Thrombus formation on an atrial septal defect closure device: a case report and review of the literature.

We report on a case of a mobile left atrial thrombus formation on an atrial septal defect occluder system (28 mm StarFLEX-Occluder) despite 6 months of postprocedural anticoagulation with phenprocoumon and platelet antiaggregation with aspirin in a 69-year-old woman. The closure was performed because of a significant left to right atrial shunt (Qp/Qs 1.8) with enlargement of the right atrial and ventricular cavities and impairment of right ventricular function in the presence of persistent atrial fibrillation and chronic heart failure (NYHA II-III). The 6-month follow up by transoesophageal echocardiography (TEE) revealed the floating thrombus located at the left atrial side of the occluder.     

Successful Retrieval of embolized atrial septal defect occluder and patent foramen ovale closure device using novel coronary wire trap technique

The use of atrial septal device occluders can lead to device embolization. This major complication can occur due to loose margins, deficient aorta, or thin and floppy posterior rim. Device embolization most often occurs after device release, and retrieval is essential. Many devices, including snare and bioptome, have been utilized for retrieval. However, performing these procedures can be difficult and time consuming. Failure to retrieve the embolized device requires open heart surgery. We report a novel and easy to perform method, “coronary wire trap technique,” in the event of retrieval failure using conventionally available devices and snare, thereby preventing open‐heart surgery. © 2017 Wiley Periodicals, Inc.     

Defect closure in the lipomatous hypertrophied atrial septum with the amplatzer muscular ventricular septal defect closure device: A case series

Variations in the anatomy of the atrial septum can confound the transcatheter closure of atrial septal defects and patent foramen ovale. While lipomatous hypertrophy of the atrial septum is not frequently encountered, attempts to use standard atrial septal occlusion devices in such patient can lead to malapposition and continued shunt. Some operators have suggested that atrial septal hypertrophy is a relative contraindication to transcatheter‐based closure techniques. We present a novel technique exploiting the features of the Amplatzer muscular ventricular septal defect occluder to treat atrial septal defects in the setting of lipomatous hypertrophy of the atrial septum in two patients. © 2011 Wiley‐Liss, Inc.     

Percutaneous patent foramen ovale and atrial septal defect closure in adults: results and device comparison in 100 consecutive implants at a single center.

Closure of interatrial septal defects with percutaneous devices is increasingly common. However, the indications for closure and techniques for device implantation are diverse. We reviewed our first 100 consecutive implants to assess and compare the indications, results, complications, and evolution of techniques for percutaneous patent foramen ovale (PFO) and atrial septal defect (ASD) closure. The mean age of patients was 52 years and 70% were female. Paradoxical embolism was the predominant indication (94%) for PFO closure and significant left-to-right shunt was the most frequent indication (89%) for ASD closure. Implantation success was 94% with major complications in 3 patients (2.8%). Transesophageal echocardiography was utilized in the initial 27 procedures and then replaced by intracardiac echocardiography in subsequent ones, with an associated reduction in procedure and physician time. During 6 months of follow-up, 3 patients were readmitted for atrial arrhythmias (2 patients) and an MRI-negative neurologic event (1 patient). Echocardiography at 6 months in 83% of the PFO patients revealed moderate and severe positive contrast studies for right-to-left shunting in one third of patients, with differences between devices and insertion techniques. This single-center experience with percutaneous device closure of PFO and ASD in adults demonstrates excellent results with few complications.     

Electrocardiographic changes and arrhythmias following percutaneous atrial septal defect and patent foramen ovale device closure

Objectives: To compare pre‐ and post‐procedure electrocardiograms (ECGs) in a large cohort of patients after percutaneous closure of atrial septal defect (ASD) and patent foramen ovale (PFO). Background: Percutaneous device closure of ASD or PFO is commonplace. Conduction and rhythm anomalies associated with percutaneous device placement have been reported. Methods: We reviewed records for all patients who underwent percutaneous device closure of ASD or PFO at our institution from 1999 to 2008. Pre‐procedure ECG and Holter studies were compared to available short term (<2 months after placement) and intermediate follow‐up (>2 months) ECG or Holter. Results: Pre‐ and post‐procedural ECGs were available in 610 patients (305 females, average age 50 ± 18.1 years, range 1–91 years, 384 PFO, 184 ASD, 42 with multiple defects, mean device size 16 mm, range 5–38 mm). We report an incidence of 5.2% (32/610) of arrhythmias in the 4 months following device placement, including 29 patients with atrial tachyarrhythmias (ATs, 22 fibrillation, 7 flutter), 1 with junctional tachycardia, and 2 with heart block. Among other findings, the average P‐wave duration was increased on intermediate follow‐up as compared to early follow‐up (P < 0.001). Development of new‐onset 1st degree AV Block after the procedure was associated with an increased risk of ATs post‐procedure (P < 0.0001). Conclusion: We report a low risk of clinically significant post‐procedure arrhythmias after device placement. Clinically significant heart block occurred in only two patients (0.3%). Changes in several markers of atrial conduction were found, suggesting an effect of device closure on intra‐atrial conduction. © 2011 Wiley‐Liss, Inc.     

