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Feasibility of Transcatheter Closure of Large Secundum Atrial Septal Defect with Absent Superior or Inferior Rim

Feasibility of Transcatheter Closure of Large Secundum Atrial Septal Defect with Absent Superior... Hindawi Journal of Interventional Cardiology Volume 2022, Article ID 2764296, 8 pages https://doi.org/10.1155/2022/2764296 Research Article Feasibility of Transcatheter Closure of Large Secundum Atrial Septal Defect with Absent Superior or Inferior Rim 1 1 2 Hussein Abdulwahab , Mohammed Rassul Husain , and Khalid A. Khalid Department of Cardiology, Ibn Albitar Center for Cardiac Surgery, Baghdad, Iraq Department of Pediatric Cardiology, Collage of Medicine, University of Basra, Basra, Iraq Correspondence should be addressed to Hussein Abdulwahab; husseinabdulwahab62@yahoo.com Received 10 November 2021; Revised 27 February 2022; Accepted 14 March 2022; Published 4 April 2022 Academic Editor: Faisal Latif Copyright © 2022 Hussein Abdulwahab et al. *is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction. Surgical closure of a large secundum atrial septal defect (ASD) with an absent superior or inferior rim is the standard method of management, but transcatheter closure of such a defect is possible and feasible. Objectives. To evaluate the feasibility, effectiveness, and safety of transcatheter closure of large secundum ASD with an absent superior or inferior rim through implantation of a cheatham platinum (CP) stent at the entrance of the superior vena cava (SVC) or inferior vena cava (IVC) into the right atrium (RA) to create a suitable rim for subsequent complete closure of the defect using a septal occluder. Patients and Methods. *is case series was carried out at Ibn Al-Bitar Center for Cardiac Surgery, Baghdad, Iraq from 2014 to 2019, five patients underwent such transcatheter approach for closure of large secundum ASD with the absent superior or inferior rim by im- plantation of CP stent at the entrance of vena cave into the RA. Result. *e ages and weights of patients who were enrolled in this study ranged from 9–31 years (15.2± 9 years) and 31.5–62 kg (42.6± 12 kg). *ree patients had absent superior rims, and the other two had absent inferior rims. *e Q /Q was ranged from 1.9–3.2 (2.78± 0.29), and the mean pulmonary arterial pressure ranged p s from 22–29 mmHg (25.4± 3 mmHg). *e defects with an absent superior rim were closed successfully by implantation of CP stents of 45, 45, and 39 mm to create a rim which supported the left atrial disc of 30, 38, and 32 mm atrial septal occluder (ASO), respectively, while large secundum ASD with an absent inferior rim could be effectively closed by implantation of two overlapping bare CP stents of 45 mm to create an IVC rim that supported 34 mm and 30 mm atrial septal occluder. Conclusion and rec- ommendation. Transcatheter closure of large secundum ASD with absent superior or inferior rim is possible and effective by implantation of covered and bare CP stents at the entrance of SVC and IVC, respectively. Although these procedures are relatively difficult and challenging, especially in the closure of large defects associated with absent inferior rim, they carry a high risk of stent migration (8 zig, 45 mm), so we recommend using a CP-stent (10 zig, 60 mm). anatomically suitable for transcatheter closure. ASD size 1. Introduction should be limited and sufficient rims of interatrial septal *e secundum type atrial septal defect (ASD) is the fourth tissue between the defect and adjacent structures are re- most common congenital heart defect with an incidence of quired to position the ASD device. Rims and the size of the 3.78 per 10,000 live births [1], corresponding to 5.9% of ASD are crucial for the success of transcatheter ASD closure. diagnosed congenital heart disease in children [2]. *e maximum diameter and dimension of the various rims *e ASD can now be treated by a transcatheter occlusion of the ASD are essential for sizing and optimal placement of st technique. Since the 1 attempt in 1976 by King and Mills the device. Morphological variations of secundum type ASD [3], transcatheter closure of secundum ASDs has evolved are common and their recognition is crucial for the selection over the past 3 decades and has become an effective alter- of suitability for percutaneous closure [7]. native therapy for most patients with ASD [4, 5]. Transesophageal echocardiogram was done to assess Transcatheter closure of ASD has become the treatment size and rims in the different views (four chamber view ° ° of choice rather than surgery [6]. However, not all ASDs are ME 0 short axis view ME 45 and bicaval view ME 2 Journal of Interventional Cardiology Table 1: Characteristics of the patients. 90–110 ). AV rim and posterior superior rim in the four chamber view, aortic and inferoposterior rim in short axis No. Sex Age/ys Wt/kg view, and IVC rim in bicaval view were measured and 1 F 14 45 documented. *e views used for ASD assessment by TEE 2 F 31 62 were as per the guidelines for echocardiographic assess- 3 M 12 34.5 ment of atrial septal defect and patent foramen ovale of 4 M 9 40 the American Society of Echocardiography and Society for 5 F 10 31.5 Cardiac Angiography and Intervention [8]. A rim less than 5 mm was termed deficient or inadequate and absent if it was <1 mm. 3. Results *e aim of this study was to evaluate our clinical ex- perience in transcatheter closure of large secundum ASD Five patients (3 females and 2 males) were enrolled in this with an absent superior or inferior rim by implantation of a study. *eir ages ranged 9 to 31 years (15.2± 9 years) and CP stent in the entrance of vena cavae into the RA to create a their weights were 31.5–62 kg (42.6± 12 kg). *ree patients septal fold by tight inflation of the stent. had absent superior rims, and two patients had absent in- ferior rims. *e Q /Q ranged from 2.5 to 3.2 (2.78± 0.29), the mean p s 2. Patients and Methods pulmonary arterial pressure ranged from 22 to 29 mmHg (25.4± 3 mmHg). A case series, which have been done at Ibn Al-Bitar Center *e first patient was a 14 year-old-female with a large ASD for Cardiac Surgery, Baghdad, Iraq from 2014 to 2020 in- secundum and an absent superior rim. She had dilated RA and troduced a transcatheter approach for closure of large RV, a Q /Q of 2.5, and a mean pulmonary artery pressure of secundum ASD with an absent superior or inferior rim by P S 23 mmHg. Successful closure of the defect was achieved by the implantation of covered and uncovered CP stents in the SVC implantation of a modified covered CP stent of 45 mm in the or IVC, respectively, to create