Transcatheter Atrial Septal Defect Closure in Children with and without Fluoroscopy: A Comparison.

OBJECTIVE: The aim of this study was to compare feasibility, effectiveness, safety, and outcome of atrial septal defect (ASD) device closure in children with and without fluoroscopy guidance. METHODS AND RESULTS: Children undergoing transcatheter ASD closure between 2002 and 2016 were included into this single center, retrospective study. Patients were analysed in two groups [1: intraprocedural fluoroscopy ± transoesophageal echocardiography (TOE) guidance; 2: TOE guidance alone]. Three-hundred-ninety-seven children were included, 238 (97 male) in group 1 and 159 (56 male) in group 2. Two-hundred-twenty-nine of 238 (96%) patients underwent successful fluoroscopy guided ASD closures versus 154/159 (97%) successful procedures with TOE guidance alone. Median weight (IQR) at intervention was 20kg (16.0-35.0) in group 1 versus 19.3kg (16.0-31.2) in group 2. Mean (SD) preinterventional ASD diameter was 12.4mm (4.4) in group 1 versus 12.2mm (3.9) in group 2. There was no significant difference in number of defects or characteristics of ASD rims. Median procedure time was shorter in group 2 [60min (47-86) versus 34min (28-44)]. Device-size-to-defect-ratio was similar in both groups [group 1: 1.07 versus group 2: 1.09]. There were less technical intraprocedural events in group 2 [10 (6.3%) versus 47 (20%)]. Intraprocedural complications were less frequent in group 2 [1 (0.6%) versus 8 (3.3%)]. CONCLUSION: Transcatheter ASD device closure with TOE guidance alone (i.e., without fluoroscopy) is as effective and safe as ASD closure with fluoroscopy guidance. As fluoroscopy remains an important adjunct to transoesophageal echocardiography, especially in complex defects and complications, procedures are always performed in a fully equipped cardiac catheterization laboratory.

Anatomical reconstruction of proximal coronary artery stenosis in children.

OBJECTIVES: Timing and method of surgical reconstruction for non-sclerotic proximal coronary artery stenosis, occurring de novo or post-coronary artery transfer, are evolving. We have pursued a technique of anatomical reconstruction of ostial and short segment proximal coronary artery stenosis and atresia in children, using patch plasty or interposition vein graft. Here, we discuss the medium- to long-term outcomes. METHODS: Nine consecutive children undergoing 10 left main coronary artery reconstructions using autologous great saphenous vein patch (n = 4), autologous pericardium (n = 4), xenopericardium (n = 1) or great saphenous vein interposition graft (n = 1) were retrospectively analysed. Complementary wedge resection of the stenotic coronary ostium was performed in chronic cases. RESULTS: The aetiology of coronary artery stenosis was post-arterial switch operation (n = 6), Takayasu's arteritis (n = 1), idiopathic left main coronary artery atresia (n = 1) and anomalous origin of the left coronary artery from the pulmonary artery (n = 1). The median age and weight at operation were 0.15 (range 0.01-13.1) years and 4.4 (range 3-13.1) kg, respectively. Survival was 100% at the medi follow-up of 12.6 (range 1-19.2) years. All patients showed normal left ventricular ejection fraction on transthoracic echocardiogram. In 1 patient, kinking of the proximal left circumflex artery resulted in non-significant obstruction. In all other cases, follow-up catheter angiography revealed unobstructed coronary arteries. Cardiac magnetic resonance tomography showed no significant perfusion deficit in any child. CONCLUSIONS: Anatomical reconstruction of the proximal left coronary artery using autologous saphenous vein may allow optimal restoration of physiological coronary blood flow, keeping the option of future coronary bypass operation open.

Serial assessment of somatic and cardiovascular development in patients with single ventricle undergoing Fontan procedure.

