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ASD Device Closure
ASD Device Closure
CLOSURE
Dr.S.R. Sruthi Meenaxshi
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).
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.
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.
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).
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.
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.
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.
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
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
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).
Percutaneous versus surgical closure for secundum ASD —
Differing types of complications occur following the two procedures as illustrated by the
following studies.
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
A perforated aneurysm may be associated with a significant left-to-right shunt and present
with clinical and hemodynamic features of an ASD.
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.
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
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.
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)
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: