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Transcatheter closure of a complex atrial septal defect after occluder device embolization
Cardiovascular Revascularization Medicine xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
Cardiovascular Revascularization Medicine
Transcatheter closure of a complex atrial septal defect after occluder device embolization Georgina Fuertes-Ferre a,⁎, Felipe Hernández Hernández b, Marta López Ramón b, Juan Sánchez Rubio a, Esther Sánchez Insa a, Jose Gabriel Galache Osuna a a b
Interventional Cardiology Unit, Miguel Servet University Hospital, Zaragoza, Spain. Interventional Cardiology Unit, 12 Octubre University Hospital, Madrid, Spain.
a r t i c l e
i n f o
Article history: Received 23 January 2017 Received in revised form 12 February 2017 Accepted 15 February 2017 Available online xxxx Keywords: Iatrogenic atrial septal defect Percutaneous closure Intracardiac echocardiography 3D transesophageal echocardiography
a b s t r a c t Percutaneous closure is nowadays considered the treatment of choice of ostium secundum atrial septal defects (ASD). However, transcatheter closure can be highly challenging when we face an ASD with complex morphological features. The combination of different imaging modalities can be very helpful. This case shows the great value of using both intracardiac and real time 3D transesophageal echocardiography for the percutaneous closure of a complex iatrogenic ASD after device embolization. © 2017 Elsevier Inc. All rights reserved.
1. Introduction Percutaneous closure of atrial septal defects (ASDs) has become a worldwide accepted alternative to surgical repair. Device embolization is a rare but recognized complication [1]. Percutaneous device retrieval can increase the size of the defect by tearing the interatrial septum. Intracardiac echocardiography (ICE) has shown positive results in guiding percutaneous ASD closure and could be especially useful in complex cases of ASD [2,3]. Real time 3D Transesophageal echocardiography (3D-RT TEE) provides incremental value for an optimal device alignment and implantation [4]. We describe a challenging case of percutaneous closure of a large iatrogenic ASD after device embolization using ICE and real time 3D-TEE for procedural guidance. 2. Case A 77-year-old woman with history of hypertension and permanent atrial fibrillation reported dyspnea with moderate exertion. She was diagnosed to have an ostium secundum atrial septal defect (ASD) of 11 × 14 mm with an atrial septal aneurysm (ASA), left to right shunt and severe right chambers dilatation. A 14 mm Amplatzer ™ Septal occluder device (St. Jude Medical, Inc.; St. Paul, Minn) was chosen for
⁎ Corresponding author at: Interventional Cardiology Unit, Miguel Servet University Hospital, Paseo Isabel la Católica 1-2, 50001, Zaragoza, Spain. Tel.: +34 976 76 55 00; fax: +34 976 56 25 65. E-mail address: [email protected] (G. Fuertes-Ferre).
percutaneous closure. When we attempted the ASD closure, the device embolized into the left atrium and was captured percutaneously with a snare catheter (Fig. 1). Device retrieval resulted in an enlargement of the defect. The 2D and 3D TEE revealed a 28 mm ASD with a larger ASA. Despite the retro-aortic rim overpassing 8 mm, the posterior rim was practically absent (Fig. 2; Supplementary movie 1). After evaluation by the heart team (interventional, imaging cardiologists and cardiovascular surgeons) it was decided to attempt percutaneous closure again, this time using real time 3D TEE (3D-RT TEE) in combination with intracardiac echocardiography (ICE) for procedural guidance. The procedure was performed under deep sedation. A 30 mm Amplatzer ™ Septal Occluder device (St. Jude Medical, Inc.; St. Paul, Minn) was successfully implanted. ICE offered direct visualization of the inferoposterior septal rim, which allowed to successfully engage the device and to guide the “push and pull maneuver”. On the other side, 3D-ETE helped us to confirm both sides of the defect were completely covered before device releasing (Fig. 3). The patient has been asymptomatic at a follow up of six months without residual shunt in the echocardiographic controls. 3. Discussion The experience gained over the last years supports that percutaneous closure of ASD is feasible and safe. However, major complications may still occur. The incidence of device embolization is low; some series reveal rates of 0.55%–1.7% [5]. It usually occurs immediately after device implantation or in the following hours. In this case the device could be fortunately retrieved percutaneously from the left atrium with a snare.
http://dx.doi.org/10.1016/j.carrev.2017.02.010 1553-8389/© 2017 Elsevier Inc. All rights reserved.
