Amplatzer Atrial Septal Defect Occluder Research Articles

Emergent Surgical Retrieval of an Embolized Atrial Septal Occluder Device from Right Ventricle – An Unusual Occurrence

Atrial septal defect (ASD) is one of the most common congenital heart defects (3.78/10,000 live births). For several decades, surgical closure has been considered the standard method of repairing an ostium secundum ASD. Surgical treatment is safe and effective, but the complications relate to bleeding, arrhythmia, and residual defects. However, over the years, percutaneous device closure using the Amplatzer ASD occluder (AGA Medical Corp., Golden Valley, Minnesota) has been widely used for the treatment of ASD and has proven to be effective and safe as traditional surgical repair. However, procedure- or device-related complications can occur; Complications commonly associated with ASD closure device includes residual shunt, device malposition or embolization, thrombosis in the vena cava or atrium and erosion of the surrounding tissue which may lead to perforation of the heart, which could be fatal. We report an unusual case of a 16-year-old female with embolization of the ASD occluder device into the right ventricle immediately after device deployment. We removed the device surgically and closed the ASD in a standard manner, with an autologous pericardial patch. The patient was discharged from the hospital without any complications.

Application of Transesophageal Echocardiography in Amplatzer Atrial Septal Defect Occluder for Percutaneous Closure of Large Patent Foramen Ovale.

Objective The Amplatzer patent foramen ovale (PFO) occluder is the most commonly used device for percutaneous closure of a large PFO. However, its use may predispose the patient to postoperative residual shunting. To reduce the incidence of residual shunting, we investigated the safety and effectiveness of the Amplatzer atrial septal defect (ASD) occluder for percutaneous closure of a large PFO measured by transesophageal echocardiography (TEE) and evaluated the value of TEE in this procedure. Methods Overall, 118 patients who were diagnosed with a large PFO (all with a ≥ 2 mm left atrial side height after the Valsalva maneuver (VM) excluding those with a small ASD) using contrast transthoracic echocardiography (c-TTE) and TEE underwent closure under TEE guidance at The First Affiliated Hospital of Xi'an Jiaotong University. An ASD device was used in 48 patients (group I) and a PFO device in 70 (group II). After the procedure, we verified the safety and efficacy of different devices using c-TTE, TTE, and TEE. Results In both groups, the preoperative TEE results showed a significantly increased left height of the PFO after VM compared with that at rest (all P < 0.01). Compared with the left height of the PFO measured using TEE after VM, the PFO-stretch diameter (SD) measured by TEE after the delivery sheath passed the PFO was higher (all P < 0.01). We selected the ASD occluder size according to this PFO-SD. In group II, most patients underwent the implantation of the larger PFO devices. Interventional treatment was successfully performed on all patients. The effective occlusion rate in group I at 12 months after the procedure was significantly higher than that in group II (93.7% vs. 78.6%, P < 0.05). The TEE results showed that 18 patients with a medium and large residual shunt at 12 months after the procedure exhibited an intradisc tunnel-like shunt. Conclusion The Amplatzer ASD device and Amplatzer PFO device are safe for large PFO closure, but the Amplatzer ASD device has a higher effective occlusion rate. TEE plays a crucial role in the use of the Amplatzer ASD occluder for percutaneous closure of a large PFO.

Cardiac solution for a vascular scenario!

BackgroundAscending aortic pseudoaneurysms (AAPs) constitute a rare, albeit potentially dangerous, condition that occurs in up to 13% of patients after cardiac or aortic surgeries. For patients with a history of cardiac surgery, repeat thoracotomy poses additive risks. The high morbidity and mortality rates associated with the surgical management of AAPs have led to the development of transcatheter approaches.Case reportWe report a case of AAP percutaneous closure at the site of aortic cannulation with an ASO device in a post-CABG 65-year-old man, who refused surgery.ConclusionThe use of the Amplatzer Atrial Septal Defect Occluder (ASO) device represents an acceptable alternative to surgery in treatment of Ascending aortic pseudoaneurysms.

