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MDCT Evaluation After Closure of Atrial Septal Defect with an Amplatzer Septal Occluder

¹ Department of Radiology, Taichung Veterans General Hospital, Taichung Harbor Rd., Taichung 407, Taiwan, Republic of China.
² Faculty of Medicine, Medical College of Chung Shan Medical University, Taiwan, Republic of China.
³ Department of Medicine, National Yang Ming University, Taiwan, Republic of China.
⁴ Institute of Clinical Medicine, National Yang Ming University, Taiwan, Republic of China.
⁵ Section of Pediatric Cardiology, Department of Pediatrics, Taichung Veterans General Hospital, Taiwan, Republic of China.
⁶ Section of Cardiovascular Surgery, Department of Surgery, Taichung Veterans General Hospital, Taiwan, Republic of China.

View larger version (111K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —9-year-old girl with Amplatzer septal occluder (AGA Medical Corporation) in good position. See also Figs. S1G-S1K, cine loops, in supplemental data. Oblique axial MDCT image in plane perpendicular to Amplatzer septal occluder shows anatomic features. Two metallic points (arrows) should appear simultaneously to ensure perpendicularity between plane and device. After plane is set, scrolling up and down shows device for comprehensive evaluation. Oblique axial images are useful in evaluating device and its relation to aorta, mitral valve, tricuspid valve, and coronary sinus. LA = left atrium, LV = left ventricle, RA = right atrium, RV = right ventricle.

View larger version (116K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —9-year-old girl with Amplatzer septal occluder (AGA Medical Corporation) in good position. See also Figs. S1G-S1K, cine loops, in supplemental data. Oblique sagittal MDCT image shows plane perpendicular to device. Oblique sagittal images are useful for evaluating device and its relation to superior vena cava (SVC), inferior vena cava (IVC), and coronary sinus. Device protrusion over superior and inferior portions can be easily identified. LA = left atrium, RA = right atrium.

View larger version (115K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C —9-year-old girl with Amplatzer septal occluder (AGA Medical Corporation) in good position. See also Figs. S1G-S1K, cine loops, in supplemental data. MDCT in four-chamber view shows dynamic relations between device and mitral and tricuspid annuli. LA = left atrium, LV = left ventricle, RA = right atrium, RV = right ventricle.

View larger version (101K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1D —9-year-old girl with Amplatzer septal occluder (AGA Medical Corporation) in good position. See also Figs. S1G-S1K, cine loops, in supplemental data. Multiplanar reformation image with plane through two metallic points (arrow) and coronary sinus shows severely compressed coronary sinus.

View larger version (114K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1E —9-year-old girl with Amplatzer septal occluder (AGA Medical Corporation) in good position. See also Figs. S1G-S1K, cine loops, in supplemental data. Multiplanar reformation image with plane through two metallic points and superior vena cava shows laminar flow (arrow) from superior vena cava to right atrium. In most patients with Amplatzer septal occluder, right atrial disk (arrowheads) protrudes slightly into superior vena caval to right atrial flow tract, which is normal condition. In some patients, protrusion is so prominent that normal laminar flow is interrupted (Fig. 7C).

View larger version (135K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1F —9-year-old girl with Amplatzer septal occluder (AGA Medical Corporation) in good position. See also Figs. S1G-S1K, cine loops, in supplemental data. Global multiplanar reformation image of coronary arteries shows malignant coronary anomaly. Right coronary artery arises from left sinus of Valsalva with interarterial course (arrowheads). High-pressure compression between aorta (Ao) and right ventricular outflow tract (RVOT) would expose patient to risk of sudden death during vigorous exercise. Whole-heart approach is important during interpretation because atrial septal defect can be combined with other congenital cardiac anomaly. AL = anterior leaflet, CRX = circumflex artery, LAD = left anterior descending coronary artery, RA = right atrium, RCA = right coronary artery.

View larger version (111K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —3-year-old boy after insertion of two Amplatzer septal occluders (AGA Medical Corporation). MDCT was performed with mild sedation and free breathing. See also Figs. S2D and S2E, cine loops, in supplemental data. Oblique axial MDCT image in plane through center of upper and larger Amplatzer septal occluder shows proper position of device. LA = left atrium, LV = left ventricle, RA = right atrium, RV = right ventricle.

View larger version (109K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —3-year-old boy after insertion of two Amplatzer septal occluders (AGA Medical Corporation). MDCT was performed with mild sedation and free breathing. See also Figs. S2D and S2E, cine loops, in supplemental data. Oblique axial MDCT image in plane through lower, smaller device shows suspected device migration with mild compression of coronary sinus. LA = left atrium, LV = left ventricle, RA = right atrium, RV = right ventricle.

View larger version (123K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C —3-year-old boy after insertion of two Amplatzer septal occluders (AGA Medical Corporation). MDCT was performed with mild sedation and free breathing. See also Figs. S2D and S2E, cine loops, in supplemental data. Oblique sagittal MDCT image shows two devices in proper position. Both devices cross border (dashed line) between left atrium (LA) and right atrium (RA). Device position is difficult to evaluate with transthoracic echocardiography because of limited acoustic window and severe acoustic shadow. This case emphasizes need to evaluate Amplatzer septal occluder in perpendicular plane.

View larger version (135K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —31-year-old woman after insertion of 40-mm Amplatzer septal occluder (AGA Medical Corporation), which is in good position. See also Figs. S3C and S3D, cine loops, in supplemental data. Forty-millimeter Amplatzer device is not yet approved by U.S. Food and Drug Administration. Oblique sagittal MDCT image shows proper position of device. LA = left atrium, IVC = inferior vena cava, RA = right atrium.

View larger version (118K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —31-year-old woman after insertion of 40-mm Amplatzer septal occluder (AGA Medical Corporation), which is in good position. See also Figs. S3C and S3D, cine loops, in supplemental data. Forty-millimeter Amplatzer device is not yet approved by U.S. Food and Drug Administration. Four-chamber view MDCT image shows relation between device and mitral and tricuspid valves (arrowheads) and space (arrow) between device and mitral valve. LA = left atrium, LV = left ventricle, RA = right atrium, RV = right ventricle.

View larger version (128K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —18-year-old woman with incidentally found left ventricular noncompaction after insertion of two Amplatzer septal occluders (AGA Medical Corporation), one of which is relatively large. See also Figs. S4E and S4F, cine loops, in supplemental data. Oblique sagittal MDCT image in plane through two devices shows tethered waist (arrow) and mushroom shape of larger device. Larger device was chosen to adequately clip upper smaller device and provide extra stability. LA = left atrium, RA = right atrium, SVC = superior vena cava.

View larger version (152K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —18-year-old woman with incidentally found left ventricular noncompaction after insertion of two Amplatzer septal occluders (AGA Medical Corporation), one of which is relatively large. See also Figs. S4E and S4F, cine loops, in supplemental data. Photograph shows disk shape of 20-mm Amplatzer septal occluder clipping 20-mm defect. Both left and right atrial disks are flat and in close contact with rim.

View larger version (118K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4C —18-year-old woman with incidentally found left ventricular noncompaction after insertion of two Amplatzer septal occluders (AGA Medical Corporation), one of which is relatively large. See also Figs. S4E and S4F, cine loops, in supplemental data. Photograph shows 20-mm Amplatzer septal occluder placed into 6-mm hole, which is too small for device. Mushroom shape is caused by waist tethering (arrow).

View larger version (124K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4D —18-year-old woman with incidentally found left ventricular noncompaction after insertion of two Amplatzer septal occluders (AGA Medical Corporation), one of which is relatively large. See also Figs. S4E and S4F, cine loops, in supplemental data. MDCT image of short axis of left ventricle shows prominent left ventricular trabeculation (black arrows), prominent noncompaction (NC) layer (long white arrow), and thin compaction (C) layer (short white arrow). Ratio of noncompaction layer to compaction layer is greater than 2, which meets criterion for diagnosis of left ventricular noncompaction. This rare cardiomyopathy is difficult to recognize even retrospectively on transthoracic echocardiography. Because disease is inherited, family screening was undertaken and showed same disorder in patient's 15-year-old brother. LV = left ventricle, RV = right ventricle.