a suitable rim for subsequent SVC. *e modified CP stent was carried out by cutting half its complete closure by an atrial septal occluder. circle into about 15 mm length to be projected into the RA and Under local ethical committee approval and a fully directed posteroinferiorly to be well aligned with the interatrial signed patient’s consent form, five patients (3 female and 2 septum. *e septal occluder which has been used to close the males) with a mean age of 15.2± 9 years (ranged 9–31 years) defect was an Amplatzer septal occluder size 30 mm with good and a mean weight of 42.6± 12 kg (ranged 31–62 kg) were deployment and total closure of the defect, but we found that included in this study. the device was fixed on a fold which had been created by tight *ree patients were found to have large secundum ASD inflation of the stent and not anchored on the projected or with an absent superior rim, and the other two had an absent sectioned part of the stent and that the device had never inferior rim. *ey underwent an attempt of percutaneous reached the stent (Figure 1). We started to use this new ASD occlusion using an atrial septal occluder with CP-stent technique of creation of superior or inferior rim by tight in- implantation. flation of a CP stent at the entrance of the superior or inferior All those patients refused surgery completely and vena cava without modification. We found this technique is insisted on transcatheter closure, so we were obligated to easier than the first one which is even well aligned with the offer our new technique, explaining to them all the risks of interatrial septum, but does not support the device. such challenging procedures like stent migration, vascular *e second patient was a thirty-one-year-old female with injury, arrhythmia, and complete heart block. Meanwhile we a very large ASD secundum associated with an absent su- called the surgical team to prepare all the requirements for perior rim and RV volume overload. *eQ /Q was equal to an urgent open heart operation, as shown in Tables 1–3. P S 2.8 and the mean pulmonary arterial pressure was 25 mmHg. Assessment of the defect and its surrounding rims with She has been referred to us because of increasing dyspnea the drainage of RUPV was based on transthoracic echo- and exercise intolerance with palpitation. *is patient un- cardiography (TTE) and transesophageal echocardiography derwent transcatheter closure of the defect which was car- (TEE) at the time of the procedure. ried out by the implantation of a covered CP-stent 8 zig, 45 mm at the entrance of the SVC into the RA to create new 2.1. Device and Stent. *e stent that was used in this study superior rim which would support the Occlutech septal was the CP stent, 8 zig 39 and 45 mm, which is composed of occluder size 40 mm without residual shunt. Meticulous TEE heat-tempered 90% platinum and 10% iridium metal alloy, assessment of the stent and the device revealed that the left with metal wire arranged in a “zig” pattern that enables atrial disc of the device was anchored on the septal tissue at TM expansion up to 25 mm when inflated by a Z-med the inferior edge of the stent without direct contact to the balloon (Numed R Inc., NY, USA) size 18, 20, 23, and stent. Such a septal fold was confirmed after balloon inflation 25 mm × 40 mm. and before stent implantation, therefore we did not modify *e devices that were used for the closure of ASD in the stent in the second patient (Figure 2) the study were the Amplatzer septal occluders sizes 30, *e third patient was 12 years old who had a large 36, and 39 mm and the Occlutech septal occluder sizes 30 secundum ASD with an absent superior rim and RV and 40 mm. volume overload. *e Q /Q was 2.9 and the mean P S Journal of Interventional Cardiology 3 Table 2: Echocardiographic and hemodynamic characteristics of patients. Absent ASD size in 4chamber view/ ASD size in bicaval view ASD size in bicaval view Q / No. MPAP rim mm prestenting/mm poststenting/mm Q 1 Superior 24.3 30 24.3 2.5 23 2 Superior 33.2 35.8 30.6 2.8 25 3 Superior 24 27.6 23.3 2.9 29 4 Inferior 25.2 31.4 26.2 2.5 22 5 Inferior 25.5 28.2 22.6 3.2 28 Table 3: Characteristics of the procedure. No. Balloon size Length of 8 zig CP stent Device size FT/min PT/min 1 18/20 45 32 29.5 79 2 25/40 45 38 28.8 29 3 23/40 39 30 26 65 4 25/40 Two stents 45/45 34 42 113 5 25/40 39 30 51 118 (a) (b) (c) (d) (e) (f) Figure 1: (a) Two-dimensional transesophageal echocardiography (TEE) imaging in long-axis bicaval view demonstrates a large secundum ASD with an absent rim near the SVC. (b) TEE in long axis view reveals the struts of the CP stent (yellow arrow) with the atrial septal occluder (red arrow) anchoring on the newly created superior rim by tight inflation of the covered-CP stent. (c) Cine imaging of the heart in the frontal projection demonstrates the inflation of the modified covered CP-stent 8 zig, 45 mm length by Z-med balloon size 22 × 40 mm. (d) Cine imaging of the heart in the frontal projection shows the deployed ASO in proper position with the projected part of the modified CP-stent out of RA disc before release. (e) Selective PA angiogram in four chamber view (LAO 35, cranial 35) demonstrates complete closure of the defect with no residual shunt. (f) Cine imaging of the heart in frontal projection demonstrates the inflated Z-med balloon (25 × 40 mm) slipped down in front of the septal occluder which did not capture the projected part of the modified CP stent, this balloon dilatation have been done three years later to achieve adult size of SVC. pulmonary arterial pressure was 29 mmHg. *e defect has Amplatzer septal occluder with no residual shunt. *is been closed by the implantation of a 39 mm covered CP patient develops an episode of SVT during the procedure stent 8 zig in the SVC that resulted in the creation of the that responds to I.V adenosine with no recurrence in the septal fold which supports the left atrial disc of a 36 mm follow-up period. 