Elective Closure Research Articles

Fontan Fenestration Closure Has No Acute Effect on Exercise Capacity but Improves Ventilatory Response to Exercise

The aim of this study was to prospectively examine the effects of elective Fontan fenestration closure upon exercise capacity and ventilatory abnormalities. For patients undergoing Fontan procedures as palliation of single ventricle physiology, the addition of a fenestration to the procedure mitigates perioperative morbidity. Although some fenestrations may close spontaneously, many remain patent and subject patients to arterial hypoxemia and risk for paradoxical emboli. For these reasons fenestration closure is routinely performed post-operatively in the cardiac catheterization laboratory. Although closure of Fontan fenestrations typically results in an immediate improvement in systemic arterial oxygen saturation, it is also associated with an acute decrease in cardiac index and systemic O(2) delivery. The sum result of these physiologic changes upon exercise capacity has not been examined. Twenty consecutive patients, age 5 to 46 (median 10) years, underwent pre- and post-fenestration closure exercise testing with expiratory gas analysis. Before fenestration closure, peak oxygen consumption (VO(2)) was depressed and there was systemic desaturation at rest that worsened with exercise. The ventilatory response to exercise was also abnormal, characterized by elevation of the minute ventilation (VE)/CO(2) elimination slope (VE/VCO(2)), a low end-tidal CO(2), and high end-tidal O(2) at the ventilatory anaerobic threshold. Although arterial saturation improved significantly after fenestration closure, there was no change in peak VO(2) (70.9 +/- 18.6% to 74.0 +/- 18.6%, p = NS), heart rate, or O(2) pulse at peak exercise. In contrast, ventilatory abnormalities (VE/VCO(2)) improved considerably (44.4 +/- 10.9 to 33.3 +/- 5.5, p <or= 0.001). Fontan fenestration closure does not significantly improve peak VO(2). However, ventilatory abnormalities improve considerably.

Swiss Cheese–Like Atrial Septal Defect

Atrial septal defects (ASDs), apart from the bicuspid aortic valve, are the most common congenital heart malformations, and it is not uncommon for them to go undiscovered until a patient reaches adulthood.1 An ostium secundum ASD is the most common septal defect, comprising 75% of all these defects.2 Elective closure should be considered in patients with signs of right heart dilatation and in those who have a presumed paradoxical event.3 In patients with an ostium secundum ASD, percutaneous closure–first reported in 19744—is now well established. Before a percutaneous closure attempt, the suitability of the defect for device implantation should be assessed with transesophageal echocardiography. Associated malformations (eg, partial anomalous pulmonary venous drainage) and the number, location(s), and the dimensions of the defect(s) should be known before the procedure. A defect in the atrial septum can exist when the flap valve derived from the septum primum does not overlap its rim (eg, because of atrial dilation) or because the flap …

Frequency of Severe Pulmonary Hypertension Complicating “Isolated” Atrial Septal Defect in Infancy

Atrial septal defects (ASDs) are typically asymptomatic in infancy and early childhood, and elective defect closure is usually performed at ages of 4 to 6 years. Severe pulmonary hypertension (PH) complicating an ASD is seen in adulthood and has only occasionally been reported in small children. A retrospective study was undertaken to evaluate the incidence of severe PH complicating an isolated ASD and requiring early surgical correction. During a 10-year period (1996 to 2006), 355 pediatric patients underwent treatment for isolated ASDs either surgically or by catheter intervention at 2 tertiary referral centers. Two hundred ninety-seven patients had secundum ASDs, and 58 had primum ASDs with mild to moderate mitral regurgitation. Eight infants were found with isolated ASDs (6 with secundum ASDs and 2 with primum ASDs) associated with significant PH, accounting for 2.2% of all patients with ASDs at the centers. These 8 infants had invasively measured pulmonary artery pressures of 50% to 100% of systemic pressure. They were operated in the first year of life and had complicated postoperative courses requiring specific treatment for PH for up to 16 weeks postoperatively. The ultimate outcomes in all 8 infants were good, with persistent normalization of pulmonary pressures during midterm follow-up of up to 60 months (median 28). All other patients with ASDs had normal pulmonary pressures, and the mean age at defect closure was significantly older, at 6.2 years for secundum ASDs and 3.2 years for primum ASDs. In conclusion, ASDs were rarely associated with significant PH in infancy but then required early surgery and were associated with excellent midterm outcomes in these patients.

