Feasibility and safety of transcatheter closure of atrial septal defects with deficient posterior rim.

Objectives: To evaluate the feasibility and safety of percutaneous closure of complex secundum-type atrial septal defects (ASD) in patients with posterior-inferior rim deficiency.

Background: Transcatheter approach is the method of choice for ASD closure; however, up to now 20% of the defects are not considered suitable for percutaneous intervention because of the lack of surrounding rims, especially the posterior-inferior.

Methods: A total of 268 patients were evaluated between March 2005 and April 2011 for ASD closure. Twenty-four patients (9%) were not considered suitable for a percutaneous intervention and referred to surgery due to inadequate rims or a large defect diameter. Out of the remaining 244 patients, 25 (10,2%) had posterior-inferior rim deficiency and represent our study group.

Results: After failure of the conventional approach, alternative techniques were attempted. In 16 patients, an adjusted deployment and alignment maneuver approach was successful. In 5 other patients, a slide out technique was successfully performed by exploiting the right upper pulmonary vein. Finally in the remaining 4 patients, ASD closure was obtained by completely re-orienting the system with a jugular approach. No peri-procedural complications occurred, and at 12-month transesophageal echocardiography evaluation no residual shunt could be detected.

Conclusions: Our data show the feasibility of percutaneous approach for ASD closure in presence of a deficient posterior-inferior rim. The procedural success is strictly related to correct sizing and demonstration of a balloon notch on fluoroscopy. Long-term follow-up supports efficacy of the procedure in these selected cases.