David J. Waight

Transcatheter closure of atrial septal defects and patent foramen ovale under intracardiac echocardiographic guidance: Feasibility and comparison with transesophageal echocardiography

Transesophageal echocardiography (TEE) has been employed successfully for guiding transcatheter device closure of secundum atrial septal defect (ASD) and patent foramen ovale (PFO). However, the use of TEE for device closure requires general anesthesia. Intracardiac echocardiography (ICE) can provide similar anatomical views that might replace the use of TEE for device closure. Eleven patients (eight female/three male) with secundum ASD and PFO associated with strokes underwent attempts at transcatheter closure of their defects under sequential TEE and ICE guidance (six patients) and under ICE alone (five patients). The ages of the patients ranged from 6.6 to 74.7 yr, and their weights ranged from 23 to 124.5 kg. The sizes of the defects, as measured by TEE (six patients), ranged from 3 to 27 mm and, as measured by ICE (11 patients), from 3 to 27 mm. The balloon‐stretched diameter of the ASD, as measured by TEE (six patients), ranged from 16 to 38 mm and, as measured by ICE (11 patients), from 16 to 35 mm. Both techniques correlated well for the measured two‐dimensional diameter and for the balloon‐stretched diameter (r = 0.97 and 0.98, respectively). Both TEE and ICE provided similar views of the defects and the various stages of device deployment. Owing to the proximity of the left atrium to the esophagus, however, the images obtained by ICE were more helpful and informative than those obtained by TEE. All patients experienced successful device placement (six patients under both TEE and ICE; five patients under ICE guidance alone); complete closure of the defects was effected in nine patients, whereas two patients had small residual shunts. There were no complications. We conclude that ICE provides unique images of the atrial communications and measurements similar to those obtained by TEE. ICE potentially could replace TEE as a guiding imaging tool for ASD and PFO device closure, thus eliminating the need for general anesthesia. Cathet Cardiovasc Intervent 2001;52:194–199.

Perventricular device closure of muscular ventricular septal defects on the beating heart: technique and results

OBJECTIVE Both surgical management and percutaneous device closure of muscular ventricular septal defects have drawbacks and limitations. This report describes our initial experience with intraoperative device closure of muscular ventricular septal defects without cardiopulmonary bypass in 6 consecutive patients. METHODS A median sternotomy or a subxiphoid minimally invasive incision was performed. Under continuous transesophageal echocardiographic guidance, the right ventricle free wall was punctured, and a wire was introduced across the largest defect. The Amplatzer (AGA Medical Corporation, Golden Valley, Minn) muscular ventricular septal defect occluding device (a self-expandable double-disk device) was used. An introducer sheath was fed over the wire, with the sheath tip positioned in the left ventricle cavity. The device was then advanced inside the sheath and deployed by retracting the sheath. Associated cardiac lesions, if any, can then be repaired during cardiopulmonary bypass. A similar technique can also be applied for periatrial closure of complex atrial septal defects. RESULTS The initial 6 patients are presented. Cardiopulmonary bypass was not needed in any patient for placement of the device and needed in 4 patients for repair of concomitant malformations only (double-outlet right ventricle, aortic arch hypoplasia, pulmonary artery band removal). No complications from using this technique occurred. Discharge echocardiograms showed no significant shunting across the ventricular septum. CONCLUSIONS Perventricular closure of multiple muscular ventricular septal defects is safe and effective. We believe that this could become the treatment of choice for any infant with muscular ventricular septal defects or any child with muscular ventricular septal defect and associated cardiac defects.

Comparison of transcatheter closure of secundum atrial septal defect using the Amplatzer septal occluder associated with deficient versus sufficient rims

