Relative Risk Factors for Cardiac Erosion Following Transcatheter Closure of Atrial Septal Defects: A Case-Control Study.

BACKGROUND: Transcatheter closure of secundum atrial septal defects (ASD) using the Amplatzer septal occluder is generally safe and effective, but erosion into the pericardial space or aorta has been described. Although the absolute risk of this complication is low, there has been no assessment of relative risk factors. METHODS AND RESULTS: All erosions reported to St. Jude Medical after ASD closure with an Amplatzer septal occluder (cases) were compared with controls (matched 2:1) who underwent ASD closure but did not develop an erosion. A total of 125 erosions were reported between 2002 and 2014, including 95 with an available echocardiogram. The median duration from implant to erosion was 14 days, but was >1 year in 16 patients. Nine patients (all age ≥17 years) who died were more likely to have an oversized device, and to have erosion into the aorta, than survivors. Aortic or superior vena cava rim deficiencies were more common in cases than in controls. In addition, larger balloon-sized ASD diameter, Amplatzer septal occluder device size, and device size-ASD diameter difference, and smaller weight:device size ratio were associated with erosion. On multivariable analysis, deficiency of any rim, device >5 mm larger than ASD diameter, and weight:device size ratio were associated with erosion. CONCLUSIONS: In addition to aortic rim deficiency, which was almost universal among erosion cases, there were several relative risk factors for erosion after ASD closure with the Amplatzer septal occluder device. To understand the mechanisms of and absolute risk factors for this uncommon but serious complication, an adequately powered prospective study with thorough echocardiographic evaluation will be critical.

Atrial septal hematoma after mitral valve and left coronary artery surgery in a child.

Atrial septal hematoma (ASH) has been reported mostly in adult patients to occur after spontaneous ascending aortic dissection (Circulation 46(3):537-545, 1972) and after surgery for coronary artery (Anesthesiology 83(3):620-621, 1995), mitral valve, and aortic valve (Rev Esp Cardiol 55(8):867-871, 2002). ASH in the pediatric age group is rare, and to our knowledge only two cases have been published (Am J Perinatol 27(6):481-483, 2010; J Am Soc Echocardiogr 1087-1089, 1998). We report a case of ASH diagnosed by intraoperative transesophageal echocardiography in a 28-month-old child who underwent mitral valvuloplasty and left main coronary arterioplasty for anomalous origin of the left coronary artery from pulmonary artery. ASH subsided on its own within 24 h.

Left hemitruncus associated with tetralogy of fallot: fetal diagnosis and postnatal echocardiographic and cardiac computed tomographic confirmation.

Anomalous origin of one pulmonary artery from the aorta, or hemitruncus, is a rare cardiac malformation. We report a case of left hemitruncus (aortic origin of the left pulmonary artery) associated with tetralogy of Fallot diagnosed in utero. To the authors' knowledge, this is the first such case diagnosed by fetal echocardiography to be described in the literature. The condition was documented by postnatal echocardiogram and cardiac computed tomography. Prompt recognition of this lesion is essential for early repair to improve outcome.

Reversed differential cyanosis in the newborn: a clinical finding in the supracardiac total anomalous pulmonary venous connection.

The newborn can experience two types of differential cyanosis (DC). The common type of DC occurs when oxygen saturation in the right hand is greater than in the foot. The second type of DC, reversed differential cyanosis (RDC), occurs when oxygen saturation is lower in the right hand than in the foot. This phenomenon is observed in transposition of the great arteries (TGA) with patent ductus arteriosis (PDA) and elevated pulmonary vascular resistance or in TGA with PDA and preductal aortic interruption or coarctation. This report describes a case of RDC not previously described involving an infant with supracardiac total anomalous pulmonary venous connection (TAPVC). In supracardiac TAPVC, RDC results from streaming of highly saturated superior vena cava (SVC) blood into the right ventricle, out the main pulmonary artery, through a PDA, and to the descending aorta, with streaming of more desaturated blood from the inferior vena cava (IVC) into the left atrium across the atrial septal defect (ASD)/foramen ovale. Therefore, as part of a neonatal examination to rule out congenital heart disease (CHD), simultaneous pre- and postductal oxygen saturations should be documented. The presence of RDC should initiate immediate full cardiac evaluation for CHD. Supracardiac TAPVC should be included in the differential diagnosis if RDC is observed.

