Asd device closure
Download as PPTX, PDF2 likes739 views
This document discusses atrial septal defect (ASD) closure procedures. It describes that ASDs are often asymptomatic until adulthood but can lead to complications if left untreated. Preprocedural assessment includes echocardiography and additional imaging if needed. Surgical closure is preferred for primum, sinus venosus, and coronary sinus defects. Percutaneous closure is an alternative to surgery for secundum ASDs of appropriate size and anatomy. Percutaneous closure has comparable efficacy to surgery but shorter hospital stays and fewer complications. Complications of percutaneous closure include device embolization, arrhythmias, and erosion.
![EFFECT OF DEFECT CLOSURE ON
RISK OF ATRIAL ARRHYTHMIAS
• Atrial arrhythmias, primarily atrial fibrillation and atrial flutter, occur in approximately 20 percent of adult patients with an ASD and are often
the presenting symptom.
• The risk of these arrhythmias increases with patient age (especially over age 40) and with higher pulmonary artery pressures .
• In a report of 211 adults, for example, the incidence of AF or atrial flutter prior to surgery was 1 percent for those aged 18 to 40, 30 percent
for those aged 40 to 60, and 80 percent in those over the age of 60.
• Observational data suggest that ASD closure may reduce but does not eliminate the risk of atrial tachyarrhythmias.
• The effect of surgical or percutaneous defect closure on the prevalence of atrial arrhythmias was evaluated by a systematic review, including
26 studies in which a total of 1841 patients (with median or mean age at least 18 years prior to intervention) underwent surgical closure and
945 patients underwent percutaneous closure .
• Meta-analysis demonstrated a reduction in the prevalence of atrial tachyarrhythmias after ASD closure (odds ratio [OR] = 0.66, 95% CI 0.57-
0.77).
• This effect was found after both surgical closure (OR = 0.72, 95% CI 0.60-0.87) and percutaneous closure (OR = 0.49, 95% CI 0.32-0.76). A
significant decline in atrial tachyarrhythmias was seen both at <30 days and midterm (30 days to five years) follow-up.
• Limitations of the analysis include differences in methods for monitoring arrhythmias before and after closure in most of the studies.](https://image.slidesharecdn.com/asddeviceclosure-210515124007/85/Asd-device-closure-44-320.jpg)
Asd device closure
- 1. ASD DEVICE CLOSURE Dr.S.R. Sruthi Meenaxshi
- 2. • Atrial septal defect (ASD) is the most common congenital lesion in adults after bicuspid aortic valve. • Although patients with this defect are often asymptomatic until adulthood, potential complications of an untreated ASD include atrial arrhythmias, paradoxical embolization, cerebral abscess, right ventricular failure, and pulmonary hypertension that can become irreversible and lead to right-to-left shunting (Eisenmenger syndrome).
- 3. PREPROCEDURAL ASSESSMENT • Preprocedural assessment in patients with indications for ASD closure includes review of the transthoracic echocardiogram (TTE). • Some patients require additional testing such as transesophageal echocardiogram (TEE), cardiovascular computerized tomography (CT), or cardiac magnetic resonance (CMR) imaging to confirm the diagnosis and identify or exclude associated defects prior to surgical or percutaneous closure. • In patients with pulmonary hypertension, cardiac catheterization is usually recommended to determine the best management strategy.
- 4. • Conditions that are likely to require surgical correction should be identified prior to intervention: • Primum ASD, sinus venosus ASDs, and coronary sinus defects require surgical closure. • Primum ASD is usually accompanied by a cleft mitral valve. • A cleft mitral leaflet should be repaired at the time of ASD closure, even if associated mitral regurgitation is not severe, to avoid the need for another operation since mitral regurgitation usually progresses. • Primum ASDs may also be associated with tricuspid valve abnormalities, left ventricular outflow tract obstruction, ventricular septal defects, and a more extensive defect involving the atrioventricular septum (atrioventricular septal defect).
