Ann Thorac Surg 2001;72:1746-1748
© 2001 The Society of Thoracic Surgeons
Case report
Midterm follow-up of the Amplatzer device in left ventricle-to-aorta conduits
Roberto Formigari, MD*a,
Marco Bonvicini, MDa,
Andrea Donti, MDa,
Gaetano Gargiulo, MDa,
Fernando M. Picchio, MDa
a Department of Pediatric Cardiology, St. Orsola Hospital, University of Bologna, Bologna, Italy
Accepted for publication January 13, 2001.
* Address reprint requests to Dr Formigari, Pediatric Cardiology, University of Bologna, Policlinico Sant’ Orsola, Via Massarenti 9, 40138 Bologna, Italy
e-mail: r.formigari{at}mclink.it
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Abstract
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The midterm follow-up of 2 patients with left ventricle-to-aorta conduit who underwent percutaneous closure with the Amplatzer device is described. Complete occlusion was achieved immediately in 1 patient. In the other patient, a trivial residual shunt was still present after 12 months, but disappeared after 18 months. Occlusion of dysfunctional left ventricle-to-aorta conduits by the Amplatzer device is feasible, provided that enough time is allowed for complete occlusion.
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Introduction
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Immediate results of closure of left ventricle-to-aorta conduits have been previously reported using various devices, like coils or the Rashkind occluder [1, 2]. We report on the midterm follow-up of 2 patients whose treatment used the Amplatzer Atrial Septal Defect Occluder and the Amplatzer Duct Occluder devices (AGA Medical Corporation, Golden Valley, MN).
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Case reports
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Patient 1
This patient underwent resection of subaortic stenosis at 8 months of age. Severe postoperative dynamic stenosis of the left ventricular outflow tract prompted for the implantation of a Shiley 16-mm conduit (Shiley Inc, Irvine, CA) from the left ventricle to the ascending aorta. At 11 years of age, wide arterial pulses were noted. Cardiac catheterization showed a 15 mm Hg peak systolic pressure gradient in the left ventricular outflow tract with significant regurgitation of the stenotic conduit. An Amplatzer 6-mm Atrial Septal Defect Occluder device (AGA Medical Corporation, Golden Valley, MN) was successfully implanted (Fig 1), with mild residual shunt, still present on color-Doppler 3 months later. Control cardiac catheterization after 13 months showed complete occlusion of the conduit (Fig 2). The child is asymptomatic and without medications.
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Fig 1. The Amplatzer Atrial Septal Defect Occluder (arrow) (AGA Medical Corporation, Golden Valley, MN) positioned into the prosthetic valve (PV). (LV = left ventricle.)
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Fig 2. Injection into the ascending aorta (Ao) at control cardiac catheterization shows the absence of residual shunt into the left ventricle. The arrow points towards the occluder. (C = conduit.)
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Patient 2
This patient had implantation of a 16-mm Carpentier conduit (Baxter Healthcare Corporation, Irvine, CA) from the left ventricular apex to the descending aorta at 2 years of age because of a critical dynamic subaortic obstruction after repair of supravalvular aortic stenosis. Control cardiac catheterization at 14 years of age showed complete resolution of the subaortic stenosis, mild hypoplasia of the ascending aorta, moderate aortic insufficiency, and diastolic regurgitation through the prosthesis. A 14-mm Amplatzer Duct Occluder (AGA Medical Corporation, Golden Valley, MN) was positioned inside the conduit (Fig 3) with rise of the diastolic pressure from 40 to 60 mm Hg. Control injection into the aorta showed a mild residual diastolic shunt into the left ventricle, still present at color-Doppler after 6 months. Follow-up echo after 18 months showed complete occlusion of the conduit.
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Fig 3. Injection into the left ventricle (LV) shows mild residual patency of the apico-aortic conduit. The Amplatzer Duct Occluder (arrow) (AGA Medical Corporation, Golden Valley, MN) is in position at the level of the valve. (C = conduit.)
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The sizes of the devices were selected in relation to the narrowest point of the conduit, ie, at the level of the prosthetic valve. Both have been deployed through a Mullins sheath (Cook, Bloomington, IN) retrograding into the conduit from the right femoral artery and the ascending aorta in the first patient and the descending aorta in the second patient. Balloon test-occlusion of the prostheses was not attempted because of the excellent patency of the native outflow tract at angiography and the high risk of balloon rupture against the heavily calcified conduit wall. Aspirin was given for 6 months.
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Comment
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The Amplatzer devices share in common a Nitinol wire mesh with the shape of a double-disk for the Atrial Septal Defect Occluder and a cone for the duct occluder, with the central waist acting like a stent providing complete occlusion of the defect.
At the time we managed the first patient, only the Amplatzer Atrial Septal Defect Occluder device was available. For the second patient, we preferred to use the newly affordable Duct Occluder device which, in our opinion, better suits the anatomy of stenotic conduits.
The extended indication for using percutaneous closure devices in complex postoperative patients should be viewed cautiously until long-term follow-up data is available. This may be particularly true for cases like the second patient we described, where complete occlusion was observed only between 6 and 18 months after the procedure. While the excessive growth of the thrombus seems to be a very rare event for the Amplatzer devices, the unusual location made us worry about the risk of thrombotic complications. Despite only 6 months of antiplatelet therapy, there were no signs of thrombus extension.
Closure of regurgitant left ventricle-to-aorta conduits is feasible with the Amplatzer devices, however complete occlusion may occur later, after the procedure. At least 6 to 12 months follow-up should be allowed before considering failure or partial success caused by the persistence of any kind of residual shunt.
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Acknowledgments
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We thank Mr Gabriele Cristiani for preparing the angiographic illustrations.
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References
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Hourihan M., Perry S.B., Mandell V.S., et al. Transcatheter umbrella closure of valvular and paravalvular leaks. J Am Coll Cardiol 1992;20:1371-1377.[Abstract]
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Rothman A., Tong A.D. Percutaneous coil embolization of superfluous vascular connections in patients with congenital heart disease. Am Heart J 1993;126:206-213.[Medline]
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Abstract
Introduction
