ASD.pptx

• Constitutes 10-15% of all congenital heart defects.
• The 2nd most common congenital lesion found in
adults (bicuspid aortic valve is the most common).
•1:1500 live births have an ASD
•Male: Female ratio is 1:2
•Spontaneous closure is rare in children/ adults,
Closure only seen in 4% of patients in early infancy.
INTRODUCTION

•Prolonged left-to-right shunting and excessive
pulmonary blood flow may lead to pulmonary
hypertension, Eisenmenger’s syndrome, and right heart
failure. A significant ASD should be closed irrespective of
age.
•First open heart closure of an atrial septal defect (ASD)
on September 5th, 1952.
•The first ASD closure via transcatheter approach was
performed in 1976

Embryology
• Septation of the atria
– Septum primum arises from the superior portion of the
common atria and grows caudally towards the
endocardial cushions.
– Before the septum primum closes off the atria, it
develops a fenestration called the ostium secundum.
– The septum secundum arises from the right atrial side
of the septum primum and grows caudally.
– The septum secundum does not completely divide the
atria and does not immediately fuse with the septum
primum.

MORPHOLOGICAL CONSIDERATION
The secundum defect is a true defect located in the
centre of the atrial septum involving the fossa ovalis.
This is the only ASD which is amenable to transcatheter
closure techniques.
Adequate tissue margins are a prerequisite for device
closure, lack of adequate margins predisposes to device
prolapse or embolization.

Left to Right shunt
• Increased in presence of LVOTO, LV inflow obstruction,
or LV diastolic dysfunction.
• Increase pulmonary blood flow
• Most infants with isolated ASDs are asymptomatic –
symptoms rare before 2nd/3rd decade of life.
• PA pressure is mildly increased and PVR remains
normal in most cases.
HEMODYNAMICS

•Usually RA pressure= LA pressure, but shunting is LR
, as RV is more compliant.
•Shunt direction depends on RA-to-LA pressure
difference, RVEDP-to-LVEDP difference, phase of
respiration and volume status.
•In long standing ASD, pulmonary hypertension may
ensue which can result in reversal of shunt
[Eisenmenger’s].

ASD DEVICE
CLOSURE
INDICATION
ECHO & TEE
ASSESMENT
SELECTION
OF DEVICE
PROCEDURE
COMPLICATI
ONS

Asymptomatic in the presence of
• Right-sided cardiac dilatation
• ASD > 5mm with no signs of spontaneous closure
• Hemodynamics reserved for “borderline” cases
–HD insignificant (Qp/Qs <1.5) - no closure required
until later in life for embolism prevention
–HD significant (Qp/Qs >1.5) - should be closed
In presence of PA HTN
• Defined as PAP > 2/3 systemic or PVR > 2/3 SVR
• Closure can be recommended IF:
–Net L--> R shunt of 1.5:1 or greater
–Lung biopsy evidence of reversibility to pulmonary
arterial changes

Class I
Transcatheter secundum ASD closure is indicated in patients
with hemodynamically significant ASD with suitable anatomic
features (Level of Evidence: B).
Class II a
It is reasonable to perform transcatheter secundum ASD
closure in patients with transient right-to-left shunting at the
atrial level who have experienced sequelae of paradoxical
emboli such as stroke or recurrent transient ischemic attack
(Level of Evidence: B).
CLASS OF RECOMMENDATION

It is reasonable to perform transcatheter secundum ASD
closure in patients with transient right-to-left shunting at the
atrial level who are symptomatic because of cyanosis and who
do not require such a communication to maintain adequate
cardiac output(Level of Evidence: B).
Class II b
Transcatheter closure may be considered in patients with a
small secundum ASD who are believed to be at risk of
thromboembolic events (eg, patients with a transvenous
pacing system or chronically indwelling intravenous catheters,
patients with hypercoagulable states) (Level of Evidence: C).

Class III
Transcatheter secundum ASD closure is not indicated in patients
with a small secundum ASD of no hemodynamic significance
and with no other risk factors (Level of Evidence: B).
Transcatheter ASD closure should not be performed with
currently available devices in patients with ASDs other than
those of the secundum variety. This would include defects of
septum primum, sinus venosus defects, and unroofed coronary
sinus defects (Level of Evidence: C).
Transcatheter ASD closure is contraindicated in the
management of patients with a secundum ASD and advanced
pulmonary vascular obstructive disease (Level of Evidence: C).