Comparison of costs of intracardiac echocardiography and transesophageal echocardiography in monitoring percutaneous device closure of atrial septal defect in children and adults.

The cost of percutaneous device closure of atrial septal defect in children and adults using the Amplatzer Septal Occluder under intracardiac echocardiographic guidance was compared with that of transesophageal echocardiographic guidance. Hospital and physician charges incurred by 20 patients who had intracardiac echocardiographic guidance and 20 patients who had transesophageal echocardiographic guidance during atrial septal defect closure were compared.

Transesophageal Echocardiographic Imaging for Congenital Lesions of the Left Ventricular Outflow Tract and the Aorta.

A comprehensive transthoracic echocardiographic imaging is possible for most pediatric patients. However, for patients in whom accurate anatomical and physiological assessment is not possible, transesophageal echocardiography (TEE) provides a supplemental diagnostic modality. Imaging the left ventricular outflow tract and the aorta involves a complicated technique of rotation, flexion, and changes in the depth of the transesophageal probe because the areas of interrogation involve multiple planes within the thoracic cavity. Furthermore, the relationship between the esophagus and the cardiovascular structures changes at various levels of the thorax. Transesophageal probes having characteristics of frequency agility, all forms of Doppler capability, and a higher number of crystal elements are now available. Abnormalities of the subaortic area, the aortic valve, coronary arteries, and the entire thoracic aorta can be clearly demonstrated. TEE also has played a complementary role in diagnostic and interventional catheterization. It has become vital in the operating room for the preoperative definition of certain aspects of the anatomy and for immediate postoperative evaluation of the result of surgery. (ECHOCARDIOGRAPHY, Volume 13, July 1996)

Single-ventricle palliation for high-risk neonates: the emergence of an alternative hybrid stage I strategy.

BACKGROUND: Survival after stage I palliation for hypoplastic left heart syndrome or related anomalies remains poor in high-risk neonates. We hypothesized that a less invasive hybrid approach would be beneficial in this patient population. METHODS: The hybrid stage I procedure was performed in the catheterization laboratory. Via a median sternotomy, both branch pulmonary arteries were banded, and a ductal stent was delivered via a main pulmonary artery puncture and positioned under fluoroscopic guidance. RESULTS: Between October 2003 and June 2005, 14 high-risk neonates underwent a hybrid stage I procedure. Eleven of 14 had hypoplastic left heart syndrome. Two also underwent peratrial atrial septal stenting, and 5 required percutaneous atrial stenting later. Two neonates with an intact or highly restrictive atrial septum had emergency percutaneous atrial stent placement. Hospital survival was 11 (78.5%) of 14. One patient required extracorporeal membrane oxygenation support for intraoperative cardiac arrest. He underwent cardiac transplantation but died later of sepsis. One patient died of ductal stent embolization, and a third died of progressive cardiac dysfunction. The first 4 patients required pulmonary artery band revisions. There were none after we modified our technique and added branch pulmonary artery angiograms. There were 2 interstage deaths from atrial stent occlusion and from preductal retrograde coarctation. Eight patients underwent stage II procedures, consisting of aortic arch reconstruction, atrial septectomy, and cavopulmonary shunt. Two patients died after stage II. One patient is awaiting stage II. CONCLUSIONS: The hybrid stage I palliation is a valid option in high-risk neonates. As experience is accrued, it may become the preferred alternative. However, in aortic atresia, the development of preductal retrograde coarctation is a significant problem.