Transjugular Approach to Device Closure of Atrial Septal Defect

1 downloads 0 Views 6MB Size Report
We found that device closure of the child's atrial septal defect through a jugular venous ... now considered to be the treatment of choice for secundum ASDs, with few excep- tions. ... pulmonary veins, coronary sinus ostium, and atrioven-.
Case Reports

Transjugular Approach to Device Closure of Atrial Septal Defect in a Child with Heterotaxia and Interrupted Inferior Vena Cava

Nazan Ozbarlas, MD In heterotaxia syndrome with left atrial isomerism, the distinguishing feature is interruptAlev Kiziltas, MD ed inferior vena cava with azygos continuation. We report using a transjugular approach Osman Kucukosmanoglu, MD to device closure of an atrial septal defect in an 8-year-old boy with heterotaxia syndrome. Sevcan Erdem, MD

We found that device closure of the child’s atrial septal defect through a jugular venous approach was safe when an inferior vena cava approach was not possible. To our knowledge, ours is the first report of the use of internal jugular vein access to close an atrial septal defect in a child. (Tex Heart Inst J 2012;39(3):435-7)

P Key words: Cardiac surgical procedures/instrumentation; child; heart catheterization/ instrumentation/methods; heart septal defects, atrial/ therapy; jugular veins/surgery; risk factors; treatment outcome From: Division of Pediatric Cardiology, Faculty of Medicine, University of Cukurova, 01330 Adana, Turkey Address for reprints: Alev Kiziltas, MD, Division of Pediatric Cardiology, Faculty of Medicine, University of Cukurova, Balcali, 01330 Adana, Turkey E-mail: [email protected] © 2012 by the Texas Heart ® Institute, Houston

Texas Heart Institute Journal

ercutaneous transcatheter closure of an atrial septal defect (ASD) was first described by Mills and King in 19761; however, no devices with which to perform the procedure were available until the 1990s.2 Catheter-based closure is now considered to be the treatment of choice for secundum ASDs, with few exceptions. The standard procedure is performed when patients are under general anesthesia, with percutaneous venous catheterization through the femoral vein and arterial catheterization through the femoral artery. Heterotaxia is characterized by poor or no differentiation between the left- and right-sided organs, with resulting congenital malformations of multiple organ systems. Polysplenia syndrome (left atrial isomerism) is characterized by multiple splenic tissues, absence of the sinus node, a tendency toward bilateral left-sidedness, and cardiovascular and pulmonary abnormalities. The most significant differential point is the inferior vena cava (IVC), which is mostly normal in patients with asplenia syndrome but is interrupted (with azygos continuation) in 85% of polysplenia patients. Normal hearts or only minimal cardiovascular abnormalities are present in approximately 13% of patients with polysplenia syndromes.3 We report the transjugular device closure of an ASD in a child with heterotaxia syndrome (left atrial isomerism) and an interrupted IVC.

Case Report In May 2010, an 8-year-old boy was referred to our pediatric cardiology unit with the diagnosis of a heart murmur. Findings during physical examination were normal except for a widely split and fixed S2 with a grade 2/6 systolic ejection murmur at the left sternal border. An electrocardiogram revealed right bundle branch block and wandering atrial pacemaker rhythm, with a superior P axis. A chest radiograph showed a prominent pulmonary artery segment and increased pulmonary vascular markings. Two-dimensional echocardiography revealed an interrupted IVC with azygos continuation, left atrial isomerism with right-handed topology, mild enlargement of the right side of the heart, and an 8-mm secundum ASD with deficient aortic rim. The patient had begun taking aspirin 2 days before the procedure. With the patient under general anesthesia, cardiac catheterization with transesophageal echocardiographic (TEE) guidance was performed. A 6F sheath was placed in the right femoral vein to enable examination of the interrupted vena cava with azygos continuation to the superior vena cava. A 7F sheath for the device was inserted in the right jugular vein, and a 5F sheath was placed in the left femoral artery. After insertion Transjugular Closure of ASD in a Child

435

of a femoral artery line for hemodynamic monitoring, a 100-U/kg bolus of heparin was administered. A 10-mm Amplatzer ® Septal Occluder (St. Jude Medical, Inc.; St. Paul, Minn) was selected in accordance with the defect size on TEE. A multipurpose catheter could not pass into the defect, so a 5F cobra-shaped hydrophilic-coated catheter (Slip-Cath ® Beacon ® Tip Catheter, Cook Medical Inc.; Bloomington, Ind) was used. Because of its convenient shape, this catheter passed into the defect easily (Fig. 1). A stiff exchange guidewire was placed in the upper pulmonary vein with use of this cobra catheter (Fig. 2). As soon as the delivery sheath and dilator were passed forward over the guidewire, the guidewire unexpectedly fell back from the pulmonary

Fig. 3 Fluoroscopic image (posteroanterior view) shows the tip of the Amplatzer delivery sheath in the left atrium.

Fig. 1 Fluoroscopic image (left anterior oblique view) shows the hydrophilic-coated cobra-shaped catheter in the left pulmonary vein.

Fig. 4 Fluoroscopic image (posteroanterior view) shows the occluder device’s position after release.

Fig. 2 Fluoroscopic image (left anterior oblique view) shows the guidewire in the left pulmonary vein.

