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Transcatheter closure devices


Atrial septum

CASE 14-1

Anatomy and imaging of atrial septum

See Case 7-1 in Chapter 7 , Adult Congenital Heart Disease.

CASE 14-2

PFO device closure for recurrent transient neurological events

About 3 years ago this 44-year-old female had an episode of transient dysarthria with a CT scan revealing evidence of a small cerebral infarct at that time. About 6 months ago, she had several brief episodes of right lower extremity paresthesias with the longest episode lasting several minutes in association with significant weakness in the right leg. She refused warfarin anticoagulation and has been managed with antiplatelet therapy. Transesophageal echocardiography demonstrated a patent foramen ovale, and after consenting, she was referred for transcatheter closure.

Fig 14.1, After placement of a sheath into the right femoral vein and a guidewire into the right atrium, a 6-French multipurpose diagnostic catheter was advanced to right atrium and the guidewire removed. Catheter as seen in this midesophageal bicaval view was used to gently probe across the patent foramen ovale (arrow).

Fig 14.2, J-tipped wire was then reinserted into the catheter and advanced into left pulmonary vein as seen on TEE (left) and fluoroscopy (right, arrows).

Fig 14.3, Using transesophageal echo (left) and fluoroscopic guidance (middle), a 20-mm diameter NMT sizing balloon (NMT Medical, Inc., Boston, Massachusetts) was inserted over the wire and advanced across the atrial septum. By measurement of waist in balloon (arrows), patent foramen ovale was measured at between 10 mm and 11 mm. Based on this measurement, a 28-mm CardioSeal device (NMT Medical, Inc., Boston, Massachusetts) was selected. Measurement is graphically depicted on right.

Fig 14.4, 14-French transseptal catheter and dilator was advanced to the left atrium (arrow). Dilator and wire were removed and the catheter was carefully aspirated and flushed to ensure that there was no air in the system.

Fig 14.5, CardioSeal device was then loaded into the delivery catheter and advanced into left atrium (arrow).

Fig 14.6, Transseptal sheath was pulled back to allow left atrial arms to unfold (white arrows). This was then pulled back across atrial septum (green arrow) and was seen to be well placed by fluoroscopy and by transesophageal echo.

Fig 14.7, Transseptal catheter was then pulled back further until right atrial arms (red arrows) were released and the device could be seen to be in good position across patent foramen ovale (white arrows indicate left atrial arms).

Fig 14.8, Device was then released from the delivery system and transesophageal echo was performed revealing good closure. Double arrows indicate the arms in each atrium.

Fig 14.9, Fluoroscopy of device deployment. In the left frame, the device has been advanced into left atrium (green arrow) . On the right, the left atrial arms (white arrows) as well as the right atrial arms (red arrows) have also been deployed.

Fig 14.10, Both saline contrast and color Doppler imaging confirmed closure of the PFO with no residual resting shunt.

Fig 14.11, Another patient with similar device subsequently underwent mitral valve replacement. Upon opening the right atrium, the device is seen in good position.

Fig 14.12, Device was removed as part of the valvular procedure. In top frames, the device is seen from the side, with an unused device for comparison. In lower frames, the device is seen from front.

Comments

TEE or intracardiac echocardiography (ICE) is an essential for transcatheter closure of atrial septal defects or a patent foramen ovale. As illustrated by these cases, the echo images allow visualization of the atrial septum including identification of the size, location, and shape of the atrial septal defect. During the procedure, imaging allows guidance of catheter position and correct placement of the device in the atrial septum. After device deployment, color Doppler and saline contrast imaging allow diagnosis of any residual shunt flow.

Suggested reading

  • 1.

    Tobis J, Shenoda M: Percutaneous treatment of patent foramen ovale and atrial septal defects, J Am Coll Cardiol 60:1722–1732, 2012.

  • 2.

    Saric M, Perk G, Purgess JR, et al: Imaging atrial septal defects by real-time three-dimensional transesophageal echocardiography: Step-by-step approach, J Am Soc Echocardiogr 23:1128–1135, 2010.

  • 3.

    Faletra FF, Nucifora G, Yen S: Imaging the atrial septum using real-time three-dimensional transesophageal echocardiography: Technical tips, normal anatomy, and its role in transseptal puncture, J Am Soc Echocardiogr 24:593–599, 2011.

  • 4.

