ASD Closure Research Articles

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Transcatheter ASD closure in a patient with Dextroversion: A case report

Background: Cardiac dextroversion is location of the heart in the right chest with the left ventricle remaining in the normal position to the left but lying anterior to the right ventricle. To the best of our knowledge no specific technique has been described before for successful transcatheter secundum atrial septal defect closure in patients with dextroversion. Case presentation: We present a case of secundum atrial ASD in a patient with dextroversion, situssolitus, AV concordance and VA concordance. Patient was referred for transcatheter closure of ASD. Her transthoracic echocardiography showed a 7 mm secundum ASD, Upper normal RV size, small restrictive VSD 2 mm and a dilated main pulmonary artery. Transesophagealechocardiography showed an 11 mm defect with abnormal orientation of inter atrial septum due to cardiac dextroversion. Usual technique for positioning of ASD Amplatzer device (ASO 11) failed with prolapsing of the device into right atrium. Failed right upper pulmonary vein technique. With successful positioning of the device across the interatrial septum using left upper pulmonary vein technique. Conclusion: We recommend left upper pulmonary vein technique for safe and direct positioning of ASD device across interatrial septum in patients with dextroversion.

Percutaneous ASD Closure Requiring Emergency Surgical Removal of Embolized Cardiac Occluder Devices

Percutaneous ASD Closure Requiring Emergency Surgical Removal of Embolized Cardiac Occluder Devices

Frequency of atrial septal defect in patients of rheumatic mitral stenosis undergoing percutaneous transseptal mitral commisurotomy.

Objectives: To determine the frequency of atrial septal defect in patients of rheumatic mitral stenosis undergoing percutaneous trans septal mitral commissurotomy. Study Design: Cross sectional study. Setting: Faisalabad Institute of Cardiology, Faisalabad. Period: 15-07-2018 to 14-01-2019. Material & Methods: Study was approved by hospital ethical committee. A total of 45 patients were included in the study that fulfilled the study inclusion criteria and gave written informed consent. PTMC was performed using Inoue balloon technique through right femoral venous route under local anesthesia. Transthoracic echocardiography was done after 48 hours of PTMC for ASD assessment. Results: Out of 45 patients there were 17 (37.8%) males and 28 (62.2%) females. The mean age was (29.06±10.85) years. There were 9 (20%) patients with NYHA functional class II, 28(62.2%) with NYHA functional class III and 8(17.8%) with NYHA functional class IV symptoms. ASD was detected in 15 (33.3%) patients after 48 hours of PTMC. Conclusion: In this study frequency of ASD in patients of mitral stenosis undergoing PTMC was 33.3%. Results of this study can help to identify the patients who will be potential candidates for closure of residual ASD.

Endovascular closure of atrial septal defects in children: heart remodeling

Isolated atrial septal defect is the second leading congenital heart defect after ventricular septal defect. To date, there are few studies showing the range of changes both before and after the defect closure, except single studies with limited data. Therefore, the optimal timing for the ASD closure is not clearly defined. The review presents an update on heart remodeling in children under 18 years of age after endovascular closure of atrial septal defects.

Anaesthetic Management for Minimally Invasive approach for ASD closure, Mitral valve replacement and Tricuspid valve repair in a patient with Lutembacher syndrome

Anaesthetic Management for Minimally Invasive approach for ASD closure, Mitral valve replacement and Tricuspid valve repair in a patient with Lutembacher syndrome

Transcatheter Mitral Valve Implantation (TMVI) Using Edwards SAPIEN 3 Prostheses in Patients at Very High or Prohibitive Surgical Risk: A Single-Center Experience.

Background Mitral valve surgery in patients with failing bioprosthesis, annuloplasty rings, or in patients with advanced mitral annular calcification (MAC) is associated with high morbidity and mortality rates. Percutaneous antegrade transseptal transcatheter mitral valve implantation (TMVI) has recently successfully been performed in those patients at high or prohibitive surgical risk, but data on patients treated by TMVI are sparse. This study sought to evaluate short- and midterm outcomes of patients treated by TMVI at our site in clinical practice. Methods and Results From October 2016 to February 2018, seven patients (six women and one man) at high or prohibitive surgical risk underwent TMVI at our site. Three procedures were performed as TMVI in failed mitral valve bioprostheses (TMVI-VIV, “valve-in-valve”), one procedure was performed as TMVI in a failed mitral annuloplasty ring (TMVI-R), and three procedures were performed as TMVI in advanced native mitral annular calcification (TMVI-MAC). Mean age of the population treated was 77 ± 8.1 years, and mean log EuroScore I was 39 ± 0.12%. In all patients, an Edwards SAPIEN 3 transcatheter heart valve was implanted under 3D-TOE and fluoroscopic guidance using a transvenous/transseptal access. Indication for TMVI was the presence of advanced heart failure symptoms in all patients (NYHA class III/IV). The predominant dysfunction of the mitral valve treated was severe regurgitation in 72% (n = 5) and severe stenosis in 29% (n = 2) of all patients. TMVI was technically successful in all procedures. Clinical success with functional improvement of at least one NYHA class after procedure compared with before procedure was also achieved in all patients. Median NYHA class improved significantly from 4 before procedure to 2 after TMVI (p=0.008). Mitral valve regurgitation was reduced to trace or mild in all but one patient, who showed moderate MR after TMVI-MAC. No patient-prosthesis mismatch or LVOT obstruction occurred after TMVI. Two patients underwent interventional ASD closure during the in-hospital course due to a large and persisting atrial septal defect after transseptal access. One patient underwent pacemaker implantation due to complete AV-block after TMVI. One patient died in hospital 12 days after the procedure due to severe hospital-acquired pneumonia and sepsis. In-hospital mortality rate was 14% (1/7) in this high-risk population. After hospital discharge, no death occurred and clinical improvement—according to NYHA functional class—remained stable during one-year follow-up. Conclusion In this small single-center series, TMVI appears promising for patients at high or prohibitive surgical risk with either failing mitral bioprostheses/annuloplasty rings or native mitral valve dysfunction in combination with advanced MAC. Gaining experience in TMVI and new valves will further improve safety and efficacy of this new treatment option.

P248 Changes of atrial septum defect caused by posture during three-dimensional transesophageal echocardiography ( a case of Platypnea-orthodeoxia syndrome)

Abstract Background Platypnea-Orthodeoxia syndrome (POS) is a rare phenomenon which is characterized postural hypoxia due to the intracardiac shunt from right to left through a patent foramen ovale, an atrial septal defect or a pulmonary arteriovenous malformation. POS is often underestimated because the hypoxia by postural change is difficult to be detected. We evaluated three-dimensional transesophageal echocardiography (TEE) to diagnose POS in an elderly patient. Case report A 84-year-old woman suffered from repetitive syncope for several years. She undertook twelve leads electrocardiogram (ECG), screening transthoracic echocardiography (TTE), twenty-four hours ECG and treadmill stress ECG, however, the cause of syncope was not identified. After another syncope event happened, she was transferred to the emergency room. Then, the hypoxia caused by sitting position was pointed out for the first time. Her hypoxia was improved by supine position and oxygen administration. TTE demonstrated no right heart enlargement. Shunt flow was suspected on her atrial septum; however, it was difficult to reveal it by TTE because of her obesity. Therefore, she underwent intravenous saline injection test. In the decubitus position, an intravenous injection of saline under Valsalva maneuver revealed the shunt flow from the right atrium to the left atrium. Her arterial oxygen saturation (SpO2) was 95%. In the sitting position, a visible shunt flow was observed, then her SpO2 dropped to 85%. By TEE, the shunt hole was found in the oval fossa of the atrial septum. TEE was evaluated by different positions. The atrial defect hole became larger in the sitting position (area 1.05cm2) than in the supine position (area 0.43cm2). As a result, the postural change to sitting revealed Platypnea-Orthodeoxia syndrome associated with ASD. The pulmonary blood flow/systemic blood flow ratio (Qp/Qs) was estimated at 1.6. After surgical ASD closure, she was discharged without any symptoms. Conclusion Unclearness of TTE and the absence of a right heart overload may lead to misdiagnosis of POS. If a syncope patient caused hypoxia in the only sitting position, detailed echocardiography should be needed to rule out a diagnosis of POS. This is considerably valuable case of three-dimensional TEE confirmed the changes of ASD size by postural change. Abstract P248 Figure.

P3655Right ventricular volume off-loading following atrial septal defect closure or pulmonary valve replacement: impact on tricuspid regurgitation and mid-term remodeling

Abstract Introduction Cardiac surgery or catheter intervention is nowadays commonly performed to abolish volume loading of the right ventricle (RV) in adults with congenital heart disease (ACHD). Purpose Little is known, however, of their impact on the preexisting tricuspid regurgitation (TR) following such procedures (atrial septal defect [ASD] closure and pulmonary valve replacement [PVR]), which was the aim of our study. Methods Demographics, clinical and echocardiographic characteristics were analyzed from 162 consecutive patients undergoing such interventions between July 2005 and December 2014, who had at least mild preoperative TR. Results Mean age at intervention was 42±16 years (38.3% male); 101 patients underwent ASD closure, whereas 61 patients PVR. Only 11.1% receiving concomitant tricuspid valve surgery (repair). There was significant overall improvement in severity of TR, from 38 (23.5%) patients having moderate or severe TR preoperatively to only 11 (6.8%) and 20 (12.3%) at 6 and 12 months of follow-up, respectively (p<0.05) (Figure 1) (Table 1). Improvement in TR was observed in patients who did not have concomitant TV repair, from 15.3% to 6.9% and 11,8%, 6 and 12 months, respectively (p<0.05). Echocardiographic data Echo 1 (baseline) Echo 2 (6 months) Echo 3 (12 months) p-value† ‡Echo 1 ‡Echo 2 ‡Echo 3 TR grade (none = 1, mild = 2, moderate = 3, severe = 4) 2.3±0.6 1.6±0.6 1.7±0.8 <0.0001 A B B End-diastolic tricuspid annulus diameter (cm) 4.3±0.6 3.6±0.6 3.5±0.5 <0.0001 A B B Systolic tenting area (cm2) 0.7±0.5 0.5±0.2 0.5±0.3 <0.0001 A B B Coaptation distance (cm) 0.6±0.2 0.4±0.2 0.4±0.2 <0.0001 A B B End-diastolic area (cm2) 30.3±7.5 21.7±6.0 20.6±6.0 <0.0001 A B C Fractional area change (%) 39.4±8.4 39.0±8.0 39.9±8.1 0.58 A A A RV mid diameter (cm) 4.2±0.7 3.3±0.7 3.2±0.6 <0.0001 A B B RVOT end-diastolic proximal diameter (cm) 4.4±0.6 3.8±0.6 3.6±0.5 <0.0001 A B C TAPSE (cm) 2.1±0.6 1.4±0.5 1.4±0.4 <0.0001 A B B Lateral TDi S (cm/s) 12.4±3.3 8.8±3.0 9.2±3.0 <0.0001 A B B Systolic pulmonary artery pressure (mmHg) 42.4±13.4 34.8±10.1 35.1±11.6 <0.0001 A B B LVEF (normal = 1, mild LV dysfunction = 2, moderate = 3, severe = 4) 1.0±0.2 1.0±0.2 1.0±0.2 0.80 A A A RA area (cm2) 26.1±9.6 19.5±6.6 19.2±6.7 <0.0001 A B B *One-way ANOVA comparison. ‡Tukey pairwise comparison between Echos 1, 2 and 3: means that do not share a letter are significantly different (i.e. p<0.05). Figure 1 Conclusions ASD closure or PVR are commonly associated with significant reduction of preoperative functional tricuspid regurgitation event amongst patients who did not undergo concomitant tricuspid valve surgery.

