Myocardial injury and inflammatory response in percutaneous device closures of pediatric patent ductus arteriosus.

BACKGROUND: The percutaneous device closure of patent ductus arteriosus (PDA) is widely used in clinical practice, however full data on the changes in myocardial injury and systemic inflammatory markers' levels after PDA in children are not fully reported. METHODS: We have conducted a retrospective analysis of the medical records of 385 pediatric patients in our hospital from January 2017 to December 2019. The patients were distributed into five groups. The first four (A, B, C and D) included patients divided by the type of the surgical closure methods, namely ligation, clamping, ligation-combined suturing and ligation-combined clamping, respectively. The fifth group E comprised of percutaneous device PDA patients. All recorded medical and trial data from the five groups were statistically studied. RESULTS: No serious complications in the patients regardless of the classification group were reported. Our results suggested that there were no considerable differences between the groups at the baseline (with all P > 0.05). Group E demonstrated a significantly smaller operative time (42.39 ± 3.88, min) and length of hospital stay (LOS) (4.49 ± 0.50, day), less intraoperative blood loss (7.12 ± 2.09, ml) while on the other hand, a higher total hospital cost (24,001.35 ± 1152.80, RMB) than the other four groups (with all P < 0.001). Interestingly, the comparison of the inflammatory factors such as white blood cells (WBC) count, C-reactive protein (CRP), procalcitonin (PCT) and interleukin-6 (IL-6), as well as the myocardial injury markers (CKMB and troponin I) did not show a significant increase (P > 0.05) among the four groups. On the contrary, when the aforementioned factors and markers of all the surgical groups were compared to those in group E, we observed significantly higher speed and magnitude of changes in group E than those in groups A, B, C, and D (with all P < 0.001). CONCLUSION: Although the percutaneous device closure of PDA is more comforting and drives fast recuperation in comparison to conventional surgery, it provokes myocardial injury and overall inflammation. Timely substantial and aggressive intervention measures such as the use of antibiotics before operation and active glucocorticoids to suppress inflammation and nourish the myocardium need be applied if the myocardial and inflammatory markers are eminent.

A review of the therapeutic management of multiple ventricular septal defects.

BACKGROUND AND AIM: We showed in our anatomical review, ventricular septal defects existing as multiple entities can be considered in terms of three major subsets. We address here the diagnostic challenges, associated anomalies, the role and techniques of surgical instead of interventional closure, and the outcomes, including reinterventions, for each subset. METHODS: We reviewed 80 published investigations, noting radiographic findings, and the results of clinical imaging elucidating the location, number, size of septal defects, associated anomalies, and the effect of severe pulmonary hypertension. RESULTS: Overall, perioperative mortality for treatment of residual multiple defects has been cited to be between 0% and 14.2%, with morbidity estimated between 6% and 13%. Perioperative mortality is twice as high for perimembranous compared to muscular defects, with the need for reoperation being over four times higher. Perventricular hybrid approaches are useful for the closure of high anterior or apical defects. Overall, the results have been unsatisfactory. Pooled data reveals incidences between 2.8% and 45% for device-related adverse events. Currently, however, outcomes cannot be assessed on the basis of the different anatomical subsets. CONCLUSIONS: We have addressed the approaches, and the results, of therapeutic treatment in terms of coexisting discrete defects, the Swiss-cheese septum, and the arrangement in which a solitary apical muscular defect gives the impression of multiple defects when viewed from the right ventricular aspect. Treatment should vary according to the specific combination of defects.

Outcomes and complications of percutaneous device closure in adults with secundum atrial septal defect.