BACKGROUND: The palliation of patients with single ventricle (SV) undergoing Fontan procedure led to improved long-term survival but is still limited due to cardiovascular complications. The aim of this study was to describe the somatic and cardiovascular development of Fontan patients until adolescence and to identify determining factors. METHODS: We retrospectively assessed somatic growth, vascular growth of pulmonary arteries, and cardiac growth of the SV and systemic semilunar valve from 0 to 16 years of age using transthoracic echocardiography. The Doppler inflow pattern of the atrioventricular valve was quantified by E-, A-wave and E/A ratio. All data were converted to z-scores and analyzed using linear mixed effect models to identify associations with age at Fontan procedure, gender, and ventricular morphology. RESULTS: 134 patients undergoing Fontan procedure at a median age of 2.4 (IQR 2.12 to 2.8) years were analyzed. A catch-up of somatic growth after Fontan procedure until school age was found, with lower body height and weight z-scores in male patients and patients with systemic right ventricles. An early time of Fontan procedure was favorable for somatic growth, but not for vascular growth. Cardiac development indicated a decrease of SV end-diastolic diameter z-score until adolescence. Despite a trend towards normalization, E-wave and E/A ratio z-scores were diminished over the entire period. CONCLUSIONS: There is a catch-up growth of somatic, vascular and cardiac parameters after Fontan procedure, which in our cohort depends on the time of Fontan procedure, ventricular morphology, and gender. Beside other factors, diastolic function of the SV remains altered.

Cardiac output measurement in children: comparison of Aesculon cardiac output monitor and thermodilution.

BACKGROUND: We compared cardiac output (CO) measurements by the non-invasive electrical velocimetry (Aesculon) monitor with the pulmonary artery catheter (PAC) thermodilution method in children. METHODS: CO values using the Aesculon monitor and PAC thermodilution were simultaneously recorded during cardiac catheterization in children. Measurements were performed under general anaesthesia. To compare, three consecutive measurements for each patient within 3 min were obtained. The means of the three values were compared using simple regression and Bland-Altman analysis. Data were presented as mean (sd). A mean percentage of <30% was defined to indicate clinical useful reliability of the Aesculon monitor. RESULTS: A total of 50 patients with a median (range) age of 7.5 (0.5-16.5) yr were enrolled in the study. Mean CO values were 3.7 (1.5) litre min(-1) (PAC thermodilution) and 3.1 (1.7) litre min(-1) (Aesculon) monitor). Analysis for CO measurement showed a good correlation between the two methods (r=0.894; P<0.0001). The bias between the two methods was 0.66 litre min(-1) with a precision of 1.49 litre min(-1). The mean percentage error for CO measurements was 48.9% for the Aesculon monitor when compared with PAC thermodilution. CONCLUSIONS: Electrical velocimetry using the Aesculon monitor did not provide reliable CO values when compared with PAC thermodilution. Whether the Aesculon monitor can be used as a CO trend monitor has to be assessed by further investigations in patients with changing haemodynamics.

Regional cerebral oxygenation by NIRS does not correlate with central or jugular venous oxygen saturation during interventional catheterisation in children.

PURPOSE: To evaluate whether regional cerebral oxygenation (rSO(2)) by near-infrared spectroscopy correlates with central venous (SvO(2)) or internal jugular (SjO(2)) oxygen saturation, and whether changes over time (Delta) in rSO(2) (DeltarSO(2)) predict changes in SvO(2) (DeltaSvO(2)) and SjO(2) (DeltaSjO(2)). METHODS: The rSO(2) values were measured using the INVOS 5100 cerebral oximeter in children undergoing interventional cardiac catheterization and were compared with the oxygen saturation of analysed central venous and internal jugular blood samples. Changes over time (Delta) were calculated as the difference between the values before and after catheter intervention for rSO(2).(DeltarSO(2)), SvO(2).(DeltaSvO(2)) and SjO(2).(DeltaSjO(2)). Simple regression and Bland-Altman analysis were performed. Data are presented as median (range). RESULTS: Sixty patients aged 4.3 (0.2-16.0) years were investigated. A closer correlation was found between rSO(2) and SvO(2) (r=0.728, P<0.0001) than between rSO(2) and SjO(2) (r=0.665, P<0.0001). The bias between rSO(2) and SvO(2).(SjO(2)) was 0.17% (-0.60%), with limits of agreement from -15.5% to 15. 9% (-18.6-17.4%). The sensitivity/specificity for DeltarSO(2) to indicate a fall in SvO(2) or in SjO(2) was 70.3%/65.2% and 68.6%/60.0%, respectively. CONCLUSION: Neither absolute values nor changes in rSO(2) using the INVOS 5100 allowed reliable estimation of SvO(2) or SjO(2) and their trends.