Retrograde aortic perfusion dislodges a dislodged Amplatzer device

Retrograde aortic perfusion dislodges a dislodged Amplatzer device

Use of Amplatzer occlusion devices to occlude Fontan baffle leaks during fenestration closure procedures

The authors describe the use of Amplatzer occlusion devices to successfully occlude Fontan baffle leaks in three patients. These additional right to left shunts were recognized at the time of elective transcatheter closure of surgically created fenestrations. A common site of baffle leak is described at the base of the right atrial appendage. This suture line serves to exclude the right atrial appendage from Fontan baffle flow and lies within the corrugated surface of the pectinate muscles, making it particularly vunerable to baffle leaks over time.

Clinical relevance of coronary angiography at the time of percutaneous closure of a patent foramen ovale

The value of incidental coronary angiography during percutaneous shunt closure to screen for asymptomatic coronary artery disease (CAD) is unknown. On the occasion of percutaneous closure of patent foramen ovale (PFO), incidental coronary angiography routinely offered to men >40 and women >50 years, or younger patients with particular risk patterns, was performed in 575 patients (64% men, mean age 55 +/- 10 years, mean 1.5 +/- 1.1 cardiovascular risk factors) without overt history, signs, or symptoms of CAD. CAD was found in 164 patients (29%); 53 (9%) had >or=50% diameter stenoses. Thirty patients (5%) had one-vessel, 13 (2%) two-vessel, and 10 (2%) three-vessel disease. Patients with CAD (n = 164) were older (60 +/- 9 vs. 53 +/- 10 years; P < 0.0001), more frequently male (76% vs. 59%; P = 0.0002), and had a higher body mass index (26.5 +/- 4.0 vs. 25.4 +/- 4.6; P = 0.006) and more cardiovascular risk factors (2.0 +/- 1.1 vs. 1.2 +/- 1.0; P < 0.0001). There were six procedural complications (1%). Two were unequivocally related to coronary angiography: one minor stroke (diplopia), and one iatrogenic dissection of the right coronary ostium requiring stenting. Furthermore, four arteriovenous fistulae at the puncture site requiring elective surgical closure were possibly related to coronary angiography. Forty-five patients (8% of total) underwent percutaneous (n = 43) or surgical (n = 2) revascularization. In selected asymptomatic patients referred for percutaneous PFO closure, incidental coronary angiography discloses a rather high prevalence of clinically unsuspected CAD. These findings are relevant not only for timely revascularization but also for maintenance of long-term antiplatelet therapy beyond the few months recommended after PFO closure.

Paradoxical emboli through the patent foramen ovale as the suspected cause of myocardial and renal infarction in a 48‐year‐old woman

We review the case of a 48-year-old woman who underwent elective percutaneous patent foramen ovale closure following successive renal and myocardial infarction with normal renal and coronary arteries, probably as a consequence of paradoxical emboli.

Traumatic free wall and ventricular septal rupture — ‘hybrid’ management in a child

A 8-year-old boy showed a traumatic ventricular septal rupture following a blunt chest trauma, and was scheduled for elective catheter closure. Two weeks later, a follow-up echocardiogram revealed a pseudoaneurysm of the anterior wall of the left ventricle. Because of the apical location of the VSD, it was decided to proceed with transcatheter occlusion. After successful VSD closure, the patient was taken to the operation room for surgical repair of the left ventricular pseudoaneurysm. Symptoms and signs seen in patients with ventricular pseudoaneurysms appear to be discrete and variable, and a high clinical index of suspicion with a very close echocardiographic follow-up is strongly recommended after occurrence of a blunt cardiac trauma. The combined 'hybrid' approach of transcatheter closure of the intraventricular rupture followed by surgical closure of the pseudoaneurysm allows for a less invasive and efficient management of this rare combination of post-traumatic ventricular free wall and septal rupture in a child.

