Upload
antonia-mcdaniel
View
224
Download
0
Tags:
Embed Size (px)
Citation preview
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 Closure
• Atrial septal defect– St. George’s experience
– Presentation in adults
– Indications for closure
– Techniques for closure
LA
RA
RUPV
RV
Atrial Septal Defect Closure
• 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
Atrial Septal Defect Closure
• Age at referral : – Males : 43.8 + 17 years, Range 16-77 years
– Females : 42.6 + 16 years, Range 17-77 years
Atrial Septal Defect Closure
• 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
Atrial Septal Defect Closure
• 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 Closure
• 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 Closure
• 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 Closure
• 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 Closure
• 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 Closure
• 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.
Atrial Septal Defect Closure
• Atrial septal defect – Presentation in adultsEvidence for closure
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
Atrial Septal Defect Closure
• Atrial septal defect – Presentation in adultsEvidence for closure
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 Closure
• Atrial septal defect – Devices
Amplatzer Helex
Atrial Septal Defect Closure
• Atrial septal defect – Devices
Cardioseal StarFlex
Atrial Septal Defect Closure
• Atrial septal defect – Devices– Biostar
Atrial Septal Defect Closure
• Amplatzer Septal Occluder• Self-expandable, double disc• Nitinol wire mesh, short connecting waist• Discs and waist filled with polyester fabric
Atrial Septal Defect Closure
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 Closure
• 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
Atrial Septal Defect Closure
Intracardiac Echo
Atrial Septal Defect Closure
• Atrial septal defect – Fenestrated defect
Atrial Septal Defect Closure
• Atrial septal defect – Fenestrated defect
Atrial Septal Defect Closure
• Atrial septal defect – Fenestrated defect
Atrial Septal Defect Closure
• Device deployment
Atrial Septal Defect Closure
• Atrial septal defect – Cribriform device
Atrial Septal Defect Closure
• Atrial septal defect – Cribriform device
Atrial Septal Defect Closure
• Atrial septal defect – Cribriform device
Atrial Septal Defect Closure
• Atrial septal defect – Cribriform device
Atrial Septal Defect Closure
• Atrial septal defect – Multiple defects
Atrial Septal Defect Closure
• Atrial septal defect – Multiple defects
Atrial Septal Defect Closure
• Atrial septal defect – Multiple defects
Atrial Septal Defect Closure
• Atrial septal defect – Multiple defects
Atrial Septal Defect Closure
• Atrial septal defect – Multiple defects
Atrial Septal Defect Closure
• Atrial septal defect – Multiple defects
Atrial Septal Defect Closure
• Atrial septal defect – Multiple defects
Atrial Septal Defect Closure
• Atrial septal defect – Multiple defects
Atrial Septal Defect Closure
• Atrial septal defect – Multiple defects
Atrial Septal Defect Closure
• Atrial septal defect – Multiple defects
Atrial Septal Defect Closure
• Conclusions– Majority of secundum ASDs device
closable– Excellent pre-procedure work up– Multiple defects, large defects closable– Training and skills– Imaging, ACHD, interventional skills