Comparison of cardiac output measurement using the CardioQP oesophageal Doppler with cardiac output measurement using thermodilution technique in children during heart catheterisation.

The minimally invasive CardioQP oesophageal Doppler probe estimates cardiac output by measuring blood flow velocity in the descending aorta. Individual variables to enter are patient's age, weight and height. We measured cardiac output simultaneously with CardioQP and pulmonary artery catheter thermodilution techniques during heart catheterisation in 40 paediatric patients with congenital heart defects. Median [range] age was 8.2 years [0.5-16.7 years], cardiac output values measured by thermodilution and CardioQP were 3.6 l.min(-1) [1.2-7.1 l.min(-1)] and 3.0 l.min(-1) [0.7-6.7 l.min(-1)], respectively. These values showed only moderate correlation (r = 0.809; p < 0.0001). Bias and precision were 0.66 l.min(-1) and 1.79 l.min(-1) (95% limits of agreement: -1.13 to +2.45 l.min(-1)). Based on our preliminary experience, cardiac output values measured by CardioQP in children do not reliably represent cardiac output values compared with the thermodilution technique. We suggest measurement of individual aortic diameter to improve performance of the CardioQP.

Cardiac disease in children and young adults with various lysosomal storage diseases: Comparison of echocardiographic and ECG changes among clinical groups.

BACKGROUND: Lysosomal storage disease (LSD) is a rare inherited disease group. Consecutively there are few data on cardiac changes in mucopolysaccharidosis (MPS), Anderson Fabry disease (AFD), and other LSD (oLSD) including Pompe disease (PD) and Danon disease (DD), I-cell disease ICD and mucolipidosis III (ML III). METHODS: Between 1994 and 2011, we identified 39 patients with LSD: 25 with MPS, 8 with AFD, and 6 with oLSD including PD (1), ML III (2), DD (1), and ICD (2) at our institution fulfilling the inclusion criteria of at least one echocardiogram and ECG. RESULTS: Median age was 11.4 years (range: 2-27), 22 were females (56%). Normal echocardiograms were present in 12 patients (31%): 4 with MPS (16%), 7 AFD (88%), and 1 oLSD (17%). Valvular heart disease was present in 23 patients (59%) occurring more often in MPS (76%) and oLSD (67%) than in AFD (0%) (p < 0.001). The most common ECG abnormality was a short PR interval in 10 of 35 patients (29%) occurring in all LSD groups. Median follow-up was 5.8 (0.2-22.2) years showing diminished 5-year survival compared to an age-matched group. However, no patient died due to a cardiac cause and no cardiovascular intervention was necessary. CONCLUSION: Echocardiographically detectable cardiovascular involvement in children with LSD is mostly confined to MPS and oLSD. Valve thickening in echo and a short PR interval in the ECG are the most frequent abnormalities. Routine repeat assessment is recommended in LSD. However, significant cardiac disease necessitating cardiac intervention is rare during a short follow-up.

Pectus excavatum: echocardiography and cardiac MRI reveal frequent pericardial effusion and right-sided heart anomalies.

AIMS: In patients with pectus excavatum (PEX), echocardiographic assessment can be difficult. There are little data on the impact of the chest deformity on echocardiographic findings and comparison of data obtained by echocardiography (echo) with cardiac magnetic resonance imaging (CMR) in PEX. METHODS AND RESULTS: In a prospective study, cardiac anomalies in PEX were analysed by echo and compared with CMR in consecutive patients with PEX referred for echo. If they agreed to participate, the patients were referred for CMR and included if the pectus index was ≥3.0 by CMR. Also, clinical data and electrocardiogram tracings were analysed. There were 18 patients (13 females; 72%), with a mean age of 53±16 years; mean pectus index was 4.7 (range: 3-7.3). Echo showed haemodynamically insignificant pericardial effusion in six patients (33%), tricuspid valve prolapse in five (28%), right ventricular (RV) localized wall motion anomalies (WMA) in five (28%) and diminished RV systolic function in two (11%); no patient had RV dilatation. CMR demonstrated cardiac displacement to the left in 9 patients (50%); minimal pericardial effusion was seen in 10 patients (56%; P value=0.13 compared with echo), RV localized WMA in 6 (44%; P value=1.0), diminished RV systolic function in 8 (44%; P=0.07), and RV dilatation in 5 (28%; P=0.06). A completely normal cardiac examination was found in six patients by echo (33%) and in 2 (11%) using CMR. Although some signs of arrhythmogenic RV cardiomyopathy (ARVC) were present, no patient fulfilled the ARVC criteria. CONCLUSION: In severe PEX, haemodynamically insignificant pericardial effusion, tricuspid valve prolapse and other RV anomalies possibly due to RV displacement are frequent as demonstrated by both CMR and echo. The cardiac assessment by echo and CMR did show discrepancies; however, they were not significant.

