Atrial septal defect percutaneous closure
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Priyamvada Singh, MBBS [[2]]; Cafer Zorkun, M.D., Ph.D. [3]; Assistant Editor-In-Chief: Kristin Feeney, B.S. [[4]]
Overview
The Amplatzer septal occlude devices (ASO) can be used to successfully close selected oval fossa defects in adults. With proper patient selection these devices have excellent prognosis and minimal complications. The Food and Drug Administration has only authorized the use of percutaneous closure in ostium secundum patients.
Mechanisms of benefit
The Ampltazer septal occluder (ASO) is the most commonly used device as it allows closure of large cavities, is easy to implant, and boasts high success rates. As an instrument, the ASO consists of two self-expandable round discs connected to each other with a 4-mm waist, made up of 0.004–0.005´´ nitinol wire mesh filled with Dacron fabric. Implantation of the device is relatively easy. The prevalence of residual defect is low. It occludes the opening and benefits by preventing the shunting of blood across the lesion.
Indication
Percutaneous transcatheter closure is currently only indicated for the closure of ostium secundum atrial septal defects. In patients with a secundum defect, there must be a sufficient rim of tissue around the septal defect.
Contra-indications
It should not be used in patients with sinus venosus, primum or patent foramen ovale atrial septal defects.
Types of occluders
The Food and Drug Administration has authorized the following percutaenous transcatheters for usage:[1]. The Amplatzer septal occluder (ASO) is currently the most widely used device because it is easy to implant and has high success rates. It first came to be used for human subjects in 1995. However, the device is still not approved for usage in percutaneous closure of ostium primum and sinus venosus defects.
- Amplatzer septal occluder
- CardioSEAL
- HELEX septal occluder
- Sideris patch
Pre-surgical considerations
Prior to undergoing percutaneous closure, eligible atrial septal defect patients must undergo pharmacologic preparation therapy. Most therapy regimens include antiplatelet drugs to protect patients against thrombus formation. Prior to percutaneous closure, ostium secundum atrial septal defect patients undergo antiplatelet therapy such as aspirin or clopidogrel for a minimum of six months. This antiplatelet therapy protects patients against thrombus formation.
Secundum defects are assessed via echocardiographic monitoring to determine the anatomic viability of percutaneous closure. The ideal secundum defect is less than 30mm in diameter with an accompanying rim of tissue around the defect of at least 5mm. This rim of tissue serves to prevent impingement upon the superior vena cava (SVC), inferior vena cava (IVC), as well as the tricuspid or mitral valves.[2]
Per-cutaneous closure
The salient feature of the percutaneous device closure are-
- Device is placed via femoral vein.
- Best results are for centrally located secundum defects.
- Static diameter of the defect is assessed by using transesophageal echocardiography.
- TEE used for determining the device size, position, and deployment
- A 'stop-flow' technique is used to select the proper diameter of the device.
- In the stop flow technique, the sizing balloon is inflated until no flow is visible through the defect using transesophageal echocardiography.
- The margins of the defect must be ≤5 mm to accommodate the edges of the device.
Benefits
Complications
ACC/AHA recommendations for interventional and surgical therapy
Supportive trial data
Trials comparing percutaneous v/s surgical closure
In a multicenter, non-randomized study performed in 29 pediatric cardiology centers, the patients were allotted to either the device group or the surgical closure group depending on their preference. The success rate of the surgery was similar in the per-cutaneous and the surgical groups. However, the complication rate was more in the surgical (24%) compared to the percutaneous group (7.2%). Also, the mean hospital stay was 3 days in surgical group compared to 1 day in the percutaneous device group. With appropriate patient selection, device closure could be very successful. Also, it is safe and effective compared to other modalities [3]. Another disadvantage with surgical closure is that it requires sternotomy and cardiopulmonary bypass.
Trial testing the efficacy and safety of device closure
In a study done on 236 patients with secundum atrial septal defects (ASD), to evaluate the safety and efficacy of transcatheter closure with the amplatzer septal occlude, the device was found to be very efficient. It causes atrial septal defect closure in 84.7% of the treated patient population. During a median follow up of 2.3 years complete closure was documented in 94%, with a residual shunt only in 12 patients. Two of the treated patients were reported to have procedure related complications like retroperitoneal bleeding and air embolism.[4]
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References
- ↑ Schwetz BA (2002). "From the Food and Drug Administration". JAMA. 287 (5): 578. PMID 11829678.
- ↑ Ferreira SM, Ho SY, Anderson RH (1992). "Morphological study of defects of the atrial septum within the oval fossa: implications for transcatheter closure of left-to-right shunt". Br Heart J. 67 (4): 316–20. PMC 1024841. PMID 1389707.
- ↑ Du ZD, Hijazi ZM, Kleinman CS, Silverman NH, Larntz K, Amplatzer Investigators (2002). "Comparison between transcatheter and surgical closure of secundum atrial septal defect in children and adults: results of a multicenter nonrandomized trial". J Am Coll Cardiol. 39 (11): 1836–44. PMID 12039500.
- ↑ Fischer G, Stieh J, Uebing A, Hoffmann U, Morf G, Kramer HH (2003). "Experience with transcatheter closure of secundum atrial septal defects using the Amplatzer septal occluder: a single centre study in 236 consecutive patients". Heart. 89 (2): 199–204. PMC 1767528. PMID 12527678.