Cardiol Young 2008; 18: 343–347

r Cambridge University Press

ISSN 1047-9511
doi: 10.1017/S1047951108002291
First published online 6 May 2008

Original Article

Efficiency of transcatheter closure of atrial septal defects in

small and symptomatic children
Alain Fraisse,1 Jean Losay,2 François Bourlon,3 Gabriella Agnoletti,4 Jean-René Lusson,5 François Godart,6
Bernard De Geeter,7 Jérôme Petit,2 Jean François Piechaud8
1
Cardiologie Pe´diatrique, De´partement de Cardiologie, Hoˆpital La Timone, Marseille, France; 2Centre Chirurgical
Marie-Lannelongue, Le Plessis Robinson, France; 3Centre Cardiothoracique de Monaco, Monaco; 4Service de
Cardiologie Pe´diatrique, Hoˆpital Necker-Enfants-Malades, Paris, France; 5Service de Cardiologie et Maladies
Vasculaires, CHU Clermont-Ferrand, Hoˆpital G Montpied, Clermont-Ferrand, France; 6Service des Maladies
Cardiovasculaires Infantiles et Conge´nitales, Hoˆpital Cardiologique, CHRU de Lille, Lille, France; 7Service de
Cardiologie, Clinique Sainte Odile, Strasbourg, France; 8Institut Cardiovasculaire Paris Sud, Institut Hospitalier
Jacques Quartier, Massy, France

Abstract Objectives: We report the multicentric French experience with transcatheter closure in children
weighing 15 kilograms or less, with the aim of assessing the efficacy of the procedure in this age group.
Patients: We included all children weighing 15 kilograms or less, and seen between January, 1997, and June,
2004, who had successful transcatheter closure of an interatrial communication within the oval fossa.
Results: Transcatheter closure was performed in 35 patients weighing 15 kilograms or less, of whom 14 were
male and 21 female. The procedures were undertaken in 8 different centres, the patients having a median age of
3 years, with a range from zero to 6.2 years, and a mean weight of 13 kilograms, with a range from 3.6 to
15 kilograms. All the patients were symptomatic, with associated cardiac malformations present in 4 cases, and
extracardiac anomalies in 4 patients, including Down’s syndrome in 3, and Adams Oliver syndrome in the other
case. In 1 patient, emergency cardiac surgery was needed 24 h after the procedure to correct a previously
undiagnosed divided right atrium. No other complication occurred. After a median follow-up of 2 years, with a
range from 0.5 to 5.2 years, all the patients are asymptomatic, except for one long-standing patient with
bronchodysplasia. In 1 other patient, a small residual bidirectional shunt was detected by echocardiography. No
patient presented significant arrhythmia. In the patients followed-up for more than 12 months, we found a
significant gain in weight gain. Conclusion: Transcatheter closure of an interatrial communication within the oval
fossa is efficient in children weighing 15 kilograms or less, and can be proposed as a first line of treatment in
symptomatic patients. Children with retarded growth tend to have complete recovery within one year of closure.

Keywords: Interatrial communications; oval fossa defects; interventional catheterisation

neonates and infants for murmurs, however, suggests

A
N INTERATRIAL COMMUNICATION WITHIN THE
oval fossa, the so-called ‘‘ostium secundum’’ that interatrial shunting might be found in from one-
defect, is a common congenital malformation, quarter to one-half of all neonates.2 The majority of
with a reported incidence of 7% of all congenital these patients remains asymptomatic, with sponta-
cardiac lesions.1 Echocardiographic screening of neous resolution of the shunts in nine-tenths.2 Only a
minority of infants and small children with isolated
interatrial communications, therefore, experience
Correspondence to: Alain Fraisse, Cardiologie Pédiatrique, Département de
Cardiologie, Hôpital de la Timone, 264, rue Saint-Pierre, 13385 Marseille, symptoms and require closure.3–5
France. Tel: (33) 491 38 67 50; Fax: (33) 491 38 56 38; E-mail: Despite surgical closure of such defects carrying a
[email protected] low risk, and being a widely accepted procedure,5,6
Accepted for publication 17 December 2007 the rate of complications is reduced, and length of
344 Cardiology in the Young June 2008

