Page 33 - Journal of Structural Heart Disease Volume 3, Issue 1

Original Scienti c Article
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systolic dysfunction, RA myxoma, tricuspid valve dis- ease, and pericardial e usion, were excluded. Balloon occlusion of the patent foramen ovale served to test the tolerance of the occlusion and measure the e ec- tive stretched defect size. The defect was then closed by a 24-mm ASD Amplatzer occluder, resulting in a rise of arterial PO2 from 40 to 320 mmHg.
Atrial-level right-to-left shunt (ARLS) is a rare but important cause of hypoxia. The pathophysiology arises from an interatrial defect coupled with a sec- ondary cardiac or pulmonary insult. A rise in RA pres- sure above LA pressure may precipitate ARLS [31]. Diastolic RV dysfunction may be caused by di erent mechanisms, including acute myocardial infarction, age-related undiagnosed severe pulmonary steno- sis, and pulmonary atresia with intact interventricu- lar septum years following resolution of RV out ow obstruction [32]. Treatment of ARLS involves treating the underlying cause and/or closure of the shunt to resolve hypoxemia. Observing the tolerance of a tem- porary closure of the ASD with a sizing balloon while monitoring RA pressure and systemic blood pressure should prevent RA pressure elevation and reduce car- diac output. If balloon occlusion is well-tolerated, the ASD (or patent foramen ovale) may be closed safely with a device and result in a favorable outcome.
Pulmonary arterial hypertension may also lead to ARLS in the presence of interatrial communication. However, prior to attempting to close an ASD in this situation, the reversibility of pulmonary hypertension should be demonstrated to avoid RV failure. A bal-
loon occlusion test with RA pressure monitoring is a prudent approach. A fenestrated occluder may be considered as a temporary vent mechanism [33].
Summary
We present these select cases as challenges that require pre-procedural planning and intra-procedur- al considerations to successfully perform the percuta- neous approach as an alternative to surgery without compromising patient safety. Some complex ASDs may be better treated by the surgeon, avoiding un- predictable percutaneous interventional outcome. Mature judgement and the acknowledgement of the current technology limitations is needed to hand over cases to the surgical team. However, the intervention- al team is expected to be resourceful in preparing for and performing the procedure. Learning from others’ experience, as well as the prudent use of imaging mo- dalities, personal experience, and proper selection of equipment, are bene cial when managing complex cases of ASD closure.
Con ict of Interest
The authors have no con ict of interest relevant to this publication.
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References
1. Du ZD, Hijazi ZM, Kleinman CS, Silverman NH, Amplatzer investigators. Comparison between transcatheter and surgical clo- sure of secundum atrial septal defect in children and adults: results of a multicenter nonrandomized trial. J Am Coll Cardiol. 2002;39:1836-1844. DOI: 10.1016/S0735- 1097(02)01862-4
2. Tal R, Dahud Q, Lorber A. Fenestrated atrial septal defect percutaneously occluded by a single device: procedural and nancial considerations. Cardiol Ther. 2013;2:97- 102. DOI: 10.1007/s40119-012-0009-5
3. Awad SM, Garay FF, Cao QL, Hijazi ZM. Mul- tiple Amplatzer septal occluder devices for multiple atrial communications: immedi- ate and long-term follow-up results. Cath- eter Cardiovasc Interv. 2007;70:265-273.
DOI: 10.1002/ccd.21145
4. Tillman T, Mulingtapang R, Sullebarger JT.
Approach to percutaneous closure in pa- tients with multiple atrial septal defects. J Invasive Cardiol. 2008;20:E167-E170. PMID: 18460721
5. Butera G, Romagnoli E, Saliba Z, et al. Per- cutaneous closure of multiple defects of the atrial septum: procedural results and long-term follow-up. Catheter Cardiovasc Interv. 2010;76:121-128. DOI: 10.1002/ ccd.22435
6. Szkutnik M, Masura J, Bialikowski J, Gavora P, Banaszak P, Kusa J, et al. Transcatheter closure of double atrial septal defects with a single Amplatzer device. Catheter Cardiovasc Interv. 2004;61:237-241. DOI:
10.1002/ccd.10753
7. El Saiedi SA, Attia WA. New pediatric ver- sion of balloon-assisted technique for atrial septal defect closure using self-cen- tering devices: Relation to interatrial septal thickness. J Invasive Cardiol. 2015;27:510- 515. PMID: 26524205
8. Narin N, Baykan A, Argun M, Ozyurt A, Pamukcu O, Bayram A, et al. New modi- ed balloon-assisted technique to provide appropriate deployment in the closure of large secundum atrial septal defect using amplatzer septal occluder in children. J Invasive Cardiol. 2014;26:597-602. PMID: 25364001
9. Pillai AA, Rangaswamy Balasubramanian V, Selvaraj R, Saktheeswaran M, Satheesh
Journal of Structural Heart Disease, February 2017
Volume 3, Issue 1:15-27