1. Anesthesia & ASD Occluder Presented By R3 顏郁軒 93/8/9

2. ASD Occluder The first successful device closure of an ASD was performed in 1974 by King and Mills FDA granted approval two types of ASD occluder : Amplatzer septal occluder & CardioSEAL Septal Occluder

3. CardioSEAL Septal Occluder

4. Amplatzer Septal Occluder

6. Amplatzer Structure The AMPLATZER Septal Occluder is a self- expandable, double disc device made from a nickel- titanium (Nitinol) wire mesh Left atrial disk has a radius only 7 mm greater than the waist of the device (and thus the defect) and the right atrial disk is slightly smaller, being only 5 mm larger than the defect

7. Patient Selection (1) secundum ASD measuring less than or equal to 34 mm Defect should be greater than 5 mm away from the coronary sinus, atrioventricular valves, and right upper pulmonary vein

8. Patient Selection (2) Exclusion criteria include : congenital heart disease that requires cardiac surgery partial anomalous pulmonary venous return Pulmonary vascular resistance greater than 7 Wood’s U right-to-left shunting at the atrial level with a systemic saturation of less than 94% recent myocardial infarction, unstable angina, and decompensated congestive heart failure or significant right or left ventricular decompensation with an ejection fraction of less than 30%. The initial lower weight limit was 8 kg

9. Anesthetic Consideration Ketamine for initial diagnosis watch out patient’s hemodynamic status General anesthesia later and monitored with NIBP, Oximeter, ETCO2 TEE evaluation

10. TEE Evaluation the entire rim of the defect should be visualized 要看的 view : the mid-esophageal 4- chamber view at 0°, the short-axis view at 45° to 60°, and the biatrial long-axis view at 90° to 110°

12. 五個 Rim 的看法 ASD 的 5 個 portion S  PI : bicaval view PS  AI : four chamber view AS : 和 aortic root 的距離

14. Sizing the defect (1) Two methods can be used Pull technique Static technique The proper device size is selected as the stretched ASD size plus 1 mm

20. Sizing the defect (2) As reported in the literature, TEE may underestimate the size of the ASD, as determined by the stretched balloon diameter

21. Sizing the defect (3) 原因 ： 1. ASD 形狀不是圓的 2.ASD 的 septum 可能不是在同一平面 3. ASD 的形狀大小會隨著 heart cycle 而改 變 4.ASD margin 的組織可能是軟或較硬的， 所以用 sizing balloon 來推向兩邊時會有 一些差異

26. Evaluation, procedure, and postprocedural assessment Preprocedure Define ASD location Define ASD size Define ASD number; look for fenestrations Delineate ASD rim Is it firm or pliable? Is it deficient at any point, eg, inferoposteriorly? Atrial septal aneurysm? Look for associated defects (MVP, APVD) Measure distance from ASD to MV, CS, RUPV

27. Evaluation, procedure, and postprocedural assessment Intraprocedural Confirm guide wire in LA Confirm sizing balloon free in LA before inflation Confirm inflated balloon closes the defect Confirm delivery catheter in body of LA Ensure adequate deployment and positioning of LA disk Guide positioning during waist and RA disk deployment

28. Evaluation, procedure, and postprocedural assessment Watch for deployment difficulties Cobrahead malformation Chiari network entanglement Thrombus on catheters Assess adequacy of occlusion Review device relation to MV, CS, RUPV Check position stability during "Minnesota wiggle" Document degree of residual shunt through and around device

29. Evaluation, procedure, and postprocedural assessment Postprocedural Check device position Check device structural integrity Assess residual shunt Monitor changes in right heart chambers Check relation to other structures (MV, RUPV) Look for potential complications: thrombus, infection

32. Effectiveness of percutaneous device occlusion for atrial septal defect in adult patients with pulmonary hypertension American Heart Journal November 2002 P877~880 29 adult patients follow up of 21±14 months Our findings suggest that percutaneous device occlusion of ASD in adult patients with pulmonary hypertension is safe and effective and provides significant and prolonged relief.

33. Thanks For Your Attention !!!