stay in hospital shorter, after closure with a device centiles at the time of closure and during follow-up
inserted on a catheter.7 Moreover, after surgical were analyzed by Student’s paired t-test. A value for
treatment, concerns remain concerning the impact of p of less than 0.05 was considered to be statistically
cardiopulmonary bypass on developmental outcome.8 significant.
Hence, even though there are no randomized trials
comparing transcatheter and surgical closure, most Results
centres now favour the transcatheter approach,
providing the anatomy is suitable. The previous General characteristics (Table 1, Figure 1)
nonrandomized studies on transcatheter closure have Transcatheter closure was performed in 35 patients
mostly been carried out in adults and older children.9 weighing 15 kilograms or less, of whom 14 were male
Even in small children, nonetheless, recent reports and 21 female, the procedures being performed in 8
from a single centre have shown that transcatheter different centres (Fig. 1). The median age was 3 years,
closure can be performed safely and successfully in
experienced hands,3,7 with another report showing Table 1. Clinical presentation of the 35 patients undergoing
the procedure also to be safe and effective in a smaller transcatheter closure.
centre with less experience.10 The efficiency of such
closure on clinical symptoms, however, has yet to be Value number (%)
demonstrated in small children. In this report, there- Symptoms and weight retardation Median (range)*
fore, we describe the multicentric French experience Left-to-right shunt symptoms 30 (86)
with transcatheter closure in children weighing Mild to moderate cardiac failure 23 (66)
15 kilograms or less, paying particular attention to Recurrent lower respiratory tract infection 22 (63)
the relief of symptoms and to subsequent growth. Right-to-left shunt symptoms: cyanosis 5 (14)
Transcutaneous saturation of oxygen (%) 89 (83–92)*
Patients and Methods Weight centile 12 (2–75)*
Inferior to 25th centile 20 (57)
We chose to study patients weighing 15 kilograms Inferior to 10th centile 14 (40)
or less, since the majority of the patients previously Inferior to 3rd centile 7 (20
reported in studies assessing transcatheter closure
in small children also weighed 15 kilograms or
less3,7,10,11 and because 15 kilograms represents a cut-
off below which it is necessary to use a paediatric
rather than an adult transoesophageal probe.12 With
this in mind, we sought to collect data on all children
weighing 15 kilogram of less, and seen between
January, 1997, and June, 2004, who underwent
transcatheter closure of a defect within the oval fossa.
To achieve this end, we contacted all the French
centres performing transcatheter closure of such
defects, via the good offices of the Paediatric Working
Group of the French Society of Cardiology. All agreed
to participate to the study.
We excluded all those patients with defects
considered too large for percutaneous closure before
or at the time of catheterization. We also excluded
closure of interatrial communications associated with
complex congenital cardiac disease. We reviewed the
hospital records to collect clinical features, along with Figure 1.
electrocardiographic, echocardiographic, and haemo- Participating centres, with the number of procedure(s) performed
dynamic data, at the time of closure and during the for each of the centres during the period of study. CCM, Centre
Cardiothoracique de Monaco, Monaco; CCML, Centre Chir-
follow-up.
urgical Marie-Lannelongue, Le Plessis Robinson; CHRU Lille,
We diagnosed a residual shunt if colour Doppler Hoˆpital Cardiologique du centre hospitalier re´gional de Lille,
flow mapping showed either a left-to-right or a Lille; G Montpied, Hoˆpital Gabriel Montpied, Clermont-
right-to-left shunt across the atrial septum. We have Ferrand; Jacques Quartier, Institut Hospitalier Jacques Quartier,
expressed the data as a frequency or a percentage for Massy; La Timone, Hoˆpital de la Timone, Marseille; NEM,
nominal variables, and as the median with range Hoˆpital Necker-Enfants-Malades, Paris; Ste Odile, Clinique
for continuous variables. Differences between weight Sainte Odile, Strasbourg.
Vol. 18, No. 3 Fraisse et al: Efficiency of atrial septal defect closure in small children 345