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

TCT-774 Percutaneous Closure of Septum Secundum ASD

TCT-774 Percutaneous Closure of Septum Secundum ASD

Assessment of LV/RV S and SR Before and After Percutaneous Closure of ASDs

Assessment of LV/RV S and SR Before and After Percutaneous Closure of ASDs

Percutaneous ASD closure of children weighing less than 10 kg

Background: Traditionally the procedure of percutaneous ASD closure is carried out in children weighing more than 15 kg. The aim of this study was to discuss the success, efficacy and safety of the percutaneous closure of symptomatic ASD in children weighing less than 10 kg.Material and methods: This study was performed in two centres. A total of 44 patients were included. Demographic and angiographic data of these patients were gathered retrospectively from patients’ records. Main indications for ASD closure were: failure to thrive, recurrent respiratory infections, bronchopulmonary dysplasia and genetic syndromes.Results: Median weight of patients was 9.0(8.12–9.50) kg. Bodyweight of 22 patients was less than 3 percentiles. In the follow-up, this number was lowered to 9 patients at 12 months. Median age of patients was 18.0(12.0–285) months. Minimum age and weight of patients was 3 months and 4.5 kg, respectively. Median mean pulmonary pressure was 24.0(20.0–29.5). The values of median defect size were measured in Cath lab as 13.0(10.75–15.3) mm. Median device size was 13(9–15) mm. Defect size was evaluated according to body weight and body surface area. The ratio of weight per defect size was 0.65(0.54–0.84) also the ratio of body surface area per defect size was 0.032(0.028–0.04). The ratio of total septum per device diameter was 2.5(2.1–3.1). Types of devices used were Amplatzer Septal Occluder, Cera Flex Septal Occluder, Figulla Flex II Atrial Septal Occluder, Memopart Septal Occluder. All cases were closed successfully, but the device had to be retrieved in one patient after successful positioning because it was detected that device compressed the aorta. No major complications were seen.Conclusion: In the experienced centres, percutaneous ASD closure can be done effectively and safely in symptomatic children weighing less than 10 kg.

P607Bi-ventricular remodeling after ASD closure in adult patients using CMR volumetric assessment and strain analysis

P607Bi-ventricular remodeling after ASD closure in adult patients using CMR volumetric assessment and strain analysis

Successful Retrieval of Embolized Amplatzer Septal Occluder from Descending Thoracic Aorta: A Surgical Emergency.

Amplatzer septal occluder is widely used by the cardiac interventionists as an effective alternative to traditional surgery for atrial septal defects. However, although rare, device may embolize during or after procedure due to several reasons. We report a case of device embolization into the descending thoracic aorta during percutaneous closure of ASD in a 14-year-old girl which was successfully retrieved by emergency surgery at Department of Cardiac Surgery, University Cardiac Centre, Bangabandhu Sheikh Mujib Medical University, Bangladesh.
 University Heart Journal Vol. 15, No. 1, Jan 2019; 37-39

