Ann Thorac Surg 2008;86:998-1000. doi:10.1016/j.athoracsur.2008.02.077
© 2008 The Society of Thoracic Surgeons
Case Reports
Highly Fenestrated Septum Primum Leads to Failure of Amplatzer Septal Defect Closure
Jeremy McGarvey, BSa,
Takeyoshi Ota, MD, PhDa,
William Anderson, MDb,
William Katz, MDc,
Marco A. Zenati, MDa,*
a Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
b Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
c Department of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
Accepted for publication February 25, 2008.
* Address correspondence to Dr Zenati, Division of Cardiac Surgery, University of Pittsburgh, C700 PUH, 200 Lothrop St, Pittsburgh, PA 15213 (Email: zenatim{at}upmc.edu).
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Abstract
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A patient presenting with a history of transient ischemic attacks was initially diagnosed with a large secundum-type atrial septal defect by transesophageal echocardiography. Subsequent attempts to percutaneously repair the defect using an Amplatzer septal occlude device (AGA Medical, Plymouth, MN) failed to position correctly on multiple attempts. At the time of surgery, a largely deficient and highly fenestrated septum primum was found, which was likely the cause of the Amplatzer device (AGA Medical) failure. The defect was then definitively repaired using a bovine pericardial patch without incident.
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Introduction
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Although percutaneous closures of atrial septal defects have been generally shown to be safe and effective, there is a small subset of defects that are not amenable to this method. Pre-interventional intracardiac and transesophageal echocardiography may prevent subsequent failure of these devices through better characterization of the defect. In this case, a highly dynamic septum primum on echocardiography was later found to be an indicator of a highly fenestrated defect, which made closure of the Amplatzer septal occlude device (AGA Medical, Plymouth, MN) unachievable.
A 57-year-old woman with a history of transient ischemic attacks presented with an acute episode of diplopia. A subsequent transesophageal echocardiogram revealed a large secundum atrial septal defect (ASD) with biventricular shunting and a severely dilated right atrium and ventricle. At that time, a right heart catheterization revealed oxygen saturations consistent with right atrial step-up (SaO2 inferior vena cava, 85%; superior vena cava, 80%; right atrium, 88%). A computed tomographic head scan and carotid Doppler ultrasound were both normal. The patient was then referred for percutaneous closure of the defect.
Initial cardiology evaluation with magnetic resonance imaging of the heart excluded anomalous pulmonary venous return and found the ratio of pulmonary blood flow to system blood flow (shunting) (ie, Qp/Qs ratio) was 2.9. The patient was then scheduled for simultaneous transesophageal echocardiogram and left and right heart catheterizations for ASD closure. A transesophageal echocardiogram reconfirmed a secundum-type ASD, characterized by a small anterior superior rim and an aneurysmal posterior superior rim (Fig 1). A transesophageal echocardiogram was also notable for mild tricuspid regurgitation and a prominent Eustachian valve. The right atrium was accessed through the right femoral vein, and the ASD was found to be 36 mm in diameter using a sizing balloon (AGA Medical). A 36-mm Amplatzer septal occluder (AGA Medical) was then advanced to the defect under transesophageal echocardiographic guidance. In spite of multiple deployments, the left atrial disc of the occluder device could not be successfully positioned to remain on the left atrial side, a failure that was attributed to the large size of the ASD. Percutaneous closure of the defect was then deemed to be not feasible, and the patient was then referred for surgical closure of the atrial septum.
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Fig 1. Transesophageal echocardiograph illustrating a large atrial septal defect with an extremely dilated right atrium. When in motion, the septum primum was highly dynamic and flapping erratically.
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In the operating room, the right atrium was accessed through a median sternotomy and longitudinal pericardiotomy. Routine cardiopulmonary bypass was initiated. The heart was arrested with cardioplegia and a right atriotomy was performed. The ostium secundum-type defect was located and found to have an ecchymotic superior rim secondary to prior Amplatzer device deployment. In addition, a deficient and highly fenestrated septum primum was then discovered to comprise the inferior aspect of the defect (Fig 2A), which was a finding that would have likely precluded successful percutaneous closure of the ASD. The fenestrated primum was extensively resected to normal tissue margins, and the ASD dimensions were subsequently found to be 40 mm x 32 mm. An appropriately sized bovine pericardial patch was then sewn in place to the edges for successful closure of the defect (Fig 2B), which was confirmed by intraoperative transesophageal echocardiographic bubble study. The postoperative course of the patient was uneventful, and she was discharged on postoperative day 4.
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Fig 2. (A) Intraoperative view of deficient and fenestrated septum primum (in forceps) with deficient and ecchymotic septum secundum (arrows) and (B) view after successful placement of the bovine pericardial patch across the mixed-type atrial septal defect.
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Comment
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Percutaneous closure using the Amplatzer device has become a popular, effective, and safe method to treat secundum ASDs. Based on this report and published multicenter experiences, there appears to be a small subset of ASDs that are not amenable to repair using an Amplatzer device [1] due to size or morphology. In addition, large ASDs are at potentially increased risk for serious complications, such as device embolization [2].
At present, adult patients are typically selected for percutaneous closure based on echocardiographic criteria [3], although, as exemplified in this case, certain anatomical deformities (ie, a highly fenestrated septum primum) may not accurately predict successful closure by current standards. In the case presented, the hallmark echocardiographic finding was a highly dynamic and flapping septum primum, which may be an indicator for poor Amplatzer outcomes. The advent of intracardiac echocardiography may facilitate more accurate evaluation of septal defects and improve guidance and deployment of percutaneous occlusion devices [4]. Accordingly, although percutaneous occlusion of secundum ASDs is often safe and effective, re-consideration of the treatment approach for ASD closure may be beneficial in patients when size or morphologic complexity is of concern for successful percutaneous closure.
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References
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- Hein R, Buscheck F, Fischer E, et al. Atrial and ventricular septal defects can safely be closed by percutaneous intervention J Interven Cardiol 2005;18:515-522.[Medline]
- Kannan BR, Francis E, Sivakumar K, Anil SR, Kumar RK. Transcatheter closure of very large (
25 mm) atrial septal defects using the Amplatzer septal occlude Catheter Cardiovasc Interv 2003;59:522-527.[Medline] - Prokselj K, Kozelj M, Zadnik V, Podnar T. Echocardiographic characteristics of secundum-type atrial septal defects in adult patients: Implications for percutaneous closure using Amplatzer septal occluders J Am Soc Echocardiogr 2004;17:1167-1172.[Medline]
- Rigatelli G, Cardaioli P, Braggion G, et al. Transesophageal echocardiography and intracardiac echocardiography differently predict potential technical challenges or failures of interatrial shunts catheter-based closure J Interven Cardiol 2007;20:77-81.[Medline]
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Abstract
Introduction