with a range from birth to 6.2 years, and median

weight was 13 kilograms, with range from 3.6 to
15 kilograms. All the patients had been clinically
symptomatic (Table 1), related to a significant left-
to-right shunt in the majority, with several children
experiencing significant cyanosis due to right-to-left
shunt. In 1 of these patients, supplementation with
oxygen was needed as part of long-standing hospita-
lisation. The majority of the patients had also
experienced poor weight gain, including failure to
thrive (Table 1). An associated cardiac malformation
was present in 4 cases, with valvar pulmonary stenosis
in 3 cases, and a persistent patency of the arterial duct
in the other. In 2 cases, the stenotic pulmonary valve Figure 2.
was dilated with a balloon at birth, followed by Evolution of the mean centiles for weight in 17 children followed
construction of a modified Blalock-Taussig shunt in for more than 12 months after closure of the defect in the
one patient. Other associated cardiac features included oval fossa.
drainage of a persistent left superior caval vein to the
coronary sinus in one case. In 5 patients, birth had Follow-up
been premature, with bronchodysplasia in 2 cases. After a median follow-up of 2 years, with a range
Down’s syndrome was present in 3 cases, and Adams from 0.5 to 5.2 years, all the patients are asympto-
Oliver syndrome in another. matic except the long-standing patient who still
remains hospitalised with supplemental oxygen at the
last follow-up one year after closure of the atrial
Results and complications defect. In 1 patient with a previous right-to-left
All procedures were performed under general anaes- shunt, there is a small bidirectional residual shunt of
thesia, using fluoroscopy and transoesophageal echo- less than 2 millimetres as detected by colour Doppler
cardiographic guidance. In 2 cases, the procedure flow mapping. No patient has presented a significant
was performed under fluoroscopy with transthoracic arrhythmia or high degree atrioventricular block. In
echocardiographic guidance. After obtaining femoral 17 patients, 7 boys and 10 girls, with previous left-
venous access, we administered 50 to 100 units per to-right shunt and more than 12 months follow-up,
kilograms of heparin, and proceeded to catheterisation we have found a significant gain in weight when
of the right heart. In one patient born prematurely at comparing the mean centiles at the time of closure
27 weeks with bronchodysplasia at the time of the (p 5 0.02, Fig. 2).
procedure, the mean pulmonary arterial pressure was
elevated, at 50% of systemic levels, whereas pressures
Discussion
were within the normal range in the remaining
34 patients. The procedure for sizing and closure Our multicentric study has confirmed the feasibility
of the defects was as previously described.3,4,7,10,11 and safety of percutaneous transcatheter closure of
We implanted 35 Amplatzer septal occluders (AGA defect within the oval fossa in very young children,
Medical Corp.), the sizes ranging from 4 to even in small and less experienced centres (Fig. 1).
24 millimetres, with a median of 13 millimetres. Fluoroscopy and transoesophageal echocardiography
During the same procedure, one patient underwent provide appropriate guidance for such procedures,
closure of a persistently patent arterial duct with an and even transthoracic echocardiography can occa-
Amplatzer occluder (AGA Medical Corporation), and sionally be used.13 Others have reported the
a modified Blalock-Taussig shunt was occluded with a successful use of intracardiac echocardiographic
coil in another patient. We administered oral aspirin guidance when closing such defects in children
in a dose of 3 to 5 milligrams per kilogramme per day weighing less than 15 kilograms, with the potential
for 6 months after implantation. of eliminating the need for general anaesthesia,
There was no mortality, albeit that 1 patient although this must be set against the need for
required emergency cardiac surgery 24 hours after insertion of an 11 French sheath so as to obtain
the procedure to resect a previously undiagnosed intracardiac echocardiographic venous access.11
shelf dividing the right atrium, with a favourable Not all defects within the oval fossa need to be
outcome. There was no other major complication. treated, since they can still close spontaneously
Transthoracic echocardiography after the procedure beyond infancy,2,14 especially when measuring less
showed a small residual shunt in 5 cases. than 8 millimetres.2 In our study, however, we
346 Cardiology in the Young June 2008

closed only symptomatic defects. Although no intracardiac echocardiographic guidance that re-
official guidelines have been published, referring quired insertion of 11 French sheaths, or Butera
interventionists from the Paediatric Working and colleagues.3 Conversely, Vogel and associates4
Group of the French Society of Cardiology have reported embolization of 2 devices requiring surgi-
stated that transcatheter closure of defects within cal retrieval. The erosion that can be produced by
the oval fossa should be avoided in small children the Amplatzer septal occluder device has not been
(Jérome Petit, personal communication, 1st Journée shown to be related to younger age.20
Choussat, September 2003, Dijon, France). This Our study has its limitations. Beside its retro-
probably explains the small number of procedures spective nature, there was lack of specificity regarding
reported in our study, especially when compared to the symptoms of the left-to-right shunting that
a similar survey in Belgium, when 52 patients prompted closure in a heterogeneous population of
weighing 15 kilograms or less underwent transcath- patients, frequently with associated extracardiac
eter closure within 4 years.10 The shunt was also diseases. Relief of the symptoms after closure, as well
rarely assessed in our patients during the catheter- as the documented gain in weight, suggests that the
ization, since the symptomatology already reflected defect had played a prominent role in the clinical
a significant shunt. Moreover, there is no way state, although this cannot be fully demonstrated.
exactly measure the content of oxygen in so-called We conclude, therefore, that transcatheter closure
mixed venous blood, this usually involving estima- of defects within the oval fossa in children weigh-
tion from the saturations of oxygen in the superior ing 15 kilograms or less is feasible and efficient.
and inferior caval veins. With the use of general The technique can be proposed as a first line of
anaesthesia, the contribution from the inferior caval treatment in symptomatic patients. Children with
vein is stronger, and such estimation of mixed retarded growth tend to have complete recovery
venous saturation is even more unreliable.14,15 within one year of closure.
We were able to show a significant gain in weight
after closure of the defects. This is in agreement with
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