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Closure of a coexisting ostium secundum atrial septal defect and patent foramen ovale using a single Amplatzer patent foramen ovale occluder device
Cardiovascular Revascularization Medicine 11 (2010) 63 – 66
Closure of a coexisting ostium secundum atrial septal defect and patent foramen ovale using a single Amplatzer patent foramen ovale occluder device☆ Michael Luna, Subhash Banerjee, Emmanouil S. Brilakis⁎ Division of Cardiovascular Diseases, VA North Texas Healthcare System; and University of Texas Southwestern Medical Center, Dallas, Texas, USA Received 16 July 2008; received in revised form 9 September 2008; accepted 10 September 2008
Abstract
We report the case of a 59-year-old man with cryptogenic stroke who was found to have both an ostium secundum atrial septal defect and a patent foramen ovale (PFO) by intracardiac echocardiography. Both defects were successfully occluded using a single 35-mm Amplatzer PFO occluder device inserted through the atrial septal defect. Published by Elsevier Inc.
Keywords:
Heart septal defects, atrial/therapy; Prosthesis implantation; Heart catheterization
1. Introduction
2. Case report
Patients with cryptogenic stroke who are found to have an atrial septal defect (ASD) or a patent foramen ovale (PFO) are often referred for percutaneous closure of the defect in an attempt to prevent future paradoxic embolism, although the effectiveness of this approach has not been proven in randomized controlled trials. Frequently, multiple ASDs are discovered at the time of the procedure in those patients [1], often necessitating use of multiple closure devices [2]. We describe a patient with cryptogenic stroke who was found by intracardiac echocardiography to have both an ASD and a PFO. Successful closure of both defects was achieved using a single 35-mm Amplatzer PFO occluder device (AGA Medical, Plymouth, MN, USA) inserted through the ASD.
A 59-year-old man presented with complete, acute right hemiplegia and was diagnosed with a stroke. He had an extensive evaluation that included carotid Doppler ultrasonography and magnetic resonance angiography of the head and neck, all of which were normal. Transesophageal echocardiography demonstrated a secundum ASD. The patient was placed on oral anticoagulation with warfarin and was subsequently referred for percutaneous ASD closure. After discussion of the risks and potential benefits of the procedure emphasizing the lack of prospective randomized-controlled data on the efficacy of ASD or PFO closure for the prevention of recurrent strokes, the patient elected to proceed with percutaneous closure of the defect as part of a prospective study. On right heart catheterization, the right atrial pressure was 10 mmHg, the right ventricular pressure was 28/7 mmHg, the pulmonary artery pressure was 26/11 mmHg (mean 19 mmHg), and the mean pulmonary capillary wedge pressure was 11 mmHg. No oxygen saturation step-up could be identified. Intracardiac echocardiography confirmed the presence of the ASD but also revealed a previously undiscovered PFO (Fig. 1). Intermittent right to left shunting through both defects was seen by color Doppler imaging (Fig.
☆ Emmanouil S. Brilakis receives support from the Clark R. Gregg Fund, Harris Methodist Health Foundation (6100 Western Place, Suite 1001, Fort Worth, TX 76107, USA), and a Veterans Affairs VISN 17 startup award (Waco, Texas, USA). ⁎ Corresponding author. Dallas VA Medical Center (111A), 4500 South Lancaster Road, Dallas, TX 75216. Tel.: +214 857 1547; fax: +214 302 1341. E-mail address: [email protected] (E.S. Brilakis).
1553-8389/08/$ – see front matter. Published by Elsevier Inc. doi:10.1016/j.carrev.2008.09.004
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1A and C) and was confirmed by agitated saline administration. The distance between the ASD and the PFO was 12 mm. The distance between the PFO and the aorta was 13 mm, and the distance between the PFO and the superior vena cava was 12 mm. The PFO measured 7.6 mm by intracardiac echocardiography imaging and 7.8 mm by balloon sizing (Fig. 1D). We were unable to advance the sizing balloon through the ASD, likely because of its small size. Closure of each defect using separate devices was initially considered using two Amplatzer devices: a PFO and an ASD occluder device. According to the manufacturer's recommendation, if the shortest distance between the PFO to either the aorta or the superior vena cava is between 9.0 and 12.4 mm, then an 18-mm device is recommended. If the shortest distance is between 12.5 and 17.4 mm, then a 25-mm device is recommended. We first deployed an 18-mm Amplatzer PFO occluder through the PFO, but residual shunt remained through the ASD, and the PFO device edge was very close to the ASD making implantation of a second ASD device difficult. The PFO occluder was recaptured and we elected to attempt closure of both defects using a single device. A 25-mm Amplatzer PFO occluder was inserted through the PFO
stopping shunting through the PFO, but residual shunting through the ASD remained (Fig. 2A). Due to its small size, the ASD was difficult to wire, yet wiring was successful after the PFO was transiently occluded with the 25-mm Amplatzer PFO occluder. We attempted closure of both defects using the same 25-mm Amplatzer PFO occluder device, now inserted through the ASD. Color Doppler again demonstrated residual shunting through the PFO (Fig. 2B). At the time of this procedure, the cribriform ASD occluder was not available. The 25-mm device was recaptured, and a 35-mm Amplatzer PFO occluder device was inserted through the ASD, occluding flow through both the ASD and the PFO. The device appeared to be well seated and did not impinge on the aortic root. The PFO Amplatzer device was released. Intracardiac echocardiography showed good seating of the device with minor central residual shunt (Fig. 2C). Over the following month, the patient's hemiplegia completely resolved. Follow-up transthoracic echocardiographic imaging was obtained 1 month after closure and showed no residual interatrial shunting by color flow Doppler or with agitated saline administration (Fig. 3). Thirteen months after
Fig. 1. Intracardiac echocardiographic imaging of the atrial septum with color Doppler showing both an ASD (arrow) and a PFO (arrowhead) with right to left shunting through both defects (Panel A). Panel B demonstrates the PFO and Panel C shows intermittent interatrial shunting with color Doppler imaging. The PFO measured 7.8 mm (Panel D).
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intracardiac echocardiography imaging, and (b) multiple defects can sometimes be closed with a single closure device. Although closing an incidentally discovered ASD or PFO in patients with cryptogenic stroke remains controversial in the absence of randomized, controlled trials showing benefit, such patients are frequently referred for percutaneous closure of the defect [3]. At the time of the procedure, some of these patients are found to have multiple coexisting defects [1], underscoring the importance of performing a detailed intracardiac echocardiographic imaging before closure [1,4,5]. The coexisting defects may not always be detected at precatheterization transesophageal echocardiography, as was the case in our patient [1]. Earing et al. [1] reported that 16 (17%) of 94 patients referred for percutaneous closure of an ASD or a PFO for cryptogenic stroke in a large tertiary care center had an additional defect when examined with intracardiac echocardiography. Awad et al. [6] reported that 46 (9%) of 540 patients referred for ASD closure over 108 months had multiple defects. Complete closure of multiple defects is important in order to prevent future paradoxic embolization, and this may be achieved either by using two or more devices, or with a single large device as in our case. Two devices were required
Fig. 2. (Panel A) Intracardiac echocardiographic imaging after placement of an 18-mm Amplatzer PFO occluder (arrow) through the PFO; there is residual shunting through the ASD (not shown). (Panel B) After placement of a 25-mm PFO Amplatzer device through the ASD (arrow) there is residual shunting through the PFO (arrowhead). (Panel C) After insertion of a 35-mm Amplatzer PFO occluder device through the ASD (arrows), there is residual shunting only through the center of the device (arrowhead).
this cerebrovascular event and 12 months since closure of the defects, he did not have any recurrent neurologic events. 3. Discussion Our case illustrates that, in patients with cryptogenic stroke who are found to have an ASD and are referred for percutaneous closure, (a) additional unsuspected ASDs or a PFO may be found at the time of the procedure using
Fig. 3. Transthoracic echocardiography 1 month after implantation of the Amplatzer PFO occluder device showing no residual interartial shunting during agitated saline administration (Panel A) or by color flow Doppler imaging (Panel B).
