Transcatheter closure for residual atrial septal defect resulting from surgical patch closure 44 years previously

Excerpt

A 75-year-old woman was admitted to our hospital because of exertional dyspnea. When she was 31, she underwent surgical patch closure with a Teflon patch for an ostium secundum atrial septal defect (ASD) in our hospital. Transthoracic echocardiography (TTE) revealed dilated right ventricle with basal diameter of 39 mm and base-to-apex length of 79 mm, and dilated right atrium with 38 × 50 mm. The left ventricular end-diastolic and end-systolic diameters and ejection fraction were 41, 22 mm, and 65%, respectively, and mild-to-moderate tricuspid regurgitation was also shown. Transesophageal echocardiography (TEE) revealed an ASD measuring 5.9 × 9.1 mm with a left-to-right cardiac shunt (Fig. 1a and 1b). Moreover, the atrial septum constituting part of the sinus of Valsalva was highly echogenic, suggesting it was the Teflon patch from the previous surgical procedure, whereas the inferior part of the atrial septum was likely to be the native atrial septum (Fig. 1c). In contrast to the area including the Teflon patch, other rims of tissue surrounding the defect were neither floppy nor short. The left-to-right shunt of the pulmonary and systemic blood flow ratio was 1.8 by right heart catheterization. Pulmonary hypertension was not observed by means of right heart catheterization, but she showed significant decreased oxygen saturation during effort. Although vulnerability of the Teflon patch from the previous surgical procedure was a growing concern, transcatheter closures of the ASD was planned. During the balloon-sizing procedure, the stop-flow diameter of the ASD was 9.5 mm as measured by TEE, and the rim of the Teflon patch appeared to be sturdy (Fig. 1d). Next, a 7-French delivery sheath was placed in the left atrium via the right femoral venous approach for delivery of a 12-mm Amplatzer septal occluder (AGA Medical Corp., Golden Valley, MN, USA), which was performed without any complications (Fig. 1e). After transcatheter closure of the ASD, TTE disclosed complete absence of any residual ASD and improvement in the severity of tricuspid regurgitation and right ventricular dilatation. The postoperative course was uneventful, and the patient has been asymptomatic during the follow-up period.

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