Percutaneous closure of patent foramen ovale or atrial septal defect
Foramen ovale is an opening in the atrial septum that allows blood to flow between the atria in the fetus prior to birth. Shortly after birth, the foramen ovale closes, usually within a few weeks. if the foramen ovale does not close, it is referred as patent foramen ovale, or PFO.
A PFO may allow a blood clot or emboli to cross from right atrium to the left atrium. This is called a paradoxical embolism, which can travel to the brain and may result in a TIA or stroke. Patients diagnosed with TIA or stroke may be placed on Coumadin or another type of anticoagulation therapy. Although the presence of PFO is relatively common in the general population, a small percentage of these patients are at risk of cryptogenic stroke (stroke of unknown origin) due to an embolism.
Atrial septal defect (ASD) is an abnormal opening or communication between the left and right atrium. This causes an increase in blood flow to the right side of the heart, and a resulting right ventricle volume overload. Patients may complain of fatigue, unexplained shortness of breath, or be more prone to respiratory infections such as colds and pneumonia. In some circumstances, echocardiogram or tee may show bi-directional flow through the septum. In rare cases, asd and PFO may both be found.
Purpose of the device
The Amplatzer septal occluder and the amplatzar PFO occluder are percutaneous, transcatheter devices intended for the non-surgical closure of ASD and PFO, respectively. The device is a wire mesh made of nickel and titanium. The mesh is filled with polyester fabric to help close the defect. The polyester fabric is securely sewn into the device with a polyester thread.
Placement of either device involves standard interventional cardiac catheterization techniques. The procedure and placement of the device is usually guided and confirmed by cine pictures and TEE-produced echographic views.
Potential risks:
- allergic dye reaction
- reaction of sedation
- apnea
- arrhythmia
- bruising at the groin or arm
- bleeding around the introducer sheath, hematoma
- dislodgement of the device
- embolus, thrombus
- endocarditis
- fever
- risks associated with tee (ie. perforation of esophagus etc)
- stroke or tia
Benefits of the percutaneous approach vs. surgical approach:
- shorter hospital stay
- recovery time
- no chest scar
Procedure is done in the cath lab. The patient is prepped in the usual fashion as in any cath lab procedure. Transesophageal echocardiogram (TEE) is also performed to ensure placement of the occluder device. The catheter is inserted through a vein (most common access is the femoral vein, but the jugular vein and brachial vein can be accessed as well). Angiogram, right and left heart cath and O2 saturations may also be performed. Once the exact measurement of the ASD or PFO is determined, the appropriate size device is screwed onto a cable, put into a special catheter and advanced. When the disc of the device sits on each side of the hole and the proper placement is confirmed via cine and sonographic pictures, the device is deployed and implanted.
Duration of the procedure is approximately 1-2 hours. Patients can technically be discharged to home after recovery and bed rest for a few hours. Most, however, are kept at the hospital overnight due to insurance coverage reasons.
Discharge disposition:
1. Activities: all strenuous activities should be avoided for one month after the procedure. avoid heavy lifting that would increase pressure within the heart. (10# limit). instruct the patient that even if they feel well enough to resume normal activity, they should take it easy for a month.
2. Meds: plavix 75 mg. one tablet daily x 6 months.
3. Aspirin 325 mg. one daily chronically
*If patient was on Coumadin prior to procedure, most generally it is not resumed. The cardiologist will make the determination if coumadin needs to be resumed.
Follow-up:
1. Transthoracic echocardiogram in one month
2. TEE in 6 months with follow-up appt. in 6 months
3. Instruct patient regarding need for SBE prophylaxis for the first 6 months following implantation to minimize the risk of device infection. (scrip is given for the antibiotic for 6 month TEE)
*Please note: general guidelines per American Heart Association are recommended, i.e.:
· amoxicillin 2 gms orally 1 hr prior to procedure or
· clindamycin 600 mg orally 1 hr prior to procedure (for amoxicillin, pcn and ampicillin allergy)
General questions that may be asked by the patient:
· Safety with MRI - instruct patient that the device is MRI compatible. If an MRI has to be performed, the MRI staff should be informed about the presence of the implant. An ID card is given to the patient upon discharge.
· What happens to the device once it is implanted? The device is permanently implanted and should take about 3-6 months before complete endotheliazation takes place. The device becomes part of the septal wall and will be visible by x-ray.
To refer a patient with PFO or ASD for consultation, contact Dr. Mark Tannenbaum at (515) 235-5000.
