Percutaneous Atrial Septal Defect Research Articles

Asymptomatic Embolization After Percutaneous Ostium Primum Atrial Septal Defect Closure: a Rare Complication

Percutaneous device closure of atrial septal defects (ASD) has proven to be safe and it is nowadays the standard treatment for ASDs. Immediate or late device embolization is a rare but potential complication of every attempted ASD device closure. We report a case of asymptomatic Amplatzer Septal Occluder into the left ventricular outflow tract (LVOT) detected by routine transthoracic echocardiography 3 months after successful implantation in a stable patient.

Electrical remodeling after percutaneous atrial septal defect closure in pediatric and adult patients

BackgroundSeveral studies have reported changes in electrocardiographic variables after atrial septal defect (ASD) closure. However no temporal electro-and vectorcardiographic changes have been described from acute to long-term follow-up at different ages. We aimed to study electrical remodeling after percutaneous ASD closure in pediatric and adult patients. MethodsECGs of 69 children and 75 adults (median age 6 [IQR 4–11] years and 45 [IQR 33–54] years, respectively) were retrospectively selected before percutaneous ASD closure and at acute (1–7 days), intermediate (4–14 weeks) and late (6–18 months) follow-up. Apart from electrocardiographic variables, spatial QRS-T angle and ventricular gradient (VG) were derived from mathematically-synthesized vectorcardiograms. ResultsIn both pediatric and adult patients, the heart rate decreased immediately post-closure, which persisted to late follow-up. The P-wave amplitude also decreased acutely post-closure, but remained unchanged at later follow-up. The PQ duration shortened immediately in children and at intermediate follow-up in adults. The QRS duration and QTc interval decreased at intermediate-term follow-up in both children and adults. In both groups the spatial QRS-T angle decreased at late follow-up. The VG magnitude increased at intermediate follow-up in children and at late follow-up in adults, after an initial decrease in children. ConclusionIn both pediatric and adult ASD patients, electrocardiographic changes mainly occurred directly after ASD closure except for shortening of QRS duration and QTc interval, which occurred at later follow-up. Adults also showed late changes in PQ duration. At 6-to-18 month post-closure, the spatial QRS-T angle decreased, reflecting increased electrocardiographic concordance. The initial acute decrease in VG in children, which was followed by a significant increase, may be the effect of action potential duration dynamics directly after percutaneous ASD closure.

Successful atrial septal defect transcatheter closure in a patient with pentalogy of Cantrell and ectopia cordis.

Pentalogy of Cantrell (PC) is an extremely rare multiple congenital anomaly syndrome, characterized by the presence of five major malformations: midline supraumbilical abdominal wall defect (which results in omphalocele), lower sternal defect, diaphragmatic pericardial defect, anterior diaphragmatic defect and various intracardiac malformations (mostly ventricular septal defect) [1]. Additionally, although not part of the classic PC, some severe cases have been associated with herniation of the heart through the diaphragmatic defect, resulting in ectopia cordis (EC) [2]. Such a diagnosis carries a disastrous prognosis without surgical correction or palliation [3]. Furthermore, miscellaneous intracardiac abnormalities even worsen the survival. Multiple chest interventions and complex anatomy impede their surgical treatment; therefore, the transcatheter approach may be the only possibility. According to our best knowledge, no percutaneous atrial septal defect (ASD) closure has been reported in a patient with PC.

In vitro comparison of endothelialisation process and biocompatibility of 3 percutaneous atrial septal defect devices using human endothelial cells

