Atrial Disc Research Articles

The role of transesophageal echocardiography in transcatheter closure of secundum atrial septal defects by the Amplatzer septal occluder

Background Our purpose was to determine the role of transesophageal echocardiography (TEE) in the closure of atrial septal defects by the Amplatzer septal occluder (ASO) (AGA Medical, Golden Valley, Minn). Methods A total of 240 patients with atrial septal defect (ASD) secundum were examined by transthoracic 2-dimensional echocardiography (TTE) and TEE to determine the ASD morphologic features, diameter, and rims. During transcatheter closure TEE was used for determination of the ASD diameter and guidance of the ASO implantation. Results Sixteen (6%) patients were found not suitable for transcatheter closure with TTE, 35 (14%) with TEE, and 2 during catheterization. Twenty-eight patients (18%) had partial or total deficiency of the posterior, inferoanterior, or inferoposterior rim, 54 (27%) had a centrally positioned ASD, 92 (46%) had insufficient superoanterior rim, and 9 had multiple ASDs, whereas 8 had a septal aneurysm associated with a single defect and 4 a multiperforated aneurysm. A total of 170 patients underwent implantation of ASO. The ASO was correctly positioned in 144 at the first attempt. In the remainder TEE revealed unstable position of the left atrial disk (12), opening of both atrial disks in the left atrium (5), deployment of the device through the smaller defect in patients with multiple ASDs (3), and, in 1 patient, the device was too small and had to be replaced by a larger one. Conclusions Morphologic variations of the ASD are common. TEE is crucial for the determination of the ASD morphologic features, diameter, and rims, which are crucial for proper patient selection. TEE allows precise guiding and positioning of the ASO, which is essential for safe and effective transcatheter ASD closure. (Am Heart J 2001;142:482-8.)

Cobrahead malformation of the amplatzer septal occluder device: An avoidable compilation of percutaneous ASD closure

During deployment of an Amplatzer atrial septal occluder device to close a secundum ASD, the right atrial disk and waist of the device twisted, resulting in the cobrahead malformation. Postulated mechanisms for this complication include twisting of the device during loading into the delivery catheter and catching of leading edge of the device on the LA free wall or appendage, causing twisting during deployment. Retrieval of the device into the catheter and even removal of the device from the patient to allow manual untwisting may be required to allow the device to return to its original conformation for successful redeployment.

Cobrahead malformation of the amplatzer septal occluder device: An avoidable compilation of percutaneous ASD closure

During deployment of an Amplatzer atrial septal occluder device to close a secundum ASD, the right atrial disk and waist of the device twisted, resulting in the cobrahead malformation. Postulated mechanisms for this complication include twisting of the device during loading into the delivery catheter and catching of leading edge of the device on the LA free wall or appendage, causing twisting during deployment. Retrieval of the device into the catheter and even removal of the device from the patient to allow manual untwisting may be required to allow the device to return to its original conformation for successful redeployment. Cathet Cardiovasc Intervent 2001;52:83–85. © 2001 Wiley-Liss, Inc.

