Transhepatic closure of patent foramen ovale

Transhepatic right heart catheterization is an uncommon procedure for adult interventional cardiologists. We report its successful use for closure of a patent foramen ovale in an elderly patient without femoral vein access. Also described is a novel method of using a vascular plug to achieve hemostasis of the hepatic venous access site. © 2009 Wiley‐Liss, 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.     

Transcatheter patent foramen ovale closure using the Premere PFO occlusion system.

OBJECTIVES: To evaluate the safety and efficacy profile of the new Premere patent foramen ovale (PFO) occlusion system. BACKGROUND: Several different devices have been used so far for transcatheter PFO closure but no data has been published so far on the efficacy and safety of the Premere PFO occlusion system. METHODS: Since September 2005, 15 patients (seven males, eight females; mean age 51.2 +/- 10.8 years) at our institution underwent transcatheter PFO closure because of cryptogenic stroke, using the Premere PFO occlusion system. The procedure was performed under fluoroscopic and transesophageal echocardiographic (TEE) guidance in all patients. Seven patients (47%) had an associated atrial septal aneurysm and two patients had had >1 stroke. Five patients (33%) had an associated thrombophilia, whereas three patients (20%) had a diagnosis of migraine headache with aura, by the referring neurologist. Residual shunt was assessed immediately after and 1 month (only in 11 patients) after the procedure by both transcranial Doppler and TEE. RESULTS: Premere PFO devices could be implanted in all patients (20 mm size in seven patients, 25 mm size in eight). Fluoroscopy time was 7.3 +/- 1.9 and procedural time was 11 +/- 3 min (range 7-17 min), reflecting our initial learning curve with this device. No complication occurred during the procedure or at follow-up. A residual shunt was noted immediately after the procedure in eight patients (53%) and at 1 month in 4/11 patients (36%). Residual shunt was mild in all patients. After a median follow-up of 4.2 months (0.2-5.8 months), no patient had a recurrent stroke. All patients with migraine headache with aura had resolution of symptoms. CONCLUSIONS: Our preliminary experience with the Premere PFO occlusion system shows that this device is safe and effective.     

Utility of on‐line three‐dimensional transesophageal echocardiography during percutaneous atrial septal defect closure

Key echocardiographic assessments during percutaneous atrial septal defect (ASD) closure are the maximal defect diameter, the presence or absence of tissue rims, and the spatial relationships between the implanted device and cardiac structures. These assessments drive device selection and may help identify situations that may place a patient at risk for device erosion or other complications. On‐line three‐dimensional (3D) transesophageal echocardiography (TEE) enables the rendering of nearly unlimited tissue planes within an acquired pyramidal‐shaped volume with minimal image post‐processing. We present several cases of percutaneous ASD closure guided by on‐line 3D TEE imaging that highlight the potential advantages of this new imaging technology. © 2009 Wiley‐Liss, Inc.     

A novel technique using a steerable guide catheter to successfully deliver an Amplatzer septal occluder to close an atrial septal defect

Correct positioning of an Amplatzer ASD occluder can be difficult in vertical hearts or in those with diminutive or missing septal rims. In this report we describe the use of a steerable sheath to position the device in the plane of the ASD to achieve success. © 2008 Wiley‐Liss, 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.     

Iatrogenic atrial septal defect, erosion of the septum primum after device closure of a patent foramen ovale as a new medical entity.

Iatrogenic atrial septal defects are described in 2 patients. They occurred after implantation of Amplatzer occluders to close a patent foramen ovale. While device erosions to the extra-atrial space have been described, erosion induced atrial septal defects are a new medical entity. They may be fairly common in the situation of an atrial septal aneurysm whipping the rim of the device incessantly. They are clinically silent and benign and require echocardiography for detection. A second device solved the problem in the cases described.     

Late free atrial wall rupture after percutaneous atrial septal defect closure and transvenous pacemaker implantation

We report a remarkable case of right atrial rupture, 3 years after transcatheter closure of a secundum atrial septal defect, and 7 months after permanent transvenous two‐chamber pacemaker implantation. The etiology of the rupture remains unclear, but the presence of the two intracardiac devices is probably not coincidental. © 2008 Wiley‐Liss, Inc.     

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.     

Feasibility of transcatheter closure in unselected patients with secundum atrial septal defect,using amplatzer devices and a modified sizing balloon technique

Objectives: We aimed to assess (1) the role of surgical versus transcatheter closure techniques and (2) the impact of a modified implantation technique to optimize closure of secundum septal defects with the Amplatzer device. Background: Despite several comparative studies, the respective roles of surgical and transcatheter closure are not clarified. Additionally, the impact of modified method of implantation on device closure remains unknown. Methods: Fifty‐seven unselected patients were referred for secundum atrial septal defect closure in 2009, at a median age and weight of 27.5 (0.8–88) years and 40.6 (5.6–97) kg, respectively. Transcatheter closure was attempted in 53 cases under transesophagal echocardiography guidance in children (n = 28) and intracardiac echocardiography guidance in adults. If standard closure failed, a sizing balloon catheter inflated in the left atrium was used as a support to secure the position of the device upon deployment. Results: Fifty of the 57 cases (88%) were successfully closed with a median Amplatzer Septal Occluder size of 20 (10–40) mm, using the sizing balloon technique in eight (16%) cases. No major complication occurred. A trivial residual shunt remained in two patients (4%) whereas a mild mitral regurgitation appeared in one. By univariate analysis, a deficient superior–posterior rim and a large defect (>15 mm²/m²) were associated with the use of the sizing balloon technique (P = 0.04 and 0.03, respectively). A deficient superior–posterior rim and pulmonary hypertension were associated with failure to close the defect (P = 0.02 and 0.03, respectively). Conclusion: The majority of secundum atrial septal defect is amenable to transcatheter closure, using a modified implantation technique in 16% of cases. © 2011 Wiley‐Liss, Inc.     

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.     

Suture-mediated closure of a patent foramen ovale during surgery without cardiopulmonary bypass.

A patent foramen ovale (PFO) is associated with an increased risk of recurrent ischemic strokes and transient ischemic attacks due to paradoxical emboli in patients with prior neurological events. We report a case of a surgical suture-mediated of a PFO closure without cardiopulmonary bypass in a patient with recurrent cerebral ischemic events, who was intolerant of medical therapy, was a poor candidate for catheter-based PFO closure, and presented as a potentially high risk for poor wound healing from traditional surgical closure.