- 5. • Sinus venosus ASDs are usually associated with one or more anomalous right-sided pulmonary veins. • Sinus venous ASDs and the associated anomalous veins are often missed on standard TTE. • Agitated saline contrast administered during a TTE should demonstrate prompt filling of the left heart chambers with bubbles in the presence of a sinus venosus atrial septal defect. • Additional imaging options include TEE, CT, or CMR. However, these types of ASDs and anomalous pulmonary veins can be missed even with advanced imaging techniques. • These defects should be sought in patients with right heart enlargement. • Our practice is to delineate the anatomy, including all of the anomalous pulmonary veins, before the patient goes to the operating room for surgical intervention.
- 6. • Coronary sinus defects (also known as "unroofed coronary sinus") are often missed despite echocardiography. • They are often associated with left-sided superior vena cava and may accompany other congenital anomalies including ostium primum or secundum ASDs. • Observation of agitated saline in the left atrium initially, rather than the right atrium, after injection into a left-sided arm vein suggests the presence of a coronary sinus defect and left-sided superior vena cava.
- 7. • Multiple ASDs may be present (eg, concurrent secundum and primum ASDs). • Some patients with multiple small secundum ASDs are amenable to percutaneous closure; others require surgical closure.
- 8. • Some patients with ASDs have concomitant valve disease (in addition to cleft mitral valve with primum ASD as discussed above). • Moderate or more tricuspid regurgitation may persist after ASD closure in the adult. • We favor surgical ASD closure when there is moderate or more tricuspid regurgitation to facilitate both ASD closure and tricuspid repair at the time of operation
- 9. CHOICE OF CLOSURE PROCEDURE • Percutaneous transcatheter device closure is an alternative to surgical repair for the majority of patients with secundum ASDs. Surgical closure is recommended for patients with secundum ASD requiring closure when percutaneous repair is not feasible or appropriate . • Anatomic requirements for percutaneous closure are discussed below. • A secundum ASD with a large atrial septal aneurysm or a multifenestrated atrial septum requires careful evaluation to determine whether percutaneous device closure is appropriate
- 10. • Sinus venosus, coronary sinus, and ostium primum defects are preferably closed surgically, as they are not generally amenable to percutaneous device closure (although there are case reports of percutaneous closure of these defects).
- 11. • Percutaneous versus surgical closure for secundum ASD — • Observational studies comparing surgical and percutaneous transcatheter closure of secundum ASD suggest that mortality rates are similar, the rate of procedural success is comparable or slightly better with surgery, and the rate of early complications and length of hospital stay are reduced with the percutaneous approach. • Differing types of complications occur following the two procedures as illustrated by the following studies.
- 12. • An atrial septal aneurysm (ASA) is defined as redundant and mobile interatrial septal tissue in the region of the fossa ovalis with phasic excursion of at least 10 to 15 mm during the cardiorespiratory cycle. • ASA is commonly associated with patent foramen ovale or one or more ASDs
- 13. • A perforated aneurysm may be associated with a significant left-to-right shunt and present with clinical and hemodynamic features of an ASD. • Perforated aneurysms can be closed surgically or percutaneously, depending upon their morphology. • In a retrospective review of 50 patients, perforated aneurysms were classified as follows
- 15. Atrial Septal Aneurysm • Type A - aneurysm with persistent foramen ovale • Type B - aneurysm with single ASD • Type C - aneurysm with two perforations • Type D - aneurysm with multiple perforations
- 16. PERCUTANEOUS CLOSURE OF SECUNDUM ASD • Percutaneous device closure is an alternative to surgical closure in patients with secundum ASDs who have appropriate anatomic characteristics. • Two devices have both US Food and Drug Administration approval and CE-mark and are commercially available in the United States and Europe for percutaneous ASD closure the Amplatzer Septal Occluder and the Gore CARDIOFORM Septal Occluder. • The Occlutech ASD Occluder, the Ceraflex ASD Occluder, and the Nit- Occlud ASD-R have received CE-mark and are in clinical use in Europe
- 21. • Of note, the Gore CARDIOFORM Septal Occluder does not have self- centering properties, which limits its use for larger defects and it is used mostly for patent foramen ovale closure. • However, in selected patients with centrally located ASDs or multiperforated atrial septum, the CARDIOFORM Septal Occluder is a valid alternative device with less foreign material and excellent occlusion properties.