4 Journal of Interventional Cardiology (a) (b) (c) (d) Figure 2: (a) TEE imaging in long-axis bicaval view demonstrates a large secundum ASD with an absent superior rim. (b, c) TEE imaging in long axis bicaval view demonstrates large secundum ASD with color follow mapping after inflation of the covered CP-stent creating a new superior rim (red arrow) with the clear struts of the stent (blue arrow). (d) TEE imaging in modified long axis bicaval view clearly demonstrates the struts of the covered CP-stent (blue arrow) creating a new superior rim (red arrow) which has been captured by two discs of the Occlutech septal occluder size 40 mm (red arrow). *e forth patient was 9 years old male who had a large *e fifth patient was a 10-year-old female with large secundum ASD with an absent inferior rim (IVC) rim, secundum ASD with an absent inferior rim who had RV dilated RA and RV, Q /Q 2.5 and the mean pulmonary volume overload, Q /Q of 3.2, and a mean pulmonary P S P S arterial pressure of 22 mmHg. *e transcatheter closure of arterial pressure of 28 mmHg. *e defect has been closed such defects is more difficult than those associated with an by the implantation of an uncovered CP stent 8 zig, 45 mm TM absent superior rim because the entrance of the IVC into the which was tightly inflated by a Z-med balloon size of RA is almost always wider than that of the SVC, so the 25 × 40 mm at the entrance of the IVC, creating a septal mounted uncovered CP stent 8 zig, 45 mm over the Z-med fold at the site of the IVC rim and the posteroinferior part TM balloon size 25 × 40 mm migrated upward into the RA on of the interatrial septum. TEE revealed the projection of the stiff Amplatzer guide wire after inflation, so the deflated the inferior rim over which the 30 mm Occlutech device balloon pushed upward inside the migrated CP stent and anchored on this rim with total closure of the defect inflated to pull the stent downward to the IVC to be inflated without residual shunt (Figures 4 and 5) (Supplementary tightly again, and another uncovered CP stent that was Materials Videos 1–5). TM mounted over the Z-med balloon 25 × 40 mm pushed over the guide wire to be inflated half in the migrated stent and the remaining part inflated in the IVC in order to fix the 3.1. Follow-Up. At the mean follow-up period (45± 13) st 1 stent (Figure 3). Meticulous TEE assessment of the stent months, four patients completed the follow-up period of 5 with creating septal fold of the IVC rim and posteroinferior years, except the last patient had a 2-year follow-up. No one portion of the interatrial septum makes us proceed to missed the follow-up. compete closure of the defect using an Amplatzer septal *e follow-up included clinical examination, electro- occluder size of 34 mm with no residual shunt. cardiography, chest X-ray, and echocardiographic study, at Journal of Interventional Cardiology 5 (a) (b) (c) (d) (e) (f) (g) (h) (i) (j) (k) (l) Figure 3: (a) Transthoracic echocardiogram, subcostal bicaval view demonstrates a large secundum ASD with an absent inferior rim. (b) TEE in long axis bicaval view shows large secundum ASD with absent inferior rim with right sided volume overload. (c, d) TEE in long axis view demonstrates the struts of the distal part of the inflated CP stent (yellow arrow) at the entrance of the IVC creating a new inferior rim (red arrow). (e) TEE imaging in a modified long axis view demonstrates struts of the inflated uncovered CP stent (yellow arrow) at the entrance of the IVC creating a new inferior rim (red arrow) which has been captured by two discs of the ASO (white arrow). (f) Cine angiogram of the IVC in frontal view demonstrates the uncovered CP stent mounted over the Z-med balloon size (25 × 40 mm) at the entrance of the IVC under the guidance of the TEE for proper position of the stent. (g) Cine imaging of the heart in four chamber view demonstrates the inflation of the uncovered CP stent, 8 zig, 45 mm, using Z-med balloon size (25 × 40 mm) at the entrance of the IVC into the RA under the guidance of the TEE. (h) Cine imaging of the heart in frontal view demonstrates the inflation of the second CP-stent 8 zig, 39 mm, overlapping with previous stent for proper fixation. (i) Cine imaging of the heart in the frontal projection demonstrates the proper deployment of the Amplatzer septal occluder size 34 mm before release. (j) RA angiogram in four chamber view through cook sheath 14F demonstrates the deployed septal occluder which was well aligned with IAS. (k) Cine imaging of the heart in aneteroposterior projection demonstrates both the two overlapping uncovered CP stents in the IVC with the proper position of the atrial septal occluder. (l) Cine imaging of the heart in four chamber projection demonstrates two overlapping uncovered CP-stents and the device which is well aligned with IAS under the guidance of the TEE, the device is not anchored the CP stent at all. 24 hours, 1 month, 3 months, 6 months, and annually after 4. Discussion the procedure. TTE was performed at 24 hours, 1 month, and 3 months, while TEE was used at 6 months to evaluate *e ASO was designed to close ASDs with a deficient rim the proper position of CP stent and ASO. using two different mechanisms: stenting the defect with its We kept all the patients on aspirin (5 mg/kg/day up to connecting waist and eliminating any flow across the septum 100 mg/day) and clopidogrel (3 mg/kg/day up to 75 mg/day) by the 2 flat discs. Because the right atrial disc is 8–10 mm and the left atrial disc is 12–16 mm larger than the con- for six months. We encountered no significant complications acutely or necting waist, a minimum of a 5 mm rim of atrial septum around the defect has been suggested as a prerequisite for the on follow-up except one patient with absent inferior rim had stent migration at the time of implantation, including no device closure with an ASO [9–11]. However, due to its patient developed complete heart block as we inflated the CP design, it is believed that the ASO would not require an stent at the entrance of SVC into the RA. anterior rim for anchorage and the device would wrap 6 Journal of Interventional Cardiology (a) (b) (c) (d) (e) (f) (g) (h) (i) (j) (k) (l) Figure 4: (a) Transthoracic echocardiorgraghy (TTE) imaging in subcostal view demonstrates a large secundum ASD with a totally absent inferior rim. (b) TEE imaging in long axis bicaval view demonstrates large secundum ASD. (c) TTE imaging in subcostal view demonstrates the inflated Z-med balloon with the created inferior rim (arrows). (d) TEE in modified oblique plane demonstrates the inflated balloon at the entrance of IVC with created inferior rim. (e) TTE imaging in the subcostal bicaval view demonstrates the inflated balloon with a created inferior rim. (f) TTE imaging in subcostal bicaval view shows the mounted uncovered CP stent at the entrance of the IVC before the inflation. (g) TTE imaging in subcostal bicaval view demonstrates the inflated uncovered CP stent at the entrance of the IVC with the created inferior rim. (h, i) TEE imaging in a modified long axis view (angle 67 ) demonstrates the created inferior rim (upper arrow) by tight inflation of an uncovered CP stent at the entrance of the IVC (lower arrow). (j, k) TTE imaging in subcostal long axis view demonstrates the atrial septal occluder