Intracardiac echocardiographic guidance during transcatheter device closure of atrial septal defect and patent foramen ovale

OBJECTIVES: To describe our experience with intracardiac echocardiographic (ICE) guidance during transcatheter device closure of atrial septal defect (ASD) and patent foramen ovale (PFO) and to describe a detailed stepwise approach for performing ICE examinations. PATIENTS AND METHODS: We reviewed the ICE results of all patients who underwent transcatheter device closure of ASD/PFO at the Mayo Clinic in Rochester, Minn, between October 2000 and November 2002. Conscious sedation was used, and all ICE studies were performed using a diagnostic ultrasound catheter. RESULTS: Ninety-four patients (47 male; median age, 51 years [range, 17-81 years]) underwent ICE during transcatheter device closure of ASD/PFO. Total procedure time was 128 minutes (range, 27-320 minutes). ICE identified a previously unrecognized anatomical diagnosis in 32 of 94 patients. An additional ASD or PFO was found in 16 patients; a redundant atrial septum or an atrial septal aneurysm was found in 12 patients. There were few ICE complications (4%): 3 patients developed atrial fibrillation, and 1 developed supraventricular tachycardia; of these 4, 2 resolved spontaneously, and 2 required cardioversion with no recurrence. CONCLUSION: ICE provides anatomical detail of ASD/PFO and cardiac structures facilitating congenital cardiac interventional procedures. ICE eliminates major drawbacks related to the use of transesophageal echocardiographic guidance for transcatheter device closure of ASD/PFO, specifically problems related to airway management. Finally, ICE gives the interventional cardiologist the ability to control all aspects of imaging without relying on additional echocardiographic support. We believe that ICE should be considered the preferred imaging technique for guidance of transcatheter device closure of ASD/PFO in adults and larger pediatric patients.     

Paradoxical emboli in children and young adults: role of atrial septal defect and patent foramen ovale device closure

OBJECTIVE: To describe a multicenter experience with patent foramen ovale (PFO) and atrial septal defect (ASD) device closure for presumed paradoxical emboli in children and young adults (<35 years old). PATIENTS AND METHODS: Medical records were reviewed of patients who had device closure of an ASD or PFO, who were younger than 35 years, and who had a history of presumed paradoxical embolus between January 1999 and August 2005 at Mayo Clinic, Rochester, Minn, University of Parma, Parma, Italy, and Loyola University Medical Center, Maywood, Ill. RESULTS: Forty-five patients fulfilled the inclusion criteria. Median patient age was 29.0 years (range, 5.0-34.9 years), and 23 patients (51%) were male. Clinical diagnoses included the following: stroke, 30 (67%); transient ischemic attack, 13 (29%); myocardial infarction, 1 (2%); and renal infarct, 1 (2%). Overall, 42 patients (93%) had a PFO, and 3 (7%) had an ASD. Seventeen patients had known cardiovascular disease risk factors: tobacco use (10 patients), hypercoagulable states (7 patients), systemic hypertension (3 patients), and hyperilpidemia (2 patients). No major procedural complications occurred. Median follow-up evaluation was performed at 5.3 months (range, 2.5-40.0 months). Forty-four patients (98%) had no recurrent neurologic events and no residual atrial shunt by contrast transthoracic echocardiography. CONCLUSIONS: Cryptogenic ischemic events occur in young patients and have serious sequelae. The potential for paradoxical embolization through a PFO or an ASD should be assessed in all such patients. In our short-term follow-up, device closure was a safe alternative therapeutic option for children and young adults with presumed paradoxical emboli.     

