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Treatment of patients with concomitant patent foramen ovale (PFO),
atrial septal aneurysm (ASA), and multi fenestrated ASDs (mfASD) poses
many challenges and may need several devices placed across the atrial
septum which is more challenging, problematic and expensive. (1) It is
important to have an accurate evaluation of the atrial septum to rule in
or out the possibility of multiple defects. This is done by careful
interrogation of the atrial septum by color doppler echocardiography,
preferably by transoesophageal or three-dimensional transesophageal
echocardiography (3D TEE) at the time of catheterization (2) As
three-dimensional echocardiography becomes more available, it will
likely have a role in defining anatomy in preprocedure period as well.
(3) We report one case who referred for PFO closures that were found to
have an atrial septal aneurysm and multiple small holes. we used one
occluder device Uni occlutech to close the PFO and fenestrations that
this technique was with high success and without complication.
This patient was a 32-year-old lady with a history of percutaneous
transcatheter pulmonary commissurotomy (PTPC) at age 20, chronic
palpitation and dizziness referred to our clinic with recurrent symptoms
of transient ischemic attack (left hemiplegia for 3 times) for doing the
transesophageal echocardiography for evaluation of emboli source. Her
general appearance was normal. The cardiac examination and ECG were
unremarkable. The transesophageal echocardiography and three-dimensional
transesophageal echocardiography showed normal left ventricle size and
preserved systolic function (Ejection Fraction=50-55%), normal right
ventricle size with normal systolic function, normal biatrial size,
normal drainage of all pulmonary veins to the left atrium, no clot or
smoke in the left atrium and its appendage, no mitral stenosis, mild
mitral regurgitation , normal and tricuspid aortic valve with no
stenosis and insufficiency, thickened and dome shape pulmonary valve, no
significant pulmonary stenosis ( Peak Pressure Gradient:18mmHg, Mean
Pressure Gradient:10 mmHg), mild to moderate pulmonary insufficiency,
mild tricuspid regurgitation, aneurysmal interatrial septum with large
patent foramen oval (4 millimeters ) and at least three fenestrations
(larger one = 4 millimeters) with left to right shunt with the distance
between first and last hole was 12mm and the nearest distance to PFO was
10mm and most far distance is 24mm (figure 1,2). The holes had
sufficient rims but the septum was very aneurysmal. The present patient
experienced a recurrent cerebrovascular attack at a relatively young
age. A thorough investigation did not disclose any apparent etiology for
this event other than a cryptogenic stroke due to a paradoxical embolus
through the PFO or mfASD. The expected benefits for the present patient
included the prevention of a recurrent stroke due to a presumed
paradoxical embolus. So we scheduled the patient for PFO and multi
fenestrated ASD device closure. We decided to perform percutaneous
intervention but the most important factor was covering all of the
defects. We selected a Uni device occlutech 33 mm for the procedure
started with mild conscious sedation, there was aneurysmal interatrial
septum, large patent foramen oval, and three small holes with sufficient
all rims. During transcatheter closure, hemodynamic and saturation were
obtained that the hemodynamic study showed normal blood pressure and
heart rate with O2 saturation about 95%. A Guidewire was advanced from
a femoral vein, across one of the holes, into the left upper pulmonary
vein under transesophageal echocardiography guidance. The tricky part of
the procedure was passing the central hole for covering all
fenestrations and Patent Foramen Ovale. The delivery sheath was then
advanced over a wire, across the defect into the left atrium and left
upper pulmonary vein, then closure device (Uni device occlutech, size=33
mm) was selected and advanced through the sheath into the left atrium,
The left disc of the device was deployed with the catheter in the left
atrium and then the catheter and device were withdrawn until the left
disc gets parallel with the left atrium aspect of the interatrial
septum. The right dick was then opened completely. At the first and
second try, we could not obtain a good result and residual flow was
seen. Finally, by guiding Three Dimensional Transesophageal
Echocardiography we could pass the central fenestration (figure
3, movie 1) and the device covered all fenestrations and Patent Foramen
Ovale and also aneurysmal part of the septum (figure 5). Before
the device was released from the catheter, appropriate positioning was
confirmed by interrogating all rims with echocardiography, and a
wiggling maneuver was performed to confirm device stability)Movie 2 ). The benefits of using a single device are a shorter
procedure duration and lesser chance of interference with venous blood
flow, atrioventricular valves function, or adjacent tissue erosion (4).
Then, after releasing of the device at the two weeks, two months, six
months and one-year’ follow-up visit, no complication was detected (no
pericardial effusion, no compressive effect on contiguous structures
such as an aortic valve, mitral and tricuspid valve, superior vena cava,
inferior vena cava or pulmonary veins, no residual leakage even after
contrast injection (movie3) and no recurrence of Transient
Ischemic Attack). The immediate success rate of closure in this patient
was very high due to the exact Three Dimensional Transesophageal
Echocardiography and also due to the operator experience with this
device. We empirically recommend the patient to receive antiplatelet
agents (Aspirin and Plavix) for a period of at least 6 months to prevent
any potential thromboembolic episodes.