in proper position capturing the created inferior rim (red arrow). (l) TEE imaging in long axis bicaval view demonstrates the proper position of the atrial septal occluder capturing the new inferior rim (upper arrow) which has been created by inflation of uncovered CP stent (lower arrow) at the entrance of IVC. around the posterior wall of the aorta. Furthermore, as long and IVC entrance into the RA by cutting part of the stent as the defect has equal or more than three sufficient rims, the circumference (10–15 mm length) to be projected into the RA TM device would seat well and effectively eliminate the shunt. A (Figures 1(d) and 1(f)) after inflation by the Z-med bal- deficient anterior, inferior, or posterior rim as assessed by 2 loon. We found that the device did not capture the projected dimensional echocardiography does not exclude the pos- part of the stent but it captured the newly created rim by tight sibility that the defect could be closed using the ASO [8]. *e inflation of the CP stent at the entrance of vena cavae into RA findings of this study demonstrated that such defects as- ((Figures 2(b)–2(d)), (Figure 3(e)), and (Figure 4(g), 4(h), sociated with only one deficient rim and all defects had a and 4(l))), there after we change our technique in which the distance of> 5 mm from vital cardiac structures(AV- valves, CP stent did not modified but just tightly inflated at the coronary sinus, right upper pulmonary vein) [8]. *is is entrance of vena cavae into the RA. Before the stenting of the TM relatively comparable with our study in which either the vena cavae we inflate Z-med balloon to see whether the superior or inferior rim is absent. inflated balloon can create a new superior or inferior rim Our initial concept was to provide a stable rim to device (Figure 4), thereafter we proceed with balloon mounted CP anchorage in the case of transcatheter closure of a large stent (covered stent at the entrance of SVC and bare stent at secundum ASD with an absent superior or inferior rim. We the entrance of IVC) to be inflated at the entrance of vena have used a modified covered and bare CP stent in the SVC cavae (5–15 mm) into the RA creating a new superior or Journal of Interventional Cardiology 7 (a) (b) (c) (d) (e) (f) (g) (h) Figure 5: (a, b) IVC angiogram in frontal and lateral views demonstrates the diameter of the IVC at its entrance into the right atrium in order to select the proper size of the balloon. (c, d) Cine angiogram of the heart in frontal and lateral projections demonstrates the inflated Z- med balloon 25 × 40 mm at the entrance of the IVC to document that the inflated balloon can created an inferior rim. (e, f) Cine angiogram of the heart in frontal and lateral projection demonstrates the inflated uncovered CP stents at the entrance of the IVC into the right atrium. (g, h) Cine angiogram of the heart in frontal and lateral projection demonstrates proper implantation of uncovered CP stent at the entrance of the IVC, creating an inferior rim which makes the closure of the ASD secundum with an absent inferior rim possible and effective by the atrial septal occluder. inferior rim, respectively ((Figure 2(b) and 2(c)), where the initial stich in the floor of the IVC is tied. *e large (Figures 3(c) and 3(e)), and (Figures 4(g) and 4(h))). All the secundum ASD becomes almost slit-like before complete the five cases of large secundum ASD with absent rim (3 superior repair, where a fold or flap will be formed at the site of the and 2 inferior) were successfully closed without taking inferior rim which would be the future rim. Other stiches oversized ASO just we selected devices 4–6.5 mm larger than will be carried out at the anterior and posterior parts of this the new diameter of the defect. fold [12, 13], which also could be created by tight inflation of We thought that the mechanism of our technique could the bare CP stent at the entrance of IVC into the RA. Also, be explained by the concept of surgical repair of large this concept could be applied to the absent superior rim secundum ASD with an absent superior or inferior rim which is easier than the absent inferior rim. 8 Journal of Interventional Cardiology [4] J. E. Lock, J. J. Rome, R. Davis et al., “Transcatheter closure of 5. Conclusion atrial septal defects. Experimental studies,” Circulation, vol. 79, no. 5, pp. 1091–1099, 1989. Although surgical repair of large secundum ASD with an st [5] B. D. *anopoulos, C. V. Laskari, G. S. Tsaousis, absent superior or inferior rim is 1 option. A. Zarayelyan, A. Vekiou, and G. S. papadopoulos, “Closure of But this case series study explain that such defects can be atrial septal defects with the amplatzer occlusion device: closed by transcatheter approach using tight inflation of the preliminary results,” Journal of the American College of CP stent at the entrance of vena cavae into the RA to create Cardiology, vol. 31, no. 5, pp. 1110–1116, 1998. new stable superior or inferior rim for anchorage of the [6] J. S. McGhie, A. E. van den Bosch, M. G. Haarman et al., device. Our result was comparable to that of surgical repair. “Characterization of atrial septal defect by simultaneous *is technique is comparable to our initial technique for multiplane two-dimensional echocardiography,” European transcatheter closure for sinus venosus atrial septal defect Heart Journal-Cardiovascular Imaging, vol. 15, no. 10, with anomalous pulmonary venous drainage which was pp. 1145–1151, 2014. carried out in 2011 at Ibn Al-Bitar center for cardiac surgery, [7] T. Podnay, P. Martanovic, P. Gavora, and J. Masura, “Mor- phological variations of secundum type atrial septal defects Baghdad, Iraq, and published in 2019 [14]. *erefore, we :feasibility for percutaneous closure using amplatzer septel recommend using 3D printing and image fusion guidance in occluders,” Catheterization and Cardiovascular Interventions, the transcatheter closure of large secundum ASD with an vol. 53, pp. 386–391, 2001. absent superior or inferior rim as done in catheter closure of [8] F. E. Silvestry, M. S. Cohen, L. B. Armsby et al., “Guidelines for sinus venosus ASD [15]. Although these procedures are the echocardiographic assessment of atial septal defect and relatively difficult and challenging, especially in the closure patent foramen ovale: from the American society of echo- of a large defect associated with an absent inferior rim, they cardiography and society for cardiac angiography and in- carry high risk of stent migration (8 zig, 45 mm), so we terventions,” Journal of the American Society of recommend using a CP- stent (10 zig, 60 mm). Echocardiography, vol. 28, pp. 910–958, 2015. [9] Q. Cao, W. Radtke, F. Berger, W. Zhu, and Z. M. Hifazi, “Transcatheter closure of multiple atrial septal defects. 