Occlusion of Fontan fenestrations using Amplatzer septal occluder

Abstract

The objective of the study is to assess efficacy and safety of the Amplatzer septal device for percutaneous occlusion of Fontan fenestration. Fenestration improves postoperative outcomes in children undergoing Fontan repair. Many of these fenestrations close spontaneously; persistent fenestrations ultimately cause desaturation and can be a potential cause of paradoxical embolism. This is a retrospective review of 26 consecutive patients who underwent transcatheter closure of Fontan fenestration in a tertiary cardiac center in Kuwait. After assessment of hemodynamic suitability for fenestration closure, appropriate balloon sizing of fenestration was obtained. The median age was 9.2 years (range = 1.5-18.3 years). Occlusion was accomplished using a 4-7 ml single Amplatzer septal device in 12 patients and 8-13 ml devices in the other 13 patients; 2 devices were deployed in one patient. Median fluoroscopic and procedure times were 22 and 143.5 min, respectively. One immediate complication was the embolization and successful retrieval of the Amplatzer duct occluder. The fenestration was subsequently occluded by Amplatzer septal device. A 100% occlusion rate of fenestration was achieved in both lateral tunnel and extracardiac conduit types of Fontans. Mean (SD) arterial oxygen saturation increased from 84.7% (4.7) to 95.2% (1.7, P < 0.001) 10 min after deployment of the occluder; Fontan mean circuit pressure had a minimal acceptable increment from 12.9 mmHg (3.2) to 14.6 mmHg (2.6, P < 0.001). No complications or device failures were seen during follow up. The Amplatzer septal occluder device is effective in closing both Fontan fenestrations. Longer single or dual anti-platelet therapy may be considered to prevent thrombotic events. Long-term outpatients follow up with transthoracic echocardiographic monitoring for systemic venous congestion or thrombosis is warranted.

Impact on clinical outcomes from transcatheter closure of the Fontan fenestration: A systematic review and meta-analysis

“…The long-term answer surrounding the question of what to do for the other 60% of patients was not clear. A persistent fenestration may be a surrogate for physiologic intolerance of the Fontan circulation, and this difference may not be readily apparent by pre-Fontan hemodynamic parameters ( 41 – 75 ). This has led some centers to either shift from routine closure to not closing any fenestrations ( 76 ) or to be very selective in which patients are referred for transcatheter closure ( 54 , 62 ).…”

Decision-making for surgery in the management of patients with univentricular heart

“…While some centers have retreated from the use of a fenestration ( 166 ), others are using it with increasing frequency ( 167 ). Arguments against routinely leaving incomplete atrial partitioning include: ongoing hypoxemia with a potential continued impetus for collateral formation ( 168 ), risk for paradoxical embolus ( 169 ), decreased exercise tolerance ( 170 ), and the potential for conduit thrombosis following interventional fenestration closure ( 171 , 172 ). However, many of these risks are only theoretical, and no studies have demonstrated a statistically significant increase in the most important complications including stroke and conduit thrombosis ( 148 , 167 ).…”

Cardiovascular imaging 2011 in the International Journal of Cardiovascular Imaging

“…Al-Hay et al describe the efficacy and safety of the Amplatzer septal device for percutaneous occlusion of Fontan fenestration in [7] in a retrospective review of 26 consecutive patients, who underwent transcatheter closure of Fontan fenestration in a tertiary cardiac center in Kuwait. They reported a 100 % occlusion rate and that no complications or device failures were seen during follow-up.…”