Roberta M. Bini

Early and late complications associated with transcatheter occlusion of secundum atrial septal defect

OBJECTIVES The goal of this study was to report the early and late complications experienced in atrial septal defect (ASD) transcatheter closure. BACKGROUND Atrial septal defect transcatheter occlusion techniques have become an alternative to surgical procedures. A number of different devices are available for transcatheter ASD closure. The type and rate of complications are different for different devices. METHODS Between December 1996 and January 2001, 417 patients (mean age: 26.6 +/- 19 years) underwent transcatheter occlusion of secundum type ASD. Complications were categorized into major and minor. Two different devices were used: the CardioSEAL/STARFlex in 159 patients and the Amplatzer septal occluder in 258 patients. RESULTS Thirty-four patients experienced 36 complications during the hospitalization (8.6%, 95% confidence interval: 6.1% to 11.1%). Ten patients underwent elective surgical repair because of device malposition (three patients) or device embolization (seven patients). Twenty-four patients experienced 25 minor complications: unsatisfactory device position or embolization. Devices were retrieved using a gooseneck snare and/or a basket; 11 patients experienced arrhythmic problems. Other complications were: pericardial effusion, thrombus formation on the left atrial disc, right iliac vein dissection, groin hematoma, hemorrhage in the retropharynx and sizing balloon rupture. Two patients had late complications: peripheral embolization in the left leg one year after implantation of an Amplatzer device and sudden death 1.5 year later. CONCLUSIONS Our series of patients with ASD by transcatheter occlusion shows that the procedure is safe and effective in the vast majority of cases. To further reduce the complications rate, the criteria of device selection according to ASD morphology and some technical tips during implantation are discussed.

Congenital pulmonary vein stenosis

Congenital pulmonary vein stenosis is a rare and serious form of congenital heart disease. Between 1969 and 1982 10 patients with this lesion were studied. In 2 patients the condition was diagnosed at autopsy; these patients died before the presence of congenital heart disease was suspected. Of the 8 in whom the condition was diagnosed during life, it was suspected clinically in 6 and found unexpectedly at cardiac catheterization in 2. All underwent operation, and 5 were hospital survivors. In all survivors rapid and progressive restenosis of the pulmonary veins occurred over the next several months. Three of the 5 underwent reoperation, but progressive restenosis recurred and all eventually died of this condition. Thus, despite partial surgical relief of pulmonary vein stenosis, the lesion is apparently one of relentless progression. No surgical repair has been successful in the cure or long-term palliation of this lethal lesion.

Investigation and management of primary cardiac tumors in infants and children.

Seven children with primary cardiac tumors are discussed. The diagnosis was achieved by cardiac catheterization in all seven patients. In four patients, surgical excision was undertaken with one long-term good result. One of the other three surgical patients died of acute heart failure at the discontinuation of cardiopulmonary bypass. One of the other two surgical patients died suddenly late postoperatively, presumably from arrhythmia. The other, affected by fibrosarcoma, also died suddenly while undergoing chemotherapy. The histologic findings on the tumor masses were available in six patients. There were three rhabdomyomas, one fibrosarcoma, one fibroma and one hamartomatous mass. In one patient with tuberous sclerosis, a presumptive diagnosis of rhabdomyoma was made clinically on the basis of multiple masses infiltrating the left ventricle. Two-dimensional echocardiography is the best noninvasive tool to determine the extent and location of the tumor and suitability for surgery. When surgery is indicated, cardiac catheterization for pressure data is also required. Surgery is recommended in symptomatic solitary lesions that most likely are fibromas and have an overall good surgical outcome.

Usefulness of transesophageal echocardiography in the pediatric catheterization laboratory

Transesophageal echocardiography was performed in 51 children (aged 2 to 14 years, mean 4; weight 9 to 50 kg, mean 21) undergoing elective diagnostic or therapeutic cardiac catheterization. The interventional procedures were percutaneous balloon dilation of pulmonary (n = 8) and aortic (n = 2) valve stenosis, percutaneous closure of patent ductus arteriosus (n = 8), and attempted occlusion of Potts anastomosis by the double umbrella device (n = 1). The diagnostic catheterizations were performed on preoperative children of whom 5 had undergone previous palliative procedures. Precise placement of the balloon across the valve, timing of balloon inflation and deflation according to real-time monitoring of ventricular function and immediate evaluation of results and complications were accomplished with transesophageal monitoring. The exact position of distal and proximal umbrellas of patent ductus occlusive devices was checked on transesophageal imaging and completeness of occlusion controlled on color Doppler. The only relevant information in the preoperative cases was the detection of a septic thrombus in a severely ill patient. With more experience and smaller probes, transesophageal echocardiography may become a new method of monitoring cardiac catheterization also in smaller children where it may reduce duration of the procedure and amount of contrast material.