A Round Peg for a Torn Hole – Percutaneous Closure of Anterior Mitral Valve Leaflet Perforation With Amplatzer Atrial Septal Defect Occluder

A 63-year-old male underwent planned percutaneous mitral valve repair for severe symptomatic mitral regurgitation (MR) due to a perforation of his anterior mitral valve leaflet (AMVL) following a past episode of infective endocarditis (Figure 1). He was deemed unsuitable for surgery following a heart team discussion due to comorbidities.

Modified Technique to Control the Eutachian Valve During Transcatheter Closure of Atrial Septal Defect/Patent Foramen Ovale

Abstract Objective to describe an approach to perform safe transcatheter closure of Atrial Septal Defect (ASD)/Patent Foramen Ovale (PFO) associated with large redundant Eustachian Valve. Background Transcatheter device closure of ASD/PFO is feasible in a great majority of patients. However, the presence of a huge mobile Eustachian Valve can compromise device placement. Patients and Methods Six patients (3 PFO and 3 ASD patients) with a huge redundant Eustachian valve were included. Two patients had PFO with long tunnel and were closed with Occlutech FigullaFlex II PFO occluders sized 23/25 and 27/30 respectively. The other PFO patient had an associated atrial septal aneurysm (ASA) and was closed with a 25 mm Amplatzer Multi-Fenestrated Septal Occluder “cribriform” device (St. Jude Medical – Abbott Vascular). The three ASDs were closed by regular ASD occluders (2 Flex II ASD Occluders sized 30 and 33 mm and 1 Amplatzer ASD Occluder sized 24 mm). Eustachian valve was successfully held with a steerable ablation catheter to deflect it against the lateral right atrial wall, keeping it away from the inter-atrial septum to prevent its entrapment or interference with the cable, the sheath or the device. Results All ASDs/PFOs have been successfully closed with no complications with free inferior vena cava (IVC) flow, with no residual inter-atrial shunt and the eustachian valve is not interfering with the device. Conclusions Safe percutaneous ASD/PFO closure can be achieved with proper control of a large redundant Eustachian valve.

Is This a Satellite Orbiting Unchartered Territory?

SummaryA 27-year old female i.v. drug user presented to our institution with chest pain. She had a history of bicuspid aortic valve endocarditis with aortic root abscess repaired with bioprosthetic aortic valve replacement and pericardial patch reconstruction of the left ventricular outflow tract and non-coronary sinus 6 weeks previously.Echocardiographic and cardiac CT imaging confirmed three foci of breakdown of the pericardial patch repair with active bleeding into a large posterior pseudoaneurysm (92 mm diameter) compressing the left atrium and pulmonary artery. Following multidisciplinary discussion, the consensus was to attempt urgent percutaneous closure of the defect, given the prohibitive surgical risks.The procedure was performed under fluoroscopic and 3D-transoesophageal guidance. TOE demonstrated the pericardial patch breaches and active bleeding into the large pseudoaneurysm (Figs 1 and 2). Initial deployment of an Amplatzer atrial septal defect occluder resulted in significant flow reduction, but there remained two small peri-device leaks (Fig. 3).During an attempt to implant an additional smaller Amplatzer vascular plug (AVP-2) to rectify this, the initial device dislodged and embolised into the pseudoaneurysm. This was felt irretrievable and unlikely to be clinically significant given its containment. The embolised device freely floated within the pseudoaneurysm, uniquely akin to a satellite orbiting in space (Video 1). The secondary device was removed and initial breach was satisfactorily closed with a 15-mm-sized Amplatzer atrial septal defect occluder (third device). This was confirmed to be well-seated on real-time 3D imaging (Video 2), with negligible residual leak on TOE (Fig. 4). This is the first published case of percutaneous cardiac device embolization into a pseudoaneurysm cavity that we are aware of.