    Silvestry FE, Cohen MS, Armsby LB, et al: Guidelines for the echocardiographic assessment of atrial septal defect and patent foramen ovale, J Am Soc Echocardiogr 28:910–958, 2015.

CASE 14-3

Embolization of ASD closure device

This 40-year-old man was recently diagnosed with a large atrial septal defect resulting in significant right ventricular dysfunction and dilation. He was referred for transcatheter closure of the defect.

Fig 14.13, Using intracardiac echocardiography, one of the ASD diameters is measured at 23 mm (left). 34-mm Amplatzer sizing balloon showed that an inflation diameter of 27–28 mm, measured both by intracardiac echocardiography and fluoroscopy, resulted in complete closure of atrial defect with no evident flow that led to the decision to use a 30-mm Amplatzer septal occluder device.

Fig 14.14, Occluder is passed up from the femoral vein to right atrium and through defect.

Fig 14.15, At left, device is seen fully deployed. At center, device is seen in place, and at right, color Doppler confirms adequate closure of defect.

Fig 14.16, After procedure, patient was admitted for overnight monitoring and ongoing management of chronic congestive heart failure and pulmonary hypertension. In the early hours of the next morning, patient began complaining of nausea and headache and was noted to have frequent premature ventricular beats. Bedside TEE study showed that the septal occluder had embolized into the left ventricular outflow tract and was bobbing freely within the left ventricle without obstruction to blood flow through the left heart. In real time, chaotic movement of the device can be appreciated.

Fig 14.17, In 3D TEE image in a view comparable to midesophageal long axis, the relationship of the device to the aortic valve is seen.

Fig 14.18, In a midesophageal view at 14 degrees, color Doppler again demonstrates left-to-right flow at level of atrial septum (arrow).

Fig 14.19, Biplane imaging of defect shows diameters of 27 and 25 mm.

Fig 14.20, Using multiplanar reconstruction, large oval shape of defect can be appreciated.

Fig 14.21, Patient was urgently taken back to catheterization laboratory. Bronchial grasping catheter was used to recapture wire mesh of occluder and it could be easily brought through and extracted from the 24-French sheath. Using a similar technique, a 38-mm Amplatzer septal occluder was placed, with good results. At left, cropped midesophageal 3D image shows left and right atrial portions of the device. At right, en face view of device from right atrial perspective is shown.

Fig 14.22, In midesophageal view at 34 degrees, 2D and color Doppler imaging show device in good position with no residual shunt.

CASE 14-4

Prolapsing atrial septal defect closure device

This 59-year-old man had two previous neurologic events. Five years ago, he had 1 minute of aphasia and was treated with aspirin. Then 3 months before admission he had left leg weakness that lasted approximately 3 minutes. Echocardiography showed an atrial septal defect with an enlarged right atrium and ventricle, and mildly decreased right ventricular function, with mildly elevated pulmonary pressures of 30 mm Hg.

Fig 14.23, Intracardiac echocardiography reveals saline contrast appearing in left atrium (LA) (arrows) within one to two beats of appearance in right atrium. In real time, an atrial septal aneurysm is appreciated.

Fig 14.24, Fluoroscopy demonstrates position of the device; in real time, excessive movement of device can be appreciated.

Fig 14.25, After deployment of device (CardioSEAL, Boston, Massachusetts), amount of saline contrast seen in the left atrium was significantly decreased. However, upon Valsalva, the superior limb of the occluder device prolapsed into the PFO (arrow) with associated passage of echo-contrast from right to left atrium.

Fig 14.26, Patient was taken to the OR for surgical removal of device and complete closure of the ASD and septal aneurysm. Intraoperative TEE revealed the device in the atrial septum, with a persistent defect around the device that appeared open and was confirmed by color flow Doppler (arrow, left and center frames) and with injected saline contrast (right frame).

Comments

Complications after transcatheter atrial septal defect closure occur in less than 5% of cases. The most common complication is a mild residual shunt, detectable by color Doppler or saline contrast imaging. Device embolization is rare but is more likely to occur with very large defects (diameter > 32 mm), or with an insufficient rim of tissue around the defect to adequately anchor the transcatheter closure device. Thus major imaging goals are accurate measurement of defect size in order to choose the correct size of closure device along with assessment of the rim of tissue around the defect. The tissue rim may not be well appreciated on en face 3D images. Instead a full 3D volume should be acquired with careful assessment to the tissue rim in tomographic views derived from the full 3D volume.

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