Ann Thorac Surg 1997;63:1456-1458
© 1997 The Society of Thoracic Surgeons
Case Report
Surgical Repair of a Large Residual Atrial Septal Defect After Transcatheter Closure
Khosro Hekmat, MD,
Uwe Mehlhorn, MD,
E. Rainer de Vivie, MD
Department of Thoracic and Cardiovascular Surgery, University of Cologne, Koeln, Germany
Accepted for publication December 13, 1996.
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Abstract
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Transcatheter closure of ostium secundum atrial septal defects is a less invasive method of repairing atrial septal defects in comparison with an open heart operation. In selected patients the transvenous closure of atrial septal defects may be an effective alternative. Defects with circumferential septal rims, secundum atrial defects, and patent foramen are the best candidates for this method. We report a case in which a large residual atrial septal defect after transvenous closure with a Sideris occluder device required surgical closure.
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Introduction
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Transcatheter closure of an atrial septal defect (ASD) was first reported by King and associates [1] in 1976. Since then, transvenous ASD closure has been performed by a number of groups employing different techniques and devices. The Bard clamshell double umbrella [2] (USCI Division, C.R. Bard, Billerica, MA) and the Sideris buttoned intracardiac occluder [3] (Custom Medical Devices, Amarillo, TX) are the most commonly used devices for closure of ostium secundum ASD in the absence of other congenital cardiac malformations. Preliminary follow-up showed successful closure in 85% [2], 79% [3], and 92% [4] of patients in three studies. We report surgical closure of a large residual ASD 4 years after transcatheter closure with a Sideris device.
At the age of 8 years a girl with an ostium secundum ASD had a transcatheter closure with a 40-mm Sideris buttoned device. Before device implantation the ASD was measured at 13 mm in diameter by stretched balloon sizing. Transcatheter occlusion was aided by simultaneous transesophageal echocardiography. Postimplantation echocardiography and chest radiography revealed satisfactory position of the device and no residual shunt. However, a follow-up color Doppler study showed a residual shunt. The initially trivial shunt became larger over the years. When the child was 11.9 years of age, the parents decided on surgical ASD closure.
At physical examination a splitting of the second heart sound and a grade 2/6 systolic ejection murmur over the left sternal border were found. Precordial echocardiography showed significant residual shunting of the ASD. The electrocardiogram showed signs of right ventricular hypertrophy. The operation was performed through a median sternotomy with cardiopulmonary bypass. After cardioplegic arrest, a right atriotomy was made and a residual ASD approximately 10 mm in size was visualized (Fig 1
). The wire skeleton of the occluder and counteroccluder were well endothelialized. Two wires were positioned in the right atrium and one wire was in the free cavity of the left atrium. The polyurethane foam patch was not visible. After careful preparation and extraction of the Sideris device the ASD was closed with a pericardial patch. The girl recovered without complication and was doing well 6 months postoperatively.
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Fig 1. . Intraoperative situs with residual atrial septal defect (ASD). The Sideris device is located at the inferior rim of the ASD. Obviously one arm of the occluder was pulled through the ASD into the right atrium. (AS = atrial septum; CO = counteroccluder; OC = occluder.)
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Comment
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The repair of an ostium secundum ASD by an open heart operation is a safe procedure associated with a very low mortality rate [5]. The transcatheter closure of ASDs is a less invasive method managed by interventional cardiologists. International experience with secundum ASD occlusion using the Sideris buttoned device indicates that this method is relatively safe and effective, according to Rao and associates [4]. In that multiinstitutional trial 180 transcatheter ASD occlusions were performed. Successful implantation was accomplished in 166 of 180 patients. Doppler echocardiographic studies performed immediately after device implantation showed no residual shunts in 55%. Sixty-two patients had trivial, 11 small, and 3 moderate residual shunts. Complications included unbuttoning [6], whole device embolization, atrial perforation, and significant residual shunting. Twenty patients underwent operation (14 for device dislodgements, 3 for residual shunts or atrial perforation, 2 for device inspections for wire distortion, and 1 for paradoxical embolism) a few hours to 9 month after device implantation.
Experiences with the clamshell double umbrella device showed complete closure in 85% of 150 ASDs [2]. Complications included 2 strokes, 1 death, and 4 umbrella embolizations. Follow-up studies showed that up to 40% of umbrellas had at least one arm that was fractured. However, these fractures had not led to any clinical problems, and the closure rate was the same for umbrellas with and without fractures. Lloyd and colleagues [3] observed in 46 patients by Doppler echocardiography that residual left-to-right shunting decreased significantly over time. The prevalence of clinically significant residual shunts decreased from 15% immediately after implantation to 0% at 12 months, whereas the prevalence of complete closure increased from 30% to 81%.