View larger version (126K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5 —7-year-old boy with minimal residual shunt due to rim deficit after insertion of Amplatzer septal occluder (AGA Medical Corporation). Oblique axial MDCT image shows 1-mm residual defect (arrow) near superior vena cava (SVC). In some patients, focal rim deficit results in residual defect even with proper position of device. Because of high position and device blocking, transthoracic echocardiography could not be used to evaluate residual defect. Because patient's condition was asymptomatic, outpatient follow-up was suggested because small defect can be sealed during epithelialization. Ao = aorta, LA = left atrium, LAA = left atrial appendage, RAA = right atrial appendage, RVOT = right ventricular outflow tract. See also Fig. S5, cine loop, in supplemental data.

View larger version (124K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A —34-year-old woman with minimal protrusion due to rim deficit but no residual shunt after insertion of Amplatzer septal occluder (AGA Medical Corporation). See also Figs. S6C and S6D, cine loops, in supplemental data. Oblique sagittal MDCT image shows upper portion of device protruding into right atrium (RA). Both left and right atrial disks (arrow) are in right atrium. IVC = inferior vena cava, LA = left atrium, SVC = superior vena cava.

View larger version (107K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B —34-year-old woman with minimal protrusion due to rim deficit but no residual shunt after insertion of Amplatzer septal occluder (AGA Medical Corporation). See also Figs. S6C and S6D, cine loops, in supplemental data. Oblique coronal MDCT image confirms position in another plane. Arrow indicates protruded upper portion of device. IVC = inferior vena cava, LA = left atrium, RA = right atrium, SVC = superior vena cava.

View larger version (118K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A —8-year-old girl with minimal residual shunt between left atrium and inferior vena cava after insertion of Amplatzer septal occluder (AGA Medical Corporation). See also Figs. S7E-S7G, cine loops, in supplemental data. Oblique sagittal MDCT image shows residual shunt from left atrium (LA) to inferior vena cava (arrow). Shunts appear as radiopaque jet projecting from defect to right side of heart. RA = right atrium.

View larger version (120K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B —8-year-old girl with minimal residual shunt between left atrium and inferior vena cava after insertion of Amplatzer septal occluder (AGA Medical Corporation). See also Figs. S7E-S7G, cine loops, in supplemental data. MDCT image shows protrusion and residual shunt related to different inherent curves of atrial septum (black line) and device (white line). LA = left atrium, RA = right atrium, RAA = right atrial appendage, SVC = superior vena cava.

View larger version (99K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7C —8-year-old girl with minimal residual shunt between left atrium and inferior vena cava after insertion of Amplatzer septal occluder (AGA Medical Corporation). See also Figs. S7E-S7G, cine loops, in supplemental data. Oblique sagittal MDCT image in diastolic phase shows absence of shunt (arrow). Because of pressure change during heart cycle and check-valve effect of device, left-to-right shunt was present only in systolic phase. Because of low location and blocking by device, residual shunt was missed on routine follow-up echocardiography.

View larger version (105K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7D —8-year-old girl with minimal residual shunt between left atrium and inferior vena cava after insertion of Amplatzer septal occluder (AGA Medical Corporation). See also Figs. S7E-S7G, cine loops, in supplemental data. Oblique sagittal MDCT image in plane through device and superior vena cava shows upper portion of right atrial disk (arrowheads) protruding into superior vena caval to right atrial flow tract, causing turbulent flow (arrows).

View larger version (151K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8A —43-year-old man with marked device protrusion after insertion of Amplatzer septal occluder (AGA Medical Corporation). See also Figs. S8H-S8J, cine loops, in supplemental data. Lateral chest radiographs show marked device protrusion in patient (A) and normal position of Amplatzer septal occluder in different patient of same age (B). Occluder in good position is in vertical orientation, which represents orientation of atrial septum. If there is marked protrusion into right atrium, marked anterior tilting with nearly horizontal orientation is present.

View larger version (163K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8B —43-year-old man with marked device protrusion after insertion of Amplatzer septal occluder (AGA Medical Corporation). See also Figs. S8H-S8J, cine loops, in supplemental data. Lateral chest radiographs show marked device protrusion in patient (A) and normal position of Amplatzer septal occluder in different patient of same age (B). Occluder in good position is in vertical orientation, which represents orientation of atrial septum. If there is marked protrusion into right atrium, marked anterior tilting with nearly horizontal orientation is present.

View larger version (126K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8C —43-year-old man with marked device protrusion after insertion of Amplatzer septal occluder (AGA Medical Corporation). See also Figs. S8H-S8J, cine loops, in supplemental data. Oblique sagittal MDCT image shows marked protrusion of upper portion of both left and right atrial disks (arrowheads) in right atrium. Residual defect (arrow) also is evident. LA = left atrium, RA = right atrium.