OBJECTIVE: To assess immediate outcome and complications of Amplatzer septal occluder percutaneous device for closure of secundum atrial septal defect in adults, and to determine regression in right ventricular size, reduced pulmonary arterial systolic pressure and incidence of device embolization at follow-up. METHODS: The single-cohort, ambi-directional, observational study was conducted at the Tabba Heart Institute, Karachi, from January 2013 to July 2018, and comprised patients admitted consecutively for percutaneous atrial septal defect closure. Pre-closure trans-oesophageal echocardiogram was performed in all cases to ensure adequacy of defect margins necessary for device stability. Immediate procedure success and complications were determined by trans-oesophageal echocardiogram, while transthoracic echo was done on follow-up. Data was analysed using SPSS 21. RESULTS: Of the 64 patients, 41(71.9%) were females. The overall mean age was 36.6±14 years. Median size of atrial septal defect was 21mm (interquartile range: 17-26mm). Immediate success was observed in 59(92.2%) patients, and there were 5(8%) acute device embolization events. Small residual atrial septal defect was found in 4(6.3%) cases. On 20-month follow-up, 54(84.4%) patients showed improved symptoms. Repeat transthoracic echo was performed in 39(60.1%) cases, and there were no late embolic events or residual atrial septal defect. Right ventricular size normalized in 34(89.5%) cases, mean pulmonary arterial systolic pressure reduced significantly compared to pre-closure measurement (p<0.001). CONCLUSIONS: Percutaneous atrial septal defect closure was found to be safe and effective in adults with secundum atrial septal defect. Timely closure resulted in improved symptoms, right ventricular remodelling and reduced pulmonary arterial systolic pressure at intermediate-term follow-up.

Venous flow patterns after percutaneous atrial septal defect closure: Does the mechanical device decrease right atrial compliance?

INTRODUCTION: Systemic venous flow patterns become abnormal and restrictive after surgical closure of ostium secundum atrial septal defect (ASD) but rarely studied after percutaneous device closure. METHODS: From January 2017 to January 2018, systemic venous Doppler flow patterns were documented prospectively in 50 subjects who underwent percutaneous closure of ASD, prior to, after procedure, and at 6-month follow-up and correlated with defect size and device size. RESULTS: In hepatic veins and superior venacava post device-closure closure, the velocity time integral (VTI) of forward flow in both systole (S) and diastole (D) increased. Overall S was higher than D, and D/S ratio was <1. The D/S ratio increased after device closure significantly reflecting that the improvement in atrial filling increase in diastolic flow more than the increase in systolic flow. Increase in flow velocities was more prominent at 6 months with further increase in D/S VTI ratios. When correlated with the defect size, in those with defect size less than 15 mm/sq.m (mean device size 13.05 ± 3.21 mm), the changes in S- or D-wave, D/S ratio were less prominent and statistically not significant, while in subjects with defect size ≥ 15 mm/sq.m (mean device size 23.02 (±4.77 mm), these changes were greater and statistical significant. CONCLUSION: Residual filling defects with restriction of systolic venous flow were observed in subjects after device closure, correlating with larger device sizes, implying the compliance abnormality conferred by them which progresses at 6 months. Subjects with persistent abnormalities would need careful follow up for incomplete remodeling and increase in atrial size related arrhythmias.

Percutaneous Device Closure of Congenital Isolated Ventricular Septal Defects: A Single-Center Retrospective Database Study Amongst 412 Cases.

To identify suitable cases and reduce failure/complication rates for percutaneous ventricular septal defect (VSD) closure, we aimed to (1) study causes of device failure and (2) compare outcomes with different VSD types and devices in a high-volume single center with limited resources. Retrospective data of 412 elective percutaneous VSD closure of isolated congenital VSDs between 2003 and 2017 were analyzed. Out of 412, 363 were successfully implanted, in 30 device implantation failed, and in 19 the procedure was abandoned. Outcome was assessed using echocardiography, electrocardiography, and catheterization data (before procedure, immediately after and during follow-up). Logistic regression analyses were performed to assess effects of age, VSD type, and device type and size on procedural outcome. Median [interquartile range] age and body surface area were 6.6 [4.1-10.9] years and 0.7 [0.5-1.0] m2, respectively. Device failure was not associated with age (p = 0.08), type of VSD (p = 0.5), device type (p = 0.2), or device size (p = 0.1). Device failure occurred in 7.6% of patients. As device type is not related to failure rate and device failure and complication risk was not associated with age, it is justifiable to use financially beneficial ductal devices in VSD position and to consider closure of VSD with device in clinically indicated children.

Echocardiography-guided percutaneous closure of perimembranous ventricular septal defects without arterial access and fluoroscopy.