Please cite this article as: Fuertes-Ferre G, et al, Transcatheter closure of a complex atrial septal defect after occluder device embolization, Cardiovasc Revasc Med (2017), http://dx.doi.org/10.1016/j.carrev.2017.02.010
2
G. Fuertes-Ferre et al. / Cardiovascular Revascularization Medicine xxx (2017) xxx–xxx
Fig. 1. A, Ostium secundum atrial septal defect (OS-ASD) with left to right shunt and atrial septal aneurysm (ASA) assessed by 2D Transesophageal echocardiography. Right atrium (RA), Left atrium (LA). B, Percutaneous retrieval of the embolised Amplatzer occluder device with a goose-neck snare catheter (GNC). C, Amplatzer retrieved device. ICE: intracardiac echocardiography catheter.
Fig. 2. Iatrogenic atrial septal defect (ASD) assessment. A, 2D Transesophagic echocardiography (TEE) showing the atrial septal aneurysm (ASA). B, 2D-TEE depicts the insufficient posterior rim. C, 3D-TEE view of the hypermobile ASA. D, 3D-TEE showing the ruptured ASD and teared interatrial septum (IAS). LA: Left Atrium, RA: Right atrium, A: aorta, PR: posterior rim, AV: aortic valve.
Please cite this article as: Fuertes-Ferre G, et al, Transcatheter closure of a complex atrial septal defect after occluder device embolization, Cardiovasc Revasc Med (2017), http://dx.doi.org/10.1016/j.carrev.2017.02.010
G. Fuertes-Ferre et al. / Cardiovascular Revascularization Medicine xxx (2017) xxx–xxx
3
Fig. 3. Echocardiographic monitoring of the iatrogenic atrial septal defect (ASD) percutaneous closure. A, Intracardiac echocardiography showing the hypermobile atrial septal aneurysm (ASA) and the left disk of the Amplatzer occluder device (AOD) open in the left atrium, close to the ASD. B, 3D Transesophageal Echocardiography en-face view of the left sided disc before deployment. C, “Push and pull maneuver” of the Amplazter occlude device (AOD) assessed by fluoroscopy. D, ICE shows the device is anchored in the interatrial septum.
Nonetheless, the case was complicated with a large iatrogenic ASD. There are some reported cases of ostium secundum (OS) ASD ≥ 30 mm in which the Amplatzer has been safely used [6]. This time, not only the large ASD, but also the friable ASA and deficient posterior rim made the case more complex (Fig. 2). To undergo another percutaneous attempt, an accurate imaging of ASD anatomic features was crucial to prepare for and guide the procedure. Device size was selected according to the ASD diameter. Balloon sizing of the defect has been classically considered as a relevant part of trans-catheter closure of ASD. However, ASD device closure is increasingly being performed without balloon sizing due to the improvement in imaging modalities [7]. We believed balloon sizing in this case of a large ASD with an ASA may had caused an overestimation of the defect size, as described in other cases [8]. For this reason, we preferred the use of both ICE and 3D-TEE for peri-procedural guidance. ICE is the preferred guiding tool in many centers, usually performed by interventional cardiologist and has demonstrated to be superior to 2D-TEE monitoring [9]. Although ICE has a limited field of view in comparison to TEE, it can be especially helpful in cases with small or deficient inferior and posterior rims, offering a clear visualization of the posteroinferior rim (Fig. 2A). On the other side, the advantages of 3D-TEE in guiding percutaneous closure of
interatrial communications have been published in recent years. An echocardiographer is commonly required to perform it. Morphologic features and exact dimensions of ASD are very well defined with 3DTEE, as well as septal tissue conformability and pliability. In this report, the 3D-TEE provided a precise characterization of the ASD margins in the preprocedural study. The better understanding of the defect morphology motivated us to attempt another percutaneous closure. In addition, 3D-RT TEE improved the spatial resolution of ICE during the procedure, ensuring an optimal final result (Fig. 2). The concomitant use of ICE and 3D-TEE is not required in most of ASDs that undergo percutaneous closure. However, when facing a large atrial septal defect with deficient inferior or posterior rims, the use of ICE in combination with real time 3D-TEE is especially useful and may allow for a safe and optimal transcatheter closure, thus avoiding the need for surgery. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.carrev.2017.02.010.
Disclosure Felipe Hernandez is a consultant for St Jude Medical.
