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Difficult atrial septal defect closure: Intracardiac echocardiographic visualization of an unexpected caveat
International Journal of Cardiology 115 (2007) 417 – 418 www.elsevier.com/locate/ijcard
Letter to the Editor
Difficult atrial septal defect closure: Intracardiac echocardiographic visualization of an unexpected caveat Gianluca Rigatelli a,⁎, Gabriele Braggion a , Paolo Cardaioli a , Loris Roncon a , Massimo Giordan a , Milan Tranquillo a , Alberto Favero b , Pietro Zonzin a a
Interventional Cardiology Unit, Department of Urgency Medicine, Division of Cardiology, Rovigo General Hospital, Rovigo, Italy b Boston Scientific Italia, Milan, Italy Received 1 December 2005; accepted 9 January 2006 Available online 19 June 2006
To the Editor: The functional incompetence of the ASD anteroinferior rim due to partial presence of the flap valve is an infrequent caveat for transcatheter closure [1]. An 18-year-old boy with transesophageal echocardiographic diagnosis of 20 mm secundum atrial septal defect (Panel A: AI rim, anteroinferior rim) with Qp/Qs = 2.1 and severe dilatation of right cardiac chambers underwent attempt of transcatheter closure. On intraoperative intracardiac echocardiography, the anteroinferior rim was recognized to be composed by flap valve remnant and it appeared clear that the entire anteroinferior rim was extremely floppy with a thickness of 1.1–1.4 mm (Panel B: ASD, atrial septal defect; LA, left atrium; RA, right atrium; AI rim, anteroinferior rim). Real diameter of the defect on aortic valve and four-chamber view measured at the point of minimal bulging and maximal thickness of the rim was 20.1 and 28 mm, respectively. Atrial septal defect closure was attempted (Panel C: ASO, Amplatzer septal Occluder left disk) with the maximal waist diameter (28 mm) of Amplatzer ASD Occluder (AGA Medical Corporation, Golden Valley, MN) which was compatible with the length
⁎ Corresponding author. Via T. Speri 18, 37040 Legnago, Verona-Italy. Tel.: +39 3471912016; fax: +39 44220164. E-mail address: [email protected] (G. Rigatelli). 0167-5273/$ - see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2006.01.063
of the entire atrial septum (33 mm) but it was unsuccessful despite several manoeuvre due to a completely prolapsed device (Panel D: ASO, Amplatzer septal Occluder) (Fig. 1). The patient was referred to the cardiac surgeon who performed a successful path closure. The particular anatomy presented above can be better visualized with intracardiac echocardiography which allows for a more precise measurement of the real thickness of the rim and thus, of the real diameter of the defect [2]. Use of oversized device to close ASD in presence of such peculiar anatomy should be avoided for the risk of device thrombosis and/or aortic erosion related to oversized disks. References [1] Zanchetta M, Rigatelli G, Pedon L, Zennaro M, Maiolino P, Onorato E. Role of intracardiac echocardiography in atrial septal abnormalities. J Interv Cardiol 2003;16:63–77. [2] Rigatelli G. Expanding the use of intracardiac echocardiography in congenital heart disease catheter-based interventions. J Am Soc Echocardiogr 2005;18:1230–1.
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G. Rigatelli et al. / International Journal of Cardiology 115 (2007) 417–418
Fig. 1.
Letter to the Editor
Difficult atrial septal defect closure: Intracardiac echocardiographic visualization of an unexpected caveat Gianluca Rigatelli a,⁎, Gabriele Braggion a , Paolo Cardaioli a , Loris Roncon a , Massimo Giordan a , Milan Tranquillo a , Alberto Favero b , Pietro Zonzin a a
Interventional Cardiology Unit, Department of Urgency Medicine, Division of Cardiology, Rovigo General Hospital, Rovigo, Italy b Boston Scientific Italia, Milan, Italy Received 1 December 2005; accepted 9 January 2006 Available online 19 June 2006
To the Editor: The functional incompetence of the ASD anteroinferior rim due to partial presence of the flap valve is an infrequent caveat for transcatheter closure [1]. An 18-year-old boy with transesophageal echocardiographic diagnosis of 20 mm secundum atrial septal defect (Panel A: AI rim, anteroinferior rim) with Qp/Qs = 2.1 and severe dilatation of right cardiac chambers underwent attempt of transcatheter closure. On intraoperative intracardiac echocardiography, the anteroinferior rim was recognized to be composed by flap valve remnant and it appeared clear that the entire anteroinferior rim was extremely floppy with a thickness of 1.1–1.4 mm (Panel B: ASD, atrial septal defect; LA, left atrium; RA, right atrium; AI rim, anteroinferior rim). Real diameter of the defect on aortic valve and four-chamber view measured at the point of minimal bulging and maximal thickness of the rim was 20.1 and 28 mm, respectively. Atrial septal defect closure was attempted (Panel C: ASO, Amplatzer septal Occluder left disk) with the maximal waist diameter (28 mm) of Amplatzer ASD Occluder (AGA Medical Corporation, Golden Valley, MN) which was compatible with the length
⁎ Corresponding author. Via T. Speri 18, 37040 Legnago, Verona-Italy. Tel.: +39 3471912016; fax: +39 44220164. E-mail address: [email protected] (G. Rigatelli). 0167-5273/$ - see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2006.01.063
of the entire atrial septum (33 mm) but it was unsuccessful despite several manoeuvre due to a completely prolapsed device (Panel D: ASO, Amplatzer septal Occluder) (Fig. 1). The patient was referred to the cardiac surgeon who performed a successful path closure. The particular anatomy presented above can be better visualized with intracardiac echocardiography which allows for a more precise measurement of the real thickness of the rim and thus, of the real diameter of the defect [2]. Use of oversized device to close ASD in presence of such peculiar anatomy should be avoided for the risk of device thrombosis and/or aortic erosion related to oversized disks. References [1] Zanchetta M, Rigatelli G, Pedon L, Zennaro M, Maiolino P, Onorato E. Role of intracardiac echocardiography in atrial septal abnormalities. J Interv Cardiol 2003;16:63–77. [2] Rigatelli G. Expanding the use of intracardiac echocardiography in congenital heart disease catheter-based interventions. J Am Soc Echocardiogr 2005;18:1230–1.
418
G. Rigatelli et al. / International Journal of Cardiology 115 (2007) 417–418
Fig. 1.