Effect of atrial septal mobility on transcatheter closure of interatrial communications

BACKGROUND: Transcatheter techniques have evolved as alternatives to surgical closure of interatrial communications due to its less invasive nature and low morbidity. The technique may be limited by the inability to deploy the device and, thus, may be complicated by significant residual shunting. Mobile or redundant septal tissue has been implicated as a possible cause of unsuccessful closure. METHODS: To determine if atrial septal hypermobility precludes successful transcatheter device closure of interatrial communications, 69 patients (mean age 46.4 +/- 17.5 years [male:female ratio 34:35]) with periprocedural transesophageal echocardiograms were reviewed. Septal excursion was defined as the maximal transit of the interatrial septum between either side of the plane connecting the superior and inferior attachment points. Unsuccessful closure was defined as subsequent cardiac surgery to close the defect, inability to deploy the device, recurrent attempts at closure, device malalignment, residual shunting greater than mild in degree on follow-up transthoracic study, and procedural complications. RESULTS: Reasons for closure were the following: embolic events (n = 48); platypnea/orthodeoxia (n = 15); atrial septal defect with right ventricular dilatation and paroxysmal atrial tachycardia (n = 2); atrial septal defect (n = 3); and prophylactic patent foramen ovale closure in a scuba diver (n = 1). Successful closure occurred in 76% of patients (n = 53). Compared with those patients with successful transcatheter closure, the mean septal excursion in patients with failed closure was 0.66 +/- 0.56 cm versus 0.76 +/- 0.47 cm (P = not significant [NS]). CONCLUSION: Our results do not support the concern that exaggerated septal mobility compromises successful device closure of interatrial communications.     

Transgastric: A forgotten view for atrial septal defect device closure procedures?

Percutaneous closure of an atrial septal defect in the cardiac catheterization laboratory requires noninvasive imaging to assist in characterization of the atrial septal defect and deployment of the device. Transesophageal echocardiography is the modality most often used in these circumstances. Transesophageal echocardiographic guidelines exist for the assessment and guidance for atrial septal defect closures, but these guidelines do not mention transgastric views. In this case, we demonstrate that transgastric views are helpful in describing the atrial septal defect, especially as it concerns the inferior vena cava rim.     

Thrombosis after septal closure device placement: a review of the current literature.

Thrombus formation has been described for all types of commercially available transcatheter septal occlusion devices. Most reports have been single-institution case studies. Screening for hypercoagulable conditions prior to device placement and anticoagulation after device deployment has been variable. The objective of this study was to synthesize the current experience with device thrombosis; the Medline database from 1980 until 2004 was searched. Seventeen articles identified 54 unique patients with device thrombosis. Thrombus developed on eight different types of transcatheter devices. All commercially available devices had at least one reported case of thrombosis. Patient mean age was 44.2 +/- 9.8 years. Thrombosis was diagnosed at a mean of 5 months after device deployment. Prior to device placement, 12 patients had normal coagulation evaluations and 5 had coagulopathies. For 37 patients, no mention was made in the report of coagulation studies. Prior to device thrombosis, 26 patients received aspirin and clopidogrel, 15 patients received aspirin alone, 8 received warfarin, 2 heparin alone, 1 aspirin and warfarin. One patient with hemophilia A received no anticoagulation and in one case treatment prior to thrombosis was not reported. After device thrombosis, 35 patients were treated with warfarin with thrombus resolution, 2 had successful lytic therapy, 1 was treated with heparin alone. Sixteen patients had surgical explantation of the device. Septal occlusion device thrombosis is rare. All types of commercially available devices have been associated with thrombosis. All patients should have early (< or = 3 months) echocardiographic surveillance for device thrombosis. Thorough coagulation evaluation is imperative prior to transcatheter device placement.     