Please cite this article as: Fuertes-Ferre G, et al, Transcatheter closure of a complex atrial septal defect after occluder device embolization, Cardiovasc Revasc Med (2017), http://dx.doi.org/10.1016/j.carrev.2017.02.010
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G. Fuertes-Ferre et al. / Cardiovascular Revascularization Medicine xxx (2017) xxx–xxx
Role of the funding source No funding was received related to this manuscript. References [1] Levi DS, Moore JW. Embolization and retrieval of the Amplatzer septal occluder. Catheter Cardiovasc Interv 2004;61:543–7. [2] Mullen MJ, Dias BF, Walker F, Siu SC, Benson LN, McLaughlin PR. Intracardiac echocardiography guided device closure of atrial septal defects. J Am Coll Cardiol 2003;41:285–92. [3] Hernández F, Martín R, Jiménez C. Iatrogenic atrial septal defect: intracardiac ultrasound-guided percutaneous closure. Rev Esp Cardiol 2007;60:1106–7.
[4] Yared K, Baggish AL, Solis J, Durst R, Passeri JJ, Palacios IF, et al. Echocardiographic assessment of percutaneous patent foramen ovale and atrial septal defect closure complications. Circ Cardiovasc Imaging 2009;2:141–9. [5] Tobis J, Shenoda M. Percutaneous treatment of patent foramen ovale and atrial septal defects. J Am Coll Cardiol 2012;60:1722–32. [6] Guan Z, Qin Y, Zhao X, Ding J, Zheng X, Nguyen V. Transcatheter closure of large atrial septal defects in 18 patients. Clin Cardiol 2008;31:24–7. [7] Amin Z, Daufors DA. Balloon sizing is not necessary for closure of secundum atrial septal defects. J Am Coll Cardiol 2005;45(Suppl. 1):317. [8] Harikrishnan S, Narayanan NK, Sivasabramonian S. Sizing balloon-induced tear of the atrial septum. J Invasive Cardiol 2005;17:546–7. [9] Bartel T, Konorza T, Arjumand J, Ebradlidze T, Eggebrecht H, Caspari G, et al. Intracardiac echocardiography is superior to conventional monitoring for guiding device closure of interatrial communications. Circulation 2003;107:795–7.
Please cite this article as: Fuertes-Ferre G, et al, Transcatheter closure of a complex atrial septal defect after occluder device embolization, Cardiovasc Revasc Med (2017), http://dx.doi.org/10.1016/j.carrev.2017.02.010
Contents lists available at ScienceDirect
Cardiovascular Revascularization Medicine
Transcatheter closure of a complex atrial septal defect after occluder device embolization Georgina Fuertes-Ferre a,⁎, Felipe Hernández Hernández b, Marta López Ramón b, Juan Sánchez Rubio a, Esther Sánchez Insa a, Jose Gabriel Galache Osuna a a b
Interventional Cardiology Unit, Miguel Servet University Hospital, Zaragoza, Spain. Interventional Cardiology Unit, 12 Octubre University Hospital, Madrid, Spain.
a r t i c l e
i n f o
Article history: Received 23 January 2017 Received in revised form 12 February 2017 Accepted 15 February 2017 Available online xxxx Keywords: Iatrogenic atrial septal defect Percutaneous closure Intracardiac echocardiography 3D transesophageal echocardiography
a b s t r a c t Percutaneous closure is nowadays considered the treatment of choice of ostium secundum atrial septal defects (ASD). However, transcatheter closure can be highly challenging when we face an ASD with complex morphological features. The combination of different imaging modalities can be very helpful. This case shows the great value of using both intracardiac and real time 3D transesophageal echocardiography for the percutaneous closure of a complex iatrogenic ASD after device embolization. © 2017 Elsevier Inc. All rights reserved.
1. Introduction Percutaneous closure of atrial septal defects (ASDs) has become a worldwide accepted alternative to surgical repair. Device embolization is a rare but recognized complication [1]. Percutaneous device retrieval can increase the size of the defect by tearing the interatrial septum. Intracardiac echocardiography (ICE) has shown positive results in guiding percutaneous ASD closure and could be especially useful in complex cases of ASD [2,3]. Real time 3D Transesophageal echocardiography (3D-RT TEE) provides incremental value for an optimal device alignment and implantation [4]. We describe a challenging case of percutaneous closure of a large iatrogenic ASD after device embolization using ICE and real time 3D-TEE for procedural guidance. 2. Case A 77-year-old woman with history of hypertension and permanent atrial fibrillation reported dyspnea with moderate exertion. She was diagnosed to have an ostium secundum atrial septal defect (ASD) of 11 × 14 mm with an atrial septal aneurysm (ASA), left to right shunt and severe right chambers dilatation. A 14 mm Amplatzer ™ Septal occluder device (St. Jude Medical, Inc.; St. Paul, Minn) was chosen for
⁎ Corresponding author at: Interventional Cardiology Unit, Miguel Servet University Hospital, Paseo Isabel la Católica 1-2, 50001, Zaragoza, Spain. Tel.: +34 976 76 55 00; fax: +34 976 56 25 65. E-mail address: [email protected] (G. Fuertes-Ferre).
