CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 1, February 2012
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AFRICA
CARDIOVASCULAR JOURNAL F AFRICA • Vol 22, No 5, September/October
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Case Report
Percutaneous closure of patent foramen ovale and atrial
septal aneurysm using the Atriasept™ II PFO occluder:
clinical and technical implications
STEPHEN BROWN, DANIËL BUYS
Abstract
Two patients with a patent foramen ovale associated with
redundant and fenestrated atrial septal aneurysms and a
history of multiple transient ischaemic episodes underwent
percutaneous device closure using the Atriasept™ II septal
occluders. After release of the devices, the aneurysms were
stabilised and no residual shunts were detected. Certain clini-
cal and technical considerations are outlined.
Keywords:
patent foramen ovale, percutaneous closure, congen-
ital heart disease in adults, Atriasept II
Submitted 27/8/10, accepted 22/8/11
Cardiovasc J Afr
2011;
22
: 00–00
DOI: 10.5830/CVJA-2011-043
Patent foramen ovale (PFO) occurs in up to 27% of the general
population and is generally considered to be of limited clinical
importance.
1
However, studies have shown a significant associa-
tion between cryptogenic stroke and PFO, especially in patients
younger than 55 years.
2-4
No dedicated treatment (other than
surgical closure) was possible until percutaneous PFO closure
methods became available, and percutaneous PFO closure has
been shown to be effective and safe in the prevention of recurrent
thromboembolic events.
4-7
Atrial septal aneurysm (ASA) is frequently associated with
PFOs. The prevalence of ASA associated with interatrial defects
has been reported to range from 1.2% in adults to 4.9% in
the paediatric population, and even as high as 10% in adults
studied with transoesophageal echocardiography (TEE).
4,8-11
Furthermore, the co-existence of PFO and ASA is significantly
linked to the severity of white matter lesions in ischaemic stroke
patients.
12
We describe two patients with fenestrated ASA associated
with PFO who echocardiographically seemed to be suitable for
transcatheter device closure. Initial inspection of the interatrial
septum suggested that the PFO was small but the ASA was large
and associated with additional defects. We proposed to use a
single device to close the PFOs at the upper margin of the fossa
ovalis and to simultaneously cover the more posterior defects in
the lower portion of the ASA.
Case report
The first patient, a 50-year-old male with diabetes mellitus
type 2 and a history of multiple transient ischaemic episodes
was referred for transcatheter PFO closure. Transoesophageal
echocardiography demonstrated a tunnel-like PFO with a thick
septum secundum as well as a hyper-mobile ASA with addi-
tional defects in the lower aspect (Fig. 1). Significant right-to-left
shunt during Valsalva contrast echocardiography was verified.
Moreover, a prominent flap-like membrane (Eustachian valve)
attached to the floor of the inferior vena cava (IVC) was present.
The second patient was a 39-year-old male who had a history
of repeated episodes of transient hemiparesis. TEE showed a
septal aneurysm and PFO tunnel of 5 mm in length with at least
one additional shunt (Fig. 2). The thick septum secundum was
measured at 12 mm in length.
Closure of the PFOs was accomplished using a 30-mm
Atriasept™ II PFO occluder (Cardia
©
Inc, Eagan, MN, USA)
in both cases. Procedures were performed under general anaes-
thesia to allow continuous imaging of the atrial septum and
adjacent cardiac structures by means of TEE. Antibiotics and
heparin were administered and a 12-F long sheath was advanced
through the PFO via a right femoral venous approach. Particular
care was taken to prevent the occurrence of air embolism. Under
fluoroscopic and TEE guidance, a 30-mm device was advanced,
the left disk was released in the left atrium and pulled against
the septum. The right-sided disk was subsequently deployed in
the right atrium by withdrawing the sheath, and the device was
released after opening the locking mechanism of the delivery
forceps.
Final TEE was performed to assess the position of the device
and the presence of residual shunting. Most defects (PFO and
other) were covered by the respective devices and contrast echo
showed no residual shunting (Figs 1–3). Furthermore, the aneu-
rismal atrial septum was stabilised and partially sandwiched
between the two disks of the device with a nice flat profile and
no interference by the Eustachian valve.
The following day, fluoroscopy and echocardiography showed
the devices in the correct position and the patients were
discharged from the hospital on aspirin (100 mg/day) for six
months and clopidogrel (75 mg/day) for one month. Endocarditis
prophylaxis was also recommended for six months. Follow-up
Department of Paediatric Cardiology, Faculty of Health
Sciences, University of the Free State, Bloemfontein, South
Africa
STEPHEN BROWN, MMed, FCPaed, Cert Card (SA), DCH, gnpd-
DANIËL BUYS, MMed (paed)
r i
s fr
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