Cor triatriatum dextro iatrogenica: an unusual complication of atrial septal defect closure device

We present a case of a rare complication of atrial septal defect (ASD) device closure causing cor triatriatum dextro iatrogenica. A 29-year-old female presented with sudden onset dysarthria and ataxia and was found to have basilar and thalamic infarcts. Further evaluation using transthoracic echocardiography revealed an ASD which was repaired using the Gore HELEX septal occluder. Transesophageal echocardiography done after 2 months of ASD closure revealed an interesting finding termed cor triatriatum dextro iatrogenica. We briefly describe the case and discuss the relevant literature.     

Live three-dimensional transthoracic echocardiographic assessment of transcatheter closure of atrial septal defect and patent foramen ovale

We report the usefulness of live three-dimensional transthoracic echocardiography in the accurate assessment of the morphology and efficacy of Amplatzer transcatheter devices used for closure of atrial septal defect and patent foramen ovale.     

Right atrial appendage aneurysm complicated with atrial septal defect: A rare case report

Right atrial appendage aneurysms (RAAAs) are rare heart malformations, presenting as isolated anomalies or co-existing with other structural heart diseases. We describe a rare case of RAAA complicated with an atrial septal defect (ASD). The diagnosis was established using transthoracic echocardiography and confirmed using cardiac magnetic resonance imaging. To treat the ASD and reduced right atrium volume load, ASD transcatheter closure was performed. On echocardiography performed 3 months post discharge, the RAAA was observed to have reduced in size compared to that presurgery. Six years later, she was in good condition without any adverse events.     

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.     

Transhepatic closure of atrial septal defect and assisted closure of modified Blalock/Taussig shunt.

The details of transhepatic closure of moderate - large size atrial septal defect as well as assisted closure of a modified Blalock Taussig shunt in a 2 1/2 year old patient with occluded femoral vessels are discussed. The technical variations as well as the potential advantages of this route are outlined.     

Patent foramen ovale in a large population of ischemic stroke patients: diagnosis, age distribution, gender, and race

BACKGROUND: Patent foramen ovale (PFO) is a well-recognized risk factor for ischemic strokes. The true prevalence of PFO among stroke patients is still under debate. Transesophageal echocardiography (TEE) is the "gold standard" in diagnosing PFO but the physiology requires right-to-left atrial shunting. In this report, we evaluate the prevalence of PFO in a diverse group of ischemic stroke patients studied by TEE. METHODS: TEE of 1,663 ischemic stroke patients were reviewed for cardiac source of embolism, including PFO and atrial septal aneurysm (ASA). Agitated saline bubble injection was performed to look for right to left atrial shunting. Success of maneuvers to elevate right atrial pressure (RAP) was noted by looking at the atrial septal bulge. RESULTS: Among 1,435 ischemic stroke patients analyzed, the presence or absence of PFO could not be determined in 32.1% because bulging of the septum could not be demonstrated in patients with negative contrast study despite aggressive maneuvers to elevate RAP. Of the remaining 974 patients, 294 patients (30.2%) had a PFO. The mean age was 61.5 years in both groups, with a bimodal distribution of PFO and the highest prevalence occurring in < or =30-year-old group. Prevalence of PFO was similar in men (32.4%) and women (28.15%, P = 0.15); and in Caucasian (32.1%) and African American (27.7%; P = 0.15). ASA was present in 2.02% and hypermobile septum in 2.49% of the 1,435 patients. PFO was seen in 79.3% of the patients with ASA. CONCLUSION: Successful elevation of RAP cannot be achieved in a significant number of patients undergoing TEE and determination of PFO may be difficult. In our series, the true prevalence of PFO among ischemic stroke patients was 30.2% taking into account only those patients who showed no shunting despite bulging of the atrium septum into the left atrium (PFO absent group) during the contrast study. There was no gender or racial difference in the prevalence of PFO, but there was a bimodal distribution in prevalence with age.     

Staged percutaneous atrial septal defect closure and pulmonic balloon valvuloplasty in an adult with congenital heart disease

Combined atrial septal defect and pulmonic stenosis, while a common occurrence in children, is relatively uncommon in adults. There is no widely accepted order in which the defects should be corrected. We report a case that highlights the hemodynamics and the technical dilemma of deciding which lesion to correct first. © 2008 Wiley‐Liss, Inc.