Haemodynamic effects of patent foramen ovale and atrial septal defect closure: a comparison during percutaneous shunt closure

Objectives: We investigated the haemodynamic effect of percutaneous closure of an intra‐atrial shunt, using non‐invasive finger pressure measurements. Background: Percutaneous closure of both patent foramen ovale (PFO) and atrial septal defect (ASD) is widely practised. Currently no data are available on short‐term haemodynamic changes induced by closure. Methods: Twenty‐five consecutive patients (mean age 49 ± 17 years, 10 men) who underwent a percutaneous closure of a PFO (n = 15) or ASD (n = 10) were included in this study. During the procedure blood pressure and heart rate (HR) were monitored continuously with a Finometer^®. Changes in systolic, mean, and diastolic pressure, stroke volume (SV), cardiac output (CO) and total peripheral resistance (TPR) were computed from the pressure registrations using Modelflow^® methodology. Results: Baseline characteristics were similar for the PFO and ASD patients. After PFO closure none of the haemodynamic parameters changed significantly. After ASD closure the systolic, mean, and diastolic pressures increased 7·1 ± 5·4 (P = 0·003), 3·8 ± 3·5 (P = 0·007) and 2·0 ± 3·0 mmHg (P = ns) respectively. HR decreased 5·1 ± 5·3 beats per minute (P = 0·01). SV, CO and TPR increased 8·5 ± 6·4 ml (13·5%; P = 0·002), 0·21 ± 0·45 l min^?1 (5·6%; P = ns) and 0·02 ± 0·14 dynes (4·1%; P = ns) respectively. The changes in SV differ between the PFO and ASD patients (P = 0·009). Conclusions: Using non‐invasive finger pressure measurements, we found that SV, mean and systolic blood pressure increased immediately after percutaneous closure of an ASD in adults, whereas the percutaneous PFO closure had no effect on haemodynamic characteristics.     

Pulmonary embolism complicated by patent foramen ovale and paradoxical embolization

We present the case of a 74-year-old male with chest pain, dyspnea, and syncope secondary to an acute pulmonary embolism complicated by a patent foramen ovale with straddling thrombus and paradoxical embolization. We review the literature with specific focus on the pathogenesis and acute treatment of this life-threatening occurrence.     

Differential diagnosis between patent foramen ovale and pulmonary arteriovenous fistula in two patients with previous cryptogenic stroke caused by presumed paradoxical embolism.

Development of improved devices for interventional closure of atrial septal defect and patent foramen ovale increased the number of adult patients who are being referred for transcatheter closure. We report two cases that were scheduled for patent foramen ovale closure because of a right-to-left atrial shunt detected at contrast transesophageal echocardiography in another institution and that were found to have pulmonary arteriovenous fistulas. Embolization of pulmonary arteriovenous fistulas was carried out successfully by transcatheter technique.     

Discontinuous-flow plasmapheresis and patent foramen ovale: a possible cause of paradoxical embolism

A 68-year-old woman was admitted for a subacute polyradiculoneuropathy and submitted to PE. A central right jugular venous access was placed after the third PE procedure due to a failing peripheral blood access. During the fourth PE, performed with a discontinuous-flow system (continuous-flow used for 3 procedures), she developed multiple embolic ischemic lesions in the left middle cerebral artery (MCA) territory. A thorough cerebrovascular screening showed only a patent foramen ovale (PFO). In our case, a possible increase of the right atrium blood pressure induced by the positive flux of the discontinuous-flow PE could have been responsible for a paradoxical embolism through the PFO. Plasma exchange (PE) is used in several neurologic disorders. It is commonly thought to be a relatively safe procedure. However, a number of adverse events may occur: paradoxical embolism has not been reported to occur.     

Transcatheter closure for decompression sickness with a patent foramen ovale: A case report

A patent foramen ovale is one of the predisposing factors of neurotic decompression sickness. Transcatheter closure of a patent foramen ovale is effective in the secondary prevention of decompression sickness associated with intracardiac shunt. The size of the umbrella should not be limited to the diagnosis of a patent foramen ovale or an atrial septal defect but should be determined by the supporting force of the soft margin of the atrial septum. The surgical method of patent foramen ovale closure is the same as that of the closure of an atrial septal defect, but the closure umbrella of a patent foramen ovale is different from that of the closure umbrella of an atrial septal defect. The size of the umbrella of the right atrium is larger than that of the left atrium, and it is better to close the atrial septum.     