- 22. • The Amplatzer septal occluder and the CARDIOFORM device are characterized by relatively stiff delivery mechanisms, so the angulation of the device changes after device release. • In contrast to these occluders, the Occlutech and Ceraflex occluders have more flexible delivery mechanisms, which enable optimal septal alignment prior to device release. • The device remains in its final configuration and does not change its angulation at release. • An additional advantage of the flexible properties of the Occlutech and Ceraflex occluders is that the left atrial disc has less of a tendency to slip along the aortic root into the right atrium during device placement, and hence, fewer adjunctive procedures (eg, device deployment with an additional balloon) are needed.
- 23. • A few other devices that had been approved and were previously used for ASD closure are no longer available, including the CardioSEAL Septal Occlusion System, the STARFlex device (a next-generation version of the CardioSEAL device), and the Gore HELEX (a predecessor of the CARDIOFORM device). • The following discussion will review the efficacy and complications associated with percutaneous device closure of secundum ASD.
- 24. Contraindications and cautions • Pulmonary hypertension — Severe fixed pulmonary hypertension is considered a contraindication to ASD closure. • However, advances in the medical management of patients with pulmonary vascular disease together with the development of novel percutaneous closure techniques may make ASD closure feasible in this setting. • It has been suggested that patients with a net left-to-right shunt, a pulmonary vascular resistance less than 800 to 960 dyne sec cm (-5) m2 (10 to 12 Wood units), and a resting systemic arterial oxygen saturation ≥90 percent might benefit from ASD closure
- 25. • The potential efficacy of percutaneous closure was demonstrated in a report of 29 patients with a secundum ASD and a baseline peak pulmonary artery pressure >40 mmHg (mean 65 mmHg) in whom an Amplatzer device was implanted . • Complete ASD occlusion was achieved in 28 patients (97 percent). Immediately after the procedure, the mean peak pulmonary artery pressure decreased to 54 mmHg; at a mean of 21 months, it decreased further to 31 mmHg. • There were no procedural complications. Functional status was improved after the procedure and was maintained at a mean of 21 months. • Six of 12 patients who had AF at baseline recovered sinus rhythm by discharge.
- 26. Diastolic dysfunction • Unrecognized left ventricular diastolic dysfunction may be present in older patients with ASDs. • The presence of the left-to-right shunt at the atrial level may function to "offload" the stiff left ventricle in these patients. • One series demonstrated that temporary test occlusion of the ASD with a soft balloon catheter in adult patients may help identify individuals whose left heart filling pressures will worsen if device closure is performed . • Our practice is to generally perform ASD test occlusion in patients 40 years old or older. • If the mean left atrial or pulmonary capillary wedge pressure or left ventricular end-diastolic pressure increases significantly with test occlusion, then we forego device closure in most cases. • Further research needs to be conducted to identify a threshold increase in filling pressures, above which ASD closure may be detrimental.
- 27. ASD rims
- 32. • Anatomic requirements — Percutaneous device closure is generally applicable only to secundum ASDs . • Sinus venosus, primum, and coronary sinus defects are not often amenable to percutaneous repair, although cases of percutaneous repair of these defects have been reported
- 33. • The ideal lesion for percutaneous closure is a secundum defect ≤38 mm in diameter with a rim of tissue around the defect of at least 5 mm to prevent obstruction of the coronary sinus, right pulmonary veins, venae cavae, or atrioventricular valves. • The presence of a "retroaortic" superior-anterior atrial septal rim is favorable for device closure, but septal deficiency in this region is common and not necessarily a contraindication to percutaneous closure. • Retroaortic rim deficiency has been associated with risk of erosion, as discussed below.
