Feasibility and safety of transcatheter closure of atrial septal defects with deficient posterior rim.

OBJECTIVES

To evaluate the feasibility and safety of percutaneous closure of complex secundum-type atrial septal defects (ASD) in patients with posterior-inferior rim deficiency.

BACKGROUND

Transcatheter approach is the method of choice for ASD closure; however, up to now 20% of the defects are not considered suitable for percutaneous intervention because of the lack of surrounding rims, especially the posterior-inferior.

METHODS

A total of 268 patients were evaluated between March 2005 and April 2011 for ASD closure. Twenty-four patients (9%) were not considered suitable for a percutaneous intervention and referred to surgery due to inadequate rims or a large defect diameter. Out of the remaining 244 patients, 25 (10,2%) had posterior-inferior rim deficiency and represent our study group.

RESULTS

After failure of the conventional approach, alternative techniques were attempted. In 16 patients, an adjusted deployment and alignment maneuver approach was successful. In 5 other patients, a slide out technique was successfully performed by exploiting the right upper pulmonary vein. Finally in the remaining 4 patients, ASD closure was obtained by completely re-orienting the system with a jugular approach. No peri-procedural complications occurred, and at 12-month transesophageal echocardiography evaluation no residual shunt could be detected.

CONCLUSIONS

Our data show the feasibility of percutaneous approach for ASD closure in presence of a deficient posterior-inferior rim. The procedural success is strictly related to correct sizing and demonstration of a balloon notch on fluoroscopy. Long-term follow-up supports efficacy of the procedure in these selected cases.