The first cause of congenital heart disease is atrial septal defect (ASD). Several devices were developed to close secundum ASD but complications can occur (thromboembolic, infectious…). Providers claim different coatings supposed to improve device haemocompatibility. To study, in vitro, the ability of 3 devices to be endothelialized by endothelial cells derived from circulating human endothelial progenitors cells (EPCs), to induce platelet or complement activations or coagulation intrinsic pathway activation. EPCs from umbilical cord blood were extracted, cultured and characterized (CD31, VE-cadherin and von Willebrand factor). Devices were seeded with 100,000 cells/cm 2 . EPC adhesion, at 3 and 24 hours, was investigated (biological activity of N acetyl β-D-hexosaminidase). EPC proliferation was monitored with Alamar blue® test which allowed a longitudinal follow-up (Days1, 3, 6, 8, 10 and 12). C3a assay was performed after blood-contacting devices (standard ASTM F1984). Thereafter, platelet activation (via Pselectin and GPIIBIIA) and blood coagulation on biomaterials (standard ASTM F2888, F2382) were explored. With regard to EPCs adhesion and proliferation, no statistically significant differences were found between 3 devices. There was a significant EPC proliferation on each device as a function of time appearing at Day 8 for devices 2 and 3 and Day10 for device 1. No complement activation was detected by the C3a assay (device 1: 3584 ± 978 ng/mL, device 2: 3386 ± 1092 ng/mL and device 3: 4612 ± 1657 ng/mL). No platelet activation occurred within 15 min of contact with devices. However, there was a minimal activation of coagulation for 3 devices (mean time for PTT test on device 1: 183 ± 23.3 s, device 2: 170.7 ± 22.2 s and device 3: 167 ± 22.6 s). Despite different coatings, the haemocompatibility of 3 devices was comparable. The benefit of effective anticoagulation should be confirmed by future clinical studies.

Long-term effects of combined percutaneous atrial septal defect occlusion and pulmonary valvuloplasty in children < 2.5 years old.

Long-term effects of combined percutaneous atrial septal defect occlusion and pulmonary valvuloplasty in children < 2.5 years old.

Abstract 17051: Neurocognitive Disorders on Long-Term Follow up of Congenital Heart Disease Patients Undergoing Procedures in Childhood

Introduction: Neurocognitive disorders (NCD) are a growing concern in congenital heart disease (CHD) patients. We hypothesized that early life cardiopulmonary bypass (CBP) as well as age at intervention (AAI) were risk factors for NCDs on long-term follow-up in CHD patients. Methods: Data source was the Quebec CHD database. We defined NCD based on ICD 9 and 10 codes including autism spectrum disorder, global developmental disorder, specific developmental disorder, attention deficit hyperactive disorder, intellectual disability or specific learning deficit. We compared NCD risk from 1983-2010 in 3 cohorts of patients undergoing procedures in childhood: percutaneous atrial septal defect (ASD) closure (no CBP group), surgical ASD closure (short CBP group), and complex CHD lesion repair surgeries (long CBP group). Patients were followed from intervention until NCD diagnosis, death, or administrative censoring whichever came first. Results: By 27 years of follow-up, the cumulative risk of NCD was significantly higher in the complex surgery group compared to the ASD surgery group (crude, 24.9% and 13.4%; p&lt;0.0001) and with adjustments for AAI and sex (Cox regression, p=0.043). By 12 years of follow-up, the cumulative risk of NCD was significantly higher in the complex surgery group compared to the other two groups where the risk was almost identical. Cox models with different follow-up lengths identified younger AAI and male sex being significantly associated with increased risk in NCD. Conclusions: In long-term follow-up of CHD patients, younger AAI of CBP and male sex were associated with increased risk of NCD. Our findings suggest that CBP duration in a wide range of CHD lesions and cohort effects are important predictors of NCD. &lt;!--EndFragment--&gt;

Transesophageal echocardiography and fluoroscopy for percutaneous closure of atrial septal defects