- 34. • Approximately one-half to two-thirds of secundum ASDs in adults meet these criteria . • While smaller defects are often more amenable to device closure, larger defects can also be closed percutaneously. • The Amplatzer device is available in sizes ranging from 4 to 38 mm, reflecting the diameter of the central device of the waist and generally correlating with the size of the ASD to be closed. • By comparison, the CARDIOFORM device comes in only three sizes (20, 25, and 30 mm), reflecting the diameter of the device disk at full deployment. • The CARDIOFORM device can be used to close defects up to approximately 18 mm in diameter. • Closure of multiple ASDs has been performed using one or more closure devices, including use of an Amplatzer multifenestrated "cribriform" septal occluder device or one or more CARDIOFORM device .
- 35. • Rarely, secundum ASD is associated with a partial anomalous pulmonary venous connection that should generally be managed with surgical ASD closure and concomitant baffling of the anomalous pulmonary venous return. • Thus, prior to percutaneous closure, a search for anomalous pulmonary veins or other concurrent lesions that might require surgery should be undertaken, particularly if right heart chamber enlargement is out of proportion to the size of the ASD.
- 36. Echocardiographic monitoring • The use of transesophageal echocardiography (TEE) or intracardiac echocardiography (ICE) can facilitate the deployment of percutaneous ASD closure devices. • Measurement of the size and location of the ASD by TEE can help select the appropriate device. • In addition, TEE and ICE can be used to guide the procedure in real time, an approach that may eliminate the need for fluoroscopy. • Two- and three-dimensional (3D) TEE is particularly helpful when multiple devices are inserted to close multiple ASDs . • TEE during the procedure can also determine whether disruption of systemic or pulmonary venous inflow or valve function occurs with device placement.
- 37. • In one series, 94 patients underwent ICE during percutaneous closure of an ASD or patent foramen ovale (PFO) . • All devices were deployed successfully. During the procedure, ICE identified a previously unrecognized anatomical diagnosis in 32 patients (an additional ASD or PFO, a redundant atrial septum, or an atrial septal aneurysm). • Procedural complications occurred in four patients: atrial fibrillation (AF) in three and supraventricular tachycardia in one. Two of the arrhythmias resolved spontaneously and two required cardioversion with no recurrence. • 3D echocardiography enables direct and complete visualization of the ASD, so that the area of the defect can be estimated and the anatomy of the entire interatrial septum can be defined. • This 3D information facilitates optimal deployment and positioning of all types of interatrial closure devices. • Clinical series suggest that percutaneous ASD closure can be safely and effectively be performed using only echocardiographic guidance without fluoroscopy
- 38. Outcomes of percutaneous closure Observational studies of percutaneous closure have generally reported efficacy rates similar to surgical closure with shorter hospital stays and lower rates of complications . Defect closure is associated with a reduction in left atrial volume and improvements in right and left ventricular function and functional capacity even in adults who were asymptomatic at baseline.
- 39. Complications • Complications associated with transcatheter closure of a secundum ASD include device embolization or malposition, access site complications, atrial arrhythmias, atrioventricular conduction block (often transient), erosion/perforation, and sudden death (in at least some cases related to erosion)
- 40. • Early — The type and frequency of early complications were evaluated in a report of 417 patients (mean age 27 years) who underwent secundum ASD closure with the AMPLATZER or CardioSEAL/STARFlex device . • Thirty-four patients (8.6 percent) experienced a complication during hospitalization: ●Device embolization or malposition requiring surgery in 2.4 percent and managed percutaneously in 1 percent. ●AF or supraventricular tachycardia in 2.4 percent. ●Other complications (heart block, pericardial effusion, thrombus formation on the left atrial portion of the device, iliac vein dissection, groin hematoma) in 2.2 percent.
- 41. • A similar rate of early complications (11.5 percent) and no mortality were reported in a multi-center study of 688 patients undergoing ASD closure with the Amplatzer, CardioSEAL/STARflex, or HELEX septal occluder . • Device embolization occurred in 1.4 percent of patients with 0.4 percent of cases requiring surgical device removal. • In contrast, in another series of 124 patients, 6.5 percent required surgery for device malposition or embolization . • Embolized Amplatzer ASD occluders may be removed relatively safely by snaring the detachment hub and withdrawing through an adequately sized sheath. • The Occlutech and Ceraflex occluders, especially the larger sizes, are more difficult to be removed since a snare may slip off the detachment hub. The additional use of a dedicated biotome can be very helpful in these rare cases . • Transient atrioventricular block has been described with a frequency ranging from 1 to 6 percent . • Atrioventricular block may be more common with larger devices and smaller patients. This problem appears to resolve or improve spontaneously in most cases.