ASD device closure in elderly adults

Background: Closure of ASDs in elderly patients caused significant clinical and hemodynamic improvement after device closure.
 Aims and Objective: We aim to share our experience of ASD device closure in elderly adults.
 Materials and Methods: It was a prospective single center study done at Shahid Gangalal National Heart Centre. All elderly patients (>50years) who underwent ASD device closure fromFeb 2016 to July 2018 and completed three months of device closure were prospectively follow up for the symptoms, RA and RV dimension, Tricuspid Regurgitation and Tricuspid Regurgitation pressure gradient (TRPG).
 Results: During the study period 48 elderly adults underwent successful ASD device closure. Except one patient we could follow up all patients. Among the patient’s 33 were female, Age ranged from 50years to 72years with the mean age of 55 years. Shortness of breath was the most common symptom during presentation. ASD size ranged from 10mm to 33mm with the mean of 23mm. Device size ranged from 14mm to 40mm with the mean of 29mm. Amplatzer septal occluder was used in 47 patients. RA and RV were dilated in all patients. Mild TR was present in 26 patients, Moderate TR in 17 patients, Severe TR in 5 patients. Mean follow-up time was 12 months. Symptoms reduced in all patients expect one. RA and RV size reduced in all patients. Tricuspid regurgitation pressure gradient reduced from mean of 56 mmHg to Mean of 16 mmHg. During the follow up level of tricuspid regurgitation reduced, 11 patients had mild TR, Trace TR in 15 patients.
 Conclusion: ASD device closure can result in improvement in clinical and hemodynamic in elderly adults.

TCTAP C-156 Squeezed Out

### Patient Initials or Identifier Number JML ### Relevant Clinical History and Physical Exam A 37-year-old lady, underlying ASD with moderate pulmonary artery hypertension in whom ASD closure was not done due to contraindication. She presented with on and off exertional chest pain despite normal

Less Delayed Chest Closure, Systemic Edema, and Postoperative Bleeding in Lung Transplantation Using ECMO, Compared with CPB

Purpose Cardiopulmonary bypass (CPB) and extracorporeal membrane oxygenation (ECMO) may be used as extracorporeal circulation (ECC) during lung transplantation. We aimed to compare CPB and ECMO in terms of short-term outcomes in lung transplantation (LTx). Methods Among 185 patients undergoing LTx including 81 living-donor-related LTx from 2008 to June, 2018 in our institution, CPB was used in 41 patients and ECMO in 89 patients. Since 2013, we have routinely used ECMO, while CPB has been selectively used in pediatric and complicated cases requiring PA replacement or ASD closure. We retrospectively evaluated perioperative factors and short-term outcomes including delayed chest closure (DCC), in comparison of CPB group and ECMO group. DCC is required due to primary graft dysfunction manifesting as hypoxia, pulmonary hypertension, and lung edema. Assuming that CPB causes systemic inflammation leading to systemic edema, we also investigated perioperative increase ratio of body weight. Results Gender, surgical procedure (single or bilateral), and donor (cadaveric or living) and indications were not significantly different between the two groups, while patients in ECMO group were significantly older (40 vs 32 years, p=0.038), and weighed more (47 vs 38 kg, p=0.001). Thirty-day mortality was similar (1.1% in ECMO group; 2.4% in CPB group). The operation time, ECC time, and the amount of blood loss were not significantly different, while ECMO group was associated with significantly less transfusion intraoperatively (4339 ml in ECMO group; 6753 ml in CPB group, p=0.002). Reoperations for bleeding were less frequently required in ECMO group than in CPB group (7% vs 29%, p=0.003). DCC was less frequently required in ECMO group than in CPB group (9% vs 29%, p=0.013). The increase of body weight measured at the time of ICU admission was significantly remarkable in CPB group than in ECMO group (increased by 9.7% vs by 4.7%, p=0.006). Conclusion LTx using ECMO was associated with less intraoperative transfusion, and less postoperative re-exploration to CPB. ECMO was associated with less frequent delayed chest closure, possibly related to less systemic edema.

Outcomes of Transcatheter ASD Closure Guided by 3D-TEE

Outcomes of Transcatheter ASD Closure Guided by 3D-TEE

ATRIAL SEPTAL DEFECT OCCLUSION DEVICE MIGRATION PRESENTING AS ACUTE HEART FAILURE

ASD occlusion device embolization is a potential complication of ASD repair and occurs in 0.4 to 1.1% cases of ASD repair. We present a case of migration of an ASD occlusion device to the right pulmonary artery one month after ASD closure. A 61-year-old female with history of diastolic heart