Amplatzer堵闭器与外科手术治疗继发孔型房间隔缺损的比较

房间隔缺损(ASD)是一种常见的先天性心脏病,大约占先天性心脏病总数的10%~15%[1]。心脏直视手术治疗ASD一直作为标准的治疗方法,疗效较好。近几年,随着介入医学的发展,ASD的介入治疗逐渐成为主流[2]。本院自2002年开始开展介入方法治疗房间隔缺损。为了探讨该方法的效果,并对其     

Percutaneous successful closure of dual atrial septal defect with two Amplatzer septal occluder devices

We report a case of percutaneous dual atrial septal defect closure with two Amplatzer septal occluder devices.     

主动脉根部缺如的房间隔缺损经导管介入治疗疗效分析

目的:探讨主动脉根部缺如的继发性房间隔缺损(atrial septal defect,ASD)患者介入治疗的安全性及有效性。方法:采用回顾性的研究方法,收集了自2016年1月至2018年1月复旦大学附属中山医院心血管内科收治的402例ASD患者的临床资料。分为主动脉根部缺如组和正常组,所有患者均接受单一封堵器介入治疗,探究主动脉根部缺如组ASD患者行介入封堵治疗的安全性及有效性。结果:主动脉根部缺如与边缘正常所有患者术后均未出现重大手术并发症,术后右心重构明显改善,肺动脉压力下降,三尖瓣反流减少,但左室射血分数无明显变化。结论:主动脉根部缺如的ASD的介入封堵治疗是安全可行性,能够显著改善患者的右心功能,改善心室重构。     

Migraineurs with patent foramen ovale have larger right-to-left shunt despite similar atrial septal characteristics

The objective of the study was to assess differences in proportion of large right-to-left shunt (RLS) and atrial septal characteristics between migraineurs and non-migraineurs referred for transcatheter closure of patent foramen ovale (PF0). This retrospective study took place in a large metropolitan medical centre. The patients were migraineurs with aura (n=52), migraineurs without aura (n=19) and non-migraineurs (n=149). RLS was evaluated before closure using bilateral power m-mode transcranial Doppler at rest and after calibrated, sustained Valsalva manoeuvre, and graded with a validated 0–5 scale. Intracardiac echocardiography was used to assess atrial septal characteristics. Migraineurs had a higher proportion of large RLS (Grade IV or V) than nonmigraineurs at rest and after calibrated Valsalva (rest, p=0.04; Valsalva, p=0.01). Atrial septal characteristics were similar between groups. Migraine is associated with larger RLS at rest and strain; however migraine status does not predict PFO characteristics.     

双平面经食管超声心动图在Amplatzer堵塞器经心导管关闭小儿房间隔缺损中的价值

目的评价经食管超声心动图(TEE)在Amplatzer堵塞器经心导管关闭房间隔缺损(ASD)中的应用价值.方法对57例继发孔型ASD患者,在TEE监测下应用Amplatzer堵塞器经心导管关闭ASD.结果48例获得成功,由于术前经胸超声心动图诊断不准确,9例未成功.ASD的经胸超声测量值与球囊伸展径间差异有显著性意义(P＜0 01),但相关(r=0.87,P＜0.01);TEE测值与球囊伸展径间高度相关(r=0.93,P＜0.01).术后即刻TEE检查显示7例患者存在微量残余分流.结论TEE可以准确地显示ASD的大小、部位及其边缘的解剖形态,有利于术前病例的选择、术中闭合器的安置及术后即刻疗效的判定,是一种安全、有效的监测手段.     

Intracardiac thrombus traversing a patent foramen ovale: impending paradoxical embolism demonstrated by transoesophageal echocardiography

Paradoxical embolism is a rare but potentially catastrophic complication of deep venous thromboses and pulmonary embolism. We describe a patient in whom transoesophageal echocardiography demonstrated a large clot traversing the atrial septum which was successfully removed by surgery.     