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Bharati, M. Lev, and J. W. KirKlin, Cardiac Surgery End the view demonstrates an inflated balloon (yellow arrow) with ConductionSystem, Futura Publishing Company, Mout·Kisco, the creation of an inferior rim (red arrow). Video 3: TTE in NY, USA, 2nd edition, 1992. bicaval view demonstrates an inflated CP stent at the en- [13] B. G. Bavratt Boyes, “*e results of repair of atrial septal defect trance of the IVC (yellow arrow) with a created inferior rim using the atrial well method,” Annals of the Royal College of (red arrow). Video 4: TEE in bicaval view demonstrates the Surgeons of England, vol. 33, no. 4, p. 209, 1963. [14] H. A. M. Abdullah, H. A. Alsalkhi, and K. A. Khalid, inflated CP stent (yellow arrow) and inferior rim (red ar- “Transcatheter closure of sinus venosus atrial septal defe3ct row). 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L. wilkinSon, “Congenital heart disease among 160 480 liveborn children in Liverpool 1960 to 1969. Implications for surgical treatment,” Heart, vol. 46, no. 1, pp. 55–62, 1981. [3] T. D. king and N. L. Nills, “Secundum atrial septal defects :nanoperative closure during cardiac,” JAMA, vol. 235, no. 23, pp. 2506–2509, 1976. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Interventional Cardiology Hindawi Publishing Corporation

Feasibility of Transcatheter Closure of Large Secundum Atrial Septal Defect with Absent Superior or Inferior Rim

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Abstract

Hindawi Journal of Interventional Cardiology Volume 2022, Article ID 2764296, 8 pages https://doi.org/10.1155/2022/2764296 Research Article Feasibility of Transcatheter Closure of Large Secundum Atrial Septal Defect with Absent Superior or Inferior Rim 1 1 2 Hussein Abdulwahab , Mohammed Rassul Husain , and Khalid A. Khalid Department of Cardiology, Ibn Albitar Center for Cardiac Surgery, Baghdad, Iraq Department of Pediatric Cardiology, Collage of Medicine, University of Basra, Basra, Iraq Correspondence should be addressed to Hussein Abdulwahab; husseinabdulwahab62@yahoo.com Received 10 November 2021; Revised 27 February 2022; Accepted 14 March 2022; Published 4 April 2022 Academic Editor: Faisal Latif Copyright © 2022 Hussein Abdulwahab et al. *is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction. Surgical closure of a large secundum atrial septal defect (ASD) with an absent superior or inferior rim is the standard method of management, but transcatheter closure of such a defect is possible and feasible. Objectives. To evaluate the feasibility, effectiveness, and safety of transcatheter closure of large secundum ASD with an absent superior or inferior rim through implantation of a cheatham platinum (CP) stent at the entrance of the superior vena cava (SVC) or inferior vena cava (IVC) into the right atrium (RA) to create a suitable rim for subsequent complete closure of the defect using a septal occluder. Patients and Methods. *is case series was carried out at Ibn Al-Bitar Center for Cardiac Surgery, Baghdad, Iraq from 2014 to 2019, five patients underwent such transcatheter approach for closure of large secundum ASD with the absent superior or inferior rim by im- plantation of CP stent at the entrance of vena cave into the RA. Result. *e ages and weights of patients who were enrolled in this study ranged from 9–31 years (15.2± 9 years) and 31.5–62 kg (42.6± 12 kg). *ree patients had absent superior rims, and the other two had absent inferior rims. *e Q /Q was ranged from 1.9–3.2 (2.78± 0.29), and the mean pulmonary arterial pressure ranged p s from 22–29 mmHg (25.4± 3 mmHg). *e defects with an absent superior rim were closed successfully by implantation of CP stents of 45, 45, and 39 mm to create a rim which supported the left atrial disc of 30, 38, and 32 mm atrial septal occluder (ASO), respectively, while large secundum ASD with an absent inferior rim could be effectively closed by implantation of two overlapping bare CP stents of 45 mm to create an IVC rim that supported 34 mm and 30 mm atrial septal occluder. Conclusion and rec- ommendation. Transcatheter closure of large secundum ASD with absent superior or inferior rim is possible and effective by implantation of covered and bare CP stents at the entrance of SVC and IVC, respectively. Although these procedures are relatively difficult and challenging, especially in the closure of large defects associated with absent inferior rim, they carry a high risk of stent migration (8 zig, 45 mm), so we recommend using a CP-stent (10 zig, 60 mm). anatomically suitable for transcatheter closure. ASD size 1. Introduction should be limited and sufficient rims of interatrial septal *e secundum type atrial septal defect (ASD) is the fourth tissue between the defect and adjacent structures are re- most common congenital heart defect with an incidence of quired to position the ASD device. Rims and the size of the 3.78 per 10,000 live births [1], corresponding to 5.9% of ASD are crucial for the success of transcatheter ASD closure. diagnosed congenital heart disease in children [2]. *e maximum diameter and dimension of the various rims *e ASD can now be treated by a transcatheter occlusion of the ASD are essential for sizing and optimal placement of st technique. Since the 1 attempt in 1976 by King and Mills the device. Morphological variations of secundum type ASD [3], transcatheter closure of secundum ASDs has evolved are common and their recognition is crucial for the selection over the past 3 decades and has become an effective alter- of suitability for percutaneous closure [7]. native therapy for most patients with ASD [4, 5]. Transesophageal echocardiogram was done to assess Transcatheter closure of ASD has become the treatment size and rims in the different views (four chamber view ° ° of choice rather than surgery [6]. However, not all ASDs are ME 0 short axis view ME 45 and bicaval view ME 2 Journal of Interventional Cardiology Table 1: Characteristics of the patients. 