Atrial Septal Defect Closure

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Atrial Septal Defect Closure

• Stephen Brecker
• Director,
• Cardiac Catheterisation Labs

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ADVANCED ANGIOPLASTYIncorporating The Left Main
5 Plus Course

• Conflicts of Interest
• The following companies have supported
  educational courses held at St. Georges
• AGA Medical (BVM)
• Gore
• NMT Medical, Inc.
• St. Jude

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Atrial Septal Defect Closure

• Atrial septal defect
• St. Georges experience
• Presentation in adults
• Indications for closure
• Techniques for closure

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RV
RA
LA
RUPV
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Atrial Septal Defect Closure

• Atrial septal defect

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RA
RA
LA
LA
Fig 9
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Atrial Septal Defect and Patent Foramen Ovale
Closure

• St. Georges Hospital 7 Year Experience
• 1st October 1998 31st January 2007
• 414 procedures
• 174 ASDs 114 female, 60 male
• 240 PFOs 115 female, 125 male

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Atrial Septal Defect Closure

• Age at referral
• Males 43.8 17 years, Range 16-77 years
• Females 42.6 16 years, Range 17-77 years

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Atrial Septal Defect Closure

• Out of 174 intention to treat procedures
• 151 patients received a single device
• 9 patients received two devices
• 1 patient had 2 procedures
• 1 patient received three devices
• 2 procedures
• 13 patients received no device
• Defect gt 40 mm 5
• Insufficent rim 5
• Three defects 1
• Multiple fenstrations 1
• Iliac vein access 1

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Atrial Septal Defect ClosureDevices Used
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Atrial Septal Defect ClosureAmplatzer ASO Sizes
(mm)
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Atrial Septal Defect Closure

• Dual Devices
• 2 ASOs 6 cases (20/2213/167/1032/3213/148/1
  0)
• 1 ASO / 1 PFO 2(A11/P25 P35/Cribriform 35)
• 2 Helex 1 (20/25)
• Three Devices
• 3 ASOs (7/10/17)
• Combined Procedures
• 3 cases combined with PCI, one with mitral
  valvuloplasty, one flutter ablation
• 1 set of non-identical twins

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Atrial Septal Defect Closure

• Atrial septal defect
• Types
• Secundum defect
• Single, multiple, fenestrated
• Primum defect
• Isolated or part of AV septal defect
• Superior caval vein defect
• Sinus venosus
• Inferior caval vein defect
• Unroofed coronary sinus

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Atrial Septal Defect Closure

• Atrial septal defect Presentation in adults
• Commonly missed in infancy and childhood
• Often no symptoms in early life
• Children increased incidence of chest
  infections
• Symptoms increase with age
• gt70 of adults symptomatic by 40 years
• Palpitation
• Dyspnoea
• Cough chest infections
• Fatigue
• Ankle swelling
• Symptoms of paradoxical emboli central and
  peripheral

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Atrial Septal Defect Closure

• Atrial septal defect Presentation in adults
• Physical signs
• Normal or low-volume pulse
• Normal or raised venous pressure
• Prominent right ventricular impulse
• Second sound widely split fixed in inspiration
  expiration
• Ejection flow murmur in pulmonary area
• Mid-diastolic tricuspid flow murmur
• Pansystolic murmur tricuspid regurgitation or
  mitral regurgitation (ostium primum defect)

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Atrial Septal Defect Closure

• Atrial septal defect Presentation in adults
• Investigations
• ECG Right bundle branch block
• Right axis deviation secundum defect
• Left axis deviation primum defect
• Prolonged PR interval
• CXR
• Moderate cardiac enlargement
• Small aortic knuckle
• Large pulmonary arteries
• Pulmonary plethora

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Atrial Septal Defect Closure

• Atrial septal defect Presentation in adults
• Complications
• Atrial arrhythmias
• Pulmonary hypertension right ventricular
  disease
• Eisenmenger syndrome and shunt reversal
• Paradoxical embolus
• Infective endocarditis (primum defect only)
• Investigations
• Echocardiography
• Transthoracic
• TOE mandatory size, rim, pulmonary venous
  anatomy
• Cardiac catheterisation

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Atrial Septal Defect Closure

• Atrial septal defect Presentation in adults
• Evidence for closure
• ASD in patients ages 60 years or older
  operative results and long-term postoperative
  follow-up
• 1955-1977
• 66 patients aged 60 years or older underwent
  operative closure
• 4 deaths (6)
• 47 patients followed up for 2-20 years
• 41 improved by at least one functional class
• Actuarial survival curves suggested improved
  mortality compared to age / sex matched medically
  treated controls
• St. John Sutton MG et al, Circulation
  198164402-409.