CLOSURE OF A BRONCHOPLEURAL FISTUAL USING AN AMPLATZER DEVICE UNDER FLUOROSCOPIC AND BRONCHOSCOPIC GUIDANCE

SESSION TITLE: Case Report Semifinalists 4 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Bronchopleural fistula (BPF) is a rare complication with potentially fatal consequences following pulmonary resection. Incidence has been reported at 0.5% following lobectomy and is more prevalent in patients undergoing resection for malignant versus benign conditions. Correction of BPF is accomplished utilizing surgical and endoscopic techniques. Here, we describe an endobronchial closure of a BPF using an Amplatzer device in a patient who was deemed a poor surgical candidate. CASE PRESENTATION: A 76 year-old female with history of bronchioloalveolar carcinoma status-post right upper and right middle lobectomy complicated by BPF and invasive aspergillus pneumonia who presented with worsening dyspnea. She was treated with anti-fungal therapy for aspergillus. However despite appropriate treatment, her dyspnea worsened with associated productive cough. Computed tomography (CT) of the chest revealed a loculated pneumothorax which communicated with the bronchus stump and a 5mm bronchopleural fistula. Thoracic surgery evaluation deemed her to be a poor candidate for surgical closure given her frailty, age, anatomy, and chronicity of the BPF. Institutional review board approved the off-label and compassionate humanitarian use of the Amplatzer ASD occluder device. The procedure was done under general anesthesia. A 7mm device was chosen. After general anesthesia, a rigid bronchoscope was introduced into the trachea. Through this, a flexible bronchoscope was advanced to the right bronchus and the fistula visualized. A Jag wire was advanced into the pleural cavity via the BPF and position confirmed by fluoroscopy. The 7F delivery catheter and delivery system was prepared and the ASD closure device loaded. Delivery catheter was advanced into the pleural space over the wire. The left atrial disc was deployed in the right upper lobe pleural cavity under fluoroscopy. The disc was retracted to the bronchial wall and then the right atrial disc was deployed in the right mainstem bronchus under direct bronchoscopic visualization. The device was released after it was seen to be in good position with rims appearing flush against the bronchial wall. The patient tolerated the procedure well. At follow-up, the patient reported significant improvement in symptoms and exercise tolerance. Repeat bronchoscopy revealed a small air leak that is currently being monitored. DISCUSSION: Postoperative complication following pulmonary resection is the most common etiology of BPF. As these patients may be particularly frail and poor surgical candidates it is important to present all available therapeutic options. We described a case of BPF closure using an Amplatzer device with good results. Further studies should be performed to assess true safety and efficacy. CONCLUSIONS: Amplatzer occluder devices may be a viable option to correct BPF in patients who are poor candidates for surgical correction. Reference #1: Cerfolio, Robert James. “The Incidence, Etiology, and Prevention of Postresectional Bronchopleural Fistula.” Seminars in Thoracic and Cardiovascular Surgery, vol. 13, no. 1, Jan. 2001, pp. 3–7 Reference #2: Lois, Manuel, and Marc Noppen. “Bronchopleural Fistulas: An Overview of the Problem With Special Focus on Endoscopic Management.” Chest, vol. 128, no. 6, Dec. 2005, pp. 3955–65. Reference #3: Endobronchial closure of bronchopleural fistula using Amplatzer device. J Thorac Dis. 2015 Aug; 7(8): 1478–1482. DISCLOSURES: No relevant relationships by Amarbir Bhullar, source=Web Response no disclosure on file for Pravachan Hegde; no disclosure on file for Elliot Ho; No relevant relationships by Kassra Poosti, source=Web Response No relevant relationships by Chirag Rajyaguru, source=Web Response No relevant relationships by Uday Sandhu, source=Web Response no disclosure on file for Rohit Srivastava

Fulminant cytomegalovirus myocarditis in an infant with concomitant large atrial and ventricular septal defects: medical intervention strategy for functional cardiac regeneration.

