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From the Departments of *Anesthesiology, Surgery, and Cardiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
Address correspondence and reprint requests to Brenda M. MacKnight, MD, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, 600 North Wolfe St., Tower 711, Baltimore, MD 21287. Address e-mail to bmm181{at}hotmail.com.
A 58-yr-old woman with a known patent foramen ovale (PFO), which was diagnosed 3 yr ago by transesophageal echocardiogram (TEE) after a transient ischemic attack, presented with chest pain, and was referred for cardiac catheterization with possible intervention. Up to this point, the PFO was being medically managed with warfarin; however, because of her history of a cerebrovascular event, percutaneous closure of the PFO was planned in conjunction with coronary evaluation. After successful coronary stenting, a CardioSEAL® septal occluder (NMT Medical Products, Boston, MA) was deployed but pulled through the PFO. The CardioSEAL device was then removed and an Amplatzer® septal occluder (AGA Medical Corp., Golden Valley, MN) was deployed using intracardiac echocardiography (ICE) and fluoroscopy. The Amplatzer device appeared to be properly positioned across the PFO but subsequently embolized into the left atrium after being fully deployed. The device was noted to have crossed the mitral valve into the left ventricle when surgical consultation was promptly obtained. The patient was emergently brought to the operating room with stable vital signs, and after induction of general anesthesia, TEE demonstrated further migration of the device into the left ventricular outflow tract (LVOT). Despite turbulent flow in the LVOT, no hemodynamic perturbations were observed in spite of its position just below the aortic valve (Fig. 1 and please see video loop available at www.anesthesia-analgesia.org). Doppler-derived pulse and continuous wave interrogation across the LVOT and the aortic valve, respectively, revealed normal pressure gradients and no evidence of obstruction. After institution of cardiopulmonary bypass, the Amplatzer device was retrieved intact via an oblique right atriotomy through the interatrial septal defect and mitral valve (Fig. 2). The interatrial septum was eventually closed with a bovine pericardial patch, and the patient was weaned uneventfully from cardiopulmonary bypass. Postoperative TEE images revealed no residual interatrial shunt, and normal structure and function of both the mitral and aortic valve. Aside from nonsustained atrial fibrillation, the patient experienced a benign postoperative course and was discharged home on the seventh postoperative day.
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Currently, in the United States, there are two brands used to percutaneously close an interatrial defect, the Amplatzer and the CardioSEAL. The safety of the Amplatzer Septal Occluder is well established (1,2), with uncommon reported complications, including sepsis, arrhythmia, residual shunt, cardiac tamponade, air embolus, and device embolization. In a retrospective review by Levi and Moore, 3824 Amplatzer device placements resulted in 11 (0.3%) embolizing to the left side of the heart (3). Of these 11 cases, 5 required surgical removal and 7 required surgical closure of the atrial septal defect. In the case of our patient, further attempts at percutaneous device retrieval were abandoned in favor of direct surgical retrieval.
Several features of TEE make its use vital to percutaneous interatrial septal defect closure. First, the diagnosis and clear delineation of an interatrial defect is best obtained with TEE (4). Second, it is important to evaluate nearby cardiac structures, specifically the mitral valve, tricuspid valve, right and left upper pulmonary veins, and coronary sinus, as they are most vulnerable to impingement by an occluder device. Third, PFO closure devices require specific measurements to accurately size the occluder and identify correct positioning of the device (5). Interventional cardiologists often pass a percutaneously placed sizing balloon across the defect and inflate. By measuring the waist of the balloon with electronic calipers using either TEE or ICE, the cardiologist can determine which size device to deploy (4). Lastly, once the device is deployed and in position, a final scan should be performed to make certain that there is no disruption of adjacent cardiac structures, while assessing for any residual shunt (5).
Although some centers routinely use TEE under general anesthesia for percutaneous interatrial septal defect closure, the cardiologists at our institution typically use ICE. Access for the ICE probe is usually obtained via the femoral vein. It is important to note that ICE is a separate modality from intravascular ultrasonographic imaging. In fact, newer models of ICE use a phased array transducer with full Doppler capabilities, including color, tissue, and spectral (6). Although ICE is an often useful and convenient tool for use during interventional cardiac procedures, TEE continues to be the primary modality for preprocedure evaluation for complex procedures and in the perioperative setting.
ACKNOWLEDGMENTS
Special thanks to William T. Merritt, MD, and Brett A. Simon, MD, PhD.
Footnotes
This article has supplementary material on the Web site: www.anesthesia-analgesia.org.
Accepted for publication June 28, 2007.
REFERENCES
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