To evaluate the feasibility of transcatheter closure of secundum atrial septal defects (ASDs) associated with deficient rims (<5 mm) using the Amplatzer septal occluder (ASO), 23 patients (median age 10.7 years) underwent an attempted transcatheter closure. The patients had a deficient anterior rim of 0 to 4 mm (n = 20), an inferior rim of 2 mm (n = 2), or a posterior rim of 4 mm (n = 1) as assessed by transesophageal echocardiography (TEE) or intracardiac echocardiography (ICE). Forty-eight patients with sufficient rims (>5 mm) who underwent closure served as controls. There were no differences between the 2 groups in ASD stretched diameter and device size (p >0.05). Of 23 patients with deficient rims, 17 (74%) had immediate complete closure compared with 44 of 48 patients (92%) with sufficient rims (p <0.05). At 24-hour and 6-month follow-up, the complete closure rates were not significantly different between the 2 groups (91% for patients with deficient rims vs 94% for patients with sufficient rims at 24 hours and 100% vs 93% at 6 months, respectively). The fluoroscopic time and procedure time were longer in patients with deficient rims (13 +/- 7 and 72 +/- 26 minutes, respectively) compared with those with sufficient rims (10 +/- 4 and 61 +/- 22 minutes, respectively). No major complications were encountered either during or after the closure procedure in both groups. Thus, transcatheter closure of ASDs associated with small anterior, inferior, or posterior rims is feasible using an ASO. Long-term follow-up data are still needed to assess long-term safety and efficacy.

Catheter therapy of Swiss cheese ventricular septal defects using the Amplatzer muscular VSD occluder.

The medical and surgical management of patients with multiple muscular ventricular septal defects (VSDs) is associated with morbidity and mortality. Three children with Swiss cheese VSDs were treated with transcatheter occlusion of their multiple defects using the Amplatzer muscular VSD occluder. Seventeen defects were closed in five catheterization procedures. One patient had three devices placed in two procedures, the second had five defects closed in one procedure, and the third had nine defects closed in two procedures. Two patients had previously been treated with pulmonary artery banding and required subsequent surgical band removal. There was immediate reduction in the left‐to‐right shunting and clinical improvement in all patients. Complications included the need for blood transfusion during the two longest procedures and tricuspid valve regurgitation in one. Transcatheter occlusion of multiple VSDs is an acceptable alternative or adjunct to surgical therapy for these complex patients. Cathet Cardiovasc Intervent 2002;55:355–361.

Closure of patent foramen ovale in patients with orthodeoxia-platypnea using the amplatzer devices

We present a series of four patients with orthodeoxia‐platypnea who underwent successful transcatheter closure of their patent foramen ovale using the Amplatzer devices (Amplatzer septal occluder/Amplatzer PFO occluder). The average saturation increased from 81% to 96% with complete resolution of symptoms. The Amplatzer devices are safe and effective treatment options for patients with orthodeoxia‐platypnea. Cathet. Cardiovasc. Intervent. 50:195–198, 2000.

Transcatheter closure of patent foramen ovale in patients with paradoxical embolism: intermediate-term risk of recurrent neurological events.

Closure of patent foramen ovale (PFO) has been proposed as an alternative to anticoagulation in patients with presumed paradoxical emboli. We report our preliminary intermediate results of patients who underwent transcatheter PFO closure for paradoxical embolism using DAS‐Angel Wings occluder or Amplatzer devices. Eighteen patients (8 male/10 female) underwent catheter closure of their PFOs at a median age of 42 years. The complete closure rate was 67% immediately after the procedure and 100% at a mean follow‐up interval of 2.2 ± 1.8 years. The mean fluoroscopy time and procedure time in the Amplatzer group were 8.5 ± 3.2 min and 65 ± 21 min, respectively, which were significantly shorter than those of DAS‐Angel Wings group (18.9 ± 4.7 min and 137 ± 28 min, respectively). There were no recurrent embolic neurological events following device placement in this subset of patients. No complications were encountered either during or after the closure procedure. In conclusion, transcatheter closure of PFO seems to be an effective alternative therapy in the prevention of presumed paradoxical emboli. Further study is needed to identify patients most likely to benefit from this intervention. Cathet Cardiovasc Intervent 2002;55:189–194.

Successful Combined Orthotopic Liver Transplant and Transcatheter Management of Atrial Septal Defect, Patent Ductus Arteriosus, and Peripheral Pulmonic Stenosis in a Small Infant with Alagille Syndrome

We report on a 4-kg infant with Alagille syndrome and congenital heart disease consisting of atrial septal defect (ASD), patent ductus arteriosus (PDA), and severe peripheral pulmonic stenosis. He underwent successful orthotopic liver transplant along with catheter closure of the ASD and PDA using the Amplatzer device and placement of Palmaz stents in both pulmonary arteries.