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in six of 16 patients reported by Earing et al. [1] and in 33 of the 46 patients reported by Awad et al. [6]. Khositseth et al. [7] found that 10 of 103 patients referred for ASD or PFO percutaneous closure had both a PFO and an ASD (eight with two ASDs and two with three ASDs); all patients were successfully occluded a single device. Compared to using two or more devices, using a single device for the closure of multiple defects may be technically simpler, cost less, and allow for shorter procedure times, but may lead to aortic erosion and pericardial effusion since large devices may be needed to accomplish complete closure [8,9]. The 35-mm occluder device did not impinge on the aorta in our patient; that is why implantation of a single device was performed. A cribriform ASD device was not clinically available at the time of the procedure; because we needed a large device that could also cover the patient's PFO and because of the small size of the ASD, an Amplatzer PFO occluder was used. Using a large ASD device would not be appropriate in our patient because the ASD Amplatzer occluder has a much larger waist compared to the Amplatzer PFO occluder and could significantly stretch the ASD or could fail to expand appropriately. When both a large and a small defect coexist as in our patient, it may be difficult to insert a wire through the smaller defect since the wire tends to select the larger defect. Transiently occluding the larger defect with a sizing balloon or with an occluder device may facilitate wiring of the smaller defect. In summary, patients referred for ASD closure should be carefully examined with intracardiac echocardiography because they may have other coexisting ASDs or a PFO. Multiple defects can often be successfully closed using a single large occluder device.
References [1] Earing MG, Cabalka AK, Seward JB, Bruce CJ, Reeder GS, Hagler DJ. Intracardiac echocardiographic guidance during transcatheter device closure of atrial septal defect and patent foramen ovale. Mayo Clin Proc 2004;79(1):24–34. [2] Cao Q, Radtke W, Berger F, Zhu W, Hijazi ZM. Transcatheter closure of multiple atrial septal defects. Initial results and value of two- and threedimensional transoesophageal echocardiography. Eur Heart J 2000;21 (11):941–7. [3] Egred M, Andron M, Albouaini K, Alahmar A, Grainger R, Morrison WL. Percutaneous closure of patent foramen ovale and atrial septal defect: procedure outcome and medium-term follow-up. J Interv Cardiol 2007;20 (5):395–401. [4] Koenig P, Cao QL, Heitschmidt M, Waight DJ, Hijazi ZM. Role of intracardiac echocardiographic guidance in transcatheter closure of atrial septal defects and patent foramen ovale using the Amplatzer device. J Interv Cardiol 2003;16(1):51–62. [5] Bartel T, Konorza T, Arjumand J, Ebradlidze T, Eggebrecht H, Caspari G, Neudorf U, Erbel R. Intracardiac echocardiography is superior to conventional monitoring for guiding device closure of interatrial communications. Circulation 2003;107(6):795–7. [6] Awad SM, Garay FF, Cao QL, Hijazi ZM. Multiple Amplatzer septal occluder devices for multiple atrial communications: immediate and long-term follow-up results. Catheter Cardiovasc Interv 2007;70(2): 265–73. [7] Khositseth A, Cabalka AK, Sweeney JP, Fortuin FD, Reeder GS, Connolly HM, Hagler DJ. Transcatheter Amplatzer device closure of atrial septal defect and patent foramen ovale in patients with presumed paradoxical embolism. Mayo Clin Proc 2004;79(1):35–41. [8] Amin Z, Hijazi ZM, Bass JL, Cheatham JP, Hellenbrand WE, Kleinman CS. Erosion of Amplatzer septal occluder device after closure of secundum atrial septal defects: review of registry of complications and recommendations to minimize future risk. Catheter Cardiovasc Interv 2004;63(4):496–502. [9] Mahadevan VS, Horlick EM, Benson LN, McLaughlin PR. Transcatheter closure of aortic sinus to left atrial fistula caused by erosion of Amplatzer septal occluder. Catheter Cardiovasc Interv 2006;68(5): 749–53.