View larger version (133K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8D —43-year-old man with marked device protrusion after insertion of Amplatzer septal occluder (AGA Medical Corporation). See also Figs. S8H-S8J, cine loops, in supplemental data. Systolic (D) and diastolic (E) MDCT images of same section show waving of atrial septum (arrows). Intracardiac sonogram immediately after deployment of device showed good position of device with only minimal shunting. After 1 week, marked protrusion was found on chest radiograph and transthoracic echocardiogram. Cause of migration was not clear but was considered to be related to rim deficit and redundant and waving atrial septum.

View larger version (133K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8E —43-year-old man with marked device protrusion after insertion of Amplatzer septal occluder (AGA Medical Corporation). See also Figs. S8H-S8J, cine loops, in supplemental data. Systolic (D) and diastolic (E) MDCT images of same section show waving of atrial septum (arrows). Intracardiac sonogram immediately after deployment of device showed good position of device with only minimal shunting. After 1 week, marked protrusion was found on chest radiograph and transthoracic echocardiogram. Cause of migration was not clear but was considered to be related to rim deficit and redundant and waving atrial septum.

View larger version (127K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8F —43-year-old man with marked device protrusion after insertion of Amplatzer septal occluder (AGA Medical Corporation). See also Figs. S8H-S8J, cine loops, in supplemental data. Virtual angioscopic image from workstation shows relations between device and septum. Residual defect and extent of protrusion are evident. ASO = Amplatzer septal occluder, LSPV = left superior pulmonary vein, RIPV = right inferior pulmonary vein, RSPV = right superior pulmonary vein.

View larger version (160K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8G —43-year-old man with marked device protrusion after insertion of Amplatzer septal occluder (AGA Medical Corporation). See also Figs. S8H-S8J, cine loops, in supplemental data. Surgical photograph shows protruding device. To prevent further migration, surgical removal of device with concomitant atrial septal defect closure was performed. After incision of right atrium, migrated upper portion (arrowheads) and normally positioned lower portion (arrow) clipping lower atrial septum were identified. Forceps indicates protruded upper portion of device in right atrium.

View larger version (181K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8H —43-year-old man with marked device protrusion after insertion of Amplatzer septal occluder (AGA Medical Corporation). See also Figs. S8H-S8J, cine loops, in supplemental data. Virtual angioscopic image viewed from right atrium shows findings identical to surgical findings, that is, migrated upper portion (arrowheads) and normally positioned lower portion (arrow) clipping lower atrial septum.

View larger version (117K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9A —35-year-old man with incidental finding of left main coronary artery compressed by right pulmonary artery during evaluation after insertion of Amplatzer septal occluder (AGA Medical Corporation). Patient had experienced long-term chest tightness and was found to have atrial septal defect, which was closed with Amplatzer septal occluder. Chest tightness did not subside after procedure. Because of unusual clinical course, MDCT was performed for further device evaluation. See also Fig. S9C, cine loop, in supplemental data. Oblique sagittal MDCT image shows good device position. IVC = inferior vena cava, LA = left atrium, RA = right atrium, SVC = superior vena cava.

View larger version (108K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9B —35-year-old man with incidental finding of left main coronary artery compressed by right pulmonary artery during evaluation after insertion of Amplatzer septal occluder (AGA Medical Corporation). Patient had experienced long-term chest tightness and was found to have atrial septal defect, which was closed with Amplatzer septal occluder. Chest tightness did not subside after procedure. Because of unusual clinical course, MDCT was performed for further device evaluation. See also Fig. S9C, cine loop, in supplemental data. Oblique coronal MDCT image in section through left main coronary artery (LM) shows dilated right pulmonary artery (RPA) compressing proximal portion of left main coronary artery with 90% diameter stenosis. Because pulmonary artery diameter and pressure were expected to decrease after closure of atrial septal defect, patient was discharged with oral ß-blocker and advice to avoid vigorous exercise. Symptoms subsided gradually within 6 months. This case emphasizes importance of whole-heart evaluation, especially when clinical course cannot be explained. Ao = aorta, ASO = Amplatzer septal occluder, CPA = central pulmonary artery, LV = left ventricle, RV = right ventricle.

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