Atrial Septal Defect Closure. Stephen Brecker Director, Cardiac Catheterisation Labs

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1 Stephen Brecker Director, Cardiac Catheterisation Labs

2 ADVANCED ANGIOPLASTY Incorporating 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

3 Atrial septal defect St. George s experience Presentation in adults Indications for closure Techniques for closure

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5 RV RA LA RUPV

6 Atrial septal defect

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8 RA RA LA LA Fig 9

9 Atrial Septal Defect and Patent Foramen Ovale Closure St. George s Hospital 7 Year Experience 1 st October st January procedures 174 ASDs : 114 female, 60 male 240 PFOs : 115 female, 125 male

10 Age at referral : Males : years, Range years Females : years, Range years

11 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

12 Devices Used Amplatzer ASO Amplatzer Cribriform 25 Amplatzer Cribriform 35 Helex 20 Helex 25 Cardioseal Starflex 38 Cribriform 25

13 Amplatzer ASO Sizes (mm)

14 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

15 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

16 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

17 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)

18 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

19 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

20 Atrial septal defect Presentation in adults Evidence for closure ASD in patients ages 60 years or older : operative results and long-term postoperative follow-up 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 controls St. John Sutton MG et al, Circulation 1981;64:

21 Atrial septal defect Presentation in adults Evidence 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:

22 Atrial septal defect Presentation in adults Evidence 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:

23 Atrial septal defect Devices Amplatzer Helex

24 Atrial septal defect Devices Cardioseal StarFlex

25 Atrial septal defect Devices Biostar

26 Amplatzer Septal Occluder Self-expandable, double disc Nitinol wire mesh, short connecting waist Discs and waist filled with polyester fabric

27 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

28 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

29 Intracardiac Echo

30 Atrial septal defect Fenestrated defect

31 Atrial septal defect Fenestrated defect

32 Atrial septal defect Fenestrated defect

33 Device deployment

34 Atrial septal defect Cribriform device

35 Atrial septal defect Cribriform device

36 Atrial septal defect Cribriform device

37 Atrial septal defect Cribriform device

38 Atrial septal defect Multiple defects

39 Atrial septal defect Multiple defects

40 Atrial septal defect Multiple defects

41 Atrial septal defect Multiple defects

42 Atrial septal defect Multiple defects

43 Atrial septal defect Multiple defects

44 Atrial septal defect Multiple defects

45 Atrial septal defect Multiple defects

46 Atrial septal defect Multiple defects

47 Atrial septal defect Multiple defects

48 Conclusions Majority of secundum ASDs device closable Excellent pre-procedure work up Multiple defects, large defects closable Training and skills Imaging, ACHD, interventional skills