- 42. • Thrombus formation — Antiplatelet therapy (aspirin and clopidogrel) is given for at least six months to all patients receiving a percutaneous closure device to protect against thrombus formation . • Thrombus formation can occur in the left and/or right atrium . • Anticoagulation is used in patients with ASD closure devices who have another indication for anticoagulation therapy, such as AF. • The frequency with which thrombus formation occurs was evaluated in a review of 407 consecutive patients with an ASD and 593 consecutive patients with a PFO who were treated with a variety of devices . The following findings were noted: ●Thrombus on the device was detected by TEE at four weeks in 14 patients (1.4 percent) and at six months in six patients (0.6 percent). The overall rate of thrombus formation was 1.2 percent in patients with an ASD and 2.5 percent in patients with a PFO.
- 43. • After the investigators discontinued use of heparin therapy after implantation, thrombus occurred in only 1 of 183 patients (0.5 percent) treated with aspirin and clopidogrel. ●Thrombus formation was significantly more common with the CardioSEAL and STARFlex devices than with the Amplatzer device (5.9 versus 0 percent). An intermediate rate of 3.6 percent was noted with the Atrial-Septal-Defect-Occlusion-System (ASDOS) device. ●The thrombus resolved in 17 of 20 patients after anticoagulation with heparin and/or warfarin; in the remaining three patients, the thrombus was removed surgically. Four of the 20 patients suffered embolic events (strokes in three and a transient ischemic attack in one). • Left atrial thrombus formation with transient ischemic attacks has been described as late as three years after implantation
- 44. EFFECT OF DEFECT CLOSURE ON RISK OF ATRIAL ARRHYTHMIAS • Atrial arrhythmias, primarily atrial fibrillation and atrial flutter, occur in approximately 20 percent of adult patients with an ASD and are often the presenting symptom. • The risk of these arrhythmias increases with patient age (especially over age 40) and with higher pulmonary artery pressures . • In a report of 211 adults, for example, the incidence of AF or atrial flutter prior to surgery was 1 percent for those aged 18 to 40, 30 percent for those aged 40 to 60, and 80 percent in those over the age of 60. • Observational data suggest that ASD closure may reduce but does not eliminate the risk of atrial tachyarrhythmias. • The effect of surgical or percutaneous defect closure on the prevalence of atrial arrhythmias was evaluated by a systematic review, including 26 studies in which a total of 1841 patients (with median or mean age at least 18 years prior to intervention) underwent surgical closure and 945 patients underwent percutaneous closure . • Meta-analysis demonstrated a reduction in the prevalence of atrial tachyarrhythmias after ASD closure (odds ratio [OR] = 0.66, 95% CI 0.57- 0.77). • This effect was found after both surgical closure (OR = 0.72, 95% CI 0.60-0.87) and percutaneous closure (OR = 0.49, 95% CI 0.32-0.76). A significant decline in atrial tachyarrhythmias was seen both at <30 days and midterm (30 days to five years) follow-up. • Limitations of the analysis include differences in methods for monitoring arrhythmias before and after closure in most of the studies.
- 45. • The risk of AF after ASD closure is presumably primarily related to irreversible factors, such as incomplete atrial remodeling, that predispose to the arrhythmia. • Surgical techniques, such the Maze procedure performed at the time of surgical ASD closure, decrease the long-term incidence of AF in selected patients. • This procedure involves the placement of incisions or cryolesions in the atria to interrupt the macroreentrant circuits that sustain atrial flutter and AF . • The use of radiofrequency ablation to create endocardial lesions is also effective in preventing recurrences of AF, although data are limited in the patients with ASD
- 46. Thankyou