Percutaneous Closure of a Persistent Atrial Septal Defect Following Patch Repair

Abstract

The most common form of congenital malformation in adults is the secundum atrial septal defect (ASD), accounting for approximately 70% of all defects at the atrial level. Management of clinically significant ASD is achieved by closure with surgical suture or patch, or via catheter-based devices. We present a rare case of a persistent ASD following surgical patch repair, requiring overlying percutaneous device closure.

Case report

A 50-year-old female with a known history of ASD surgical patch repair presented with recurrent transient ischemic attack (TIA) on anticoagulation. She had tubal ligation performed 8 years prior and postoperatively suffered a cerebrovascular accident (CVA) with right-sided hemiparesis. Further workup revealed a secundum ASD and subsequent surgical patch repair. Postoperatively, she had a TIA, from which she recovered without residual deficits. She was maintained on anticoagulation with warfarin, without incident, until she presented on this visit with another episode of transient right-sided weakness, attributed to a second TIA. The patient underwent a transesophageal echo (TEE) and was diagnosed with having a possible defect on her ASD patch site, with an independently mobile mass (Figure 1).

She was referred for a right heart catheterization and intracardiac echocardiography (ICE) in the cardiac catheterization laboratory. The shunt run revealed a step-up in the right atrium (superior vena cava: 70%; RA: 78%) consistent with left-to-right shunting, with a Qp/Qs ratio of 1.4. ICE images revealed an interatrial patch with a small, residual, tunneled defect between the patch and the aneurysmal interatrial septum with an independently mobile mass, which was implicated to be a detached suture. However, color Doppler and agitated saline could not confirm interatrial shunting, although there seemed to be some flow into a tunnel within the patch.

With ICE imaging under conscious sedation and a 6 French multipurpose guide directed towards the tunnel, a Glidewire (Terumo Medical) was easily advanced across the defect into the left atrium (Figure 2). Left atrial angiogram and oxygen saturation (LA: 100%) confirmed the left atrial position. At this point, in the setting of recurrent TIA on anticoagulation, a decision was made to percutaneously close the persistent ASD. 

The defect was measured as 14 mm, with a longitudinal septal length of 27 mm on ICE imaging. A Helex 30 mm septal occluder (W. L. Gore) was then deployed successfully under fluoroscopy and ICE imaging, with sufficient disc apposition on both atrial sides surrounding the tunneled defect, detached suture, and majority of the ASD patch (Figure 3).

Repeat right heart catheterization with a shunt run showed no evidence of a residual left-to-right shunt. The patient tolerated the procedure well and she was placed on dual antiplatelet therapy with aspirin and clopidogrel for 3 months. A repeat transesophageal echo at 2 weeks post-procedure showed intact device positioning without interatrial shunting (Figure 4). The patient has had no further recurrence of neurologic deficits since her defect closure.

Discussion

Herein, we describe a unique case of a patient who had initial open surgical ASD patch repair complicated by persistent tunneled defect and recurrent neurologic events on anticoagulation, requiring percutaneous device closure of the defect within the patch, with complete resolution of symptoms. ASD is the most common congenital lesion in adults after bicuspid aortic valve. Although the defect is often asymptomatic until adulthood, potential complications of an undetected ASD include right ventricular failure, atrial arrhythmias, paradoxical embolization, cerebral abscess, and pulmonary hypertension that can become irreversible and lead to right-to-left shunting (Eisenmenger syndrome).

The two main indications for closure of an ASD are the development of symptoms and a high rate of shunt flow. Patients with a patent foramen ovale (PFO) or, much less often, an ASD with right-to-left shunt, are at risk for stroke due to paradoxical embolization.

PFO is a relatively frequent variant of physiological state and a common finding in general population. It is an anatomic, tunnel-like structure between the upper rim of the fossa ovalis limb and the fossa ovalis valve, and is the result of the lack of fusion of the septum primum and septum secundum. PFO is common in patients with cryptogenic stroke.¹ As documented in the study by Lamy et al, patients with a PFO are younger and less likely to have traditional risk factors for stroke (hypertension, hypercholesterolemia, smoking) than those without a PFO.¹

The traditional surgical approach for ASD repair has been a median sternotomy², although a right anterolateral submammary subpectoral approach to produce a cosmetic incision has been preferred in females.^3,4 However, there has been an increased use of minimally invasive surgery, which has become an alternative to open repair in selected patients with large defects or insufficient rims. A large, pivotal, multicenter, nonrandomized, concurrent study comparing outcomes for device closure using the Amplatzer septal occluder (AGA Medical) versus surgical repair⁵ found that percutaneous closure was efficacious with lower complications and consequently, triggered the popularity of the less invasive approach. The thinner Helex septal occluder allows closure of small to moderate ASDs with sufficient rims⁶ and an intuitively lower rate of erosions due to its slender nitinol design.

This article received a double-blind peer review from members of the Cath Lab Digest editorial board.

The authors may be contacted via Dr. Jon George at georgej@deborah.org.

References

1. Lamy C, Giannesini C, Zuber M, et al. Clinical and imaging findings in cryptogenic stroke patients with and without patent foramen ovale: the PFO-ASA study. Atrial septal aneurysm. Stroke 2002; 33:706-711.
2. Hopkins RA, Bert AA, Buchholz B et al. Surgical patch closure of atrial septal defects. Ann Thorac Surg 2004; 77:2144-2149.
3. Dietl CA, Torres AR, Favaloro RG. Right submammarian thoracotomy in female patients with atrial septal defects and anomalous pulmonary venous connections. Comparison between the transpectoral and subpectoral approaches. J Thorac Cardiovasc Surg 1992; 104:723-727.
4. Grinda JM, Folliguet TA, Dervanian P, et al. Right anterolateral thoracotomy for repair of atrial septal defect. Ann Thorac Surg 1996; 62:175-178.
5. Du Z, Hijazi Z, Kleinman C, Silverman N, Larntz K. Comparisons between transcatheter and surgical closure of secundum atrial septal defect in children and adults: results of a multicenter nonrandomized trial. J Am Coll Cardiol 2002; 39: 1836-1844.
6. El-Sisi AM, Gendi S, Dilawar M, Numan M. Helex septal occluder: feasibility study of closure of atrial septal defect. Pediatr Cardiol 2008; 29(1): 84-89.

Disclosure: Dr. George, Dr. Desai, and Dr. Moussa report no conflicts of interest regarding the content herein.