Balloon valvuloplasty in the treatment of congenital aortic valve stenosis--a retrospective multicenter survey of more than 1000 patients.

BACKGROUND: The value of balloon valvuloplasty of the aortic valve in childhood is still under debate. OBJECTIVE: To evaluate the results of the procedure in a retrospective multicenter survey of a large cohort over a long time interval. METHODS: Retrospective analysis of 1004 patients with balloon valvuloplasty of the aortic valve performed between 9/1985 and 10/2006 at 20 centers in Germany, Austria and Switzerland. Amongst others, the following parameters were evaluated before and after the procedure as well as at the end of follow-up or before surgery: clinical status, left ventricular function, transaortic pressure gradient, degree of aortic regurgitation, freedom from re-intervention or surgery. PATIENTS: Patients from 1 day to 18 years of age with aortic valve stenosis were divided into four groups: 334 newborns (1-28 days); 249 infants (29-365 days); 211 children (1-10 years), and 210 adolescents (10-18 years). RESULTS: Median follow-up was 32 months (0 days to 17.5 years). After dilatation the pressure gradient decreased from 65 (± 24)mm Hg to 26 (± 16)mm Hg and remained stable during follow-up. The newborns were the most affected patients. Approximately 60% of them had clinical symptoms and impaired left ventricular function before intervention. Complication rate was 15% in newborns, 11% in infants and 6% in older children. Independently of age, 50% of all patients were free from surgery 10 years after intervention. CONCLUSIONS: In this retrospective multicenter study, balloon valvuloplasty of the aortic valve has effectively postponed the need for surgery in infants, children and adolescents up to 18 years of age.

Early results of balloon dilatation of the stenotic bovine jugular vein graft in the right ventricular outflow tract in children.

UNLABELLED: The aim of this study was to evaluate the early results of interventional balloon dilatation of stenotic bovine jugular vein (BJV) grafts implanted for reconstruction of the right ventricular outflow tract (RVOT) in children. METHODS: From May 2001 to December 2005, 153 BJV grafts were implanted in children in our institution. An average of 16.9 (7.6-41.1) months after implantation, 17 balloon dilatations in a significant stenosis proximal (n = 1), distal anastomosis (n = 8), BJV valve (n = 3), or at multiple sites (n = 5) were performed in 15 children (male:female = 9:6) with a mean age of 3.9 (0.8-13.0) years. Balloon diameter was 75-133.3% (mean 100.3) of the original BJV size. Mean follow-up was 8.8 (2 days to 22.8 months) months. RESULTS: In 10 interventions (58.8%) the instantaneous peak gradient was reduced below 50 mmHg. A balloon diameter > or =100% of the original BJV size correlated significantly with a successful intervention. No major complications, two minor (nonobstructive floating membranes at the dilatation site and one septicemia) occurred afterward. Freedom from reintervention after 6 months was 58.2% for all, 77.8% for dilatations of the proximal anastomosis and mixed stenotic lesions, and 33.3% for the distal anastomosis. CONCLUSION: Balloon dilatation of stenotic BJV grafts is safe and can significantly reduce the pressure gradient in two-thirds of interventions. Balloon diameters above the original graft size should be aimed for. The most frequent stenosis of the distal anastomosis tends to renarrow early after dilatation. Nevertheless, balloon dilatation should be considered in nearly every stenotic graft to gain time until a surgical or interventional graft exchange.