Interventional occlusion of atrial septum defects larter than 20 mm in diameter

Over the last few years, various devices for the interventional closure of atrial septal defects (ASD) up to a diameter of 20 mm have been developed. We report our clinical experience in closing ASD with a diameter larger than 20 mm diameter with the Amplatzer Septal Occluder (ASO). The stretched diameter of the ASD was measured by inflating a sizing balloon within the defect until an indentation in the circumference in the balloon could be observed. An ASO with a stent diameter 2-4 mm larger than the indentation in the circumference of the balloon was chosen and implanted via 9-12 French sheaths. In contrast to the closure of smaller defects, pullback of the device onto the atrial septum was only performed when the connecting stent of the ASO was completely deployed in order to achieve maximal centering characteristics and optimal support of the retention skirt of the left atrial disc on the edges of the defect. Only then was the right atrial disc deployed and actively configured by advancing the sheath and the delivery cable against the atrial septum. Implantation was only attempted if the atrial septal rims (except the anterior rim around the aorta) measured more than 7 mm by echocardiography to avoid injury or disturbance of sensitive intracardiac structures. After placement, the fixation of the device and the mechanical stability was proven by an extensive "Minnesota wiggle". The ASO was released only when TEE showed no or a trivial residual color flow through the connecting stent; otherwise repositioning was performed. Out of 352 patients (P) with successful closure of interatrial defects, 70 P (age: 1.1-77.3 years) had stretched defects larger than 20 mm diameter (median 22 mm diameter (20-36), 25/75% quartiles = 20/26 mm). Mean shunt size was Qp:Qs 2.1:1 (0.7-3.9:1), mean fluoroscopy time 10.9 min (0-63). Complete closure could be achieved in 85.7/93.1/100% after 3 months, 1 and 2 years, respectively. Besides 3 P with persistent atrial fibrillation, only 5 P showed transient atrial tachyarrhythmias, 2 only periprocedural and 3 within the first 3 months after implantation were treated with beta-blocker. In one patient, an acute embolization of the device occurred because a diminished posterior rim was not visualized by a monoplane TEE probe necessitating surgical explantation and defect occlusion. Despite oversizing the device, no "mushrooming" misconfiguration were observed. Transcatheter closure of large atrial septal defects with the Amplatzer Septal Occluder is feasible, safe and effective. Risk of complications do not seem to occur more frequently than after closure of smaller defects if one adheres to certain sizing and implantation measures. The incidence of transient atrial tachyarrhythmias seems to be low.

New self‐expanding patent foramen ovale occlusion device

Our purpose was to evaluate a new self-expanding device for closure of the patent foramen ovale (PFO). A transeptal catheter passage through the flap of the fossa ovalis was performed with a transeptal needle inside a catheter, creating a PFO in two minipigs. In an additional five animals, a naturally occurring PFO was found. The device is made from 0.005 inch nitinol wire mesh with polyester fabric inside, similar in construction to the Amplatzer atrial septal occluder. However, the left atrial disc is smaller (18 mm) than the right atrial disc (26 mm). Both discs are connected by a very short flexible waist (3 mm) that allows free movement of both retention discs. Pulmonary and right atrial angiography were performed after placement, at 1 month, and at 3 months follow-up. Placement of the device was technically successful in six animals. One animal died from ventricular fibrillation during placement. Pulmonary angiography and echocardiography showed complete occlusion of the PFO in six animals. Two animals were sacrificed after 1 month and four animals after 3 months. In the animals sacrificed at 1 month, histopathological examination showed partial (n = 2) endothelialization, and in the 3 months follow-up group (n = 4) endothelialization was complete. The device appears to be highly effective for occlusion of PFOs. This procedure may be performed as an outpatient procedure due to the small 7 Fr delivery system sheath. Cathet. Cardiovasc. Intervent. 47:370–376, 1999. © 1999 Wiley-Liss, Inc.

New self-expanding patent foramen ovale occlusion device.

Our purpose was to evaluate a new self-expanding device for closure of the patent foramen ovale (PFO). A transeptal catheter passage through the flap of the fossa ovalis was performed with a transeptal needle inside a catheter, creating a PFO in two minipigs. In an additional five animals, a naturally occurring PFO was found. The device is made from 0.005 inch nitinol wire mesh with polyester fabric inside, similar in construction to the Amplatzer atrial septal occluder. However, the left atrial disc is smaller (18 mm) than the right atrial disc (26 mm). Both discs are connected by a very short flexible waist (3 mm) that allows free movement of both retention discs. Pulmonary and right atrial angiography were performed after placement, at 1 month, and at 3 months follow-up. Placement of the device was technically successful in six animals. One animal died from ventricular fibrillation during placement. Pulmonary angiography and echocardiography showed complete occlusion of the PFO in six animals. Two animals were sacrificed after 1 month and four animals after 3 months. In the animals sacrificed at 1 month, histopathological examination showed partial (n = 2) endothelialization, and in the 3 months follow-up group (n = 4) endothelialization was complete. The device appears to be highly effective for occlusion of PFOs. This procedure may be performed as an outpatient procedure due to the small 7 Fr delivery system sheath. Cathet. Cardiovasc. Intervent. 47:370-376, 1999.