The aim of the study was to compare transesophageal echocardiography (TEE) and fluoroscopy for percutaneous atrial septal defect (ASD) closure.This was a retrospective analysis of children who underwent percutaneous ASD closure. The procedure was guided by TEE without fluoroscopy in 130 patients (TEE group) and by fluoroscopy in 163 patients (fluoroscopy group). Baseline demographic/clinical characteristics were recorded. Patients were followed until hospital discharge. Outcomes were procedure duration, peri/postoperative complications, hospital stay, and costs.The TEE and fluoroscopy groups showed no significant differences in age (71.7 ± 40.7 vs 62.5 ± 38.8 months), male/female ratio (54/76 vs 66/97), weight (22.0 ± 12.0 vs 20.1 ± 9.0 kg), ASD diameter (9.9 ± 4.2 vs 9.3 ± 3.9 cm), distances to the superior vena cava (13.4 ± 4.6 vs 13.3 ± 4.2 cm), inferior vena cava (13.4 ± 4.3 vs 13.9 ± 4.1 cm) and atrial septal roof (12.1 ± 4.0 vs 12.3 ± 3.2 cm), or atrial septal size (38.2 ± 6.2 vs 39.4 ± 26.6 cm); distance to the mitral valve was greater in the TEE group (13.2 ± 4.4 vs 11.3 ± 3.9 cm; P < .001). The TEE and fluoroscopy groups showed no significant differences in occlusion device size (14.3 ± 4.6 vs 13.8 ± 4.0 cm) or sheath size (8.7 ± 1.8 vs 8.7 ± 0.9 cm), but procedure duration was shorter in the TEE group (21.5 ± 14.6 vs 28.6 ± 10.9 minutes; P < .001). Postoperative fever (>38°C) occurred less frequently in the TEE group than in the fluoroscopy group (0.8% vs 9.2%; P < .001); there were no significant differences for the other complications. No patient had postoperative residual shunt, occlusion device shedding/displacement, or pericardial effusion. The TEE group had longer hospital stay (3.2 ± 0.6 vs 2.9 ± 0.6 days; P < .001) and higher procedure cost (29,687 ± 4218 vs 28,530 ± 1668 CNY (China Yuan); P = .002) than the fluoroscopy group.TEE-guided percutaneous ASD closure can be used as an alternative to fluoroscopy-guided procedures and avoids the use of radiation or contrast agents.

Feasibility, Safety and Accuracy of Echocardiography-Fluoroscopy Imaging Fusion During Percutaneous Atrial Septal Defect Closure in Children

Imaging fusion between echocardiography and fluoroscopy was recently developed. The aim of this study was to assess its feasibility and accuracy during pediatric cardiac catheterization. Thirty-one patients (median weight, 26kg; interquartile range [IQR], 21-37kg) who underwent percutaneous atrial septal defect closure were prospectively included. The feasibility and accuracy of various imaging fusion modalities (live two-dimensional, live color two-dimensional, live three-dimensional and markers) with EchoNavigator software were assessed. To assess the accuracy of spatial registration of the echocardiogram on the fluoroscopic image, the occluder screw, an object that appeared on each image, was used as a reference tool, and the distance between the two when fused was measured. A distance was measured on the fusion screen between a marker positioned on the screw from the echocardiography screen and from the fluoroscopy screen (distance 1). Another distance was measured on the fusion screen between the screw visualized by three-dimensional echocardiography and by fluoroscopy (distance 2). The two distances were measured on four C-arm orientations in end-systolic and end-diastolic frames. Fusion and marker positioning were feasible in real time in all cases. On the fusion screen, median systolic and diastolic distance 1 were 0.5mm (IQR, 0.3-1mm) and 2mm (IQR, 1.5-2.5mm; P<.0001), respectively. The marker positioned from the echocardiography screen was fixed on the fusion screen anddid not follow the movement of the screw. Median systolic and diastolic distance 2 were 0.5mm (IQR, 0-0.5mm) and 2mm (IQR, 1.5-2.5mm; P<.0001), respectively. Echocardiographic fluoroscopic imaging fusion is feasible, safe, and accurate in children weighting >20kg. This technique offers a new method of imaging guidance in the catheterization laboratory for complex procedures and training.

Role of animal models for percutaneous atrial septal defect closure.