436

Transjugular Closure of ASD in a Child

vein to the left atrium (Fig. 3). Despite this, the occluder device was introduced into the left-sided atrium. The left atrial disc of the device was extruded and pulled against the defect, the sheath was pulled back, and the central waist and right atrial disc of the device were deployed. The device’s shape and the flow patterns of the pulmonary veins, coronary sinus ostium, and atrioventricular valves were evaluated by means of TEE and transthoracic echocardiography, and the occluder was then released (Fig. 4). There was no residual defect. Aspirin therapy was recommended for 6 months after the procedure. At the 1-week, 1-month, and 1-year follow-up examinations, the patient had no major rhythm disturbances or other problems. Volume 39, Number 3, 2012

Discussion To our knowledge, ours is the first report of the use of internal jugular vein access to close an ASD in a child. Device closure is the preferred method for managing secundum ASDs.4 The procedure has been performed conventionally with femoral vein puncture and use of the IVC connection to the right atrium. This approach is not possible in situations such as femoral venous occlusion or interrupted IVC. Under such circumstances, alternative routes for catheterization have been reported. In 1995, Sommer and colleagues5 reported a percutaneous transhepatic approach as an alternative catheterization route in pediatric patients. In 1999, Shim and associates6 reported 2 cases of ASD closure via the percutaneous transhepatic approach. Oliveira and co-authors7 reported transhepatic ASD occlusion in an 18-year-old patient with congenital absence of the vena cava. Major complications of the transhepatic approach include retro- or intraperitoneal bleeding, hemobilia, perforation of the gall bladder, portal vein thrombosis, pneumothorax, pleural effusions, and liver abscess or peritonitis and liver injury. Transjugular ASD closure is an alternative when the conventional approach is not possible. Abdel-Massih and colleagues8 reported the transjugular device closure of an ASD in a 71-year-old patient with severe scoliosis, and Sullebarger and associates9 used the technique in a 77-year-old patient with iatrogenic total occlusion of the IVC. Difficulties in the transjugular approach include placing a large sheath in the jugular vein, directing the catheter through the septum, manipulating it past the defect, and placing a catheter or guidewire in the upper left pulmonary vein. Furthermore, there is a risk of air embolism during the procedure. In our patient, we used the transjugular approach because of the IVC interruption. Because it is difficult to place a large sheath in the jugular vein of pediatric patients, the Amplatzer device—with its smaller, feasible delivery-sheath size—provided some advantage. Passing the catheter into the defect and placing the guidewire in the pulmonary vein were more difficult than a transfemoral approach would have been. We overcame these difficulties by using a hydrophilic-coated cobra-shaped catheter. As soon as the delivery sheath was installed, the guidewire fell from the pulmonary vein to the left atrial cavity, but fortunately this caused no difficulty in deploying the device. Had we used the delivery sheath of the Amplatzer Duct Occluder (St. Jude Medical) because of the 180° curve, perhaps better position across the ASD could have been maintained during device delivery. Despite aortic rim deficiency in our patient, we encountered no difficulties during device placement. In our pediatric patient, we found that the jugular venous approach was safe. Venous complications were Texas Heart Institute Journal

prevented by using a device with a smaller delivery system. Finally, the risk of air embolism must be kept in mind when performing the transjugular procedure. The proximal end of the sheath must be carefully manipulated below the level of the heart, to prevent air embolism.

References 1. Mills NL, King TD. Nonoperative closure of left-to-right shunts. J Thorac Cardiovasc Surg 1976;72(3):371-8. 2. Masura J, Gavora P, Formanek A, Hijazi ZM. Transcatheter closure of secundum atrial septal defects using the new selfcentering Amplatzer septal occluder: initial human experience. Cathet Cardiovasc Diagn 1997;42(4):388-93. 3. Park MK. Heterotaxia (atrial isomerism, splenic syndromes). In: Park MK, editor. Pediatric cardiology for practitioners. 5th ed. Philadelphia: Mosby Elsevier; 2008. p. 293-8. 4. Amin Z, Hijazi ZM, Bass JL, Cheatham JP, Hellenbrand WE, Kleinman CS. Erosion of Amplatzer septal occluder device after closure of secundum atrial septal defects: review of registry of complications and recommendations to minimize future risk. Catheter Cardiovasc Interv 2004;63(4):496-502. 5. Sommer RJ, Golinko RJ, Mitty HA. Initial experience with percutaneous transhepatic cardiac catheterization in infants and children. Am J Cardiol 1995;75(17):1289-91. 6. Shim D, Lloyd TR, Beekman RH 3rd. Transhepatic therapeutic cardiac catheterization: a new option for the pediatric interventionalist. Catheter Cardiovasc Interv 1999;47(1):415. 7. Oliveira EC, Pauperio HM, Oliveira BM, da Silva RA, Alves FM, Adjuto GL. Percutaneous closure of atrial septal defect using transhepatic puncture [in Portuguese]. Arq Bras Cardiol 2006;87(2):193-6. 8. Abdel-Massih T, Boudjemline Y, Agnoletti G, Acar P, Iserin F, Douste-Blazy MY, et al. Percutaneous closure of an interatrial communication via the internal jugular route using an Amplatzer prosthesis [in French]. Arch Mal Coeur Vaiss 2002;95(10):959-61. 9. Sullebarger JT, Sayad D, Gerber L, Ettedgui J, Jimmo-Waumans S, Alcebo PC. Percutaneous closure of atrial septal defect via transjugular approach with the Amplatzer septal occluder after unsuccessful attempt using the CardioSEAL device. Catheter Cardiovasc Interv 2004;62(2):262-5.

Transjugular Closure of ASD in a Child

437