A cytomegalovirus-associated heart failure in a young infant with atrial and ventricular septal defects is reported in this case report. The patient recovered by an anti-congestive and anti-viral therapy with an extra percutaneous transcatheter treatment strategy. In the context of bi-ventricular predominant right heart failure associated with supra-systemic pulmonary hypertension, the already closed arterial duct was re-opened and stented to unload the right ventricle and thereby augment the systemic blood flow. Either the left-to-right shunting atrial septal defect or bi-directional shunting ventricular septal defect was involved in the disease process and was not able to avoid global heart failure. After clinical improvement, the stented duct was shunted left-to-right and was occluded with an ADO-II-AS. During the same procedure the atrial septal defect was closed with an Amplatzer-ASD occluder, while the peri-membranous ventricular septal defect was closed with an ADO-II occluder 2 months later.

Fenestrated ASD device “angioplasty”: How to adjust a “pop‐off” mechanism when needed

We report on three cases of atrial septal defect (ASD) closure where a handmade fenestration had to be modified after device implantation. Two patients suffered from left ventricular diastolic dysfunction and one had severe pulmonary arterial hypertension. Amplatzer ASD occluder fenestration was created in all patients. Devices were implanted using an "over-the-wire" implantation technique. Due to a sub-optimal hemodynamic result, fenestration was upsized by using a new technique.

Nickel hypersensitivity reaction following Amplatzer atrial septal defect occluder device deployment successfully treated by explantation of the device

Nickel hypersensitivity reaction following Amplatzer atrial septal defect occluder device deployment successfully treated by explantation of the device

Percutaneous closure of traumatic ventricular septal defects: device selection and reasoning

Dear Editors, A ventricular septal defect (VSD) is one or more holes in the wall that separates the right and left ventricles of the heart. VSD is one of the most common congenital (present from birth) heart defects. Many types of VSDs have been reported, including congenital VSDs, post-infarction VSDs 1, and post-traumatic VSDs 2. Furthermore, there are four types of congenital VSDs; perimembranous VSD is the most common, while outlet, atrioventricular, and muscular VSDs are less common 3. VSDs vary in size, number, and location within the interventricular septum, and their clinical implications often depend on these factors. Childhood mortality has continuously decreased in recent decades, and mortality has shifted almost entirely to adulthood as a result of both conservative and surgical treatments 4. Small congenital VSDs often close on their own as the heart grows, and such patients may be treated conservatively 5. However, some patients may require surgical intervention. Percutaneous closure of VSDs has emerged as a good alternative to address important and difficult cardiac surgical problems and prevent issues related to cardiopulmonary bypass in selected patients 2. The most important issue prior to percutaneous closure is to decide whether the defect can be closed via a percutaneous approach and which device should be chosen. Various devices that have been used for VSD closure have been reported in previous articles. These devices include amplatzer® VSD Occluder, atrial septal defect (ASD) Occluder, and patent ductus arteriosus (PDA) Occluder 2,6,7. However, there is no clear consensus on device selection 8. The investigators present their experience with choosing devices for percutaneous VSD closure in this paper. The main factor in choosing a device is the length of the occluder's waist. The Amplatzer Muscular VSD Occluder and ASD Occluder are designed for congenital heart disease, and congenital VSDs are uniformly straight and short. Therefore, the length of occluder's waist is limited to approximately 4 mm. This device is also suitable for post-infarction VSDs and other straight and short VSDs 6,7. Post-traumatic VSDs, as described by Xi EP, Zhu J, Zhu SB and their colleagues, are angled 2. The length of this type of VSD is typically longer, frequently more than 9 mm. Therefore, the Amplatzer Muscular VSD Occluder and ASD Occluder are not appropriate. The use of the PDA Occluder for post-traumatic VSD closure suggested a new way of approaching treatment for the closure of different types of VSDs and provided a new standard for the design of occlusion devices. The use of the PDA Occluder for VSD closure has several advantages compared with the Amplatzer Muscular VSD Occluder and the ASD Occluder. First, if the right-sided opening of the VSD is near the right ventricular outflow tract, the right disc may obstruct the ventricular outflow tract when VSD or ASD Occluders are used. The PDA Occluder cannot cause ventricular outflow tract obstruction because it only has a left disc; furthermore, this single disc reduces the cost of the closure device. In addition, the metal waist of a PDA Occluder is both more flexible and softer than other occluder implants, so it is more easily released and molded. The implant also moves in synchrony with the heartbeat. Fatigue damage to an occluder's metal material 9 occurs under the action of the dynamic load, and an implant's main cause of failure is fatigue rupture. This type of rupture is more likely to occur in occluders that have two discs and a very narrow waist, which are more likely to experience fatigue rupture because of the loads on the two discs. Based on our limited experience and a lower observed morbidity rate, our view is detailed below. The use of PDA Occluder devices for percutaneous closure of post-traumatic VSDs is feasible, safe and effective. This method could allow all types of VSDs to be closed via a percutaneous approach. Furthermore, the use of a PDA Occluder provides a new standard for the design of occluder devices. However, in the absence of larger studies comparing surgical options, observational management and skillful clinical intervention, and most clinicians have more clinical experience using these devices, we suggest continuing to use a VSD Occluder or ASD Occluder in general VSD cases for routine repair for a longer experience on clinical application. But due to different types of VSD, different options of the device should be taken to solve them.