Echocardiographic characteristics of successful deployment of the Das AngelWings atrial septal defect closure device: initial multicenter experience in the United States

The AngelWings device is a newer transcatheter device used for closure of secundum atrial septal defects (ASD) and patent foramen ovale (PFO), which consists of a self-centering, 2-disk system. Transesophageal echocardiography (TEE) plays a pivotal role in the deployment of the 2 disks of this device, on the appropriate sides of the atrial septum. The objective of this study is to describe the echocardiographic findings associated with successful deployment of the AngelWings device for closure of ASD and PFO. We evaluated the TEE studies of 70 patients enrolled in 4 United States centers, for closure of ASD and PFO with the AngelWings device. The TEE characteristics of successful and unsuccessful deployments were analyzed. Residual shunts across the atrial septum were assessed by TEE at the end of the procedure, 24 hours later by transthoracic echocardiography, and at 6 months by TEE. The deployment of the device was successful in 65 patients (93%). In the unsuccessful group, ASD size by TEE was larger (13.4 ± 3.1 vs 8.9 ± 4.7 mm, p <0.05). TEE was successful in identifying snagging of the device by intracardiac structures and prolapse of corners of the left or right atrial disk through the ASD, features that were difficult to identify by fluoroscopy. The echocardiographic characteristics outlined here are important guidelines for successful deployment of the AngelWings device.

Percutaneous closure of secundum atrial septal defect with a new self centring device (“angel wings”)

ObjectiveTo investigate the safety, efficacy, and clinical application of a new self centring device (“angel wings”) for closure of secundum atrial septal defects (ASD II) and persistent foramen ovale in...

Atrial Catheter and Lumbar Disk Surgery

To the Editor.— Our group of neurosurgical anesthesiologists disagrees with the belief of Albin et al (239:496, 1978) that patients undergoing lumbar disk surgery in the knee-chest position should have a right atrial catheter placed preoperatively. Although the venous pressure at the lumbar incision is probably low and air embolism is a theoretic possibility, there is a conspicuous absence of reports of hemodynamically significant air embolism in patients undergoing this common operation. Albin et al refer to the case of Shenkin and Goldfedder (210:726, 1969) as an example of fatal air embolism occurring in a prone patient. However, that patient's operation was not a laminectomy but posterior-fossa exploration for an arteriovenous malformation. Furthermore, the air embolism occurred after hemorrhage and after the venous pressure was further lowered by ganglionic blockade in addition to head-up tilt and mechanical ventilation with a negative-pressure phase. We place a right atrial catheter and use

Atrial catheter and lumbar disk surgery

Atrial catheter and lumbar disk surgery

Atrial Catheter and Lumbar Disk Surgery

To the Editor.— We disagree with the opinion of Tarlov (238:253, 1977) that insertion of a right atrial catheter is unnecessary in patients undergoing lumbar disk surgery. It is a common misunderstanding among the medical community that venous air embolism can occur only in the sitting position and that only the large noncollapsible veins and dural sinuses are involved. The entrainment of venous air into the right atrium necessitates a relatively negative gravitational gradient between the incised vessel and the right atrium. Naturally, in the 90° sitting position this gradient is severely enhanced. On the other hand, Shenkin and Goldfedder (210:726, 1969) reported a fatal case of venous air embolism in the prone position where the head was raised only by 10.0 cm above heart level and where 6.0 to 8.0 cm of negative pressure was applied to the expiratory phase of the ventilatory cycle, which further enhanced the gradient.