzer devices implanted simultaneously via two separate delivery systems. During catheterization, two dimensional transoesophageal echocardiography was performed in all but one patient, during and after transcatheter closure, while three dimensional transoesophageal echocardiography was performed in six patients before and after transcatheter closure. RESULTS: Forty-four devices were deployed in all patients to close 45 defects (one patient with three defects closed by two devices). Two dimensional transoesophageal echocardiography was helpful in selection and in guiding correct deployment of the devices. The mean size of the larger defect, as measured by transoesophageal echocardiography was 12.8+/-5.9 mm and the mean size of the smaller defect was 6.6+/-3.0 mm. The mean size of the larger devices was 15+/-7.5 mm, and 8.4+/-3.7 mm for the smaller. Three dimensional transoesophageal echocardiography provided superior imaging and demonstrated the number, shape and the surrounding structures of the atrial septal defects in one single view. The median fluoroscopy time was 28.7 min. Device embolization with successful catheter retrieval occurred in one patient. Forty-four devices were evaluated by colour Doppler transoesophageal echocardiography immediately after the catheterization with a successful closure rate of 97.7%. On follow-up colour Doppler transthoracic echocardiography demonstrated successful closure in 97.5% at 3 months. CONCLUSIONS: The use of more than one Amplatzer septal occluder to close multiple atrial septal defects is safe and effective. The use of two- and three-dimensional transoesophageal echocardiography provided useful information for transcatheter closure of multiple atrial septal defects using two devices. Three-dimensional transoesophageal echocardiography enhanced our ability to image and understand the spatial relationship of the atrial septal defect anatomy.     

Percutaneous transcatheter closure of interatrial septal defect in adults: Procedural outcome and long‐term results

Background : Percutaneous transcatheter closure of patent foramen ovale (PFO) and atrial septal defect (ASD) has been shown to be feasible. Aim : The aim of this study was to evaluate the safety and efficacy of transcatheter interatrial septal shunt closure with prosthesis implantation in adults patients during long‐term follow‐up. In addition, the impact of thrombophilia and pulmonary hypertension on the outcome were investigated. Methods : Between June 1999 and November 2009, 287 patients (112 males, 43 ± 14 years) were treated in our institution by transcatheter closure of PFO (N = 175) or ASD (N = 112). Clinical and echocardiographic follow‐up were prospectively performed at 1, 6 and 12 months followed by a 1 once a year evaluation. Results : All procedures were successful with eight procedural complications (2.7%): one stroke, two femoral pseudoaneurysms, three transient atrial fibrillation, two minors pericardial effusions. Among patients with presumed paradoxical embolism, thrombophilia was observed in 29 patients (17%); only one of them experienced a recurrent stroke. Among patients with ASD, pulmonary hypertension was observed in 32 cases (28%) and significantly reduced 6 months after shunt closure (from 47 ± 7 to 31 ± 11 mm Hg, P < 0.0001). 99% of patients achieved a complete follow‐up. Clinical improvement was observed in 93%. Freedom from death, cardiac surgery or recurrent embolism was 98 ± 1% at 5 years. Conclusion : Percutaneous transcatheter interatrial septal defect closure is a safe and effective treatment in adults patients, even in case of thrombophilia or pulmonary hypertension, during a long‐term follow‐up, up to 11 years. © 2011 Wiley Periodicals, Inc.