Page 28 - Journal of Structural Heart Disease Volume 3, Issue 1

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Original Scienti c Article
ventional closure of ASD in the presence of complex and extensively de cient aortic rim may occur not during the procedure but might become evident af- ter the period of hospital stay. The complexity of the morphological anomaly should prompt questions about the safety and possible outcomes of the inter- ventional procedure and the consideration of alter- native surgical options that are safe and have a high likelihood of successful and uneventful outcomes. New technologies such as magnetic resonance im- aging with 3-dimensional printing of a model repre- senting the abnormal morphology may assist in deci- sion-making in cases of complex anatomy.
Pulmonary Vein-Assisted Deployment of ASD Occluder
An asymptomatic 3-year-old boy was admitted for elective closure of a secundum ASD. TEE showed that the ASD measured 11 mm and had a de cient antero-superior aortic rim. In the catheterization laboratory, multiple attempts were made to achieve an adequate device position; however, the device slipped through the defect or resulted in a posture perpendicular to the defect (Video 17). To overcome this di culty, we rst deployed the right atrial disc and swiftly advanced it to the right aspect of the IAS, which allowed an optimal alignment of the left atrial disc with the IAS, occluding the defect. To delay the deployment of the left atrial disc, we started the de- ployment in the left upper pulmonary vein (LUPV). When the left disc was uncovered in the LUPV, we held it stationary in an elongated form, allowing un- sheathing of the septal occluder so that the proximal disc would deploy in the RA, engaging the right as- pect of the IAS. A short wiggle of the delivery system then released the left atrial disc from the LUPV po- sition, engaging the IAS from the left aspect with a perfect con guration for ASD closure (Video 18). TEE investigation showed that the device embraced the aortic root and was in an adequate position in the presence of de cient aortic rim (Video 19). The pul- monary vein slide-out technique has also been used to aid closure of ASDs with de cient posterior rim [20]. This morphology is considered a risk factor for device migration.
Video 16. Atrial septal defect with de cient aortic rim with an occluder in situ embracing the aortic root. View supplemental video at http://dx.doi.org/10.12945/j.jshd.2016.005.16.vid.16.
Video 17. The device was malaligned with the septum. View sup- plemental video at http://dx.doi.org/10.12945/j.jshd.2016.005.16. vid.17.
Video 18. The left disc was partially deployed in upper left pulmo- nary vein, allowing proper right disc deployment. View supple- mental video at http://dx.doi.org/10.12945/j.jshd.2016.005.16. vid.18.
Tal, R. et al.
Atrial Septal Defect Occlusion Challenges