percutaneous closure. When we attempted the ASD closure, the device embolized into the left atrium and was captured percutaneously with a snare catheter (Fig. 1). Device retrieval resulted in an enlargement of the defect. The 2D and 3D TEE revealed a 28 mm ASD with a larger ASA. Despite the retro-aortic rim overpassing 8 mm, the posterior rim was practically absent (Fig. 2; Supplementary movie 1). After evaluation by the heart team (interventional, imaging cardiologists and cardiovascular surgeons) it was decided to attempt percutaneous closure again, this time using real time 3D TEE (3D-RT TEE) in combination with intracardiac echocardiography (ICE) for procedural guidance. The procedure was performed under deep sedation. A 30 mm Amplatzer ™ Septal Occluder device (St. Jude Medical, Inc.; St. Paul, Minn) was successfully implanted. ICE offered direct visualization of the inferoposterior septal rim, which allowed to successfully engage the device and to guide the “push and pull maneuver”. On the other side, 3D-ETE helped us to confirm both sides of the defect were completely covered before device releasing (Fig. 3). The patient has been asymptomatic at a follow up of six months without residual shunt in the echocardiographic controls. 3. Discussion The experience gained over the last years supports that percutaneous closure of ASD is feasible and safe. However, major complications may still occur. The incidence of device embolization is low; some series reveal rates of 0.55%–1.7% [5]. It usually occurs immediately after device implantation or in the following hours. In this case the device could be fortunately retrieved percutaneously from the left atrium with a snare.
http://dx.doi.org/10.1016/j.carrev.2017.02.010 1553-8389/© 2017 Elsevier Inc. All rights reserved.
Please cite this article as: Fuertes-Ferre G, et al, Transcatheter closure of a complex atrial septal defect after occluder device embolization, Cardiovasc Revasc Med (2017), http://dx.doi.org/10.1016/j.carrev.2017.02.010
2
G. Fuertes-Ferre et al. / Cardiovascular Revascularization Medicine xxx (2017) xxx–xxx
Fig. 1. A, Ostium secundum atrial septal defect (OS-ASD) with left to right shunt and atrial septal aneurysm (ASA) assessed by 2D Transesophageal echocardiography. Right atrium (RA), Left atrium (LA). B, Percutaneous retrieval of the embolised Amplatzer occluder device with a goose-neck snare catheter (GNC). C, Amplatzer retrieved device. ICE: intracardiac echocardiography catheter.
Fig. 2. Iatrogenic atrial septal defect (ASD) assessment. A, 2D Transesophagic echocardiography (TEE) showing the atrial septal aneurysm (ASA). B, 2D-TEE depicts the insufficient posterior rim. C, 3D-TEE view of the hypermobile ASA. D, 3D-TEE showing the ruptured ASD and teared interatrial septum (IAS). LA: Left Atrium, RA: Right atrium, A: aorta, PR: posterior rim, AV: aortic valve.
Please cite this article as: Fuertes-Ferre G, et al, Transcatheter closure of a complex atrial septal defect after occluder device embolization, Cardiovasc Revasc Med (2017), http://dx.doi.org/10.1016/j.carrev.2017.02.010
G. Fuertes-Ferre et al. / Cardiovascular Revascularization Medicine xxx (2017) xxx–xxx
3
Fig. 3. Echocardiographic monitoring of the iatrogenic atrial septal defect (ASD) percutaneous closure. A, Intracardiac echocardiography showing the hypermobile atrial septal aneurysm (ASA) and the left disk of the Amplatzer occluder device (AOD) open in the left atrium, close to the ASD. B, 3D Transesophageal Echocardiography en-face view of the left sided disc before deployment. C, “Push and pull maneuver” of the Amplazter occlude device (AOD) assessed by fluoroscopy. D, ICE shows the device is anchored in the interatrial septum.