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Atrial Septal Defect Closure

• Atrial septal defect Presentation in adults
• Evidence for closure
• Surgical treatment for secundum atrial septal
  defects in patients
• gt 40 years old
• 521 patients with secundum ASDs
• Randomised to surgical closure (n232) or medical
  treatment (n241)
• Median follow up 7.3 years
• End point composite of death, PE, major
  arrhythmic event, embolic CVA, recurrent
  pulmonary infection, functional class
  deterioration or heart failure
• Risk of end point higher in medical group
• Hazard ratio 1.99
• Survival advantage when corrected for age, mean
  PAP, and cardiac index
• Attie F et al. J Am Coll Cardiol 2001382035-42

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Atrial Septal Defect Closure

• Atrial septal defect Presentation in adults
• Evidence for closure
• Improvement in exercise capacity in asymptomatic
  and mildly symptomatic adults after atrial septal
  defect percutaneous closure
• 37 patients with mean shunt of 2.1
• V02 max and echo measurement of RV dimensions pre
  post percutaneous closure
• Significant improvement in V02 max
• Significant reduction in RV dimensions
• Brochu M-C et al. Circulation 20021061821-1826.

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Atrial Septal Defect Closure

• Atrial septal defect Devices
• Amplatzer Helex

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Atrial Septal Defect Closure

• Atrial septal defect Devices
• Cardioseal StarFlex

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Atrial Septal Defect Closure

• Atrial septal defect Devices
• Biostar

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Atrial Septal Defect Closure

• Amplatzer Septal Occluder
• Self-expandable, double disc
• Nitinol wire mesh, short connecting waist
• Discs and waist filled with polyester fabric

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Atrial Septal Defect Closure

• Assessing for Percutaneous Closure
• Transoesophageal echoardiography
• Unstretched size
• Colour flow diameter
• Rim
• Anterosuperior rim often deficient
• Assess all rims anterior, posterior, inferior,
  superior
• Clearance
• Atrioventricular valves
• Inferior and superior vena cava
• Coronary sinus

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Atrial Septal Defect Closure

• Atrial septal defect Technique
• TOE vs ICE vs Fluoroscopy
• Local anaesthesia vs general anaesthesia
• 11F Sheath RFV
• 7F MPA2
• Saturations and pressure
• RUPV Angiogram
• Balloon sizing vs unstretched colour flow
  diameter
• Delivery sheath
• Device delivery
• Stability
• Release

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Atrial Septal Defect Closure

• Intracardiac Echo

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Atrial Septal Defect Closure

• Atrial septal defect Fenestrated defect

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Atrial Septal Defect Closure

• Atrial septal defect Fenestrated defect

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Atrial Septal Defect Closure

• Atrial septal defect Fenestrated defect

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Atrial Septal Defect Closure

• Device deployment

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Atrial Septal Defect Closure

• Atrial septal defect Cribriform device

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Atrial Septal Defect Closure

• Atrial septal defect Cribriform device

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Atrial Septal Defect Closure

• Atrial septal defect Cribriform device

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Atrial Septal Defect Closure

• Atrial septal defect Cribriform device

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Atrial Septal Defect Closure

• Atrial septal defect Multiple defects

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Atrial Septal Defect Closure

• Atrial septal defect Multiple defects

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Atrial Septal Defect Closure

• Atrial septal defect Multiple defects

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Atrial Septal Defect Closure

• Atrial septal defect Multiple defects

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Atrial Septal Defect Closure

• Atrial septal defect Multiple defects

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Atrial Septal Defect Closure

• Atrial septal defect Multiple defects

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Atrial Septal Defect Closure

• Atrial septal defect Multiple defects

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Atrial Septal Defect Closure

• Atrial septal defect Multiple defects

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Atrial Septal Defect Closure

• Atrial septal defect Multiple defects

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Atrial Septal Defect Closure

• Atrial septal defect Multiple defects

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Atrial Septal Defect Closure

• Conclusions
• Majority of secundum ASDs device closable
• Excellent pre-procedure work up
• Multiple defects, large defects closable
• Training and skills
• Imaging, ACHD, interventional skills