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Concurrent Percutaneous Closure of Patent Foramen Ovale and Patent Ductus Arteriosus Using Occluder Devices
- Operator: Seung-Jung Park, MD
Case presentation
A 43 year-old women was admitted for known congenital cardiac defect and mild exertional dyspnea. Although, she has known her congenital heart disease, she has not continued medical follow-up. Transthoracic echocardiography (TTE) showed left to right trans inter-atrial septal shunt flow suggestive of patent foramen ovale (PFO; Image 1) and continuous left to right shunt flow from descending aorta to left pulmonary artery suggestive of patent ductus arteriosus (PDA; Image 2, Image 3). Transesophageal echocardiography (TEE) also showed a 3 mm sized PFO (Image 4) with left to right shunt (Image 5) and a 3 mm sized PDA (Image 6) with continuous left to right shunt flow (Image 7). Heart scan demonstrated a ratio of pulmonary blood flow to systemic blood flow of 2.5
After general anesthesia, she underwent right and left heart catheterization using a 6F sheath in the right femoral artery and a 7F sheath in the right femoral vein. A 6F pig-tail catheter was placed to aortic arch and a 6F cournand catheter was advanced from the venous side into the PDA and placed in the descending aorta. A descending aortogram was performed to evaluate the size, position and shape of the ductus (Image 8). The cournand catheter was exchanged with the delivery sheath (8F) over a 0.035 inch exchange guidewire and the dilator was removed, leaving the sheath in the descending aorta. The delivery cable was passed through the loader and the 10/8 mm sized Amplatzer PDA occlusion device (ususally 2 mm larger than the narrowest size of the PDA) was screwed clockwise into the tip of the delivery cable. The device and the loader were immersed in saline solution as the Amplatzer duct occluder was pulled into the loader. The loader was introduced into the delivery sheath and without rotation the device was advanced into the descending aorta. The sheath was retracted until the retention disk was opened in the proximal descending aorta. The sheath with the delivery cable was pulled back as one unit until the retention disk was snug against the aortic end of the ampulla. While maintaining tension on the delivery cable, the introducing sheath was withdrawn into the pulmonary artery to deploy the tubular frame of the prosthesis into the PDA (Image 9), similar in a way to deployment of a self-expandable stent. With the device still attached to the cable, a descending aortogram was performed in the lateral projection to confirm device position. After proper device position was confirmed, the device was released by turning the cable counterclockwise using the pin vise. A repeat descending aortogram was performed 5 minutes after the release to assess the degree of residual shunt, which showed much reduced shunt flow (Image 10).
Then, an 9Fr sheath was exchanged into right femoral vein. Intraprocedural TEE was used for guidance in the catheterization laboratory. Initially multipurpose catheter was advanced into left atrium through the PFO. The multipurpose catheter was replaced with a 0.035inch J-tipped exchange length guidewire and the tip was located in the left upper pulmonary vein for stability. Usually PFO defect size is underestimated on TEE, so we chose a 25mm sized Amplatzer device. Selected Amplatzer device was loaded into the delivery tube. And then, delivery sheath, a long dilator, was inserted into left atrium over a 0.035inch guidewire. And the prepared device was loaded into delivery sheath. The device was advanced until it reached the tip of the sheath. The device was at the tip of the sheath and the sheath was in the lumen of left atrium. The device was slowly advanced while at the same time slightly withdrawing the sheath to ensure that the left atrial disk opened in the lumen of left atrium. The device was advanced to compensate the device shortening as it was released from the sheath. Once the left atrial disk is fully opened in the left atrium, the sheath was withdrawn further to exposure central waist of the device. Then, the device and sheath were simultaneously withdrawn to the septum until the resistance by the septum was encountered. The sheath was further withdrawn to allow the right atrial disk open fully in the right atrium. Once the Amplatzer device has been fully opened, it was confirmed by TEE that both atrial disks are flattened and both atrial disk is entirely in each atrium respectively (Movie 1). After the stability of the device has been confirmed, the delivery cable was released by counterclockwise rotation. As the atrial septum returns to its natural position, the device typically springs superiorly and leftward radiologically (Image 11) and significant interatrial shunting through the device on TEE was eliminated on color Doppler (Movie 2). Post procedure TTE showed well positioned both devices (PFO: Image 12, PDA: Image 13).
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