title: Intracardiac echocardiography-guided atrial septal defect transcatheter closure of a very old surgical residual shunt.
abstract: Although some studies have suggested excellent long-term outcome, arrhythmias, pulmonary hypertension, and paradoxical cerebral embolism are mentioned as results of residual shunts in the long-term follow-up after surgical atrial septal defect (ASD) closure at a young age. In cases of previous patch closure, transcatheter repair of residual shunts can be problematic due both to clinical decision-making in the presence of elevated pulmonary pressure and to a very old patch. A 70-year-old woman operated for an ASD with synthetic patch closure when she was 35 years old was referred to our center because of recurrent paroxysmal atrial fibrillation, initially decompensated right heart failure with rest and exercise-induced dyspnea as results of a residual shunt and moderate pulmonary hypertension. Complete right heart catheterization confirmed a mean pulmonary pressure of about 55 mm Hg and a Qp:Qs ratio of 1.78. A mechanical intracardiac echocardiography study with a 9F 9 MHz UltraICE catheter (Boston Scientific Corp.) showed a highly echogenous interatrial patch with a very stiff appearance and a very high residual defect of 8.7 and 11.2 mm on the aortic valve plane and on the four-chamber views, respectively. An occlusion test with a compliant AGA medical balloon demonstrated a decrease in mean pulmonary pressure to 36 mm Hg. A 10 mm Amplatzer's ASD occluder was implanted after a first unsuccessful attempt due to patch stiffness. Three-month echocardiography follow-up demonstrated almost normal pulmonary pressure and only slight dilation of the right chambers. At six-month follow-up, the patient no longer experienced dyspnea. This case demonstrates that transcatheter closure of a residual shunt following surgical ASD repair can be successfully accomplished also in elderly patients with a very old patch and decompensated right heart failure: the balloon occlusion test and intracardiac echocardiography appear to be effective in the operative decision-making process.
authors.affiliation: Section of Congenital and Structural Heart Disease Interventions, Cardiovascular Diagnosis and Endoluminal Interventions Unit, Rovigo General Hospital, Rovigo, Italy. jackyheart@hotmail.com
authors.forename: G
authors.initials: G
authors.lastname: Rigatelli
authors.forename: F
authors.initials: F
authors.lastname: Dell'Avvocata
authors.forename: L
authors.initials: L
authors.lastname: Roncon
authors.forename: P
authors.initials: P
authors.lastname: Cardaioli
authors.forename: M
authors.initials: M
authors.lastname: Giordan
authors.forename: S
authors.initials: S
authors.lastname: Cominato
mesh_terms: D000368:Aged; D006328:Cardiac Catheterization / Q000379:methods*; D002404:Catheterization; D017548:Echocardiography, Transesophageal; D005260:Female; D006344:Heart Septal Defects, Atrial / Q000000981:diagnostic imaging* / Q000628:therapy*; D006801:Humans; D012086:Reoperation; D016896:Treatment Outcome