Comparison of tracheal tube cuff diameters with internal transverse diameters of the trachea in children.

BACKGROUND: In this study, we evaluated the ratio of the cuff diameters of the Microcuff paediatric tracheal tube (Microcuff PET, Weinheim, Germany) to fluoroscopically measured internal transverse tracheal diameters in children from birth to adolescence. METHODS: With Institutional Ethics Committee approval and parental consent, we measured the internal transverse tracheal diameters from fluoroscopy images in children undergoing cardiac catheterization requiring general anaesthesia with oro-tracheal intubation. Minimal tracheal sealing pressures were assessed at standardized respirator settings. Internal transverse tracheal diameters were compared with cuff diameters at 20 cmH2O cuff pressure. Linear regression analysis was employed to assess the correlation of tracheal diameters with age, height and weight, and to assess the correlation of the cuff/tracheal diameter ratio with sealing pressures. For all tests, P < 0.05 was considered to be statistically significant. RESULTS: One hundred and forty-five patients were studied (62 girls; 83 boys). Transverse tracheal diameters correlated well with age (r = 0.890; P < 0.0001), height (r = 0.900; P < 0.0001) and weight (r = 0.882; P < 0.0001). Tracheal sealing pressures ranged from 4 to 18 cmH2O. The ratio of the tracheal tube cuff diameter to the internal transverse tracheal diameter ranged from 1.06 in tubes with internal diameters of 6.0 and 4.5 mm to 2.01 in a tube with an internal diameter of 3.5 mm (median, 1.43), and did not correlate with tracheal sealing pressures (r = 0.021, P = 0.7999). CONCLUSIONS: The residual diameters of the Microcuff paediatric tracheal tube cuffs were sufficient to cover the measured internal transverse tracheal diameters of children from birth to adolescence. This allowed the internal tracheal mucosal surface to be draped and the trachea to be sealed at very low cuff pressures.

Tracheal tube-tip displacement in children during head-neck movement--a radiological assessment.

BACKGROUND: Aims of this study were to assess the maximum displacement of tracheal tube tip during head-neck movement in children, and to evaluate the appropriateness of the intubation depth marks on the Microcuff Paediatric Endotracheal Tube regarding the risk of inadvertent extubation and endobronchial intubation. METHODS: We studied children, aged from birth to adolescence, undergoing cardiac catheterization. The patients' tracheas were orally intubated and the tracheal tubes positioned with the intubation depth mark at the level of the vocal cords. The tracheal tube tip-to-carina distances were fluoroscopically assessed with the patient supine and the head-neck in 30 degrees flexion, 0 degrees neutral position and 30 degrees extension. RESULTS: One hundred children aged between 0.02 and 16.4 yr (median 5.1 yr) were studied. Maximum tracheal tube-tip displacement after head-neck 30 degrees extension and 30 degrees flexion demonstrated a linear relationship to age [maximal upward tube movement (mm)=0 0.71 x age (yr)+9.9 (R(2)=0.893); maximal downward tube movement (mm)=0.83 x age (yr)+9.3 (R(2)=0.949)]. Maximal tracheal tube-tip downward displacement because of head-neck flexion was more pronounced than upward displacement because of head-neck extension. CONCLUSIONS: The intubation depth marks were appropriate to avoid inadvertent tracheal extubation and endobronchial intubation during head-neck movement in all patients. However, during head-neck extension the tracheal tube cuff may become positioned in the subglottic region and should be re-adjusted when the patient remains in this position for a longer time.

[Interventional treatment of congenital heart defects in infants with a body weight up to 2,500 grams]. / Interventionelle Behandlung angeborener Herzfehler bei einem Körpergewicht bis 2500 Gramm.

