Presentation1.pdf
- 1. ASD Device Closure Why and How Dr. Chandra Mani Adhikari Cardiologist Shahid Gangalal National Heart Centre Associate Professor National Academy of Medical Sciences
- 2. ASD secundum • Accounts for 10% of congenital heart disease at birth. •As much as 30% to 40% in adults who present with congenital heart disease. •More frequent in Females. J Cardiovasc Ultrasound 2007;15(1):1-7
- 3. Surgical closure for ASD • For many years has been the gold standard treatment. • is a safe and effective with negligible mortality. N Engl J Med 2000;342:256-63.
- 4. Surgical closure is associated with morbidity • Bypass related complications • Sternotomy/thoracotomy • Scar (specially young unmarried patients) N Engl J Med 1990;323:1645-50.
- 5. Even the surgeon needs to think of cosmetic things • As most of the patients are young females • Emphasis has been placed on shorter incisions • “less” or “minimally” invasive techniques, including minimal access, port access, robotics, video-assisted, etc. • Goal is to improve cosmetic results. • These approaches are not associated with decreased morbidity or mortality. J Cardiovasc Thorac Res, 2014, 6(4), 205-210
- 6. cosmesis has now become a concern to surgeons and patients especially among young females.
- 7. Surgery vs. Device closure • Mild complications: small pericardial effusions, headaches, AV delay, atrial rhythm disturbances • Moderate complications: pneumonia, paroxysmal SVT, AV junctional rhythm • Severe complications: bleeding requiring reoperation, transient neurologic events. Device closure is associated with lower complication rate. Bialkowski J, et al. Tex Heart Inst J 2004; 31: 220-3.
- 8. • Successful closure is achieved by both methods. • Device closure results in lower rate of complication and hospital stay • Cost of the procedure tends to be higher than surgery. J Cardiovasc Thorac Res, 2014, 6(4), 205-210 Pakistan
- 9. Benefit of device closure • Avoidance of surgery • Avoidance of pain • Avoidance of cardiopulmonary bypass and its risk • Residual thoracotomy scar • Short time of procedure • Rapid recovery • Shorter hospital stay Safe, Simple and Effective
- 10. Study in Canada shows decrease in surgical closure
- 11. Device closure for ASD is the treatment of choice. Comparable procedural success Lower complications rate Shorter hospital stays No scar We can easily conclude that AS
- 12. How ASD device closure is done •Proper ECHO evaluation to look for indication and contraindication. •Proper ECHO to evaluate and size of the ASD. •Transesophageal ECHO to evaluate the rims
- 13. TEE Three views for ASD Device closure Four chamber view for AV and Posterior rim Bicaval view for IVC and SVC rim Short axis 45Âş Aortic and posterior rim
- 14. TEE evaluation of ASD rims
- 15. TEE evaluation should begin in the mid-esophageal 4-chamber view at 0Âş
- 16. Mid-esophageal Four-Chamber View. • Relation of ASD to the AV valves. • Larger devices used to close secundum ASD can interfere AV valve function.
- 17. Short Axis view mid-esophageal level, at 45-60Âş
- 18. Mid-esophageal short axis view • mid-esophageal level, at 45º with a leftward (counter-clock) rotation of the probe. • To view the Aortic rim • Though Aortic rim in absent in many patients. • Is not important.
- 19. Bicaval view:provides an excellent view of IAS
- 20. Bicaval view • From the mid-esophageal four- chamber view, the multiplane angle is rotated approximately 90 to 120. With slight clockwise rotation of the shaft of the probe), • To identify IVC and SVC.
- 21. Which rim is important • Inferior rim in particular must be of adequate size for successful transcatheter closure. • Absent IVC rim is contraindication for device closure.
- 22. How to size the ASD? • Correct sizing of the ASD is crucial to select the ideal ASD device. • ASD size changes during the cardiac cycle • must be measured at the end of ventricular systole. • The defect should not be measured with Color Doppler (CD), as this technique leads to overestimation of true ASD size.
- 23. How to size the ASD? • It is recommended to measure the defect in three views with TEE. • At least in two orthogonal views. • Maximal transverse diameter in 4- chamber view. • Maximal longitudinal diameter in the bi-caval view.
- 24. How to choose the ideal ASD Device size? Sizing balloon • Ideal way • Add cost • 1 to 2 mm bigger than the sizing balloon diameter-stop flow diameter Simple way formula • Maximum size of ASD + 1 to 2mm for good rims • Maximum size of ASD + 2 to 4mm if absent aortic rim or floopy rims.
- 25. How to choose the ideal Device size? ASD size • <16 mm • 17 to 32 • >32 • Limited rim (inferior,posterior ,or the anterior superior ) Device size • Same size • ASD size +2mm • ASD size + 4mm • 3 or 4 mm more than ASD Practical Handbook of Advanced Interventional Cardiology
- 26. How we size the ASD and decide the ASD device
- 28. Short axis view
- 29. Bi-caval view
- 30. Four Chamber view Short Axis view Bi-caval view How we select the device size? 24mm
- 31. ASD closure steps • After we choose the ideal ASD device. • Device closure procedure starts in the cathlab. • Selection of ideal delivery system
- 32. ASD is crossed with a Judkin’s right or MP catheter. catheter tip is positioned in the left upper pulmonary vein (LUPV) A floppy tip Amplatz Super stiff guide wire placed in the LUPV.
- 33. An Amplatzer delivery sheath pushed over the Superstiff wire into the mouth of the LSPV. Delivery sheath advanced over the dilator into the mouth of LSPV.
- 34. Delivery sheath positioned in the LA just outside the LSPV. Device is passed through the delivery sheath.
- 35. LA disk of device deployed in LA. LA disk pulled back against the interatrial septum.
- 36. Delivery sheath “peeled” back over the loading cable to allow release of the waist and RA disk. Final position of the device in anteroposterior projection
- 37. Amplatzer wire and delivery system in LUPV Delivery System
- 38. Device deployment Device deployed
- 39. Before the release of the device ECHO/TEE evaluation in most Release of Device After release
- 40. Difficult ASD for device closure • Deficient aortic and other rims • Floppy, thin and aneurysmal septal rims • Large ASD >35mm • Small child with large ASD • Multiple ASD By conventional definition, a margin 5 mm is considered to be adequate. ASD with deficient aortic rim (42.1%).1 1. Catheter Cardiovasc Interv 2001;53:386 –91.
- 41. Option in difficult ASD closure
- 42. Reason for difficulty in Absent or floppy rims Device should come towards the IAS parallel
- 44. Left upper pulmonary vein for absent aortic rim
- 45. RUPV for absent Aortic rim with or without posterior rim
- 46. Deficient posterior rim Right upper pulmonary vein technique Left atrial roof technique
- 48. • For deficient aortic and posterior rim • Aortic end of the LA disk protuse into RA during deployment. • LA disc becomes parallel to septum prevents protrusion of LA disc to RA.
- 50. Deficient rims or thins rims
- 52. Catheter Assist technique Multipurpose Catheter or a dilator catheter is advanced into the LA to prevent the LA disc from prolapsing into the RA.
- 53. Balloon Assisted technique Balloon prevents the prolapse of LA disc into RA
- 54. Take home message • ASD device closure is a preferred treatment option in suitable ASD secundum. • ASD device closure is safe, effective. • It is the most cosmetic option available in the treatment of ASD.
- 55. Thank you