Brief Reports

Comparison of three different atrial septal defect occlusion devices

An atrial septal defect (ASD) is the third most common form of congenital heart disease and is often only diagnosed in adulthood. The chapter describes different forms of ASD with their symptoms and diagnoses and methods that have historically been used to repair them. Transcatheter ASD repair technology is explained and the construction and functioning of a variety of devices is described, with particular reference to the advantages and disadvantages of a variety of textile components. The chapter concludes with an overview of recent developments.

Percutaneous closure of atrial septal defect (ASD) is a valid alternative to surgical approach. Current device has significantly improved the success rate also in complex cases. The aim of this study is to assess the impact of age, defect size, and morphologic features on successfully percutaneous ASD closure.

Between January 2000 and September 2004, 1,013 consecutive patients underwent closure of an isolated type II ASD at our institution. The following outcomes have been evaluated: (1) role of percutaneous ASD closure as alternative to surgical repair, in current daily practice; (2) impact of age on the selected closure approach; (3) analysis of morphologic variety of ASD and its effect on the closure technique; (4) possible role of specific device selection according to ASD morphology to improve procedural success.

During the study period, up to 80% of secundum ASDs were suitable for percutaneous closure with the currently available devices. Need for surgical ASD closure was more common in pediatric patients, likely reflecting the more frequent diagnosis of larger and complex defects at a young age. Accurate ADS morphology assessment and appropriate device selection are key elements to obtain procedural success. In particular, among all the ASD characteristics, the rim absence is the main limiting factor to a successful percutaneous ASD closure. A trend of reduction in peri-procedural adverse events was observed during the study period, with complications needing immediate cardiac surgery occurred only in 1% of cases.

Percutaneous ASD closure is feasible and associated with low complication rate. A thorough analysis of morphologic aspects is mandatory in order to select the appropriate device and the optimal approach. Surgical closure remains the treatment of choice in selected patients.

La communication inter-auriculaire (CIA) est la malformation cardiaque congénitale la plus fréquente à l’âge adulte et elle est responsable d’une morbidité importante et d’une diminution de l’espérance de vie. La fermeture d’une CIA avec une surcharge volumique supprime ces morbidité et mortalité. Les progrès techniques dans la conception des prothèses d’obstruction de communications inter-auriculaires par voie percutanée font de cette méthode une alternative fiable à la chirurgie qui, pour sa part, génère un certain degré d’inconfort et une morbidité non négligeable.

La sélection des patients est de la plus grande importance et repose sur l’échocardiographie trans-thoracique. Elle est indiquée dans les communications inter-auriculaires isolées de type ostium secundum avec un débord d’au moins 4 mm la séparant des structures adjacentes du cœur ; la taille à l’échocardiographie ne doit pas être supérieure à 30 mm.

La fermeture se fait sous contrôle fluoroscopique et échocardiographique par voie trans-oesophagienne. Elle est rapide, simple, et entraîne une morbidité très faible. Avec la prothèse d’Amplatz, le pourcentage de fermeture complète est équivalent à celui obtenu par la chirurgie avec une morbidité moindre en ce qui concerne les arythmies. La technique de fermeture percutanée de la CIA, fiable, permet sans doute chez l’adulte d’en étendre les indications.

The inter-auricular communication (IAC) is the most frequent of congential malformations in adults and is responsible for enhanced morbidity and rduction in life expectancy. The closure of an IAC with volumic overload eradicates such morbidity and mortality. The technical progress in the conception of prostheses that obstrue the inter-auricular communications via the percutaneous route make this technique a reliable alternative to surgery that, itself, leads to a certain degree of discomfort and considerable morbidity.

The selection of patients is crucial and relies on trans-thoracic echocardiography. It is indicated in isolated ostium secundum-type inter-auricular communications with a border of at least 4 mm separating it from the adjacent structures of the heart; the size on the echocardiography must not exceed 30 mm.

The closure is made under fluoroscopic and echocardiographic control via the trans-oesophageal route. It is rapid, simple, and induces a low rate of morbidity. With Amplatz's prosthesis, the percentage of complete closure is equivalent to that obtained with surgery but with less morbidity with regard to arrhythmia. Today the reliable percutaneous closure of an IAC will probably permit the extension of the indications for the closure of this congenital abnormality in adults.

We sought to determine the incidence, nature, and predisposing factors of atrioventricular block (AVB) associated with closure of atrial septal defects (ASDs) using the Amplatzer septal occluder (ASO).

In our institution, 162 patients underwent ASD closure using ASO between December 1997 and December 2001. This includes small children with large defects.

Electrocardiographic tracings during ASO implantation and at follow-up visits were reviewed. Anatomic characteristics and device size were assessed as potential risk factors for AVB.

