Trans-Catheter Management of Congenital Heart Disease: ASD device Closure Balu Vaidyanathan, Sumantha Sekhar Padhi, Ananthen KS, BRJ Kannan, SR Anil, R Krishna Kumar Pediatric Cardiology Amrita Institute of Medical Sciences Kochi, Kerala

Introduction Catheter based treatment of Common forms of congenital heart disease is one of the most important advances in the field of Pediatric cardiology Most forms of simple congenital heart lesions are now amenable to this form of therapy In PDA, Ostium Secundum ASD, Valvar Pulmonic Stenosis etc catheter based treatment has become the preferred form of treatment over surgery The major advantages of this form of therapy include avoidance of surgical scar, shorter hospital stay and earlier return to routine activities

Trans-catheter ASD closure Only Fossa Ovalis ASDs are suitable 80% of patients with Fossa Ovalis ASD can be treated by this method Can be safely performed in patients above 3 years Long term results are comparable /better than surgical closure

Pre-Procedure Evaluation: AIMS Protocol Clinical documentation of significant shunt A thorough Echo evaluation( TTE & TEE in selected cases) Size and adequacy of margins are assessed on echo Defects measuring upto 33 mm on Echo are suitable

TEE assessment of ASD Done routinely in all adults and in children with large defects TEE much superior in identifying adequacy of rims In adults TEE is done under local anesthesia while children require GA RA LA

The Device: Amplatzer Septal Occluder Made of nitinol (nickel + titanium) Double disc (LA > RA) joined by waist Size of waist = size of ASD Sizes ranging from 4 to 40 mm

Pre- procedure management Admission on previous day evening Routine blood investigations done Children are kept fasting for 4 hours before procedure; adults fast overnight Aspirin 3-5 mg/kg given from previous day Peri-procedural antibiotics administered (Cefazolin and Gentamycin 1 dose before procedure)

Sedation for Procedure Young Children Ketamine bolus (1 mg/Kg) and infusion (0.5 mg/kg/min) Midazolam (0.1 mg/kg) Older Children and adults ( without TEE) Pentazocine (1 mg/kg) Phenergan (0.5 mg/kg) Procedures under TEE General Anesthesia

Delivery sheath being de-aired Deployed device as seen on TEE STEPS IN ASD DEVICE CLOSURE( UNDER TEE) Delivery sheath being de-aired Deployed device as seen on TEE Amplatz wire placed in the left upper PV Catheter being introduced into the heart Patient being extubated Amplatzer septal occluder being prepared Delivery Sheath being introduced Preparation of the Sizing Balloon Deployment of the device being performed Vascular Access being Obtained Minnesota Wiggle being performed Sizing of the ASD being done Device being loaded onto delivery system Induction of General Anesthesia Balloon Sizing as seen on TEE TEE probe being introduced

Post-procedure management Overnight stay in the hospital Discharged on anti-platelet doses of Aspirin for 6 months OAC in older patients, large device or h/o arrhythmia Can resume normal work on the next day Follow-up at 3 months, 1 year and then SOS

ASD Device Closure: AIMS Data Total patients 301 Very large defects (>25mm in diameter) 56; Largest Device deployed: 40 mm in 2 Procedural success 293 ( 97%) Procedural complications Device embolisation 3 requiring surgery in 2 ( all in the our early experience) Failures/Backouts 6 Complications on Follow-up Pulm embolism 1; TIA 1; atrial flutter: 3

Pediatric Trans-Catheter Therapy: AIMS Experience One of the largest programs in the country at present Largest single centre experience on PDA coil occlusions in the world Pioneered the technique of Bioptome assisted multiple coil delivery for closure of large PDA (as an alternative for the more expensive Duct Occluder) Country’s single largest experience on ASD device closure A number of innovative procedures like ductal stenting in newborns with duct dependent CHD have been performed

Pediatric Cath Procedures at AIMS Total Procedures: 2965 ( Sept 1998-May 2004)

AIMS Publications in Pediatric Trans-catheter Interventions Kumar RK, Krishnan MN, Venugopal K, Anil SR, Sivakumar, Bioptome-assisted simultaneous delivery of multiple coils for closure of the large PDA, Catheterization and Cardiovascular Interventions 2001;54:95-100 Sivakumar K, Anil SR, Ravichandra M, Natarajan KU, Kamath P, Kumar RK. Emergency Transcatheter recanalization of acutely thrombosed Blalock Taussig shunts, Indian Heart Journal 2001;53:743-748 Anil SR, Sivakumar K, Kumar RK. Coil occlusion of the small patent ductus arteriosus without arterial access, Cardiology in the Young 2002;12:51-56 Anil SR, Sivakumar K, Kumar RK, Bioptome assisted closure of coronary artery fistula. Indian Heart Journal 2002;54:189-192 Anil SR, Sivakumar K, Philip A, Francis E, Kumar RK, Management strategies for hemolysis after transcatheter closure of the patent arterial duct, Catheterization and Cardiovascular Interventions 2003;59:538-43. Kannan BRJ, Anil SR, Sivakumar K, Kumar RK, Transcatheter closure of the very large atrial septal defects using the Amplatzer septal occluder, Catheterization and Cardiovascular Interventions 2003;59:522-527. Francis E, Sivakumar K, Kumar RK, Transcatheter Closure of Fistula Between the Right Pulmonary Artery and Left Atrium Using the Amplatzer Duct Occluder, In press, Catheterization and Cardiovascular Interventions. Kumar RK, Anil SR, Philip A, Sivakumar K, Bioptome-assisted coil occlusion of moderate-large patent arterial ducts in infants and small children, Catheterization and cardiovascular interventions 2004;62:266-71. Kannan BRJ, Padhy SS, Anil SR, Kumar RK: Catheter closure of the patent ductus arteriosus in sick ventilated infants, In press, Indian Heart Journal

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