In contrast to these findings, the initially trivial shunt in the present case report became larger over the following 3 years. The Sideris device consists of two components, the occluder and the counteroccluder (Fig 2). The occluder is folded and advanced with a catheter through a sheath into the left atrium. Here the occluder assumes its square shape. The delivery wire is then passed through the "buttonhole" of the counteroccluder. The counteroccluder is advanced through the sheath into the right atrium, where it assumes a position perpendicular to the sheath. Controlled traction on the delivery device causes the "button" of the occluder to pass through the buttonhole of the counteroccluder. The reason for failure in this case report can be explained as follows: Figure 1
shows that one arm of the X-shaped wire skeleton of the occluder lies incorrectly in the right atrium. While the occluder was withdrawn to the left side of the atrial septum one arm must have passed the ASD. Tension on the polyurethane foam shifted the whole device toward the tricuspid valve.
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Fig 2. . Schematic diagram of the Sideris device. (A) Correct position of the Sideris device. (B) Position of the Sideris device in this case. (AS = atrial septum; CO = counteroccluder; LA = left atrium; OC = occluder; RA = right atrium; S = sheath.)
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Transcatheter ASD closure is not feasible in all patients. Defects with circumferential septal rims, secundum atrial defects, and patent foramen are the best candidates for this method [2]. Primum atrial septal defects are located too close to the atrioventricular valves, and sinus venosus defects are too close to the pulmonary veins for transcatheter closure [2]. Transvenous closure should also not be attempted in patients with extremely large defects [7, 8]. Rosenfeld and associates [7] reviewed 28 patients undergoing device closure with the Bard double-umbrella occluder aided by simultaneous transesophageal echocardiography to determine precatheterization predictors of outcome. Only ASD size significantly predicted effective closure. All patients with a maximum defect size less than 13 mm had effective closure. Atrial dimensions and rim size did not predict effective closure. Reddy and colleagues [8] reviewed 29 patients in a retrospective analysis to determine echocardiographic predictors for catheter closure with the Sideris device. This study identified three predictive factors for successful closure. Atrial septal defect size of 15 mm or less was the single best indicator of success. Size of ASD as a fraction of septal length of 0.35 or less and superior rim/ASD ratio greater than 0.75 indicated a greater chance of successful closure.
In summary, in selected patients transcatheter ASD closure may be an effective alternative to surgical repair. Since 1993 modifications of the buttoned device have been introduced to circumvent unsuccessful closure [7]. Delivery of the device over a guidewire should allow repositioning of the device if it is pulled through the ASD. Introduction of a centering mechanism may allow the device to be used in large ASDs greater than 25 mm [7].
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Acknowledgments
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We thank Mrs Magdalena Bergheim for the schematic diagram of the Sideris device.
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Footnotes
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Address reprint requests to Dr Hekmat, Department of Thoracic and Cardiovascular Surgery, University of Cologne, Joseph-Stelzmannstr 9, 50924 Koeln, Germany (e-mail: khosro.hekmat{at}medizin.uni-koeln.de).
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References
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- King TD, Thompson SL, Steiner C, Mills NL. Secundum atrial septal defects: nonoperative closure during cardiac catheterization. JAMA 1976;235:2506–9.[Abstract/Free Full Text]
- Perry SB, van der Velde ME, Bridges ND, Keane JF, Lock JE. Transcatheter closure of atrial and ventricular septal defects. Herz 1993;18:135–42.[Medline]
- Lloyd TR, Rao PS, Beekman RH III, Mendelsohn AM, Sideris EB. Atrial septal defect occlusion with the buttoned device (a multi-institutional U.S. trial). Am J Cardiol 1994;73:286–91.[Medline]
- Rao PS, Sideris EB, Hausdorf G, et al. International experience with secundum atrial septal defect occlusion by the buttoned device. Am Heart J 1994;128:1022–35.[Medline]
- Kirklin JW, Barratt-Boyes BG. Cardiac surgery. 2nd ed. New York: Churchill Livingstone, 1993.
- Arabia FA, Rosado LJ, Lloyd TR, Sethi GK. Management of complications of Sideris transcatheter devices for atrial septal defect closure. J Thorac Cardiovasc Surg 1993;106:886–8.[Abstract]
- Rosenfeld HM, van der Velde ME, Sanders SP, et al. Echocardiographic predictors of candidacy for successful transcatheter atrial septal defect closure. Cathet Cardiovasc Diagn 1995;34:29–34.[Medline]
- Reddy SCB, Rao PS, Ewenko J, Koscik R, Wilson AD. Echocardiographic predictors of success of catheter closure of atrial septal defect with the buttoned device. Am Heart J 1995;129:76–82.[Medline]
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Abstract
Introduction