经胸超声心动图在卵圆孔未闭封堵术中的应用

目的 探讨经胸超声心动图（TFE）在卵圆孔未闭（PFO）封堵术中的应用价值。方法回顾性分析43例PFO患者在封堵术前、术中及术后的TTE图像特征。结果 TTE在术前可清晰显示PFO的大小、形态和分流方向,能帮助介入医师选择合适的封堵器;术中可准确地评价PFO患者封堵器的位置、形态及其与周边的临近结构关系;术后可有效地监控PFO患者预后情况。结论 TTE在PFO封堵术前确诊、术中引导、监护及术后随访均具有重要的作用。     

Transcatheter closure of secundum atrial septal defects in adults with the Amplatzer septal occluder: Intermediate and long-term results

AIMS: Transcatheter closure of secundum atrial septal defects (ASD) with the Amplatzer septal occluder (ASO) has become a standard procedure in most pediatric and adult patients. However, data addressing success rates and outcome in adults is limited. We sought to define the safety profile of the ASO in the community setting and identify the percentage of adults with ASD amenable to percutaneous closure with the ASO. METHODS: We performed a retrospective analysis of patients' records referred for transcatheter ASD closure from 1999 through 2005 at a single institution. Patients were evaluated with right heart catheterization and underwent closure of the ASD according to standard indications under transesophageal and fluoroscopic guidance. RESULTS: Two hundred and seven consecutive patients were taken to the catheterization laboratory for hemodynamic evaluation and possible interventional closure of an ASD. Of those patients, 18 were excluded because the defect and the left-to-right shunt were hemodynamically insignificant (n = 7) or because there was no distinct defect, but instead a multi-perforated septum (n = 11). Nineteen cases were excluded for anatomic reasons. Of the remaining 170 patients, ASO implantation was attempted and successfully performed in 166 (83% of 200 patients with hemodynamically significant ASD). Complications occurred in 11 cases (6.5%) (device dislocation = 4, transient ST-segment elevation = 4, TIA = 1, hemoptysis = 1, pericardial effusion = 1); none of these events were associated with long-term sequelae. During a median follow-up period of 13 months (range 6-80) there were no major clinical events. CONCLUSIONS: More than 80% of adults with a distinct, hemodynamically significant secundum ASD can be successfully treated with the ASO. The immediate success rates are excellent and follow-up data suggest that the ASO is a safe device well suited for transcatheter ASD closure.     

实时三维超声心动图在Ⅱ孔型房间隔缺损介入治疗中的应用

目的前瞻性观察实时三维经胸超声心动图(RT 3-D TTE)在Ⅱ孔型房间隔缺损(Ⅱ ASD)介入治疗中的应用价值.方法对13例Ⅱ ASD患者在介入治疗术中,同时行RT 3-D TTE和经食管超声心动图(TEE)全程监控导管走行、测量ASD直径、观察封堵伞位置,并对测量结果进行比较分析.结果 RT 3-D TTE和TEE对13例患者均可达到同样的影像辅助监测作用,在对ASD直径的测量中,球囊测量均值为(20.08±3.84)mm、TEE为(19.0±3.87)mm、RT 3-D TTE为(19.38±3.01)mm,三者间相比无显著性差异(P>0.05),但回归方程中发现RT 3-D TTE的估计标准误(SEE=1.65)较TEE的估计标准误(SEE=1.95)小.结论 RT 3-D TTE检查无创、无痛苦、图像直观,显示了较强的临床实用性,但其无法使用多普勒对残余分流情况进行评价.     

经胸超声心动图引导Amplatzer封堵器经心导管封堵房间隔缺损及疗效观察

目的探讨经胸超声心动图(TTE)在引导Amplatzer封堵器经心导管封堵继发孔型房间隔缺损中的作用,并评价其初步疗效。方法运用TTE选择出适于封堵术的继发孔型ASD患者36例,并配合X线指导封堵过程,选择合适型号的封堵器并观察随访疗效。结果TTE引导封堵技术成功率100%。术后封堵完全闭合率91.7%(33/36),1个月为94.4%(34/36),3个月以上为100%。TTE所测房缺的最大直径明显小于球囊伸展径(P<0.01),但二者高度相关(r=0.93),为封堵器型号的选择提供了依据。本组36例术后随访,均未发现封堵器结构断裂、移位、血栓形成等并发症发生。结论运用TTE引导Amplatzer封堵器经心导管封堵继发孔房缺是一种安全、有效的非外科手术方法,近中期疗效可靠。较之经食管超声运用范围更广,操作更简便、安全,更易掌握及推广。