As for any preclinical development of new implantable device, bench testing has been followed by experimental studies on large animal models for the development of atrial septal defect closure devices. Various models have been used according to studied species (porcine, ovine or canine model) and whether the septal defect was percutaneously or surgically created. Animal models of percutaneous atrial septal defect closure aim to assess the healing process and device endothelialisation, as well as the development of magnetic resonance imaging guided procedures, the short-term effects of volume overload on right ventricular contractility through haemodynamic studies and the understanding of other complications such as nickel hypersensitivity. Each technique has its own advantages and drawbacks, and leads to different punch-related, acute septal injuries that could have an effect on the healing process after device implantation. It has been suggested that some long-term, major device-related complications such as thrombosis or infective endocarditis may be associated with an inappropriate healing process or insufficient endothelialisation of the device, leading industrial companies to pay a great deal of attention to the healing process. Tissue reactions in animal models were shown to adequately reproduce the healing response after device implantation in humans, with an endothelial device coverage observed as early as 30 days after implantation and complete after 3 to 6 months. Research perspectives may evaluate both animal models and in-vitro studies in parallel with a view to clarify the endothelialisation process using human endothelial cells through in-vitro experiments. Self-sensing device for detecting the presence of endothelial cells on the surface of intracardiac occluders and high-resolution imaging techniques that could non-invasively assess the complete endothelialisation of a device would also be promising tools which would need large animal models studies before their clinical application.

Short and Mid-Term Outcome of Percutaneous Atrial Septal Defect Closure in Adults

Short and Mid-Term Outcome of Percutaneous Atrial Septal Defect Closure in Adults

In vitro comparison of endothelialisation process and biocompatibility of 3 percutaneous atrial septal defect devices using human endothelial cells

The first cause of congenital heart disease is atrial septal defect (ASD). Several devices were developed to close secundum ASD but complications can occur (thromboembolic, infectious…) [1] , [2] , [3] . Providers claim different coatings supposed to improve device haemocompatibility. To study, in vitro, the ability of 3 devices to be endothelialized by endothelial cells derived from circulating human endothelial progenitors cells (EPCs), to induce platelet or complement activations or coagulation intrinsic pathway activation. EPCs from umbilical cord blood were extracted, cultured and characterized (CD31, VE-cadherin and von Willebrand factor). Devices were seeded with 100,000 cells/cm 2 . EPC adhesion, at 3 and 24 hours, was investigated (biological activity of N acetyl β-D-hexosaminidase). EPC proliferation was monitored with Alamar blue ® test which allowed a longitudinal follow-up (Days 1, 3, 6, 8, 10 and 12). C3a assay was performed after blood-contacting devices (standard ASTM F1984) [4] . Thereafter, platelet activation (via Pselectin and GPIIBIIA) and blood coagulation on biomaterials (standard ASTM F2888, F2382) [5] , [6] were explored. With regard to EPCs adhesion and proliferation ( Fig. 1 , Fig. 2 ), no statistically significant differences were found between 3 devices. There was a significant EPC proliferation on each device as a function of time appearing at Day 8 for devices 2 and 3 and Day 10 for device 1. No complement activation was detected by the C3a assay (device 1: 3584 ± 978 ng/mL, device 2: 3386 ± 1092 ng/mL and device 3: 4612 ± 1657 ng/mL) ( Fig. 3 ). No platelet activation occurred within 15 min of contact with devices (Figs 4 and 5). However, there was a minimal activation of coagulation for 3 devices (Mean time for PTT test on device 1: 183 ± 23.3 s, device 2: 170.7 ± 22.2 s and device 3: 167 ± 22.6 s). Despite different coatings, the haemocompatibility of three devices was comparable. The benefit of effective anticoagulation should be confirmed by future clinical studies.

Training in Structural Heart Disease: Call to Action.

Catheter-based therapies for congenital and structural heart diseases (SHDs) have come a long way since the pioneering work of Terry King in 1976 with the first percutaneous atrial septal defect closure, the first mitral balloon valvuloplasty by Kanji Inoue in 1984, and the first percutaneous valve replacements by Philipp Bonhoeffer and Alain Cribier in the early 2000s. More than 100 000 transcatheter aortic valve replacements (TAVRs) have been performed in the United States, and the yearly number of TAVR implants now exceeds that of isolated surgical aortic valve replacements.1 If the ongoing TAVR trials for low-risk patients demonstrate equivalence with surgery, we can expect another surge in demand for TAVR procedures. Similarly, percutaneous mitral valve repair procedures have now climbed to >15 000 in the United States.1 In addition, several percutaneous therapies for tricuspid and mitral valve repair and replacement are currently in the pipeline and will fuel continued growth in percutaneous therapies for SHD in the coming years. Recent Food and Drug Administration approvals of devices to close the left atrial appendage and patent foramen ovale further highlight this point. Furthermore, the number of adults with congenital heart disease (CHD) now exceeds the number of affected children, and many of these patients will require additional catheterization procedures.2 It is paradoxical that this nascent field has been devoid of formalized training paradigms. There is a clear and unmet need for defining the training requirements of physicians intending to perform SHD interventions. We need to ensure that future proceduralists will possess the appropriate cognitive and technical skill sets required to safely and effectively perform these …