Nonetheless, the case was complicated with a large iatrogenic ASD. There are some reported cases of ostium secundum (OS) ASD ≥ 30 mm in which the Amplatzer has been safely used [6]. This time, not only the large ASD, but also the friable ASA and deficient posterior rim made the case more complex (Fig. 2). To undergo another percutaneous attempt, an accurate imaging of ASD anatomic features was crucial to prepare for and guide the procedure. Device size was selected according to the ASD diameter. Balloon sizing of the defect has been classically considered as a relevant part of trans-catheter closure of ASD. However, ASD device closure is increasingly being performed without balloon sizing due to the improvement in imaging modalities [7]. We believed balloon sizing in this case of a large ASD with an ASA may had caused an overestimation of the defect size, as described in other cases [8]. For this reason, we preferred the use of both ICE and 3D-TEE for peri-procedural guidance. ICE is the preferred guiding tool in many centers, usually performed by interventional cardiologist and has demonstrated to be superior to 2D-TEE monitoring [9]. Although ICE has a limited field of view in comparison to TEE, it can be especially helpful in cases with small or deficient inferior and posterior rims, offering a clear visualization of the posteroinferior rim (Fig. 2A). On the other side, the advantages of 3D-TEE in guiding percutaneous closure of
interatrial communications have been published in recent years. An echocardiographer is commonly required to perform it. Morphologic features and exact dimensions of ASD are very well defined with 3DTEE, as well as septal tissue conformability and pliability. In this report, the 3D-TEE provided a precise characterization of the ASD margins in the preprocedural study. The better understanding of the defect morphology motivated us to attempt another percutaneous closure. In addition, 3D-RT TEE improved the spatial resolution of ICE during the procedure, ensuring an optimal final result (Fig. 2). The concomitant use of ICE and 3D-TEE is not required in most of ASDs that undergo percutaneous closure. However, when facing a large atrial septal defect with deficient inferior or posterior rims, the use of ICE in combination with real time 3D-TEE is especially useful and may allow for a safe and optimal transcatheter closure, thus avoiding the need for surgery. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.carrev.2017.02.010.
Disclosure Felipe Hernandez is a consultant for St Jude Medical.
Please cite this article as: Fuertes-Ferre G, et al, Transcatheter closure of a complex atrial septal defect after occluder device embolization, Cardiovasc Revasc Med (2017), http://dx.doi.org/10.1016/j.carrev.2017.02.010
4
G. Fuertes-Ferre et al. / Cardiovascular Revascularization Medicine xxx (2017) xxx–xxx
Role of the funding source No funding was received related to this manuscript. References [1] Levi DS, Moore JW. Embolization and retrieval of the Amplatzer septal occluder. Catheter Cardiovasc Interv 2004;61:543–7. [2] Mullen MJ, Dias BF, Walker F, Siu SC, Benson LN, McLaughlin PR. Intracardiac echocardiography guided device closure of atrial septal defects. J Am Coll Cardiol 2003;41:285–92. [3] Hernández F, Martín R, Jiménez C. Iatrogenic atrial septal defect: intracardiac ultrasound-guided percutaneous closure. Rev Esp Cardiol 2007;60:1106–7.
[4] Yared K, Baggish AL, Solis J, Durst R, Passeri JJ, Palacios IF, et al. Echocardiographic assessment of percutaneous patent foramen ovale and atrial septal defect closure complications. Circ Cardiovasc Imaging 2009;2:141–9. [5] Tobis J, Shenoda M. Percutaneous treatment of patent foramen ovale and atrial septal defects. J Am Coll Cardiol 2012;60:1722–32. [6] Guan Z, Qin Y, Zhao X, Ding J, Zheng X, Nguyen V. Transcatheter closure of large atrial septal defects in 18 patients. Clin Cardiol 2008;31:24–7. [7] Amin Z, Daufors DA. Balloon sizing is not necessary for closure of secundum atrial septal defects. J Am Coll Cardiol 2005;45(Suppl. 1):317. [8] Harikrishnan S, Narayanan NK, Sivasabramonian S. Sizing balloon-induced tear of the atrial septum. J Invasive Cardiol 2005;17:546–7. [9] Bartel T, Konorza T, Arjumand J, Ebradlidze T, Eggebrecht H, Caspari G, et al. Intracardiac echocardiography is superior to conventional monitoring for guiding device closure of interatrial communications. Circulation 2003;107:795–7.
Please cite this article as: Fuertes-Ferre G, et al, Transcatheter closure of a complex atrial septal defect after occluder device embolization, Cardiovasc Revasc Med (2017), http://dx.doi.org/10.1016/j.carrev.2017.02.010