Clinical Images

Percutaneous Closure of a “Doughnut Leak” Around an Atrial Septal Occluder Device in a Patient With Recurrent Migraines

Pradyumna Agasthi, MD1; Joseph N. Graziano, MD2; Stephen G. Pophal, MD2

Pradyumna Agasthi, MD1; Joseph N. Graziano, MD2; Stephen G. Pophal, MD2

J INVASIVE CARDIOL 2020;32(9):E242-E243. 

Key words: atrial septal defect, transcatheter device closure

A 10-year-old girl with pulmonary atresia status post transannular patch repair and secundum atrial septal defect (ASD) underwent percutaneous ASD closure with 14 mm Amplatzer ASD occluder (ASDO; Abbott Vascular) at the age of 5 years. There was improvement in arterial saturation from 86% to 98% with minimal residual right-to-left shunt. She subsequently developed recurrent migraines despite medical therapy. Echocardiogram with agitated saline (EAS) demonstrated moderate residual right-to-left shunt from the inferior aspect of the ASDO (Figure 1A). After extensive discussion, we elected to pursue percutaneous closure of the right-to-left shunt due to her recurrent migraines.

Cardiac catheterization was performed via femoral approach and revealed a right atrial pressure of 10 mm Hg with a pulmonary to systemic blood flow ratio of 0.9. Multiple attempts were made to advance wires into the left atrium along the ASDO without success. However, each wire passed around the waist of the ASDO in a circular fashion (Figures 1B and 1C; Video 1). After advancing the wedge catheter along the wire, angiography revealed a “doughnut-shaped” leak in a 360° loop along the waist of the ASDO connecting the right and left atrium (Figures 1D and 1E; Video 2). We elected to close this channel using a 6 x 6 mm Amplatzer Duct Occluder II (ADO2). A Glidewire (Terumo Medical) was advanced along the waist into the left atrium and the Glide catheter (Terumo Medical) was advanced into the left atrium. Several wires were used to secure the position; however, we could not advance the 5 Fr Flexor delivery sheath (Cook Medical) across the full loop due to high tortuosity within the ASDO. Therefore we advanced the ADO2 180° around the loop and deployed the device (Figure 1F; Video 2). Repeat angiogram showed complete occlusion with no right-to-left shunt (Figures 1G and 1H; Video 2). The device was released and repeat EAS confirmed no residual shunt. The patient subsequently had near complete resolution of her migraines.

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From the 1Department of Cardiovascular Diseases, Mayo Clinic, Phoenix, Arizona; and 2Department of Cardiology, Phoenix Children’s Hospital, Phoenix, Arizona.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted December 19, 2019.

Address for correspondence: Pradyumna Agasthi, MD, Department of Cardiovascular Diseases, Mayo Clinic, 5779 East Mayo Blvd, Phoenix, AZ 85054. Email: