CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 1, January/February 2013
68
AFRICA
2
National Institute for Medical Reasearch, Medical Research Council,
London, UK
3
Institute of Genetic Medicine, Newcastle University
Background
: Incomplete formation of the partition between the
two atrial chambers in the region of the oval fossa results in a
range of defects, which extend from patent foramen ovale (PFO) to
large secundum atrial septal defects (ASDs). There is wide varia-
tion in the morphology of the latter lesions. The spatial orientation
of the margins of ASDs relative to the persisting flap valve is not
easily definable with standard echocardiographic imaging. Careful
evaluation of the morphology is essential in optimising successful
trans-catheter closure to minimise complications. The advent of
three-dimensional trans-oesophageal echocardiography (3DTOE)
has changed our understanding of the morphology of these defects,
and facilitates successful percutaneous closure.
Methods and results
: Since 2007, over a 4-year period, we performed
transcatheter closure of ASDs in 104 patients. During this period
there were two instances of embolisation of the device. We evalu-
ated carefully the morphology of the defects in the patients suffering
embolisation, and noted an unusual spiral configuration of the flap
valve relative to the rims of the oval fossa. These findings were then
found in 4 additional patients, and serve as the focus of this report. To
facilitate our understanding of the unusual morphology, we compared
the clinical findings with images showing the mechanism of develop-
ment of the atrial septum in the mouse, revealing a striking similarity.
Conclusions
: Though uncommon, spiral spatial orientation of the
margins of ASDs predisposes to embolisation of devices used for
percutaneous closure. Standard cross-sectional techniques have limit-
ed use in identifying this variation. Understanding of development of
the atrial septum in the mouse heart may help explain morphogenesis
of the defect, and the mechanism predisposing to embolisation.
190: PREMATURE CLOSURE/RESTRICTION OF THE
FORAMEN OVALE WITH SEVERE PRENATAL CARDIAC
ASYMMETRY: WILL THE LEFT HEART BE SUFFICIENT
POSTNATALLY?
Karlien Carbonez
1
,
Françoise Mascart
2
, Catherine Barrea
1
1
Cliniques Universitaires Saint-Luc (UCL), Brussels, Belgium
2
Clinique Saint-Vincent (CHC), Rocourt, Belgium
Background:
Premature closure of the foramen ovale (FO) is a
rare but serious condition that can be associated with severe right
heart failure and hydrops, supraventricular tachycardia and left heart
obstructive lesions.
Methods:
We report 2 cases of early prenatal restriction/closure of
the FO.
Results:
Both patients were referred for foetal echocardiography, at
22 + 4 and 26 + 1 weeks respectively, for severe cardiac asymmetry
with suspicion of ‘hypoplastic left heart’ (HLH) at ultrasoundUS. In
the first case, a 30-year-old G1P0 woman, cardiac asymmetry was
initially attributed to an aortic coarctation (CoA). Flow in the FO
appeared normal up to 29 + 3 weeks. At 34 + 3 weeks, cardiac asym-
metry worsened with a bulging septum towards the left atrium. At 37
+ 1 weeks, the left heart appeared tiny with no visible interatrial flow.
A 2.3 kg baby boy was born at 37 + 3 weeks. Postnatal echocardio-
gram showed a tiny restrictive FO, a dilated right heart with transient
pulmonary hypertension and a smallish left heart. The aortic arch
was small and disharmonious but no CoA developed. In the second
case, a 32-year-old G2P0 patient, cardiac asymmetry was immedi-
ately attributed to a restrictive FO. A CoA was suspected at 31 + 1
weeks and the FO was closed at 34 + 4 weeks with increasing cardiac
asymmetry. A 2.5 kg baby girl was born at 38 + 1 weeks. Postnatal
echocardiography confirmed an intact atrial septum with suspicion
of HLH, a bicuspid aortic valve and CoA. She was treated with pros-
taglandins. The follow-up echocardiograms showed a progressively
better-filled left heart and reduction of pulmonary pressures. She
underwent a CoA repair on day 13. Both children are currently well
at 6-year and 2-month follow-up respectively.
Conclusions:
Premature closure of the FO may mimic HLH pre- and
post-natally. In some cases, despite severe cardiac asymmetry, post-
natal evolution may be very good. Further research is necessary to
better predict outcome.
226: ANDRASTENT IN THE MANAGEMENT OF COARCTA-
TION OF THE AORTA
Jacek Bialkowski, Malgorzata Szkutnik, Roland Fiszer
Medical University of Silesia, SCCS Zabrze, Poland
Background:
Stenting in coarctation of the aorta (CoA) has emerged
as an alternative to surgery with good intermediate result. Recently
a new bare metal stent made of a cobalt-chromium alloy (Andrastent
XL, XXL , Andramed, Germany) was introduced to clinical practice.
Its strong radial force, flexibility and good radio-opacity should be
advantageous in implantation in CoA.
Objective:
To evaluate the use of Andrastent XL and XXL in the
management of CoA at a single tertriary care centre with immediate
result and midterm follow-up.
Methods:
Andrastents were implanted over a 30-month period in 29
patients: 25 with native CoA and 4 with recurrencet after previous
surgery (ReCoA). The Andrastents were manually mounted on Maxi
LD and BIB balloons and delivered through 10 to 14 Fr Mullins
sheaths using a conventional femoral approach.
Results:
Mean patient age was 28.3
±
15.6 (range 9–65) years. The
systolic gradient across the native CoA decreased from a mean 48.3
±
20.2 before to 11.9
±
10.2 mmHg after the procedure and in case of
ReCoA from 37.8
±
20.7 before to a mean 9.7
±
12.4 mmHg after the
procedure. No aneurysm formation, stent migration or rupture of the
aorta were observed in any patient during the procedure. The mean
fluoroscopy time was 6.1
±
2.3 min. Procedural outcome remained
favourable during mean follow-up 1.1
±
0.8 without stent fracture.
Planned redilatation of implanted stent was performed between 4 and
14 months in 6 patients. In one man with secondary LV failure ejec-
tion fracture (EF) 15% (49 years old), the procedure was performed
urgently during cardiogenic shock with good clinical result.
Conclusions:
Implantation of Andrastents XL and XXL is a very
good therapeutical option for the treatment of native and recurrent
CoA.
235: PRENATAL DIAGNOSIS OF HETEROTAXY
SYNDROME: IMPACT OF SUBTYPE ON PERINATAL AND
SHORT-TERM OUTCOME
Maria Clara Escobar
1
,Yishay Salem
1
, Brian Kalish
2
, Rahul H Rathod
1
,
Tal Geva
1
, David W Brown
1
, Sitaram Emani
1
, Wayne Tworetzky
1
1
Boston Children’s Hospital, Boston, USA
2
Harvard Medical School, Boston, USA
Objective
: After prenatal diagnosis (Dx), to assess the influence
of heterotaxy syndrome (HS) subtype on perinatal and short-term
survival.
Methods:
We included foetuses with HS from 1995 to 2011. We
collected data on gestational age (GA) at Dx, cardiac anomaly,
congenital heart block (CHB), extracardiac anomalies, pregnancy
outcome, surgery, current survival and circulation.
Results:
Of the 154 foetuses, 61(40%) were categorised as asple-
nia syndrome patients (ASP) and 93 (60%) polysplenia syndrome
patients (PSP). Median GA at Dx was 21 (range 14–39 weeks).
Complex cardiac anomalies were more frequent in ASP than PSP
(98% vs 58%). Bradycardia-CHB was exclusive to PSP (18/93).
Extracardiac anomalies were present in 45%. In ASP, 24/36 (66%)
Dx at
<
24 w elected for termination of pregnancy (TOP), 3 foetuses
died from non-cardiac lesions, and 34 (56%) were liveborn. In PSP,
11/61 (18%) Dx
<
24 w elected for TOP, 5 foetuses died (4 with
CHB) and 77 (83%) were liveborn. Mean follow-up was 6.1 years (
±
4.6). In the liveborn ASP, 15/34 (44%) died, 6 with pulmonary vein
stenosis, 5 postoperatively and 4 from non-cardiac lesions. In the
liveborn PSP, 10/77 (13%) died, 6 postoperatively, 2 with CHB, and