Closure of a coexisting ostium secundum atrial septal defect and patent foramen ovale using a single Amplatzer patent foramen ovale occluder device☆ Michael Luna, Subhash Banerjee, Emmanouil S. Brilakis⁎ Division of Cardiovascular Diseases, VA North Texas Healthcare System; and University of Texas Southwestern Medical Center, Dallas, Texas, USA Received 16 July 2008; received in revised form 9 September 2008; accepted 10 September 2008
Abstract
We report the case of a 59-year-old man with cryptogenic stroke who was found to have both an ostium secundum atrial septal defect and a patent foramen ovale (PFO) by intracardiac echocardiography. Both defects were successfully occluded using a single 35-mm Amplatzer PFO occluder device inserted through the atrial septal defect. Published by Elsevier Inc.
Keywords:
Heart septal defects, atrial/therapy; Prosthesis implantation; Heart catheterization
1. Introduction
2. Case report
Patients with cryptogenic stroke who are found to have an atrial septal defect (ASD) or a patent foramen ovale (PFO) are often referred for percutaneous closure of the defect in an attempt to prevent future paradoxic embolism, although the effectiveness of this approach has not been proven in randomized controlled trials. Frequently, multiple ASDs are discovered at the time of the procedure in those patients [1], often necessitating use of multiple closure devices [2]. We describe a patient with cryptogenic stroke who was found by intracardiac echocardiography to have both an ASD and a PFO. Successful closure of both defects was achieved using a single 35-mm Amplatzer PFO occluder device (AGA Medical, Plymouth, MN, USA) inserted through the ASD.
A 59-year-old man presented with complete, acute right hemiplegia and was diagnosed with a stroke. He had an extensive evaluation that included carotid Doppler ultrasonography and magnetic resonance angiography of the head and neck, all of which were normal. Transesophageal echocardiography demonstrated a secundum ASD. The patient was placed on oral anticoagulation with warfarin and was subsequently referred for percutaneous ASD closure. After discussion of the risks and potential benefits of the procedure emphasizing the lack of prospective randomized-controlled data on the efficacy of ASD or PFO closure for the prevention of recurrent strokes, the patient elected to proceed with percutaneous closure of the defect as part of a prospective study. On right heart catheterization, the right atrial pressure was 10 mmHg, the right ventricular pressure was 28/7 mmHg, the pulmonary artery pressure was 26/11 mmHg (mean 19 mmHg), and the mean pulmonary capillary wedge pressure was 11 mmHg. No oxygen saturation step-up could be identified. Intracardiac echocardiography confirmed the presence of the ASD but also revealed a previously undiscovered PFO (Fig. 1). Intermittent right to left shunting through both defects was seen by color Doppler imaging (Fig.
☆ Emmanouil S. Brilakis receives support from the Clark R. Gregg Fund, Harris Methodist Health Foundation (6100 Western Place, Suite 1001, Fort Worth, TX 76107, USA), and a Veterans Affairs VISN 17 startup award (Waco, Texas, USA). ⁎ Corresponding author. Dallas VA Medical Center (111A), 4500 South Lancaster Road, Dallas, TX 75216. Tel.: +214 857 1547; fax: +214 302 1341. E-mail address: [email protected] (E.S. Brilakis).
