Several devices are available for transcatheter occlusion of atrial septal defect. This report describes the international experience with the buttoned device. During a 4.5-year period ending in February 1993, 180 transcatheter atrial septal defect occlusions were performed with the buttoned device. Patient age varied between 0.6 and 76 years and stretched atrial defect diameter between 5 and 25 mm. The defects were closed with 25 to 50 mm devices delivered through 8F (148 patients) or 9F (32 patients) sheaths. Twelve patients were adults whose defects were closed to prevent recurrence of cerebrovascular accidents caused by presumed paradoxic embolism. In the remaining patients the atrial defect was closed to treat the left-to-right shunt. The atrial septal defects were effectively occluded as demonstrated by (1) decrease in pulmonary-to-systemic flow ratio from 2.1 +/- 0.6 (mean +/- SD) to 1.05 +/- 0.1 (p < 0.01) by oximetry; (2) normalized S2 and disappearance of the diastolic murmur by auscultation; and (3) improvement in right ventricular volume overloading by echocardiogram. However, trivial to small shunts could be detected by color Doppler studies in 76 (45%) of 168 patients in whom such data are available. Complications included unbuttoning in 13 and whole-device embolization in 1. All patients remained stable, and retrieval of the device and surgical closure of the atrial septal defect were accomplished in 10 patients. Transcatheter retrieval was used in the remaining 4 patients. The incidence of unbuttoning, a major complication of the procedure, appeared to decrease with the increasing experience of the investigators and with device modification (third-generation). The follow-up duration varied between 1 month and 4 years. Six patients required surgery during the follow-up period. In the remaining patients (n = 160), clinical examination did not reveal signs of atrial shunts. Color Doppler studies revealed either complete disappearance of the previously demonstrated shunts or further diminution of their size. The results indicate that transcatheter occlusion of the atrial septal defects with buttoned devices is feasible, relatively safe, and effective, and it appears to be a viable alternative to surgery for some patients with secundum atrial septal defect. Complications are infrequent and should improve with experience.
We attempted percutaneous transcatheter-balloon mitral commissurotomy in eight children and young adults (9 to 23 years of age) with rheumatic mitral stenosis. The atrial septum was traversed by needle puncture, and an 8-mm angioplasty balloon was advanced over a guide wire. The atrial septal perforation was then dilated to allow passage of the valvuloplasty balloon catheter (18 to 25 mm) across the mitral annulus. Inflation of the transmitral balloon decreased the end-diastolic transmitral gradient temporarily in all patients (from 21.2 +/- 4.0 mm Hg [mean +/- S.D.] to 10.1 +/- 5.5 mm Hg; P less than 0.001). The immediate decrease in the gradient was associated with increases in cardiac output (from 3.8 +/- 1.0 to 4.9 +/- 1.3 liters per minute per square meter of body-surface area; P less than 0.01) and in the calculated mitral-valve-area index (from 0.73 +/- 0.29 to 1.34 +/- 0.32 cm2 per square meter; P less than 0.001). Murmur intensity diminished immediately after commissurotomy in all patients. The greatest reduction in pressure gradient (76 to 95 per cent) occurred when the largest balloon (inflated diameter, 25 mm) was used in the smallest patients (0.9 to 1.2 m2). The balloon commissurotomy produced minimal mitral regurgitation in only one child. Follow-up catheterization (at two to eight weeks) demonstrated persistence of hemodynamic improvement with evidence of partial restenosis in one patient. These early results indicate that balloon mitral commissurotomy can be a safe and effective treatment for children and young adults with rheumatic mitral stenosis.
Percutaneous transatrial mitral commissurotomy is an effective, safe procedure with gratifying intermediate results. It should be considered the treatment of choice for rheumatic mitral stenosis.
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