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Atrial Septal Defect Closure

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

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Atrial Septal Defect Closure

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  1. Atrial Septal Defect Closure Stephen Brecker Director, Cardiac Catheterisation Labs

  2. ADVANCED ANGIOPLASTYIncorporating 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

  3. Atrial Septal Defect Closure • Atrial septal defect • St. George’s experience • Presentation in adults • Indications for closure • Techniques for closure

  4. RV RA LA RUPV

  5. Atrial Septal Defect Closure • Atrial septal defect

  6. RA RA LA LA Fig 9

  7. 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

  8. 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

  9. 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

  10. Atrial Septal Defect ClosureDevices Used

  11. Atrial Septal Defect ClosureAmplatzer ASO Sizes (mm)

  12. 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

  13. 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

  14. 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

  15. 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)

  16. 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

  17. 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

  18. 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.

  19. 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

  20. 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.

  21. Atrial Septal Defect Closure • Atrial septal defect – Devices Amplatzer Helex

  22. Atrial Septal Defect Closure • Atrial septal defect – Devices Cardioseal StarFlex

  23. Atrial Septal Defect Closure • Atrial septal defect – Devices • Biostar

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

  25. 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

  26. 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

  27. Atrial Septal Defect Closure Intracardiac Echo

  28. Atrial Septal Defect Closure • Atrial septal defect – Fenestrated defect

  29. Atrial Septal Defect Closure • Atrial septal defect – Fenestrated defect

  30. Atrial Septal Defect Closure • Atrial septal defect – Fenestrated defect

  31. Atrial Septal Defect Closure • Device deployment

  32. Atrial Septal Defect Closure • Atrial septal defect – Cribriform device

  33. Atrial Septal Defect Closure • Atrial septal defect – Cribriform device

  34. Atrial Septal Defect Closure • Atrial septal defect – Cribriform device

  35. Atrial Septal Defect Closure • Atrial septal defect – Cribriform device

  36. Atrial Septal Defect Closure • Atrial septal defect – Multiple defects

  37. Atrial Septal Defect Closure • Atrial septal defect – Multiple defects

  38. Atrial Septal Defect Closure • Atrial septal defect – Multiple defects

  39. Atrial Septal Defect Closure • Atrial septal defect – Multiple defects

  40. Atrial Septal Defect Closure • Atrial septal defect – Multiple defects

  41. Atrial Septal Defect Closure • Atrial septal defect – Multiple defects

  42. Atrial Septal Defect Closure • Atrial septal defect – Multiple defects

  43. Atrial Septal Defect Closure • Atrial septal defect – Multiple defects

  44. Atrial Septal Defect Closure • Atrial septal defect – Multiple defects

  45. Atrial Septal Defect Closure • Atrial septal defect – Multiple defects

  46. 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

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