1553-8389/08/$ – see front matter. Published by Elsevier Inc. doi:10.1016/j.carrev.2008.09.004
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M. Luna et al. / Cardiovascular Revascularization Medicine 11 (2010) 63–66
1A and C) and was confirmed by agitated saline administration. The distance between the ASD and the PFO was 12 mm. The distance between the PFO and the aorta was 13 mm, and the distance between the PFO and the superior vena cava was 12 mm. The PFO measured 7.6 mm by intracardiac echocardiography imaging and 7.8 mm by balloon sizing (Fig. 1D). We were unable to advance the sizing balloon through the ASD, likely because of its small size. Closure of each defect using separate devices was initially considered using two Amplatzer devices: a PFO and an ASD occluder device. According to the manufacturer's recommendation, if the shortest distance between the PFO to either the aorta or the superior vena cava is between 9.0 and 12.4 mm, then an 18-mm device is recommended. If the shortest distance is between 12.5 and 17.4 mm, then a 25-mm device is recommended. We first deployed an 18-mm Amplatzer PFO occluder through the PFO, but residual shunt remained through the ASD, and the PFO device edge was very close to the ASD making implantation of a second ASD device difficult. The PFO occluder was recaptured and we elected to attempt closure of both defects using a single device. A 25-mm Amplatzer PFO occluder was inserted through the PFO
stopping shunting through the PFO, but residual shunting through the ASD remained (Fig. 2A). Due to its small size, the ASD was difficult to wire, yet wiring was successful after the PFO was transiently occluded with the 25-mm Amplatzer PFO occluder. We attempted closure of both defects using the same 25-mm Amplatzer PFO occluder device, now inserted through the ASD. Color Doppler again demonstrated residual shunting through the PFO (Fig. 2B). At the time of this procedure, the cribriform ASD occluder was not available. The 25-mm device was recaptured, and a 35-mm Amplatzer PFO occluder device was inserted through the ASD, occluding flow through both the ASD and the PFO. The device appeared to be well seated and did not impinge on the aortic root. The PFO Amplatzer device was released. Intracardiac echocardiography showed good seating of the device with minor central residual shunt (Fig. 2C). Over the following month, the patient's hemiplegia completely resolved. Follow-up transthoracic echocardiographic imaging was obtained 1 month after closure and showed no residual interatrial shunting by color flow Doppler or with agitated saline administration (Fig. 3). Thirteen months after
Fig. 1. Intracardiac echocardiographic imaging of the atrial septum with color Doppler showing both an ASD (arrow) and a PFO (arrowhead) with right to left shunting through both defects (Panel A). Panel B demonstrates the PFO and Panel C shows intermittent interatrial shunting with color Doppler imaging. The PFO measured 7.8 mm (Panel D).
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intracardiac echocardiography imaging, and (b) multiple defects can sometimes be closed with a single closure device. Although closing an incidentally discovered ASD or PFO in patients with cryptogenic stroke remains controversial in the absence of randomized, controlled trials showing benefit, such patients are frequently referred for percutaneous closure of the defect [3]. At the time of the procedure, some of these patients are found to have multiple coexisting defects [1], underscoring the importance of performing a detailed intracardiac echocardiographic imaging before closure [1,4,5]. The coexisting defects may not always be detected at precatheterization transesophageal echocardiography, as was the case in our patient [1]. Earing et al. [1] reported that 16 (17%) of 94 patients referred for percutaneous closure of an ASD or a PFO for cryptogenic stroke in a large tertiary care center had an additional defect when examined with intracardiac echocardiography. Awad et al. [6] reported that 46 (9%) of 540 patients referred for ASD closure over 108 months had multiple defects. Complete closure of multiple defects is important in order to prevent future paradoxic embolization, and this may be achieved either by using two or more devices, or with a single large device as in our case. Two devices were required
Fig. 2. (Panel A) Intracardiac echocardiographic imaging after placement of an 18-mm Amplatzer PFO occluder (arrow) through the PFO; there is residual shunting through the ASD (not shown). (Panel B) After placement of a 25-mm PFO Amplatzer device through the ASD (arrow) there is residual shunting through the PFO (arrowhead). (Panel C) After insertion of a 35-mm Amplatzer PFO occluder device through the ASD (arrows), there is residual shunting only through the center of the device (arrowhead).
this cerebrovascular event and 12 months since closure of the defects, he did not have any recurrent neurologic events. 3. Discussion Our case illustrates that, in patients with cryptogenic stroke who are found to have an ASD and are referred for percutaneous closure, (a) additional unsuspected ASDs or a PFO may be found at the time of the procedure using
Fig. 3. Transthoracic echocardiography 1 month after implantation of the Amplatzer PFO occluder device showing no residual interartial shunting during agitated saline administration (Panel A) or by color flow Doppler imaging (Panel B).