90–110 ). AV rim and posterior superior rim in the four chamber view, aortic and inferoposterior rim in short axis No. Sex Age/ys Wt/kg view, and IVC rim in bicaval view were measured and 1 F 14 45 documented. *e views used for ASD assessment by TEE 2 F 31 62 were as per the guidelines for echocardiographic assess- 3 M 12 34.5 ment of atrial septal defect and patent foramen ovale of 4 M 9 40 the American Society of Echocardiography and Society for 5 F 10 31.5 Cardiac Angiography and Intervention [8]. A rim less than 5 mm was termed deficient or inadequate and absent if it was <1 mm. 3. Results *e aim of this study was to evaluate our clinical ex- perience in transcatheter closure of large secundum ASD Five patients (3 females and 2 males) were enrolled in this with an absent superior or inferior rim by implantation of a study. *eir ages ranged 9 to 31 years (15.2± 9 years) and CP stent in the entrance of vena cavae into the RA to create a their weights were 31.5–62 kg (42.6± 12 kg). *ree patients septal fold by tight inflation of the stent. had absent superior rims, and two patients had absent in- ferior rims. *e Q /Q ranged from 2.5 to 3.2 (2.78± 0.29), the mean p s 2. Patients and Methods pulmonary arterial pressure ranged from 22 to 29 mmHg (25.4± 3 mmHg). A case series, which have been done at Ibn Al-Bitar Center *e first patient was a 14 year-old-female with a large ASD for Cardiac Surgery, Baghdad, Iraq from 2014 to 2020 in- secundum and an absent superior rim. She had dilated RA and troduced a transcatheter approach for closure of large RV, a Q /Q of 2.5, and a mean pulmonary artery pressure of secundum ASD with an absent superior or inferior rim by P S 23 mmHg. Successful closure of the defect was achieved by the implantation of covered and uncovered CP stents in the SVC implantation of a modified covered CP stent of 45 mm in the or IVC, respectively, to create a suitable rim for subsequent SVC. *e modified CP stent was carried out by cutting half its complete closure by an atrial septal occluder. circle into about 15 mm length to be projected into the RA and Under local ethical committee approval and a fully directed posteroinferiorly to be well aligned with the interatrial signed patient’s consent form, five patients (3 female and 2 septum. *e septal occluder which has been used to close the males) with a mean age of 15.2± 9 years (ranged 9–31 years) defect was an Amplatzer septal occluder size 30 mm with good and a mean weight of 42.6± 12 kg (ranged 31–62 kg) were deployment and total closure of the defect, but we found that included in this study. the device was fixed on a fold which had been created by tight *ree patients were found to have large secundum ASD inflation of the stent and not anchored on the projected or with an absent superior rim, and the other two had an absent sectioned part of the stent and that the device had never inferior rim. *ey underwent an attempt of percutaneous reached the stent (Figure 1). We started to use this new ASD occlusion using an atrial septal occluder with CP-stent technique of creation of superior or inferior rim by tight in- implantation. flation of a CP stent at the entrance of the superior or inferior All those patients refused surgery completely and vena cava without modification. We found this technique is insisted on transcatheter closure, so we were obligated to easier than the first one which is even well aligned with the offer our new technique, explaining to them all the risks of interatrial septum, but does not support the device. such challenging procedures like stent migration, vascular *e second patient was a thirty-one-year-old female with injury, arrhythmia, and complete heart block. Meanwhile we a very large ASD secundum associated with an absent su- called the surgical team to prepare all the requirements for perior rim and RV volume overload. *eQ /Q was equal to an urgent open heart operation, as shown in Tables 1–3. P S 2.8 and the mean pulmonary arterial pressure was 25 mmHg. Assessment of the defect and its surrounding rims with She has been referred to us because of increasing dyspnea the drainage of RUPV was based on transthoracic echo- and exercise intolerance with palpitation. *is patient un- cardiography (TTE) and transesophageal echocardiography derwent transcatheter closure of the defect which was car- (TEE) at the time of the procedure. ried out by the implantation of a covered CP-stent 8 zig, 45 mm at the entrance of the SVC into the RA to create new 2.1. Device and Stent. *e stent that was used in this study superior rim which would support the Occlutech septal was the CP stent, 8 zig 39 and 45 mm, which is composed of occluder size 40 mm without residual shunt. Meticulous TEE heat-tempered 90% platinum and 10% iridium metal alloy, assessment of the stent and the device revealed that the left with metal wire arranged in a “zig” pattern that enables atrial disc of the device was anchored on the septal tissue at TM expansion up to 25 mm when inflated by a Z-med the inferior edge of the stent without direct contact to the balloon (Numed R Inc., NY, USA) size 18, 20, 23, and stent. Such a septal fold was confirmed after balloon inflation 25 mm × 40 mm. and before stent implantation, therefore we did not modify *e devices that were used for the closure of ASD in the stent in the second patient (Figure 2) the study were the Amplatzer septal occluders sizes 30, *e third patient was 12 years old who had a large 36, and 39 mm and the Occlutech septal occluder sizes 30 secundum ASD with an absent superior rim and RV and 40 mm. volume overload. *e Q /Q was 2.9 and the mean P S Journal of Interventional Cardiology 3 Table 2: Echocardiographic and hemodynamic characteristics of patients. Absent ASD size in 4chamber view/ ASD size in bicaval view ASD size in bicaval view Q / No. MPAP rim mm prestenting/mm poststenting/mm Q 1 Superior 24.3 30 24.3 2.5 23 2 Superior 33.2 35.8 30.6 2.8 25 3 Superior 24 27.6 23.3 2.9 29 4 Inferior 25.2 31.4 26.2 2.5 22 5 Inferior 25.5 28.2 22.6 3.2 28 Table 3: Characteristics of the procedure. No. Balloon size Length of 8 zig CP stent Device size FT/min PT/min 1 18/20 45 32 29.5 79 2 25/40 45 38 28.8 29 3 23/40 39 30 26 65 4 25/40 Two stents 45/45 34 42 113 5 25/40 39 30 51 118 (a) (b) (c) (d) (e) (f) Figure 1: (a) Two-dimensional transesophageal echocardiography (TEE) imaging in long-axis bicaval view demonstrates a large secundum ASD with an absent rim near the SVC. (b) TEE in long axis view reveals the struts of the CP stent (yellow arrow) with the atrial septal occluder (red arrow) anchoring on the newly created superior rim by tight inflation of the covered-CP stent. (c) Cine imaging of the heart in the frontal projection demonstrates the inflation of the modified covered CP-stent 8 zig, 45 mm length by Z-med balloon size 22 × 40 mm. (d) Cine imaging of the heart in the frontal projection shows the deployed ASO in proper position with the projected part of the modified CP-stent out of RA disc before release. (e) Selective PA angiogram in four chamber view (LAO 35, cranial 35) demonstrates complete closure of the defect with no residual shunt. (f) Cine imaging of the heart in frontal projection demonstrates the inflated Z-med balloon (25 × 40 mm) slipped down in front of the septal occluder which did not capture the projected part of the modified CP stent, this balloon dilatation have been done three years later to achieve adult size of SVC. pulmonary arterial pressure was 29 mmHg. *e defect has Amplatzer septal occluder with no residual shunt. *is been closed by the implantation of a 39 mm covered CP patient develops an episode of SVT during the procedure stent 8 zig in the SVC that resulted in the creation of the that responds to I.V adenosine with no recurrence in the septal fold which supports the left atrial disc of a 36 mm follow-up period. 