Atrial Septal Defect Closure Stephen Brecker Director, Cardiac Catheterisation Labs

Atrial Septal Defect Closure

Stephen BreckerDirector,

Cardiac Catheterisation Labs

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


• Atrial septal defect– St. George’s experience

– Presentation in adults

– Indications for closure

– Techniques for closure

LA

RA

RUPV

RV


• Atrial septal defect

LALA

RARA

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


• Age at referral : – Males : 43.8 + 17 years, Range 16-77 years

– Females : 42.6 + 16 years, Range 17-77 years


• 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 ClosureDevices Used

Amplatzer ASO

AmplatzerCribriform 25AmplatzerCribriform 35Helex 20

Helex 25

CardiosealStarflex 38Cribriform 25

Atrial Septal Defect ClosureAmplatzer ASO Sizes (mm)

02

468

101214

161820

8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38


• 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– 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 – 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 – 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 – 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 – Presentation in adultsEvidence 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 controlsSt. John Sutton MG et al, Circulation 1981;64:402-409.



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



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 – Devices

Amplatzer Helex


• Atrial septal defect – Devices

Cardioseal StarFlex


• Atrial septal defect – Devices– Biostar


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


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 – 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


Intracardiac Echo


• Atrial septal defect – Fenestrated defect






• Device deployment


• Atrial septal defect – Cribriform device








• Atrial septal defect – Multiple defects




















• Conclusions– Majority of secundum ASDs device

closable– Excellent pre-procedure work up– Multiple defects, large defects closable– Training and skills– Imaging, ACHD, interventional skills

Documents

Atrial Septal Defect Closure Stephen Brecker Director, Cardiac Catheterisation Labs