BACKGROUND: Traditional percutaneous device closure of perimembranous ventricular septal defects (PmVSDs) is a minimally invasive technique, but can result in high radiation exposure and can result in potential arterial complications. Here, we aimed to assess the safety and feasibility of device closure of PmVSDs via the femoral vein approach under transesophageal echocardiography (TEE) guidance in children. METHODS: From January 2014 to December 2017, a total of 46 PmVSD patients (mean age, 6.5 ± 2.3 years [range, 4.2-12.0 years]; mean body weight 22.1 ± 6.6 kg [range, 16.0-38.5 kg]; VSD diameter, 4.1 ± 0.6 mm [range, 3.2-5.0 mm]) underwent attempted transcatheter closure via the femoral vein approach under the guidance of TEE without fluoroscopy. RESULTS: The transcatheter occlusion procedure under TEE guidance was successful in 44 (95.7%) patients. Surgery was necessary in 2 (4.3%) patients. The procedure duration was 28.2 ± 8.7 min (range, 12.0-42.0 min). One patient had immediate post-operative trivial residual shunt and three patients had immediate incomplete right bundle branch block (IRBBB) after operation; the new IRBBB in 1 case was noted in the first postoperative month. No residual shunt was noted at 3 months after the procedure, and no intervention related complications were detected at 1-24 months follow-up. CONCLUSIONS: Percutaneous device closure of PmVSDs under TEE guidance solely by femoral vein approach is effective and safe, avoids radiation exposure, potential arterial complications and a surgical incision.

Management and Outcome of Ventricular Septal Rupture Complicating Acute Myocardial Infarction: What Is New in the Era of Percutaneous Intervention?

BACKGROUND: Postinfarction ventricular septal rupture (PI-VSR) is a rare but devastating complication of acute myocardial infarction (AMI). Risk stratification in the acute phase is crucial for decision-making, and this study analyzed the risk factors for early mortality and the effects of various management options on the outcome of PI-VSR patients in the era of percutaneous intervention. METHODS: A total of 96 patients with PI-VSR were identified and divided into an acute-phase survivor group (n = 46, survived ≥2 weeks after admission) and a nonsurvivor group (n = 50, died within 2 weeks after admission). Percutaneous closure was considered in acute-phase survivors. Patients were followed up for a mean 47 (quartiles 15-71) months by clinical visit or telephone interview. RESULTS: The overall acute-phase (i.e., < 2 weeks after the diagnosis of PI-VSR) mortality rate was 52%. Female sex and Killip Class III-IV at admission were associated with an increased risk of acute-phase death. Of the 46 patients who survived ≥2 weeks, 20 underwent interventional occlusion and the procedure was successful in 19. Percutaneous closure in the acute-phase survivor group improved the immediate (21% in-hospital mortality rate) and long-term (53% mortality) outcomes. CONCLUSIONS: Patients with PI-VSR are at a high risk of acute-phase mortality. Female sex and severe cardiac dysfunction at admission are linked with a high rate of acute-phase deaths. Percutaneous closure in acute-phase survivors results in favorable short- and long-term benefits for PI-VSR patients.

A novel technique to remove a right atrial thrombotic mass attached to a patent foramen ovale (PFO) closure device.

Any percutaneously implanted foreign device carries the potential risk of thrombus formation. If a thrombus is detected after device implantation during follow-up, in most cases anticoagulation therapy is sufficient to resolve the thrombus. If the anticoagulation concept fails, surgery has been the only alternative option to remove thrombotic masses. This case of a patient with a large thrombus formation attached to a PFO closure device who denied surgery demonstrates that mechanical percutaneous clot retrieval is feasible with the AngioVac aspiration system (Vortex Medical, Inc., Norwell, MA). © 2013 Wiley Periodicals, Inc.

Single puncture approach guided by transesophageal echocardiography for atrial fibrillation ablation in a patient with prior percutaneous septal closure: case report.

Background: Atrial septal defect (ASD) is associated with a risk of developing atrial fibrillation (AF) higher than in the general population, even after percutaneous or surgical septal closure. Catheter ablation is an effective treatment strategy for preventing recurrences and reducing the AF burden. However, electrophysiologists are faced with technical difficulties and the risk of complications with the left atrium access in patients with prior ASD percutaneous closure. Case summary: We report a case of a patient with highly symptomatic paroxysmal AF, with an ASD, closed percutaneously many years before, who underwent a successful catheter AF ablation, using a single transeptal (TSP) approach guided by transesophageal echocardiography (TEE). Discussion: In patients with ASD and an occluder device implanted, there is a potential risk for septal tear during the TSP passage, device dislodgement, or thrombus formation on the device. Atrial fibrillation ablation in this subset of patients has often been protracted and scarcely reported. TEE and intra-cardiac echocardiography have been increasingly used for interventional procedure guidance during AF ablation. As described here, AF ablation using a simplified single TSP guided by TEE is feasible, safe, and effective after device ASD closure.