4 Journal of Interventional Cardiology (a) (b) (c) (d) Figure 2: (a) TEE imaging in long-axis bicaval view demonstrates a large secundum ASD with an absent superior rim. (b, c) TEE imaging in long axis bicaval view demonstrates large secundum ASD with color follow mapping after inflation of the covered CP-stent creating a new superior rim (red arrow) with the clear struts of the stent (blue arrow). (d) TEE imaging in modified long axis bicaval view clearly demonstrates the struts of the covered CP-stent (blue arrow) creating a new superior rim (red arrow) which has been captured by two discs of the Occlutech septal occluder size 40 mm (red arrow). *e forth patient was 9 years old male who had a large *e fifth patient was a 10-year-old female with large secundum ASD with an absent inferior rim (IVC) rim, secundum ASD with an absent inferior rim who had RV dilated RA and RV, Q /Q 2.5 and the mean pulmonary volume overload, Q /Q of 3.2, and a mean pulmonary P S P S arterial pressure of 22 mmHg. *e transcatheter closure of arterial pressure of 28 mmHg. *e defect has been closed such defects is more difficult than those associated with an by the implantation of an uncovered CP stent 8 zig, 45 mm TM absent superior rim because the entrance of the IVC into the which was tightly inflated by a Z-med balloon size of RA is almost always wider than that of the SVC, so the 25 × 40 mm at the entrance of the IVC, creating a septal mounted uncovered CP stent 8 zig, 45 mm over the Z-med fold at the site of the IVC rim and the posteroinferior part TM balloon size 25 × 40 mm migrated upward into the RA on of the interatrial septum. TEE revealed the projection of the stiff Amplatzer guide wire after inflation, so the deflated the inferior rim over which the 30 mm Occlutech device balloon pushed upward inside the migrated CP stent and anchored on this rim with total closure of the defect inflated to pull the stent downward to the IVC to be inflated without residual shunt (Figures 4 and 5) (Supplementary tightly again, and another uncovered CP stent that was Materials Videos 1–5). TM mounted over the Z-med balloon 25 × 40 mm pushed over the guide wire to be inflated half in the migrated stent and the remaining part inflated in the IVC in order to fix the 3.1. Follow-Up. At the mean follow-up period (45± 13) st 1 stent (Figure 3). Meticulous TEE assessment of the stent months, four patients completed the follow-up period of 5 with creating septal fold of the IVC rim and posteroinferior years, except the last patient had a 2-year follow-up. No one portion of the interatrial septum makes us proceed to missed the follow-up. compete closure of the defect using an Amplatzer septal *e follow-up included clinical examination, electro- occluder size of 34 mm with no residual shunt. cardiography, chest X-ray, and echocardiographic study, at Journal of Interventional Cardiology 5 (a) (b) (c) (d) (e) (f) (g) (h) (i) (j) (k) (l) Figure 3: (a) Transthoracic echocardiogram, subcostal bicaval view demonstrates a large secundum ASD with an absent inferior rim. (b) TEE in long axis bicaval view shows large secundum ASD with absent inferior rim with right sided volume overload. (c, d) TEE in long axis view demonstrates the struts of the distal part of the inflated CP stent (yellow arrow) at the entrance of the IVC creating a new inferior rim (red arrow). (e) TEE imaging in a modified long axis view demonstrates struts of the inflated uncovered CP stent (yellow arrow) at the entrance of the IVC creating a new inferior rim (red arrow) which has been captured by two discs of the ASO (white arrow). (f) Cine angiogram of the IVC in frontal view demonstrates the uncovered CP stent mounted over the Z-med balloon size (25 × 40 mm) at the entrance of the IVC under the guidance of the TEE for proper position of the stent. (g) Cine imaging of the heart in four chamber view demonstrates the inflation of the uncovered CP stent, 8 zig, 45 mm, using Z-med balloon size (25 × 40 mm) at the entrance of the IVC into the RA under the guidance of the TEE. (h) Cine imaging of the heart in frontal view demonstrates the inflation of the second CP-stent 8 zig, 39 mm, overlapping with previous stent for proper fixation. (i) Cine imaging of the heart in the frontal projection demonstrates the proper deployment of the Amplatzer septal occluder size 34 mm before release. (j) RA angiogram in four chamber view through cook sheath 14F demonstrates the deployed septal occluder which was well aligned with IAS. (k) Cine imaging of the heart in aneteroposterior projection demonstrates both the two overlapping uncovered CP stents in the IVC with the proper position of the atrial septal occluder. (l) Cine imaging of the heart in four chamber projection demonstrates two overlapping uncovered CP-stents and the device which is well aligned with IAS under the guidance of the TEE, the device is not anchored the CP stent at all. 24 hours, 1 month, 3 months, 6 months, and annually after 4. Discussion the procedure. TTE was performed at 24 hours, 1 month, and 3 months, while TEE was used at 6 months to evaluate *e ASO was designed to close ASDs with a deficient rim the proper position of CP stent and ASO. using two different mechanisms: stenting the defect with its We kept all the patients on aspirin (5 mg/kg/day up to connecting waist and eliminating any flow across the septum 100 mg/day) and clopidogrel (3 mg/kg/day up to 75 mg/day) by the 2 flat discs. Because the right atrial disc is 8–10 mm and the left atrial disc is 12–16 mm larger than the con- for six months. We encountered no significant complications acutely or necting waist, a minimum of a 5 mm rim of atrial septum around the defect has been suggested as a prerequisite for the on follow-up except one patient with absent inferior rim had stent migration at the time of implantation, including no device closure with an ASO [9–11]. However, due to its patient developed complete