Atrial Septal Defect Closure Stephen Brecker Director, Cardiac Catheterisation Labs
ADVANCED ANGIOPLASTY Incorporating The Left Main 5 Plus Course Conflicts of Interest The following companies have supported educational courses held at St. George’s AGA Medical (BVM) Gore NMT Medical, Inc. St. Jude
Atrial Septal Defect Closure St. George’s experience Presentation in adults Indications for closure Techniques for closure
RV RA LA RUPV
Atrial Septal Defect Closure
RA RA LA LA Fig 9
Atrial Septal Defect and Patent Foramen Ovale Closure St. George’s Hospital 7 Year Experience 1st October 1998 – 31st January 2007 414 procedures 174 ASDs : 114 female, 60 male 240 PFOs : 115 female, 125 male
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
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 > 40 mm : 5 Insufficent rim : 5 Three defects : 1 Multiple fenstrations : 1 Iliac vein access : 1
Atrial Septal Defect Closure Devices Used
Atrial Septal Defect Closure Amplatzer ASO Sizes (mm)
Atrial Septal Defect Closure Dual Devices 2 ASOs : 6 cases (20/22;13/16;7/10;32/32;13/14;8/10) 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
Atrial Septal Defect Closure 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
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 >70% of adults symptomatic by 40 years Palpitation Dyspnoea Cough – chest infections Fatigue Ankle swelling Symptoms of paradoxical emboli – central and peripheral
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)
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
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
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 1981;64:402-409.
Atrial Septal Defect Closure Atrial septal defect – Presentation in adults Evidence for closure Surgical treatment for secundum atrial septal defects in patients > 40 years old 521 patients with secundum ASDs Randomised to surgical closure (n=232) or medical treatment (n=241) 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 2001;38:2035-42
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 2002;106:1821-1826.
Atrial Septal Defect Closure Atrial septal defect – Devices Amplatzer Helex
Atrial Septal Defect Closure Atrial septal defect – Devices Cardioseal StarFlex
Atrial Septal Defect Closure Atrial septal defect – Devices Biostar
Atrial Septal Defect Closure Amplatzer Septal Occluder Self-expandable, double disc Nitinol wire mesh, short connecting waist Discs and waist filled with polyester fabric
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
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
Atrial Septal Defect Closure Intracardiac Echo
Atrial Septal Defect Closure Atrial septal defect – Fenestrated defect
Atrial Septal Defect Closure Atrial septal defect – Fenestrated defect
Atrial Septal Defect Closure Atrial septal defect – Fenestrated defect
Atrial Septal Defect Closure Device deployment
Atrial Septal Defect Closure Atrial septal defect – Cribriform device
Atrial Septal Defect Closure Atrial septal defect – Cribriform device
Atrial Septal Defect Closure Atrial septal defect – Cribriform device
Atrial Septal Defect Closure Atrial septal defect – Cribriform device
Atrial Septal Defect Closure Atrial septal defect – Multiple defects
Atrial Septal Defect Closure Atrial septal defect – Multiple defects
Atrial Septal Defect Closure Atrial septal defect – Multiple defects
Atrial Septal Defect Closure Atrial septal defect – Multiple defects
Atrial Septal Defect Closure Atrial septal defect – Multiple defects
Atrial Septal Defect Closure Atrial septal defect – Multiple defects
Atrial Septal Defect Closure Atrial septal defect – Multiple defects
Atrial Septal Defect Closure Atrial septal defect – Multiple defects
Atrial Septal Defect Closure Atrial septal defect – Multiple defects
Atrial Septal Defect Closure Atrial septal defect – Multiple defects
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