Obstruction of superior vena cava flow during transcatheter atrial septal defect closure with the Atriasept ASD occluder

In this paper, we describe a patient with a large secundum atrial septal defect ASD (26 mm) with adequate rims that were suitable for percutaneous closure. While closing this ASD, the superior vena cava (SVC) was occluded with the right atrial disc of the Atriasept ASD occluder (Cardia) and thus the device was retrieved before its release. After retrieval of this device, an Amplatzer ASD occluder was successfully implanted without disturbing the caval flow.

Transcatheter closure of left ventricular free wall rupture with Amplatzer atrial septal defect occluder

Left ventricular free wall rupture is a dramatic complication of acute myocardial infarction and is presumably responsible for as much as 20–30 % of all infarct-related deaths [1]. Surgical management is essential [2]. Needle pericardiocentesis is the conventional treatment of cardiac perforation [3]. A 79-year-old man in evolving cardiogenic shock (BP 70/40) mmHg, sinus tachycardia (120 beats/ min) was transferred to our regional cardiac center. ECG showed ST-segment elevation in II, III, aVF and V4–6 leads. Emergency coronary angiography was performed, and totally occluded obtuse marginalis and nonsignificant stenosis in others coronary arteries were detected (Fig. 1a). Bedside transthoracic echocardiography (TTE) revealed LV regional wall motion abnormality and cardiac tamponade. Cardiac rupture was detected at the LV apex. TTEguided pericardiocentesis was performed immediately. However, there was no drainage from the catheter. Hemoglobin decrease was approximately 4 mg/dL during this time. We have decided to try percutaneous closure due to lack of 7/24 surgical backup. The procedure was applied in order to gain time; as a bridge for surgery. The procedure was an emergency and the defect size was only measured with transthoracic echo and a standard Amplatzer TorqVue delivery system was used through a 7F sheath. A 10, 5-mm Amplatzer occluder (Amplatzer occluder is from St. Jude Medical) was deployed (Fig. 1b). The operation was finished in 15 min. A subsequent TTE showed the defect was successfully occluded with only a trivial residual leak (Figs. 2a, 3). The patient slightly recovered after the procedure, blood pressure could be recorded but he was still in cardiogenic shock due to the impossibility of removing the agglutinant pericardial effusion. Therefore, the patient was transferred to the operation room (Fig. 2b). A large haemorrhagic pericardial effusion was seen and the entire heart was covered in a thick fibrinous peel. But he died 6 h after the initial chest pain. This case confirms that transcatheter closure of ventricular free wall rupture with an occluder device is a bailout strategy in very skilled centers for selected cardiogenic shock patients in the absence of on-site cardio-thoracic support.

Recent Changes in Instructions for Use for the Amplatzer Atrial Septal Defect Occluder: How to Incorporate These Changes While Using Transesophageal Echocardiography or Intracardiac Echocardiography?

