European Heart Journal Advance Access originally published online on September 19, 2006
European Heart Journal 2007 28(3):309; doi:10.1093/eurheartj/ehl200
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Failed Amplatzer Septal Occluder device implantation due to an embryonic septal remnant
1 Interventional Cardiology Unit, Division of Cardiology, Rovigo General Hospital, Italy
2 Department of Cardiac Surgery, Verona University Medical School, Verona, Italy
* Corresponding author: EndoCardioVascular Therapy Research, Via WA Mozart 9, 37040 Legnago, Verona, Italy. Tel: +39 03471912016; fax: +39 044220164. E-mail address: jackyheart{at}hotmail.com
Embryonic remnants of incomplete septation may complicate occlusion device implantation in secundum atrial septal defects (sASD) even if stiff devices such as the Amplatzer Occluder are used.
A 35-year-old woman was referred to our center for evaluation of a sASD. Transesophageal echocardiography revealed a haemodinamically relevant sASD with a mean diameter of 22 mm, a virtually absent anterosuperior rim (aortic rim) and remaining floppy rims, and an apparently soft membrane at the inferior aspect of the interatrial septum which was concluded to be a remnant of incomplete septation (EM) (Panel A). Because the patient initially refused the surgical option, a percutaneous closure was attempted.
By intracardiac echocardiography (UltraICE, Boston Scientific Corp.), the diameters of the sASD at the aortic valve and four-chamber planes were 29 and 32 mm, respectively. A soft membrane (EM) was visible at the aortic valve plane but was felt to be too soft to influence device opening (Panel B; AS, antero-superior rim; EM, embryonic membrane; PI, postero-inferior rim; RA, right atrium). To test the stiffness of the rims, a sizing balloon was passed across the ASD and inflated till an indentation was evident thus obtaining a sizing balloon ASD with a diameter of 28 mm. After calculating a mean diameter from the sizing balloon and the ICE measurement, the operators opted for a 32 mm Amplatzer ASD Occluder. The device was successfully implanted (Panel C; RA, right atrium; ASO, Amplatzer Septal Occluder) with excellent pre-discharge transthoracic echocardiography. At 1-month transesophageal echocardiography follow-up, the device appeared to be perfectly stable but deviated from the true rim with a moderate high flow shunt (Panel D; ASO, Amplatzer Septal Occluder). It was postulated that once the embryonal septal remnant had been caught by the device, it became stiffer and anchored to the true septum primum rim. It was therefore decided to remove the device surgically. Direct surgical inspection confirmed the suspicion (Panel E; EM, embryonic membrane). The partially endothelized device (Panel F) was removed and the defect repaired with a patch. Embryonic remnants of interatrial septum formation, such as the one presented above, are quite rare but should be carefully evaluated for potential technical constraints to percutaneous closure. Once this structure has been caught up by the two retention disks of the device, it may become quite stiff and can deviate the disks from the true rim.
See online supplementary material for a colour version of the figure available at European Heart Journal online.
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||