Combined Atrial Septal Defect Surgical Closure and Irrigated Radiofrequency Ablation in Adult Patients

Atrial arrhythmias are relatively common among patients over 40 years old with atrial septal defect (ASD) and are a precipitating cause of heart failure. Surgical closure of the ASD in these patients is feasible and is associated with a low mortality rate and a beneficial effect on the clinical status; however the occurrence of atrial arrhythmia does not decrease after surgery. We present the results of our preliminary experience with surgical ASD closure combined with intraoperative irrigated radiofrequency (IRF) ablation in adult patients. During a 26-month period between September 2002 and December 2004, 15 patients more than 40 years old with ASD and atrial arrhythmia underwent elective surgical closure of the defect and intraoperative IRF ablation. All patients had supraventricular arrhythmias: 8 had permanent atrial fibrillation, whereas 7 had previous episodes of atrial flutter or intra-atrial reentry tachycardia. The biatrial approach (Cox-Maze III procedure) was used in 7 patients and a right-sided Maze procedure (ablation lines on the right atrium only) was carried out in the remaining 8 patients. All patients survived the procedure. Fourteen patients left the operating room in sinus rhythm and 1 had a pacemaker implanted. There were no complications resulting from the IRF ablation. All 15 patients survived over the average follow-up period of 24 months. Thirteen patients were still in sinus rhythm, 1 had pacemaker rhythm, and only 1 (1 of 15; 6.5%) suffered a recurrence of atrial fibrillation 3 months after the procedure. We suggest adding intraoperative IRF ablation during surgical closure of an ASD in all adult ASD patients with arrhythmias. The IRF ablation is easy to perform, safe, and effective.

Successful percutaneous closure of paraprosthetic aorto‐right ventricular leak using the Amplatzer duct occluder

A 55-year-old male with persisting aorto-right ventricular paraprosthetic leak after mitroaortic valve replacement was hospitalized for recurrent heart failure. Depressed left ventricular ejection fraction and severe pulmonary hypertension with increased right and left ventricular filling pressures were associated with significant left to right shunting through the leak. Elective closure of the leak was obtained with a 6-4 mm Amplatzer duct occluder. No complications were observed, and the patient experienced complete resolution of heart failure symptoms, with NYHA class I heart failure 12 months after discharge.

Managing problems with tracheoesophageal puncture for alaryngeal voice rehabilitation

The tracheoesophageal puncture (TEP) technique and the insertion of its associated voice prostheses may give rise to adverse events. We present our experience with this technique, paying special attention to the incidence and management of these adverse events. A retrospective clinical analysis was undertaken. Seventy-five laryngectomized patients underwent TEP for voice restoration. They were divided into two groups: group one, 43 patients with secondary TEP; and group two, 32 patients with primary TEP. Patient medical records were reviewed for data on the incidence, management and outcome of adverse events encountered during patients' follow up. Problems that arose in the patients were itemized as either early or late. The same patient could develop one or more problems in either group. The management of these problems, concerning the creation and maintenance of the TEP and associated prostheses, was noted. In group one, results were initially favourable in 91 per cent of patients and still positive in 81.4 per cent after three years. In group two, early results were favourable in all patients, and only two patients asked for late elective closure of the TEP (with a success rate of 93.7 per cent). Via an intensive and multidisciplinary approach to problems, most of the inevitable adverse events could be solved adequately, minimizing the discomfort of patients who had undergone laryngectomy and indwelling voice prosthesis insertion.

Anesthesia for Percutaneous Transcatheter Closure of Perimembranous Ventricular Septal Defect

To review the anesthetic management for percutaneous transcatheter closure of perimembranous ventricular septal defect (VSD) with an Amplatzer asymmetric occluder device and to highlight the hemodynamic effects and potential complications associated with its delivery. Retrospective review of prospectively collected data. University-affiliated teaching hospital. Nine consecutive children undergoing elective percutaneous transcatheter closure of perimembranous VSD. General anesthesia with sevoflurane for cardiac catheterization and percutaneous transcatheter device placement. Ten anesthetics were delivered in 9 children ages 23 to 65 months with perimembranous VSD for attempted placement of an Amplatzer asymmetric device. The device was successfully placed in 7 patients. In 1 patient the device embolized to the right femoral artery, and was retrieved with a bioptome. Fluoroscopy time (59.8 +/- 17.24 min) was prolonged compared to that in other studies of placement of this device. All patients had episodes of arrhythmia and hemodynamic disturbance. Arrhythmias ranged from atrial or ventricular ectopic events to various degrees of atrioventricular block. Complete heart block occurred during the procedure in 1 patient and after the procedure in another patient. Hypotensive episodes occurred in 7 patients, and were attributed to arrhythmias in 5 patients and hypovolemia in 2 patients. Two patients were given blood transfusions after the procedure because they had signs of hypovolemia and a greater than 10% decrease in hemoglobin levels. Anesthesia for perimembranous VSD occluder placement is associated with hemodynamic instability, arrhythmias, prolonged procedure times, and inevitable and sometimes substantial blood loss.

Transcatheter Device Closure of Interatrial Septal Defects in Patients with Hypoxia

There has been growing interest in transcatheter closure of interatrial septal defects (IASDs) for a variety of indications, but reports are limited in patients with hypoxia from right-to-left shunting. Between August 2000 and October 2004, 181 patients were referred to our institution for elective closure of a patent foramen ovale (PFO) or atrial septal defect (ASD). Among these patients, 10 (5.5%) underwent closure for hypoxia due to persistent or intermittent right-to-left shunting. Clinical evaluation, including echocardiography with color Doppler and agitated saline, was performed in all patients to determine the degree of right-to-left shunting. Defects were closed with Amplatzer (n = 4) or Cardioseal (n = 6) devices, under transesophageal (TEE) or intracardiac echocardiography (ICE) guidance. Mean age was 62.7 years (range: 31-88 years) with 70% female. Characteristics for closure included four patients with persistent hypoxia and six with intermittent hypoxia, including two with platypnea-orthodeoxia syndrome. All patients had echocardiography showing moderate (n = 6) or severe (n = 4) shunting. Patients had significant comorbidities, including chronic lung disease requiring supplemental oxygen (n = 5) and congestive heart failure (n = 2). TEE guidance was used in three patients, and ICE was performed in the remainder. Mean closure device diameter was 27 mm. Mean preprocedural arterial oxygen saturation of 86.7% improved to 95.9% immediately after closure, with color Doppler and agitated saline revealing the absence of (n = 5) or mild (n = 5) shunting. In-hospital major complications were limited to one patient with a transient ischemic attack after an initially unsuccessful closure attempt. Percutaneous closure of IASDs in a heterogeneous group of patients with hypoxia can be safely and effectively performed. The procedure results in immediate arterial saturation improvement and reduced right-to-left shunting.

Thrombus-in-transit causing paradoxical embolism in cerebral and coronary arterial circulation

We describe the case of an elderly man who was admitted to our hospital with the diagnosis of an acute anterior myocardial infarction, together with an acute bioccipital ischaemic stroke. Coronary angiography revealed embolization of the distal left anterior descendens and the first septal branch. The definite diagnosis of paradoxical embolism was made by means of a transoesophageal echocardiography which demonstrated a large snake-like floating thrombus crossing a patent foramen ovale. This diagnosis was also supported by the presence of deep venous thrombosis as a probable origin of the intra-atrial thrombus and the secondary pulmonary embolism which contributed to the elevated right heart pressure.The patient was treated with full-dose heparin and subsequently oral anticoagulation. After discharge, follow-up by transoesophageal echocardiography was organized and once the intracardiac thrombus had disappeared, elective transcatheter closure of the patent foramen ovale was performed.

Thrombus-in-transit causing paradoxical embolism in cerebral and coronary arterial circulation.

We describe the case of an elderly man who was admitted to our hospital with the diagnosis of an acute anterior myocardial infarction, together with an acute bioccipital ischaemic stroke. Coronary angiography revealed embolization of the distal left anterior descendens and the first septal branch. The definite diagnosis of paradoxical embolism was made by means of a transoesophageal echocardiography which demonstrated a large snake-like floating thrombus crossing a patent foramen ovale. This diagnosis was also supported by the presence of deep venous thrombosis as a probable origin of the intra-atrial thrombus and the secondary pulmonary embolism which contributed to the elevated right heart pressure.The patient was treated with full-dose heparin and subsequently oral anticoagulation. After discharge, follow-up by transoesophageal echocardiography was organized and once the intracardiac thrombus had disappeared, elective transcatheter closure of the patent foramen ovale was performed.

Closure of an Iatrogenic Coronary Artery Fistula With a PTFE-Coated Stent

Acquired coronary-cameral fistula is an uncommon disorder. We describe a 50-year-old man with rheumatic valvular disease who required emergency mitral and aortic valve replacement due to Staphylococcus aureus acute infective endocarditis. He underwent further surgical interventions due to bleeding and prosthetic dehiscence. During follow-up, a continuous parasternal murmur was noted. Echocardiography showed continuous coronary fistula flow from the left anterior descending artery to the right ventricle. Elective closure of the ostium was achieved with direct implantation of a 3.5 x 16 mm PTFE-coated stent (Jostent Coronary System Graft, Jomed, Germany).

