Anesthesia & ASD Occluder

Presented By R3 顏郁軒 93/8/9

ASD Occluder

• The first successful device closure of an ASD was performed in 1974 by King and Mills

• FDA granted approval two types of ASD occluder : Amplatzer septal occluder & CardioSEAL Septal Occluder

CardioSEAL Septal Occluder

Amplatzer Septal Occluder

Amplatzer Structure

• The AMPLATZER Septal Occluder is a self-expandable, double disc device made from a nickel-titanium

(Nitinol) wire mesh• Left atrial disk has a radius only 7 mm greater th

an the waist of the device (and thus the defect) and the right atrial disk is slightly smaller, being only 5 mm larger than the defect

Patient Selection (1)

• secundum ASD measuring less than or equal to 34 mm

• Defect should be greater than 5 mm away from the coronary sinus, atrioventricular valves, and right upper pulmonary vein

Patient Selection (2) Exclusion criteria include : • congenital heart disease that requires cardiac surgery• partial anomalous pulmonary venous return• Pulmonary vascular resistance greater than 7 Wood’s U• right-to-left shunting at the atrial level with a systemic satur

ation of less than 94%• recent myocardial infarction, unstable angina,• and decompensated congestive heart failure or significant ri

ght or left ventricular decompensation with an ejection fraction of less than 30%.

• The initial lower weight limit was 8 kg

Anesthetic Consideration

• Ketamine for initial diagnosiswatch out patient’s hemodynamic status

• General anesthesia later and monitored with NIBP , Oximeter , ETCO2

• TEE evaluation

TEE Evaluation

• the entire rim of the defect should be visualized

• 要看的 view : the mid-esophageal 4-chamber view at 0°, the short-axis view at 45° to 60°, and the biatrial long-axis view at 90° to 110°

五個 Rim 的看法• ASD 的 5 個 portion

• SPI : bicaval view

• PSAI : four chamber view

• AS : 和 aortic root 的距離

Sizing the defect (1)

Two methods can be used

• Pull technique • Static technique

• The proper device size is selected as the

stretched ASD size plus 1 mm

                                 

   

Sizing the defect (2)

• As reported in the literature , TEE may underestimate the size of the ASD, as determined by the stretched balloon diameter

Sizing the defect (3)

原因 ： 1. ASD 形狀不是圓的 2.ASD 的 septum 可能不是在同一平面 3. ASD 的形狀大小會隨著 heart cycle 而改 變

4.ASD margin 的組織可能是軟或較硬的，所以用 sizing balloon 來推向兩邊時會有一些差異

Evaluation, procedure, and postprocedural assessment

Preprocedure•   Define ASD location•   Define ASD size•   Define ASD number; look for fenestrations•   Delineate ASD rim•   Is it firm or pliable?•   Is it deficient at any point, eg, inferoposteriorly?•   Atrial septal aneurysm?•   Look for associated defects (MVP, APVD)•   Measure distance from ASD to MV, CS, RUPV

Evaluation, procedure, and postprocedural assessment

Intraprocedural•   Confirm guide wire in LA•   Confirm sizing balloon free in LA before inflation•   Confirm inflated balloon closes the defect•   Confirm delivery catheter in body of LA•   Ensure adequate deployment and positioning of

LA disk•   Guide positioning during waist and RA disk

deployment

Evaluation, procedure, and postprocedural assessment

• Watch for deployment difficulties•  Cobrahead malformation•  Chiari network entanglement•  Thrombus on catheters•  Assess adequacy of occlusion•  Review device relation to MV, CS, RUPV•  Check position stability during "Minnesota

wiggle"•  Document degree of residual shunt through and

around device

Evaluation, procedure, and postprocedural assessment

Postprocedural•   Check device position•   Check device structural integrity•   Assess residual shunt•   Monitor changes in right heart chambers•   Check relation to other structures (MV, RUPV)•   Look for potential complications: thrombus,

infection

Effectiveness of percutaneous device occlusion foratrial septal defect in adult patients withpulmonary hypertension• American Heart Journal

November 2002 P877~880• 29 adult patients

• follow up of 21±14 months• Our findings suggest that percutaneous device occl

usion of ASD in adult patients with pulmonary hypertension is safe and effective and provides significant and prolonged relief.

Thanks For Your Attention !!!