Visualization of pulmonary vein obstruction by pulmonary artery wedge injection

SummaryOne of the major postoperative complications of total anomalous pulmonary venous connection is obstruction of the pulmonary veins. This event may be apparent immediately after surgery when it is usually due to congenitally obstructed veins or later when it may be the result of failure of commensurate growth of the left atrium-common vein anastomosis or of scarring at the anastomotic site. The exact location of the obstruction becomes, then, of paramount importance in deciding if the patient can be helped by further surgery.At cardiac catheterization, pulmonary artery wedge injection was the only angiographic technique that visualized the site and degree of pulmonary venous obstruction in the case reported here.

Spectrum of hearts with one underdeveloped and one dominant ventricle

SummaryHearts with one underdeveloped and one dominant ventricle form a spectrum of anomalies extending from the heart with two clearly adequate chambers to those with a true single ventricle. An angiographic concept of grouping such hearts is presented. 129 patients with unequal ventricles underwent catheterization and cineangiography between 1974 and 1983. The age at first catheterization ranged from one day to 24 years (mean 3.9 years). Male-female ratio was 2:1. Five groups of hearts (with their relative frequencies in the spectrum) were established: (1) dominant left ventricle (53%); (2) dominant right ventricle (20%), each with normally related chambers; (3) dominant left ventricle (20%); (4) dominant right ventricle (3%), each with ventricular inversion; (5) true single ventricle (5%). The incidence of atrial anatomy, venous return, intracardiac connections and associated lesions within each group was assessed. From the standpoint of deranged physiology as well as surgical implications there are more similarities than differences among these hearts. The fact that one ventricle will not generate an adequate stroke volume after repair is overwhelmingly more important than most other considerations. For the diagnostic and surgical approach, we believe that the system offers many advantages.

CT diagnosis of false aneurysm of the pulmonary artery not demonstrated by angiography.

A 17-year-old patient with tricuspid atresia, palliatively corrected by a right Glenn and a left Potts anastomosis during his early childhood and a banding of the left pulmonary artery 6 years ago, developed a false aneurysm of the left pulmonary artery secondary to the erosion of the band fabric through the vascular wall with subsequent thrombosis, infection, and leakage. The diagnosis was confused by both chest roentgenography and angiography but was accurately made by postcontrast computed tomography (CT). We stress the importance and usefulness of CT in the diagnosis of a false aneurysm, not demonstrated by angiography.

Pericardial cyst diagnosed by two-dimensional echocardiography and computed tomography in a newborn

SummaryA one-day-old full-term female infant with massive “cardiomegaly” developed marked respiratory distress soon after birth. The two-dimensional (2D) echocardiogram demonstrated a 4×5-cm cystic mass adjacent to the left ventricular free wall. Computed tomography (CT) confirmed the presence and dimension of the cyst and CT number indicated the fluid within the cyst to be serous. A pericardial cyst was successfully removed at thoracotomy.Two-dimensional echocardiography and CT, both noninvasive procedures, are fully adequate tools in the diagnosis of pericardial cysts in the neonate, so that invasive investigations may be avoided.

Transcatheter Closure of an Atrial Septal Defect Within a Giant Aneurysm of the Fossa Ovalis

The prevalence of atrial septal aneurysm (ASA) detected by transesophageal echocardiography (TEE) in the general population has been estimated between 2.2% and 9.9%, with an higher frequency (7.9% to 27.7%) in patients with a cerebral ischemic event.1−3 ASA is frequently associated with an interatrial shunt.1,2 Transcatheter closure of atrial septal defect (ASD) within an ASA may be difficult with the risk of device malposition with both discs deployed in the right or left atrium.3