Percutaneous closure of a congenital coronary artery fistula complicated by an acute myocardial infarction

A coronary artery fistula is not an uncommon finding on a routine coronary angiogram. Small fistulas need no specific treatment, but if haemodynamically important, elective closure is recommended. We present the case of a 69-year-old woman in whom a fistula originating from the right coronary artery and communicating with the right atrium is closed with an Amplatzer VSD occluder. Several hours after a successful closing procedure, the patient developed an acute myocardial infarction. Angiography demonstrated a thrombus that occluded a distal branch of the right coronary artery in the blind pouch of the closed fistula. Urgent bypass surgery was necessary to stabilize the patient’s condition.The aim of this case presentation is to warn for complications related to uncommon interventional procedures.

Primary Insertion of a Silastic Spring-Loaded Silo for Gastroschisis

Gastroschisis is traditionally managed by emergency primary closure, with a temporary silo reserved for large defects unable to be closed primarily. We recently have begun primary Silastic (Dow Coming, Midland, MI) spring-loaded silo (SLS) closure followed by elective closure and report our preliminary experience. A total of 15 infants (weight range, 2.1-13.5 kg) at 2 different institutions were treated by SC by 3 different surgeons between 1998 and 2002. A 3-, 4-, or 5-cm (ring diameter) silo was used depending on size of abdominal wall defect. Elective closure was performed in the operating room or at the bedside. Surgical parameters assessed included success of SLS, peak inspiratory pressures (PIPs) pre- and post-SLS closure, total time of staged closure with SLS, time to full feedings, and intra- and postoperative complications. Fifteen of 15 infants were successfully treated by SLS closure followed by elective closure. Two of 15 (13.3%) experienced temporary dislodgement of the silo prior to permanent closure. In both cases, the silo was safely reinserted at the bedside. Comparison of PIP values measured at various stages of SLS closure revealed no significant difference (P > 0.05). Mean times to final fascial closure (3.7 days) and full enteral feedings (22 days) were similar to historical controls obtained from the surgical literature. In 1 case where there was associated intestinal atresia, SLS closure was effective in permitting concomitant elective closure and re-establishment of bowel continuity. All children are alive and well at the time of this report. SLS closure permits safe, gentle, and gradual reduction of the exposed viscera leading to successful permanent abdominal wall closure. Respiratory embarrassment and hemodynamic instability associated with emergent (primary) closure of large abdominal wall defects can thus be avoided.

Transcatheter closure of a ruptured ventricular septum following inferior myocardial infarction and cardiogenic shock

Elective transcatheter closure of congenital septal defects has emerged as a valuable method, but the clinical experience on occlusion of ventricular septal rupture after myocardial infarction is very limited. We report a case of fatal outcome in a patient with inferior myocardial infarction and cardiogenic shock despite technically successful transcatheter closure of a large complex ventricular septal defect.

Transcatheter closure of atrial septal defect in young children: Results and follow-up

ObjectivesThis study sought to analyze the safety, efficacy, and follow-up results of percutaneous closure of secundum atrial septal defect (ASD) in young children. BackgroundResults of ASD transcatheter closure in adults are widely reported but there are no large published series concerning young children. MethodsBetween December 1996 and February 2002, 48 of 553 patients percutaneously treated at our institution were children age ≤5 years. Indications for closure were: elective closure in 32 patients; frequent respiratory infections in 8; failure to thrive in 2; liver transplantation in 5; and a fenestrated Fontan in 1. The procedure was carried out under general anesthesia with fluoroscopy and transesophageal control. Two different devices were used: 1) the CardioSEAL/StarFLEX (CS/SF) and 2) the Amplatzer septal occluder (ASO). Basal physical examinations and echocardiograms were performed prior to the procedure and at follow-ups (1, 6, and 12 months, and yearly thereafter). ResultsThe mean age at closure was 3.6 ± 1.3 years. A CS/SF was used in 10 subjects; an ASO was used in 38 patients. No deaths or immediate major complications occurred. The total occlusion rate was 87% at procedure, rising to 94% at discharge. The mean follow-up was 18 ± 14 months. No midterm major or minor complications occurred. The occlusion rate rose to 100% at 12 months of follow-up. Symptomatic patients improved significantly. ConclusionsIn the current era and in experienced hands, ASD closure can be performed safely and successfully, even in very young children.