Percutaneous closure of a paravalvular leak from a prosthetic mitral valve dehiscence in a young high-risk patient: case report.

Background: Paravalvular leak (PVL) is a common, serious complication related with prosthetic valve replacement. Although surgical closure reoperation is the choice of treatment, percutaneous device closure is a good alternative with good results in patients with very high surgical risk. Case summary: In this case report, we present the percutaneous closure of PVL of mitral valve replacement (MVR), in a patient with cardiogenic shock who failed conservative medical treatment and was deemed inoperable due to recurrent operations. Successful closure of the PVL with the use of the four consecutive PVL closure devices was performed under general anaesthesia with guidance of 2D and 3D transoesophageal echocardiography. The procedure was performed with no complications and the patient has remained asymptomatic after 10 months following the PVL closure procedure with marked improvement in her NYHA class and echocardiographic values. Discussion: Percutaneous PVL closure is a very challenging and high clinical skills requiring procedure, but has a good success and low complication rate in high-risk patients. It is not a standard procedure and the type and size of device should be tailored for each patient with a good 2D and 3D echocardiographic guidance.

Successful treatment of patent ductus arteriosus accompanying right-sided aortic arch and aberrant left subclavian artery: a case report.

Background: The coexistence of a right-sided aortic arch (RAA), an aberrant left subclavian artery (ALSA), and a patent ductus arteriosus (PDA) is a rarely seen vascular ring anomaly. There is currently no general guideline consensus on the management and follow-up of this congenital defect, posing a challenge to the clinicians. At this point, the heart team plays a critical role in the management of the disease. Case summary: In the present case, a 25-year-old male patient was presented to the outpatient clinic with dyspnoea and fatigue. A transthoracic echocardiography revealed PDA with a left-to-right shunt. To evaluate the anatomy thoroughly, a thoracic computed tomographic angiography was performed and showed PDA accompanying ALSA and RAA. The patient was evaluated by the Heart Team, and a percutaneous closure of PDA was recommended due to signs of left ventricular volume overload. The closure was successfully performed with Amplatzer vascular plug II. At follow-up, the patient was free of symptoms. Discussion: Clinicians should be aware of the potential concomitant lesions during the diagnostic work-up. In selected patients, percutaneous closure of PDA may be the first-line therapy in experienced centres.

Acute Left Ventricular Systolic Dysfunction Following Device Closure of Ruptured Sinus of Valsalva Aneurysm.

Acute cardiorespiratory distress following device closure of ruptured sinus of Valsava (RSOV) aneurysm can have a battery of differentials. We report a case of acute left ventricular dysfunction with aspiration that caused cardiorespiratory distress immediately following RSOV device closure. Supportive medical therapy led to complete recovery. (Level of Difficulty: Intermediate.).

Transcatheter device closure of perimembranous ventricular septal defect associated with indirect Gerbode defect: A retrospective study.

Perimembranous ventricular septal defect (pmVSD) is a common congenital heart disease that is sometimes associated with indirect left ventricle (LV) to right atrium (RA) shunt (indirect Gerbode defect). This defect has a rare chance of spontaneous closure and therefore was usually closed surgically in the past, but more recently transcatheter closure has been reported by a few authors. In our study, we have described a series of 14 children (age ranging from 1.2 to 12 years and weight ranging from 7.2 to 25.5 kg) with the above-mentioned defect which were closed by various interventional devices. The procedures were successful in complete elimination of pmVSD and immediate reduction of indirect LV-RA shunts with negligible residual tricuspid regurgitation on follow-up. In our midterm experience, the judicious use of double-disc devices is efficacious for occluding pmVSD associated with indirect Gerbode defect.

Percutaneous closure of a secundum atrial septum defect performed under hypnosis: a case report.