heart block as we inflated the CP design, it is believed that the ASO would not require an stent at the entrance of SVC into the RA. anterior rim for anchorage and the device would wrap 6 Journal of Interventional Cardiology (a) (b) (c) (d) (e) (f) (g) (h) (i) (j) (k) (l) Figure 4: (a) Transthoracic echocardiorgraghy (TTE) imaging in subcostal view demonstrates a large secundum ASD with a totally absent inferior rim. (b) TEE imaging in long axis bicaval view demonstrates large secundum ASD. (c) TTE imaging in subcostal view demonstrates the inflated Z-med balloon with the created inferior rim (arrows). (d) TEE in modified oblique plane demonstrates the inflated balloon at the entrance of IVC with created inferior rim. (e) TTE imaging in the subcostal bicaval view demonstrates the inflated balloon with a created inferior rim. (f) TTE imaging in subcostal bicaval view shows the mounted uncovered CP stent at the entrance of the IVC before the inflation. (g) TTE imaging in subcostal bicaval view demonstrates the inflated uncovered CP stent at the entrance of the IVC with the created inferior rim. (h, i) TEE imaging in a modified long axis view (angle 67 ) demonstrates the created inferior rim (upper arrow) by tight inflation of an uncovered CP stent at the entrance of the IVC (lower arrow). (j, k) TTE imaging in subcostal long axis view demonstrates the atrial septal occluder in proper position capturing the created inferior rim (red arrow). (l) TEE imaging in long axis bicaval view demonstrates the proper position of the atrial septal occluder capturing the new inferior rim (upper arrow) which has been created by inflation of uncovered CP stent (lower arrow) at the entrance of IVC. around the posterior wall of the aorta. Furthermore, as long and IVC entrance into the RA by cutting part of the stent as the defect has equal or more than three sufficient rims, the circumference (10–15 mm length) to be projected into the RA TM device would seat well and effectively eliminate the shunt. A (Figures 1(d) and 1(f)) after inflation by the Z-med bal- deficient anterior, inferior, or posterior rim as assessed by 2 loon. We found that the device did not capture the projected dimensional echocardiography does not exclude the pos- part of the stent but it captured the newly created rim by tight sibility that the defect could be closed using the ASO [8]. *e inflation of the CP stent at the entrance of vena cavae into RA findings of this study demonstrated that such defects as- ((Figures 2(b)–2(d)), (Figure 3(e)), and (Figure 4(g), 4(h), sociated with only one deficient rim and all defects had a and 4(l))), there after we change our technique in which the distance of> 5 mm from vital cardiac structures(AV- valves, CP stent did not modified but just tightly inflated at the coronary sinus, right upper pulmonary vein) [8]. *is is entrance of vena cavae into the RA. Before the stenting of the TM relatively comparable with our study in which either the vena cavae we inflate Z-med balloon to see whether the superior or inferior rim is absent. inflated balloon can create a new superior or inferior rim Our initial concept was to provide a stable rim to device (Figure 4), thereafter we proceed with balloon mounted CP anchorage in the case of transcatheter closure of a large stent (covered stent at the entrance of SVC and bare stent at secundum ASD with an absent superior or inferior rim. We the entrance of IVC) to be inflated at the entrance of vena have used a modified covered and bare CP stent in the SVC cavae (5–15 mm) into the RA creating a new superior or Journal of Interventional Cardiology 7 (a) (b) (c) (d) (e) (f) (g) (h) Figure 5: (a, b) IVC angiogram in frontal and lateral views demonstrates the diameter of the IVC at its entrance into the right atrium in order to select the proper size of the balloon. (c, d) Cine angiogram of the heart in frontal and lateral projections demonstrates the inflated Z- med balloon 25 × 40 mm at the entrance of the IVC to document that the inflated balloon can created an inferior rim. (e, f) Cine angiogram of the heart in frontal and lateral projection demonstrates the inflated uncovered CP stents at the entrance of the IVC into the right atrium. (g, h) Cine angiogram of the heart in frontal and lateral projection demonstrates proper implantation of uncovered CP stent at the entrance of the IVC, creating an inferior rim which makes the closure of the ASD secundum with an absent inferior rim possible and effective by the atrial septal occluder. inferior rim, respectively ((Figure 2(b) and 2(c)), where the initial stich in the floor of the IVC is tied. *e large (Figures 3(c) and 3(e)), and (Figures 4(g) and 4(h))). All the secundum ASD becomes almost slit-like before complete the five cases of large secundum ASD with absent rim (3 superior repair, where a fold or flap will be formed at the site of the and 2 inferior) were successfully closed without taking inferior rim which would be the future rim. Other stiches oversized ASO just we selected devices 4–6.5 mm larger than will be carried out at the anterior and posterior parts of this the new diameter of the defect. fold [12, 13], which also could be created by tight inflation of We thought that the mechanism of our technique could the bare CP stent at the entrance of IVC into the RA. Also, be explained by the concept of surgical repair of large this concept could be applied to the absent superior rim secundum ASD with an absent superior or inferior rim which is easier than the absent inferior rim. 8 Journal of Interventional Cardiology [4] J. E. Lock, J. J. Rome, R. Davis et al., “Transcatheter closure of 5. Conclusion atrial septal defects. Experimental studies,” Circulation, vol. 79, no. 5, pp. 1091–1099, 1989. Although surgical repair of large secundum ASD with an st [5] B. D. *anopoulos, C. V. Laskari, G. S. Tsaousis, absent superior or inferior rim is 1 option. A. Zarayelyan, A. Vekiou, and G. S. papadopoulos, “Closure of But this case series study explain that such defects can be atrial septal defects with the amplatzer occlusion device: closed by transcatheter approach using tight inflation of the preliminary results,” Journal of the American College of CP stent at the entrance of vena cavae into the RA to create Cardiology, vol. 31, no. 5, pp. 1110–1116, 1998. new stable superior or inferior rim for anchorage of the [6] J. S. McGhie, A. E. van den Bosch, M. G. Haarman et al., device. 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Journal of Interventional Cardiology – Hindawi Publishing Corporation

Published: Apr 4, 2022

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