BACKGROUND: Pediatricians and neonatologists are still reluctant to consider invasive cardiological or cardiosurgical treatment in low body weight infants because it is believed to considerably increase the risk. The aim of this study was to assess the results and complications of percutaneous transcatheter interventions in infants with a weight below 2.5 kilograms. METHODS: Retrospective analysis was undertaken for all patients with a weight below 2.5 kilograms who underwent cardiac catheterization from 01/1994 to 04/1999. During this time 42 diagnostic catheterizations in 29 patients and 27 transcatheter interventions in 24 patients were performed. RESULTS: Surgery was replaced or effectively postponed in 9 (33%) out of 27 transcatheter interventions. This was possible for pulmonary stenosis, valvular aortic stenosis and aortic coarctation. A stabilization of the hemodynamic situation was possible in 14 patients. An antegrade pulmonary flow was established in 5, an effective interatrial shunt created in 5 and the arterial duct stented in 3 patients. Only 3 patients had no benefit from the intervention; however, there were no deaths nor hemodynamic complications. Arrhythmias occurred in 9% of all catheterizations and interventions but were transient in all cases. Femoral arterial complications were observed in 30% of all arterial catheterizations. CONCLUSION: Diagnostic cardiac catheterization and percutaneous transcatheter interventions can be performed with low mortality and acceptable morbidity in low weight infnats. Transcatheter interventions can replace surgery, postpone the necessity for surgery or stabilize the hemodynamic situation prior to surgery.

[Acute left heart failure after interventional occlusion of an atrial septal defect]. / Akute Linksherzinsuffizienz nach interventionellem Verschluss eines Vorhofseptumdefekts.

Congestive left ventricular failure after surgical closure of an atrial septal defect (ASD) has been repeatedly reported, particularly in the elderly. We present a case of left ventricular failure after a successful transcatheter closure of an ASD, which to our knowledge has not been described before. In a 78-year-old woman (50 kg, 160 cm) with well-preserved left ventricular function (ejection fraction 65%) and without coronary artery disease or arterial hypertension, an ASD (Qp/Qs 1.6:1) was closed with an Amplatzer Septal Occluder without a residual shunt. Two hours after the procedure, she developed pulmonary edema due to left ventricular failure (increase of end-diastolic diameter from 42 mm to 54 mm, ejection fraction 20%), had to be mechanically ventilated for 24 hours and needed catecholamines for 4 days. High doses of diuretics were supplied until the ejection fraction normalized (32%). The patient could not be discharged until two weeks after intervention. A reduced preload for decades may predispose acute left ventricular failure, particularly in the elderly with compromised ventricular compliance.

Feasibility of transcatheter closure of multiple defects within the oval fossa.

BACKGROUND: Multiple perforations in the floor of the oval fossa may be an obstacle for transcatheter closure. Thus, we analyzed the interventions in 33 patients with more than one interatrial communication in comparison with 370 procedures with a single defect. METHODS AND RESULTS: A diagnostic catheterization, which included a balloon-sizing maneuver, was performed. We implanted a total of 46 occluders, made up of 42 Amplatzers and 4 CardioSEALs. In 20 patients, the defects were closed with a single occluder, namely 18 Amplatzer and 2 CardioSEAL devices. Complete closure was achieved in 15 patients, while a tiny residual shunt remained in 5 patients. In 13 patients, two devices were implanted, without any residual shunt being found immediately after implantation. In 3 patients, the occluders did not touch each other. In 10 patients, their rims overlapped. In comparison with the control group, the group with multiple defects did not differ in the distribution of age, gender, and indications for device closure. The mean time of the procedure, and the time required for fluoroscopy, however, were significant longer (P<0.001). These times ranged from 45 to 250 minutes with a median of 140 minutes, and from 0.0 to 39.2 minutes, with a median of 12.0 minutes, respectively. Also, the association with an atrial septal aneurysm was significantly more frequent (61 vs. 17%; P<0.001). The times taken during insertion of double devices were also significantly longer than those needed for insertion of a single device (P<0.001). CONCLUSIONS: Transcatheter closure of multiple defects within the oval fossa is feasible with currently available occluders, albeit than, in selected cases it is necessary to implant two devices.

Masked left ventricular restriction in elderly patients with atrial septal defects: a contraindication for closure?