The Amplatzer septal occluder is commonly used to close secundum atrial septal defects (ASDs). Recently, the manufacturer's recommendations have been modified with regard to contraindications for its use. These changes primarily focus on evaluation of the aortic rim (anterio-superior rim) with transesophageal echocardiography (TEE) and intracardiac echocardiography (ICE). In this editorial, we will review systematically all of the sequential views in TEE and ICE that are required for thorough assessment of the aortic rim and provide explanation of what constitutes deficiency of the aortic rim as seen on ICE.

A new “tool” for transcatheter atrial defect closure: The St. Jude SL2™ sheath

Orienting the left atrial disc of an atrial septal defect (ASD) closure device parallel to the septum is important, particularly in cases of ASD with deficient retroaortic rim. Standard vascular sheaths can make this challenging. We report the use of an electrophysiologic sheath, the SL2™ St. Jude Vascular sheath (St. Jude Medical, St. Paul, MN) for closure of ASD. All patients undergoing ASD closure between July 2010 and February 2011 at The Children's Hospital at Montefiore in which the SL2 sheath was used were reviewed. Nine patients underwent transcatheter ASD or PFO (1/9) closure with the SL2 sheath. Mean age was 22.7 years (range, 3-58); weight was 46.5 kg (range, 14.7-78.6). The Amplatzer ASD Occluder (AGA Medical Corp., Plymouth, MN) was used in all cases. The mean measurement of the ASDs via "stop-flow" technique was 13.3 mm (range, 4-19). The mean device size was 13.9 mm (range, 5-20) or 105% the size of the defect. The retroaortic rim was deficient (<2 mm) in 3 of 9. ASD closure was achieved in 9 of 9. In all, the left atrial disk was brought toward the atrial septum parallel to the atrial septum, and repositioning or recapturing of the device was unnecessary in any case. Mean fluoroscopy time was 9.3 min (range, 2.2-18). No significant complications. The SL2 sheath was useful to position the ASD device parallel to the atrial septum, eliminating the need for redeployment during the procedure. This sheath was useful in those cases of deficient retroaortic rim in this study.

Home-made fenestrated amplatzer occluder for atrial septal defect and pulmonary arterial hypertension

We report the management of a patient with secundum atrial septal defect (ASD) and severe pulmonary hypertension. A 65-year-old male with recently diagnosed atrial septal defect was referred to our centre for decompensated right heart failure with rest and exercise induced dispnea and severe pulmonary hypertension. Right heart catheterization confirmed a mean pulmonary pressure of about 55 mmHg and a Qp/Qs of 2.7. An occlusion test with a compliant large balloon demonstrated partial fall of pulmonary arterial pressure. The implantation of a home-made fenestrated Amplatzer ASD Occluder (ASO) was planned in order to decrease left-to-right shunt and promote further decrease of pulmonary arterial pressure in the long-term. Thus, by means of mechanical intracardiac echocardiography study with a 9F 9 MHz UltraIce catheter (Boston Scientific Corp.), we selected a 34 mm ASO for implantation. Four millimeter fenestration was made inflating a 4 mm non-compliant coronary balloon throughout the waist of the ASO, which was successfully implanted under intracardiac echocardiography. After six months, a decrease of pulmonary arterial pressure to 24 mmHg and full compensated right heart failure was observed on transthoracic echocardiography and clinical examination. This case suggests that transcatheter closure with home-made fenestrated ASD in elderly patients with severe pulmonary hypertension is feasible.