Atrial septal defects (ASDs) are the third most common type of congenital heart diseases with ostium secundum defects (ASDsII) being responsible for approximately 75% of these defects. The treatment consists of either a transcatheter closure or a surgical intervention. The transcatheter approach offers a less invasive alternative for patients who fulfill anatomical and size criteria and is therefore increasingly used as the preferred primary intervention. As general anaesthesia is sometimes contra-indicated for some patients needing ASD or PFO closure and intracardiac echocardiography (ICE) is not always readily available, alternative "supportive" techniques as hypnosis could be of interest. In our case, a relative contra-indication for general anaesthesia was pronounced due to the severely impaired pulmonary function caused by severe deformative torsional scoliosis. Over the years several reviews have been published on hypnotic analgesia used together with usual care suggesting that hypnotic analgesia is a promising non-pharmacologic adjunct treatment for ameliorating pain and surgical distress. Also, various cardiological procedures under hypnosis have already been described in literature, but this is the first time that percutaneous ASD closure under virtual reality (VR) hypnosis is mentioned in literature.

Atrial tachyarrhythmias following percutaneous device closure of secundum atrial septal defects.

BACKGROUND: Atrial tachyarrhythmias (ATs) are a major source of morbidity in the atrial septal defect (ASD) patient cohort. The optimal timing and approach of anti-arrhythmic intervention is currently unclear. Here, we sought to determine the overall rate of ATs following percutaneous ASD closure and risk factors that may predict this. METHODS: A systematic search of the literature was performed using the search terms '(Secundum Atrial Septal Defects AND Atrial arrhythmias) AND (transcatheter closure or percutaneous closure or device closure)'. All studies in English reporting the rate of ATs following percutaneous closure of secundum ASDs in adult patients were included. The primary outcome was documented AT detection during follow-up ECG monitoring. A meta-regression was then performed to test for an interaction between demographic/procedural characteristics and the primary outcome. RESULTS: 13 observational studies including 2366 patients were analysed. The overall post-procedure AT event detection rate was 8.6%. Multivariate meta-regression analysis revealed that only male gender was associated with a higher rate of post-procedure AT detection while utilisation of the Amplatzer Septal Occluder device was associated with a lower AT detection rate and comprised 96.2% of all devices used. A high level of heterogeneity was observed (I2-statistic 92.3%, Q value 156.8). CONCLUSIONS: Our study illustrates that despite percutaneous ASD closure, a high proportion of adult patients have ATs with male gender correlating with higher AT rates. While the Amplatzer Septal Occluder device correlated with lower AT rates, this was the overwhelmingly the predominant device used hence comparison to other devices remains challenging.

[Patent foramen ovale with a license to kill]. / Permeables Foramen ovale (PFO) als Todesursache.

A patent foramen ovale (PFO) is present in about one of four, and one of its dangerous forms (large or associated with atrial septal aneurysm, Eustachian valve, or Chiari network) in one of twenty people. About 140 years ago, the PFO was shown to have the potential to result in death due to stroke and also myocardial infarction. The described decrease of the prevalence of a PFO with age may be a consequence of this. Therefore, it comes somewhat as a surprise that the PFO is taken rather lightly by the medical community. Percutaneous PFO closure with implantable devices has been around for over two decades and since then has proven to be the simplest and safest technique in interventional cardiology. Nonetheless, it is rarely applied and not recommended in current guidelines except for a few situations. Countless nonrandomised comparisons have invariably pointed to a clinical benefit of PFO closure in the secondary prevention of paradoxical cerebral events in patients with or without competitive reasons for stroke. Even a survival benefit of PFO closure was shown in a comparison over 10 years. However, the first three publications of randomised trials were not significant in the protocolled sense. PFO closure did reduce recurrent events compared to medical therapy by up to 80% but the statistical significance postulated was only reached in one of the three trials when the results were analyzed as treated or per predefined subgroups, like patients with atrial septal aneurysm, large PFO, or all PFO closure patients compared to treatment with acetylsalicylic acid only. Recently, a preplanned longer-term analysis of this trial and two additional randomised trials including higher risk PFOs reached the hypothesised statistical significance. This may be a turning point in the attitude towards PFO closure. In addition, PFO closure improves migraine and dyspnoea in certain patients. It appears, though, that it will take time until the full potential of PFO closure will be reflected in respective guidelines and reimbursement algorithms and adequately exploited by referring physicians (mostly neurologists) and interventional cardiologists. This reluctance will continue to cost innumerable preventable strokes, myocardial infarctions, and deaths around the world. The low risk of PFO closure must be weighed against even death if a PFO is left open; it is much more likely that one regrets not having closed a PFO than having closed it.

