UNUSUAL CASES -<br />
<br />
The Versatility of the Amplatzer Septal<br />
Occluder for the Management of Multiple Atrial Septal Defects in a P

Percutaneous closure of secundum atrial septal defects (ASD) has become a promising alternative to surgical closure in selected patients. Fenestrated atrial septal defects do not preclude the use of multiple Amplatzer® Septal Occluders (Cook Incorporated, Bloomington, Indiana).1 We report the case of a fenestrated atrial septal defect closed with two Amplatzer Septal Occluders in the presence of a total situs inversus (“mirror image”) in a school-age patient. Case Report. A 7-year-old male was referred to our center for evaluation of a heart murmur heard on routine check-up by his pediatrician. On physical examination he had a wide split and fixed second heart sound associated with a grade 2–3/6 systolic ejection murmur best heard on the upper right parasternal border with radiation to both axillae and the back. The point of maximum impulse was felt on the 5th–6th right intercostal space at the midclavicular line. In addition, his liver was felt on the left upper abdominal quadrant. The electrocardiogram revealed normal sinus rhythm, right ventricular hypertrophy and right ventricular conduction delay. A transthoracic echocardiographic examination revealed the presence of a dextrocardia with total situs inversus (“mirror image”) associated with moderate-size fenestrated ASDs (6 mm and 9.3 mm) with a left to right shunt and enlargement of the right atrium and ventricle. A transesophageal echocardiographic examination (TEE) revealed the presence of the two separate atrial septal defects, one superior and smaller defect measuring approximately 5.5 mm and an inferior one of about 8.2 mm. There was a rim of tissue > 7 mm between the large and the small defect. There was enlargement of the right-side chambers. Cardiac catheterization confirmed the echocardiographic findings with normal right heart pressures and a Qp/Qs of 1.9:1 (Figure 1). Balloon sizing of the 5.5 mm and 8.2 mm defects was performed separately and revealed the stretched diameter of the small defect to be 10.9 mm and of the large defect to be 15.1 mm (Figure 2). Therefore, two separate 7 French (Fr), long sheaths (AGA Medical Corporation, Golden Valley, Minnesota) were positioned in the middle of the left atrium via the small superior and the inferior defects, respectively.1 A 15 mm Amplatzer Septal Occluder was attached to the delivery cable and introduced into the 7 Fr sheath. Similarly, an 11 mm Amplatzer Septal Occluder was introduced into the other 7 Fr sheath. Under TEE and fluoroscopic guidance, both left and right atrial discs of the 11 mm device were positioned across the septum, but not released (Figure 3). Then, the left and right atrial discs of the 15 mm device were deployed but not released (Figure 4). Sequential release of the devices was performed starting with the smaller device (Figure 5). Repeat TEE revealed complete closure of the two defects. There were no complications. Fluoroscopic time was 25 minutes and total procedure time was 120 minutes. The patient was discharged the following day. The patient was started on acetylsalicylic acid 5mg/kg/day for 6 months. At the 4-month follow-up, echocardiography with color Doppler revealed complete device occlusion of both ASDs. Discussion. Transcatheter closure of atrial septal defects is becoming an attractive alternative mode of treatment for small to moderate sized interatrial communications within the oval fossa. Since the mid-1970s, many devices have been developed and have undergone various modifications with variable degrees of success. The Amplatzer Septal Occluder was built to specifically address the limitations of previous devices.2 This case illustrates the advantages of catheter closure versus surgical closure in this total situs inversus patient.3 These include the absence of a surgical scar, the avoidance of cardiopulmonary bypass, and shorter hospital stay. Our patient’s hospital course was less than 24 hours with complete recovery. The presence of a fenestrated ASD in the setting of a total situs inversus did not preclude the use of the Amplatzer. To our knowledge, this is the first report in the literature of closure of multiple ASDs using two separate Amplatzer Septal Occluder devices in a patient with total situs inversus.4 Acknowledgment. The authors wish to thank Ziyad M. Hijazi, MD for his critique of the manuscript.

1. Cao Q, Radtke W, Berger F, et al. Transcatheter closure of multiple atrial septal defects. Initial results and value of two- and three-dimensional transesophageal echocardiography. Eur Heart J 2000;21:941–947. 2. Walsh KP, Maadi IM. The Amplatzer septal occluder. Cardiol Young 2000;10:493–501. 3. Berger F, Ewert P, Bjornstad PG, et al. Transcatheter closure as standard treatment for most interatrial defects: Experience in 200 patients treated with the Amplatzer Septal occluder. Cardiol Young 1999;9:468–473. 4. Hakim F, Madani A, Samara Y, et al. Transcatheter closure of secundum atrial septal defect in a patient with dextrocardia using the amplatzer septal occluder. Cathet Cardiovasc Diagn 1998;43:291–294.