The impact of an atrial septal defect in the elderly with reduced diastolic elasticity of the left ventricle is unclear. We studied the hemodynamic changes during balloon occlusion of atrial septal defects in patients over 60 years of age. In 18 patients (61-78 years old; median, 70), the left atrial pressure and the mitral valve inflow was measured during complete balloon occlusion of the defect and after deflation of the balloon. In seven patients, the left atrial pressure and the E/A ratio of the mitral valve inflow increased markedly (P = 0.02). Mean atrial pressures reached values of 27 mm Hg and the v-wave peak values of 55 mm Hg. Two patients received a transcatheter device closure and developed congestive heart failure. In the elderly, an atrial septal defect can have a decompressive impact on the left ventricle. Therefore, caution appears to be warranted if atrial septal closure is planned.

[Interventional occlusion of atrial septum defects larter than 20 mm in diameter]. / Interventioneller Verschluss von Vorhofseptumdefekten mit einem Duchmesser grösser als 20 mm.

UNLABELLED: Over the last few years, various devices for the interventional closure of atrial septal defects (ASD) up to a diameter of 20 mm have been developed. We report our clinical experience in closing ASD with a diameter larger than 20 mm diameter with the Amplatzer Septal Occluder (ASO). METHOD: The stretched diameter of the ASD was measured by inflating a sizing balloon within the defect until an indentation in the circumference in the balloon could be observed. An ASO with a stent diameter 2-4 mm larger than the indentation in the circumference of the balloon was chosen and implanted via 9-12 French sheaths. In contrast to the closure of smaller defects, pullback of the device onto the atrial septum was only performed when the connecting stent of the ASO was completely deployed in order to achieve maximal centering characteristics and optimal support of the retention skirt of the left atrial disc on the edges of the defect. Only then was the right atrial disc deployed and actively configured by advancing the sheath and the delivery cable against the atrial septum. Implantation was only attempted if the atrial septal rims (except the anterior rim around the aorta) measured more than 7 mm by echocardiography to avoid injury or disturbance of sensitive intracardiac structures. After placement, the fixation of the device and the mechanical stability was proven by an extensive "Minnesota wiggle". The ASO was released only when TEE showed no or a trivial residual color flow through the connecting stent; otherwise repositioning was performed. RESULTS: Out of 352 patients (P) with successful closure of interatrial defects, 70 P (age: 1.1-77.3 years) had stretched defects larger than 20 mm diameter (median 22 mm diameter (20-36), 25/75% quartiles = 20/26 mm). Mean shunt size was Qp:Qs 2.1:1 (0.7-3.9:1), mean fluoroscopy time 10.9 min (0-63). Complete closure could be achieved in 85.7/93.1/100% after 3 months, 1 and 2 years, respectively. Besides 3 P with persistent atrial fibrillation, only 5 P showed transient atrial tachyarrhythmias, 2 only periprocedural and 3 within the first 3 months after implantation were treated with beta-blocker. In one patient, an acute embolization of the device occurred because a diminished posterior rim was not visualized by a monoplane TEE probe necessitating surgical explantation and defect occlusion. Despite oversizing the device, no "mushrooming" misconfiguration were observed. CONCLUSION: Transcatheter closure of large atrial septal defects with the Amplatzer Septal Occluder is feasible, safe and effective. Risk of complications do not seem to occur more frequently than after closure of smaller defects if one adheres to certain sizing and implantation measures. The incidence of transient atrial tachyarrhythmias seems to be low.

[Stent implantation as therapy of first choice in adults with coarctation]. / Stentimplantation als Therapie der ersten Wahl bei Erwachsenen mit Aortenisthmusstenose?

Stent implantation for coarctation of the aorta is an alternative to surgery or balloon dilation. We report our results in 12 patients with a median age of 22 years (10 to 28 years) and a body weight of 60 kg (32 to 97 kg). Nine patients had native stenosis and three had recoarctation after surgery. Invasively measured systolic pressure gradients ranged from 20 to 100 mmHg. Nine patients suffered from brachiocephalic hypertension. Eleven implantations were successful with a median dilatation of 17 mm (15-25 mm). Residual gradients were 0-5 mmHg in seven patients, 5-10 mmHg in three and 15 mmHg in one patient with postoperative recoarctation. Twenty-one months (2-37 months) after intervention, no hemodynamically relevant intimal proliferations, no restenosis, and no aneurysms were present. Thus, stent implantation is a very promising therapy for coarctation of the aorta in adults and is on its way to becoming the therapy of first choice.