Abstract
Percutaneous closure is nowadays considered the treatment of choice of ostium secundum atrial septal defects (ASD). However, transcatheter closure can be highly challenging when we face an ASD with complex morphological features. The combination of different imaging modalities can be very helpful. This case shows the great value of using both intracardiac and real time 3D transesophageal echocardiography for the percutaneous closure of a complex iatrogenic ASD after device embolization.
Highlights
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Percutaneous closure has become the treatment of choice for ostium secundum atrial septal defects (ASDs).
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There are some ASD that cannot undergo successful percutaneous closure, such as those with deficient rims or extremely size of the defect.
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Transesophageal echocardiography (TEE) and intracardiac echocardiography (ICE) are well known imaging techniques used in peri-procedural guidance.
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The combination of 3D-TEE and ICE allows for a better characterization of the defect and improves visualization during percutaneous closure.
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Closure of complex cases of ASD can be achieved percutaneously when using 3D-TEE in combination with ICE.
1
Introduction
Percutaneous closure of atrial septal defects (ASDs) has become a worldwide accepted alternative to surgical repair. Device embolization is a rare but recognized complication . Percutaneous device retrieval can increase the size of the defect by tearing the interatrial septum. Intracardiac echocardiography (ICE) has shown positive results in guiding percutaneous ASD closure and could be especially useful in complex cases of ASD . Real time 3D Transesophageal echocardiography (3D-RT TEE) provides incremental value for an optimal device alignment and implantation . We describe a challenging case of percutaneous closure of a large iatrogenic ASD after device embolization using ICE and real time 3D-TEE for procedural guidance.
2
Case
A 77-year-old woman with history of hypertension and permanent atrial fibrillation reported dyspnea with moderate exertion. She was diagnosed to have an ostium secundum atrial septal defect (ASD) of 11 × 14 mm with an atrial septal aneurysm (ASA), left to right shunt and severe right chambers dilatation. A 14 mm Amplatzer ™ Septal occluder device (St. Jude Medical, Inc.; St. Paul, Minn) was chosen for percutaneous closure. When we attempted the ASD closure, the device embolized into the left atrium and was captured percutaneously with a snare catheter ( Fig. 1 ). Device retrieval resulted in an enlargement of the defect. The 2D and 3D TEE revealed a 28 mm ASD with a larger ASA. Despite the retro-aortic rim overpassing 8 mm, the posterior rim was practically absent ( Fig. 2 ; Supplementary movie 1 ).
After evaluation by the heart team (interventional, imaging cardiologists and cardiovascular surgeons) it was decided to attempt percutaneous closure again, this time using real time 3D TEE (3D-RT TEE) in combination with intracardiac echocardiography (ICE) for procedural guidance. The procedure was performed under deep sedation. A 30 mm Amplatzer ™ Septal Occluder device (St. Jude Medical, Inc.; St. Paul, Minn) was successfully implanted. ICE offered direct visualization of the inferoposterior septal rim, which allowed to successfully engage the device and to guide the “push and pull maneuver”. On the other side, 3D-ETE helped us to confirm both sides of the defect were completely covered before device releasing ( Fig. 3 ). The patient has been asymptomatic at a follow up of six months without residual shunt in the echocardiographic controls.