Hypothyroidism after Percutaneous Patent Ductus Arteriosus Device Closure in an Extremely Preterm Infant: Possible Role of Iodinated IV Contrast.

We report a case of contrast-induced hypothyroidism in an extremely preterm infant after percutaneous patent ductus arteriosus (PDA) device closure. Iodine-induced hypothyroidism after exposure to iodine-containing antiseptics and contrast media has been previously reported in extremely preterm infants. However, this is the first report of contrast-induced hypothyroidism in an extremely preterm infant undergoing percutaneous PDA device closure. This is timely, given percutaneous PDA device closure is more frequently utilized. Guidelines for screening thyroid function pre and post contrast-requiring procedures may be warranted. Hypothyroidism if left untreated can have detrimental effects on developing brain, especially in the preterm population. Therefore, the earlier detection and treatment of iodine-induced hypothyroidism is imperative.

Repair of Sinus Venosus Defect and Anomalous Pulmonary Veins Associated With Vein of Galen Malformation.

Sinus venosus defect (SVD) is a deficiency in the sinus venosus portion of the atrium, often associated with partial anomalous pulmonary venous connections. In patients with vein of Galen malformation (VGAM), SVD provides a unique challenge with respect to embolization treatment. In our case, the child had percutaneous device closure of the SVD prior to VGAM embolization. Nine years later, he required surgical removal of the SVD device and Warden procedure due to progressive right-sided cardiac enlargement.

Percutaneous secundum atrial septal defect closure for the treatment of atrial arrhythmia in the adult: A meta-analysis.

BACKGROUND: Atrial arrhythmias are common in patients with atrial septal defects (ASD) but the effects of percutaneous closure on atrial arrhythmia prevalence is unclear. We investigated the effects of ASD device closure and the impact of age at time of closure on prevalent atrial arrythmia. METHODS: Meta-analysis of studies reporting atrial arrhythmia prevalence in adult patients before and after percutaneous closure was performed. Primary outcomes were prevalence of 'all atrial arrhythmia' and atrial fibrillation alone post closure. Sub-group analysis examined the effects of closure according to age in patients; <40 years, ≥40 and ≥ 60 years. 25 studies were included. RESULTS: Meta-analysis of all studies demonstrated no reduction in all atrial arrhythmia or atrial fibrillation prevalence post-closure (OR 0.855, 95% CI 0.672 to 1.087, P = .201 and OR 0.818, 95% CI 0.645 to 1.038, P = .099, respectively). A weak reduction in all atrial arrhythmia and atrial fibrillation was seen in patients ≥40 years (OR 0.77, 95% CI 0.616 to 0.979, P = .032 and OR 0.760, 95% CI 0.6 to 0.964, P = .024, respectively) but not ≥60 years (OR 0.822, 95% CI 0.593 to 1.141, P = .242 and OR 0.83, 95% CI 0.598 to 1.152, P = .266, respectively). No data were available in patients <40 years. This, and other limitations, prevents conclusive assessment of the effect of age on arrhythmia prevalence. CONCLUSIONS: Overall, percutaneous ASD closure is not associated with a reduction in atrial arrhythmia prevalence in this meta-analysis. A weak benefit is seen in patients ≥40 years of age, not present in patients ≥60 years.

Anatomy and Physiologic Roles of the Left Atrial Appendage: Implications for Endocardial and Epicardial Device Closure.

The left atrial appendage has been implicated as a major nidus for thrombus formation, particularly in atrial fibrillation. This discovery has prompted substantial interest in the development of left atrial appendage exclusion devices aimed at decreasing systemic thromboembolism risk. Its deceptively simple appearance belies the remarkable complexity that characterizes its anatomy and physiology. We highlight the key anatomic features and variations of the left atrial appendage as well as its relationships with surrounding structures. We also summarize crucial anatomic factors that should be taken into account by the interventional cardiologist when planning for or performing left atrial appendage exclusion procedures.