Immediate and short term effects of percutaneous atrial septal defect device closure on cardiac electrical remodeling in children.

BackgroundThe beneficial effects of atrial septal defect (ASD) device closure on electrical cardiac remodeling are well established. The timing at which these effects starts to take place has yet to be determined.ObjectivesTo determine the immediate and short term effects of ASD device closure on cardiac electric remodeling in children.Methods30 pediatric patients were subjected to 12 lead Electrocardiogram immediately before ASD device closure, 24 h post procedure, 1 and 6 months after. The maximum and minimum P wave and QT durations in any of the 12 leads were recorded and P wave and QT dispersions were calculated and compared using paired T test.ResultsThe immediate 24 h follow up electrocardiogram showed significant decrease in P maximum (140.2 ± 6 versus 130.67 ± 5.4 ms), P dispersion (49.73 ± 9.01 versus 41.43 ± 7.65 ms), PR interval (188.7 ± 6.06 ms versus 182.73 ± 5.8 ms), QRS duration (134.4 ± 4.97 ms versus 127.87 ± 4.44), QT maximum (619.07 ± 15.73 ms versus 613.43 ± 11.87), and QT dispersion (67.6 ± 5.31 versus 62.6 ± 4.68 ms) (P = 0.001). After 1 month all the parameters measured showed further significant decrease with P dispersion reaching 32.13 ± 6 (P = 0.001) and QT dispersion reaching 55.0 ± 4.76 (P = 0.001). These effects were maintained 6 months post device closure.ConclusionPercutaneous ASD device closure can reverse electrical changes in atrial and ventricular myocardium as early as the first 24 h post device closure.

Acute Changes on Pulmonary Pressure Following Percutaneous Closure of Secundum Atrial Septal Defect

Pulmonary hypertension is a common complication of congenital heart disease due to systemic – pulmonary circulation shunt which if left uncorrected leads to increased pulmonary artery pressure, vascular remodeling and further increase of pulmonary vascular resistance. Percutaneous closure of the defect interrupts this shunt thus reducing right heart and pulmonary circulation load and pulmonary artery pressure. In this paper we present two cases of percutaneous secundum atrial septal defect closure complicated by pulmonary hypertension along with echocardiographic evaluation of cardiopulmonary hemodynamic changes before and shortly after device closure. Forty years old and thirty three years old females presented to our clinics with classical symptoms of atrial septal defects, assessment revealed TVG of 37 mmHg and 30 mmHg,shortly after the procedure patient was re-evaluated and revealed TVG of 39 mmHg and 23 mmHg respectively. From these cases we conclude that changes in pulmonary artery pressure is not constantly found after device closure. However both patients display improvements in functional capabilities.

An extremely rare but considerably important device-related complication of percutaneous atrial septal defect closure

An extremely rare but considerably important device-related complication of percutaneous atrial septal defect closure

Intracardiac echocardiography for percutaneous patent foramen ovale and atrial septal defect occlusion.