Ten patients (6.2%) presented with new-onset (n = 9) or aggravation of preexisting (n = 1) AVB. Atrioventricular block occurred during the procedure (n = 3) or was first noted one day to one week later (n = 7). Patients had first-degree (n = 4), second-degree Wenckebach (n = 4), or third-degree (n = 2) AVB, with no symptoms or hemodynamic compromise. First-degree AVB persisted in two patients at 12 and 33 months of follow-up, whereas most recovered normal AV conduction within one (n = 7) or six months (n = 1). A larger shunt (Qp/Qs ratio 2.8 ± 0.9 vs. 2.1 ± 0.8, p < 0.01) and device size (24 ± 5 vs. 19 ± 6 mm, p < 0.01) were the only determinant factors for AVB. A device size ≥19 mm was used in 90% (9 of 10) of patients who developed AVB, as compared with 49% of those without AVB (p < 0.02).

Closure of ASDs using the large ASO can be associated with the development of AV block and mandate a closer follow-up. In our series, however, all AVBs resolved or improved spontaneously, with no recurrence at mid-term follow-up.

OBJECTIVES

The goal of this study was to evaluate percutaneous interventional and minimally invasive surgical closure of secundum atrial septal defect (ASD) in children.

BACKGROUND

Concern has surrounded abandoning conventional midline sternotomy in favor of the less invasive approaches pursuing a better cosmetic result and a more rational resource utilization.

METHODS

A retrospective analysis was performed on the patients treated from June 1996 to December 1998.

RESULTS

One hundred seventy-one children (median age 5.8 years, median weight 22.1 kg) underwent 52 device implants, 72 minimally invasive surgical operations and 50 conventional sternotomy operations. There were no deaths and no residual left to right shunt in any of the groups. The overall complication rate causing delayed discharge was 12.6% for minimally invasive surgery, 12.0% for midline sternotomy and 3.8% for transcatheter device closure (p < 0.01). The mean hospital stay was 2.8 ± 1.0 days, 6.5 ± 2.1 days and 2.1 ± 0.5 days (p < 0.01); the skin-to-skin time was 196 ± 43 min, 163 ± 46 min and 118 ± 58 min, respectively (p < 0.001). Extracorporeal circulation time was 49.9 ± 10.1 min in the minithoracotomy group versus 37.2 ± 13.8 min in the sternotomy group (p < 0.01) but without differences in aortic cross-clamping time. Sternotomy was the most expensive procedure (15,000 € ± 1,050 € vs. 12,250 € ± 472 € for minithoracotomy and 13,000 € ± 300 Marie for percutaneous devices).

CONCLUSIONS

While equally effective compared with sternotomy, the cosmetic and financial appeal of the percutaneous and minimally invasive approaches must be weighed against their greater exposure to technical pitfalls. Adequate training is needed if a strategy of surgical or percutaneous minimally invasive closure of ASD in children is planned in place of conventional surgery.

El cierre percutáneo de la comunicación interauricular es una alternativa al tratamiento quirúrgico.

Comunicar los resultados del cierre percutáneo de la comunicación interauricular con el dispositivo Amplatzer^®.

Se incluyeron los pacientes sometidos a hemodinamia de septiembre de 1997 a diciembre de 2011.

Se procedió al cierre del defecto en 721 pacientes y en 85 no se cerró por considerarse no apto anatómicamente. El diámetro expandido del defecto fue de 23 ± 6.7 mm (límites, 5-42). Todos los dispositivos se colocaron con éxito. En 15 casos (2.1%) se cambió el dispositivo por considerarse inestable y en 6 (0.8%) se presentó embolización en las primeras 24 h, 4 fueron rescatados y recolocados (éxito final con intención de tratamiento 719/806-89.2%). El control inmediato mostró oclusión completa en 247 pacientes (34.3%), fuga intradispositivo en 395 (54.9%), ligera en 75 (10.4%) y moderada en 2 (0.3%). Se hace seguimiento en 626 pacientes (87.1%) durante 33 ± 27.5 meses, presentándose cefalea en 54 (8.6%), arritmias supraventriculares nuevas en 10 (1.6%), complicaciones en el sitio de punción en 4 (0.6%) y accidente vascular cerebral en uno (0.1%).

El diseño del dispositivo Amplatzer^® permite el cierre de la comunicación interauricular con una técnica sencilla y con seguridad para el paciente.

Percutaneous closure of atrial septal defects is an alternative to surgical treatment.

We report the results of percutaneous closure of atrial septal defects with the Amplatzer^® device.

We include patients taken to the catheterization laboratory from September 1997 to December 2011.

We proceeded with defect closure in 721 patients and in 85 the defect was considered not suitable for closure. The stretched diameter of the defect was 23 ± 6.7 mm (limits, 5-42). All devices were positioned successfully. In 15 cases (2.1%) the device was changed due to instability and in 6 (0.8%) the device embolized within the first 24 h, 4 were retrieved and repositioned (final success with intention to treat 719/806-89.2%). Immediate control showed complete closure in 247 patients (34.3%), leak through the device in 395 (54.9%), mild residual leak in 75 (10.4%) and moderate in 2 (0.3%). We have follow-up in 626 patients (87.1%) for 33 ± 27.5 months, with headache in 54 (8.6%), new supraventricular arrhythmia in 10 (1.6%), puncture site complications in 4 (0.6%), and stroke in one (0.1%).

The design of the Amplatzer^® device allows effective closure of atrial septal defects with a simple technique and patient safety.