Author + information
- Received January 18, 2018
- Revision received February 9, 2018
- Accepted February 20, 2018
- Published online May 2, 2018.
- Mohamad Alkhouli, MDa,∗ (, )
- David M. Campsey, MDa,
- Luke Higgins, MD, PhDb,
- Vinay Badhwar, MDc,
- Anas Diab, MDd and
- Partho P. Sengupta, MDa
- aDivision of Cardiology, West Virginia University School of Medicine, Morgantown, West Virginia
- bDepartment of Radiology, West Virginia University School of Medicine, Morgantown, West Virginia
- cDivision of Nephrology, West Virginia University School of Medicine, Morgantown, West Virginia
- dDepartment of Cardiothoracic Surgery, West Virginia University School of Medicine, Morgantown, West Virginia
- ↵∗Address for correspondence:
Dr. Mohamad Alkhouli, Division of Cardiology, West Virginia University School of Medicine, 1 Medical Drive, Morgantown, West Virginia 26505.
A 43-year-old functional female patient with end-stage renal disease, history of failed kidney transplant and arteriovenous fistulas, and factor V Leiden deficiency on chronic anticoagulation experienced recurrent ischemic strokes in multiple vascular territories. She is maintained on hemodialysis via a tunneled right subclavian venous catheter. Echocardiography revealed a large right-to-left shunt, which was further characterized as a sinus venosus atrial septal defect (SVASD), without concomitant anomalous pulmonary veins (Figure 1, Online Videos 1 and 2).
After a detailed multidisciplinary team discussion, percutaneous closure was recommended. Peripheral access was not possible because of the chronic occlusion of the inferior vena cava and the left and right innominate veins (Figure 2). We contemplated using the dialysis catheter access site for the procedure but were advised against it because it was the patient’s last remaining dialysis access. Hence, percutaneous hepatic access was obtained under ultrasound guidance. A micropuncture needle was introduced to the right hepatic vein, and a 6-F catheter sheath was inserted. The sheath was then upsized to a 14-F catheter Cook sheath over a 0.035-inch Amplatz extra-stiff wire (Cook, Bloomington, Indiana). The pathway to the SVASD was intricate because the chronic calcified dialysis catheter was adjacent to the defect. An Agillis sheath (St. Jude Medical, Minneapolis, Minnesota) was used to navigate the complex route into the SVASD, which was accessed with a 6-F catheter multipurpose catheter and a Glide-wire (Terumo, Tokyo, Japan). A 25-mm Cardioform septal occluder (Gore, Newark, Delaware) was advanced to the left atrium over an Amplatz extra-stiff wire and deployed across the SVASD (Figure 3, Online Video 3). The 14F catheter sheath was removed and the access site was closed with an 8-mm Amplatzer-Vascular-Plug-II (St. Jude Medical). The patient remained free of further events at 3-month follow-up.
Percutaneous hepatic access provides a viable route for adult patients with structural heart diseases and no other access. Although surgery remains the first-line treatment for SVASD, transcatheter closure is a feasible alternative in high-risk surgical candidates.
All authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received January 18, 2018.
- Revision received February 9, 2018.
- Accepted February 20, 2018.
- 2018 American College of Cardiology Foundation