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in six of 16 patients reported by Earing et al. [1] and in 33 of the 46 patients reported by Awad et al. [6]. Khositseth et al. [7] found that 10 of 103 patients referred for ASD or PFO percutaneous closure had both a PFO and an ASD (eight with two ASDs and two with three ASDs); all patients were successfully occluded a single device. Compared to using two or more devices, using a single device for the closure of multiple defects may be technically simpler, cost less, and allow for shorter procedure times, but may lead to aortic erosion and pericardial effusion since large devices may be needed to accomplish complete closure [8,9]. The 35-mm occluder device did not impinge on the aorta in our patient; that is why implantation of a single device was performed. A cribriform ASD device was not clinically available at the time of the procedure; because we needed a large device that could also cover the patient's PFO and because of the small size of the ASD, an Amplatzer PFO occluder was used. Using a large ASD device would not be appropriate in our patient because the ASD Amplatzer occluder has a much larger waist compared to the Amplatzer PFO occluder and could significantly stretch the ASD or could fail to expand appropriately. When both a large and a small defect coexist as in our patient, it may be difficult to insert a wire through the smaller defect since the wire tends to select the larger defect. Transiently occluding the larger defect with a sizing balloon or with an occluder device may facilitate wiring of the smaller defect. In summary, patients referred for ASD closure should be carefully examined with intracardiac echocardiography because they may have other coexisting ASDs or a PFO. Multiple defects can often be successfully closed using a single large occluder device.
References [1] Earing MG, Cabalka AK, Seward JB, Bruce CJ, Reeder GS, Hagler DJ. Intracardiac echocardiographic guidance during transcatheter device closure of atrial septal defect and patent foramen ovale. Mayo Clin Proc 2004;79(1):24–34. [2] Cao Q, Radtke W, Berger F, Zhu W, Hijazi ZM. Transcatheter closure of multiple atrial septal defects. Initial results and value of two- and threedimensional transoesophageal echocardiography. Eur Heart J 2000;21 (11):941–7. [3] Egred M, Andron M, Albouaini K, Alahmar A, Grainger R, Morrison WL. Percutaneous closure of patent foramen ovale and atrial septal defect: procedure outcome and medium-term follow-up. J Interv Cardiol 2007;20 (5):395–401. [4] Koenig P, Cao QL, Heitschmidt M, Waight DJ, Hijazi ZM. Role of intracardiac echocardiographic guidance in transcatheter closure of atrial septal defects and patent foramen ovale using the Amplatzer device. J Interv Cardiol 2003;16(1):51–62. [5] Bartel T, Konorza T, Arjumand J, Ebradlidze T, Eggebrecht H, Caspari G, Neudorf U, Erbel R. Intracardiac echocardiography is superior to conventional monitoring for guiding device closure of interatrial communications. Circulation 2003;107(6):795–7. [6] Awad SM, Garay FF, Cao QL, Hijazi ZM. Multiple Amplatzer septal occluder devices for multiple atrial communications: immediate and long-term follow-up results. Catheter Cardiovasc Interv 2007;70(2): 265–73. [7] Khositseth A, Cabalka AK, Sweeney JP, Fortuin FD, Reeder GS, Connolly HM, Hagler DJ. Transcatheter Amplatzer device closure of atrial septal defect and patent foramen ovale in patients with presumed paradoxical embolism. Mayo Clin Proc 2004;79(1):35–41. [8] Amin Z, Hijazi ZM, Bass JL, Cheatham JP, Hellenbrand WE, Kleinman CS. Erosion of Amplatzer septal occluder device after closure of secundum atrial septal defects: review of registry of complications and recommendations to minimize future risk. Catheter Cardiovasc Interv 2004;63(4):496–502. [9] Mahadevan VS, Horlick EM, Benson LN, McLaughlin PR. Transcatheter closure of aortic sinus to left atrial fistula caused by erosion of Amplatzer septal occluder. Catheter Cardiovasc Interv 2006;68(5): 749–53.