Late erosion of an Amplatzer septal occluder device 6 years after placement

CLINICAL SUMMARY A 46-year-old man underwent transcatheter closure of a PFO at our institution after a stroke-like event. The stretched diameter of the PFO was 9 to 10 mm. A 14-mm Amplatzer septal occluder device (AGA Medical Corporation, Golden Valley, Minn) was placed. Immediately after placement, a trivial degree of left-to-right shunt was seen through the center of the device by intracardiac echocardiography; agitated saline injection revealed a trivial right-to-left shunt. The procedure was uncomplicated, and the patient was dismissed from the hospital the following day. Predismissal transthoracic echocardiogram (TTE) showed good position and stability of the device with no apparent shunt. Ten days later, the patient returned with intermittent palpitations. Electrocardiogram revealed atrial fibrillation with rapid ventricular response. He was given intravenous diltiazem and promptly returned to sinus rhythm. TTE again documentedgoodposition of the occluder devicewith no recurrent atrial shunt or pericardial effusion. He was observed in the hospital overnight and dismissed on a regimen of oral diltiazem for 1 month. He had no recurrence of atrial fibrillation. Six years later, he came to the emergency department with progressive pleuritic chest pain. He had had similar chest pains 1month prior, which were not extensively investigated, but resolved spontaneously. In the emergency department he was hypotensive with mild jugular venous distention. TTE documented moderate pericardial effusion with tamponade. Pericardiocentesis removed 325 mL of bloody fluid. Transesophageal echocardiography did not show any evidence of shunt around the device. The device was again noted to not straddle the aortic root. Transesophageal echocardiographic

A flow restrictor implanted percutaneously across a loose pulmonary artery band

Pulmonary artery banding usually is performed as a palliative procedure. In patients with elevated pulmonary vascular resistance and complex congenital heart disease, it may not be possible at the time of surgery to obtain sufficient restriction to optimize the patient for further treatment; additional restriction may be needed in time. We present a technique where we used a combination of two devices (a 10-mm Amplatzer ASD occluder fenestrated with a Palmaz Genesis 9/19 mm stent) to percutaneously further reduce the flow to the lungs 1 month after surgical placement of a pulmonary artery band in a 16-year-old girl with complex univentricular heart. Eight months after the banding the patient successfully underwent completion of the Fontan circulation by total cavopulmonary connection. This technique allows to reduce flow without redo surgery. In well-selected patients, this new percutaneous technique allows to better prepare such complex patients for future surgery.

Long-term outcome of percutaneous closure of secundum-type atrial septal defects in adults

Transcatheter closure of the secundum-type atrial septal defect (ASD) is widely practised. We report complications and efficacy of percutaneous ASD closure in adults using the Amplatzer ASD occluder and the Cardioseal/Starflex device during long-term follow-up. Between 1996 and 2008 percutaneous ASD closure was performed in 133 patients (mean age 46.8 ± 16.9 years; 36 men) by using the Amplatzer(r) device in 104 patients and the Cardioseal/Starflex device in 29. During a mean follow-up of 3.4 ± 2.8 years the occurrence of major complications was higher in patients with the Cardioseal/Starflex compared to patients with the Amplatzer(r) devices (17.2 vs. 2.9%, log rank, P=0.005), due to a higher embolisation rate (13.8 vs. 1.0%, log rank, P=0.002). In univariable analysis, the implantation of a Cardioseal/Starflex device (OR 6.0 (CI 1.4-25.2); P=0.01) and a larger device diameter (OR 1.1 (CI 1.0-1.2); P=0.04) were found to be predictors of the occurrence of major complications. Minor complications occurred in 10.5%, recurrent thrombo-embolism in 2.3% and residual shunting at six months was 13.9% without differences between devices. NYHA class improved from 1.8 ± 0.6 before to 1.2 ± 0.4 after closure (P<0.001) without differences between devices. During long-term follow-up, percutaneous ASD closure in adults is safe and effective when using the Amplatzer(r) device. Larger Cardioseal/Starflex devices are related to a higher embolisation rate. Randomised trials are needed.

Late Bacterial Endocarditis of an Amplatzer Atrial Septal Defect Occluder Device

A 66-year-old man with a large secundum atrial septal defect (ASD) that had been repaired percutaneously 30 months previously with an Amplatzer ASD occluder (ASO) presented with fevers and Staphylococcus aureus bacteremia. Transesophageal echocardiography revealed a 1.5 x 1.5 cm mobile mass on the left atrial side of his ASO consistent with a vegetation. When the ASO was explanted, the left atrial side of the device was poorly endothelialized. In conclusion, the present report is the first description of late infective endocarditis in an adult with an ASO.