Transesophageal echocardiography (TEE) plays aunique role in transcatheter closure of atrial septal defects (ASD) and patent foramen ovale (PFO). However, problems such as the need for general anesthesia, possible trauma from endotracheal intubation, presence of "blind spots," and occasional inadequate imaging of some cardiac structures have necessitated better imaging techniques. Our study aimed to compare the findings of TEE during the initial diagnostic examination with those from intracardiac echocardiography (ICE) acquired during the interventional procedure. Atotal of 65patients in whom TEE was used for the diagnosis of ASD or PFO were included. Of these, 40 patients (61.5%) had ASD with significant left to right shunt and 25(38.5%) patients had PFO associated with transient ischemic attack or stroke. ICE imaging was performed under local anesthesia in all patients to guide interatrial communication closure. ICE provided adequate views of the defects and surrounding structures during the various stages of device deployment. In eight patients (12.3%) an additional anatomical variation was detected. All patients had successful device implantation and were discharged 1day after the procedure. ICE is asafe and high-quality imaging technique for guiding transcatheter ASD and PFO occlusion. Additionally, ICE can both facilitate device implantation and detect cardiac abnormalities that are not identified with TEE during the initial diagnostic investigation.

A Novel Guide Wire Facilitates Percutaneous and Nofluoroscopic Procedure for Atrial Septal Defect Closure

Objective: The purpose of this pilot study was to assess the safety and efficacy of a novel ultrasound guided wire for the treatment of patients with atrial septal defect (ASD) who underwent percutaneous atrial septal defect closure using transthoracic echocardiographic (TTE) guidance only. Materials and methods: From November 2017 to December 2017, 10 patients with congenital ASD were recruited for echo-guiding occlusion with a new designed wire specialized for percutaneous and no-fluoroscopic procedure. The novelty of this wire lies in the elastic spindleshaped tip which helps with precise positioning under ultrasound while reducing difficulty and complications. Operations were performed by 3 doctors who had performed no more than 10 echo-guided cases. Operative successful rate was used as the main evaluation index, Secondary evaluation index included operative time, the number of times guide wire or delivery system dropped into right atrial, frequency of arrhythmia, the number of times guide wire went through tricuspid valve, cardiac perforation, cardiac tamponade and peripheral vascular complications. Result: All 10 patients successfully underwent percutaneous and no-fluoroscopic atrial septal defect closure with the novel wire. The mean operation time was 20.20±8.904 minutes. The followup time was 3 months and no severe complication occurred. Conclusion: This pilot study demonstrated that the new ultrasound guided wire can be precisely positioned under ultrasound and can facilitate percutaneous and no fluoroscopic procedure safely and effectively.

Percutaneous Atrial Septal Defect Closures in Wellington

Background: Atrial Septal Defects (ASDs) are a common form of congenital heart disease, often detected in adult life. If left untreated they can lead to right heart failure and pulmonary hypertension. It is widely accepted that indication for closure includes right ventricle (RV) dilatation/impairment, demonstration of a haemodynamically significant shunt or symptoms. In suitable patients, percutaneous closure is an effective and less invasive approach than open surgery. Method: We retrospectively analysed all patients who had ASDs closed percutaneously in Wellington between February 2011 and January 2018, by reviewing medical records and echocardiograms. Results: 33 patients underwent attempted percutaneous ASD closure. All were performed under conscious sedation. 23 were female, with an average age of 40 years. All patients had a dilated RV. 17 had objective shunt quantification, all of which were haemodynamically significant. 17 were symptomatic. The majority of closures were performed using an Amplatzer Septal Occluder, with an average size of 25 mm. 3 procedures were unsuccessful and required subsequent surgical closure. Of the 30 completed percutaneously, at 6 month follow up only 9 had ongoing RV dilatation (mild) and all had normal RV function. There was 1 small, non-significant shunt. 2 patients had ongoing symptoms (palpitations). There were few complications with 1 minor bleeding, 2 readmissions and 1 death 9 months later in a patient with significant comorbidities. 2 patients required a second procedure as the first attempt was unsuccessful. Conclusion: Percutaneous closure of ASDs in Wellington has demonstrated significant improvement in RV size/function, interatrial shunts and symptoms with a low rate of complications.

The Effects of Percutaneous Atrial Septal Defect Closure on Cardiac Remodelling at Short and Intermediate Term Follow-up

The Effects of Percutaneous Atrial Septal Defect Closure on Cardiac Remodelling at Short and Intermediate Term Follow-up

An extremely rare but considerably important device-related complication of percutaneous atrial septal defect closure

An extremely rare but considerably important device-related complication of percutaneous atrial septal defect closure