RESUMEN
BACKGROUND: Transcatheter closure for atrial septal defect (ASD) with inferior-posterior rim deficiency has been scarcely reported with proper identification of the indications and limits. We aimed to assess the safety and feasibility of transcatheter closure of ASDs with deficient rims, paying particular attention to cases with inferior-posterior rim deficiency. METHODS: From January 2008 to January 2013, 241 patients underwent transcatheter ASD closure, including 50 cases (20.7%) with deficient rims, other than the anterior-superior one. Eighteen patients (12 females) presented inferior-posterior rim deficiency. Their median age was 8 (1.4-85) years and their median weight was 24 [9-97] kg. Transcatheter closure was performed in all cases under transesophageal echocardiography (TEE) guidance in children and intracardiac echocardiography (ICE) guidance in adults. RESULTS: Out of 18 patients with inferior-posterior rim deficiency, only 8 underwent successful immediate transcatheter closure. Four cases failed to be closed. Major complications occurred in 6 patients, including 4 device embolizations, 1 pericardial effusion and 1 complete atrioventricular block that resolved after surgical removal of the device. During a median follow up of 54±13 months, a residual right-to-left shunt was documented in 2 more cases, requiring surgery in one case because of cyanosis. Transcatheter closure was successfully performed in the rest of the 223 patients, including in the 32 cases with deficient rims other than inferior-posterior. CONCLUSIONS: Transcatheter closure of ASDs with inferior-posterior rim deficiency cannot be recommended.
RESUMEN
Transcatheter closure has become an accepted alternative to surgical repair for ostium secundum atrial septal defects (ASD). However, large ASDs (>38 mm) and defects with deficient rims are usually not offered transcatheter closure but are referred for surgical closure. Transcatheter closure also remains controversial for other complicated ASDs with comorbidities, additional cardiac features and in small children. This article not only provides a comprehensive, up-to-date description of the current indications and contra-indications for ASD device closure, but also further explores the current limits for transcatheter closure in controversial cases. With the devices and technology currently available, several cohort studies have reported successful percutaneous closure in the above-mentioned complex cases. However the feasibility and safety of transcatheter technique needs to be confirmed through larger studies and longer follow-up.
RESUMEN
Combined therapeutic approach with performing mitral valve repair may be necessitated for the treatment of idiopathic hypertrophic subaortic stenosis (IHSS) with systolic anterior motion. This report includes operative technique for combined robotic septal myectomy and mitral valve repair. A 45-year-old man with IHSS was admitted to our center for surgical intervention. The transthoracic echocardiography showed typical asymmetric ventricular hypertrophy. Left ventricle posterior wall thickness was 11 mm, and interventricular septum thickness was 21 mm. Mitral valve leaflets were found to be elongated. Mild-to-severe mitral regurgitation was detected with eccentric mitral jet. Aortic peak gradient was 128 mm Hg. Robotic mitral repair and septal myectomy through left atrial exposure was performed. The anterior leaflet was detached, and the septal muscle in a mass of 1 × 0.7 × 0.5 cm was resected. Next, the anterior leaflet was reattached with continuous suture. The plication of the posterior leaflet with transverse incision was performed to diminish the length of posterior leaflet. After the magic suture for posteromedial commissure was performed, a 34 Medtronic Future ring was implanted for mitral annuloplasty. Postoperative course was uneventful. The patient was discharged on the sixth postoperative day. Combined robotic septal myectomy and mitral valve repair for IHSS with systolic anterior motion may be feasible.
