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Mm00188 (00) asd case study - hijazi lrg secundum:layout 1.qxd

Closure of Large Secundum-Type ASD with theAMPLATZER Septal Occluder Ziyad M. Hijazi, MD
George M. Eisenberg Professor
Department of Pediatrics and Medicine
Section of Pediatric Cardiology
The University of Chicago Hospital
Chicago, IL U.S.A.

Patient History
the connecting waist was deployed in the left atrium) A 67-year old female was diagnosed at the age of resulted in successful closure. Correct device 57 to have an atrial septal defect. Primary symptoms position was verified by TEE and by pulling and were shortness of breath and easy fatigability. Her pushing on the delivery cable to confirm secure anchoring of the device (“Minnesota Wiggle”). The considered to be in NYHA functional class III-IV due device was released by counterclockwise rotation of to severe right heart failure. She developed the pin vise. Repeat TEE evaluation revealed significant atrial dysrhythmias for which she was complete closure of the defect (Figure 3). An maintained on amiodarone, digoxin and Coumadin.
She was referred for the possibility of catheter catheterization laboratory failed due to heart failure closure. She was also maintained on lasix and and pulmonary edema. Therefore, the patient was allowed to recover in the Cardiac Care Unit. Shewas discharged home one week later on her above Dianostic Findings
medications. The fluoroscopic time was 30 minutes A transesophageal echocardiogram (TEE) was and total procedure time was 115 minutes. On performed and revealed the presence of a large, follow-up, her symptoms improved significantly and secundum type ASD measuring 23mm with large she is now in NYHA functional class I-II. Repeat right atrium and ventricle (Figure 1).
TEE after 4 months revealed complete closure withdecrease in the right atrium and ventricle size Procedure Description
Under general endotracheal anesthesia andcontinuous TEE monitoring, routine right and left Discussion
heart catheterization was performed. The pulmonary This case illustrates the major benefits of device artery pressure was 38/16 (24) mm Hg with closure in this high surgical risk patient. The risk of descending aortic pressure of 83/43 (56) mm Hg.
surgery would have been significantly increased due The Qp/Qs ratio was 2.2:1 The balloon diameter of to her heart failure, pulmonary edema and atrial the defect was measured to be 27mm (Figure 2). An arrhythmia. Her defect size was big with a stop-flow 8 Fr sheath (AGA Medical Corp.) was passed over diameter of 27mm. Conventionally, we would have the guidewire into the left upper pulmonary vein. A liked the device size to be equal or 1mm larger than 26mm AMPLATZER Septal Occluder was attached the stop-flow diameter of the defect. However, to the delivery cable, compressed into the loader because of her condition, we decided to implant the and introduced into the sheath. An initial attempt at largest device available at the time, a 26mm deploying the device resulted in pulling of the device AMPLATZER Septal Occluder. The fact that the across the thin septum into the right atrium.
device is easily recapturable and repositionable after Therefore, the device was recaptured and a repeat deployment of both discs increased our confidence attempt with modification of the deployment (part of in attempting the implantation which resulted incomplete closure of the defect.
Figure 1: Longitudinal TEE view revealing a 23mm secundum type ASD with left-to-right shunt and RA enlargement priorto closure. Note the thin inferior septum (arrow).
Figure 2: 4-chamber view TEE image during balloon sizing of the defect, the stop-flow diameter is 27mm.
Figure 3: Longitudinal TEE image with color after closure using a 26mm AMPLATZER Septal Occluder revealing gooddevice position and no residual shunt.
Longitudinal TEE images without (figure 4) and with color (figure 5) four months after device closure, revealing gooddevice position and no residual shunt. Note the change in the profile of the device.
Refer to Instructions for Use for a complete listing of indications and usage, contraindications, warnings, andprecautions. AMPLATZER is a registered trademark of AGA Medical Corporation. AGA Medical Corporation,2006. Not in any way connected with medical gas or equipment sold under the “AGA” brand by AGA AB orits successors. This device may not be available in all markets. Contact AGA Medical Corporation for availability.


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