William Rashkind, MD :- Developed the first Rashkind Atrial
Septal Defect Occluder.
Evolution a of ASD Devices
•Single disk
anchored by “fish
hooks”
•14-16f delivery
sheath
•25, 30 and 35mm

FDA
APPROVED
Amplatzer Septal
Occluder
(Dec 2001)
Gore Helex
Occluder
(Aug 2006)

The GORE HELEX Septal Occluder
•Soft and compliant, non-self-centering device made from a single
length Nitinol wire shaped into the left and right atrial discs
covered by a polytetraflouroethylene (Eptfe) membrane.
•The membrane is treated with a hydrophilic coating to facilitate
echocardiographic imaging of the occluder during implantation.
•A 2:1 ratio between the device size and the defect size “balloon-
stretched diameter” is used for optimal results, and the device
diameter should not exceed 90% of the measured septal length.
The device is available in sizes of 15, 20, 25, 30, and 35 mm.

1. No reported incidence of device erosion or cardiac perforation.
2. Even after locking the device in position after optimal position is
confirmed, it can still be retrieved with the help of retrieval cord
attached to the right atrial disc.
3. The HELEXR Septal Occluder is a non-self-centering device having
a narrow mid portion that makes it suitable for closure of
multifenestrated defects.
4. The device can easily be seen on fluoroscopy and
Echocardiography.
Advantages:

1. Defects larger than 18 mm cannot be closed with this device.
2. Wire frame fracture has been reported with the HELEXR Septal
Occluder, especially the larger sizes, occurring in 6.4–8.0% after 1
year.
3. In a United States multicentre study of the HELEXR Septal
Occluder, used in 143 patients for closure of ASDs, there was a rate
of residual leaks of 25.7% at 12 months.
4. There is a fixed right angle between the tip of the delivery
catheter and the device. In some cases, especially in children, this
distorts the anatomy and orientation of the atrial septum, making it
difficult to decide whether the occluder position is optimal. With
release of the device there is a pronounced repositioning when the
force from the delivery system is taken away from the septum.
Disadvantages:

Amplatzer Septal Occluder(St. Jude, Plymouth,
Minnesota, USA)
• Self-expandable, double disc device
made from Nitinol (55% nickel; 45%
titanium) wire mesh
• 2 discs linked by a short connecting
waist corresponding to the size of the ASD
• The ASO device is constructed from a
0.004–0.0075-inch Nitinol wire mesh that
is tightly woven into two flat disks.

•There is a 3–4-mm connecting waist between the two disks,
corresponding to the thickness of the atrial septum.
• Available in sizes 4 to
38 mm (4 to 20 mm at 1
mm increments and 22
to 28 at 2 mm
increments), size refers
to the diameter of the
waist.

Amplatzer Cribriform Septal Occluder
•Closure of ASDs with multiple
perforations
commonly associated with
septal aneurysm
• The two discs are linked
together by a short (3mm)
connecting waist
• Available in 18, 25, 30, 35mm
• 8-9Fr Delivery system

Advantages:
•Ease of use
•Delivery with small diameter catheters
•The facility to retrieve and reposition before
complete deployment
•The device design also permits it to self centre
across the defect

 Anticoagulation with UFH and maintain ACT > 250
 Femoral access is used and size of sheath is based on
the size and type of the device and delivery sheath
system chosen.
 Right heart catheterization should be done for Oxygen
saturation and pressures in innominate vein, SVC, right
atrium and pulmonary artery.
Measurement of left atrial pressure and LVEDP
especially in elderly is important to avoid left heart failure
in a setting of LV diastolic dysfunction(increased preload).

TWO METHODS :
TTE/TEE/ICE or,
Stop-flow technique: The sizing balloon is placed across the
ASD and inflated until there is stoppage of flow across the
defect on color-flow Doppler imaging.
The maximum width of the balloon is then measured on
TTE/TEE/ICE as well as fluoroscopy.
Waist measurement technique: The sizing balloon is placed
across the ASD and inflated until there is a waist formation
noted along both the margins of the balloon on fluoroscopy.
This waist is then measured on fluoroscopy.
DEFECT SIZING

All the components of the delivery
system are thoroughly flushed and
wiped from outside with
heparinized saline solution
Gently messaging it in heparinized
saline so as to get rid of the air
that might have been trapped in
the Dacron patches.
The ASO is slenderized within the
loader followed by thorough
flushing to get rid of the air within
the system

ASD is crossed with 0.035 inch J tipped guide wire through a 6 Fr
multipurpose catheter and wire is positioned in the LUPV

An Amplatzer delivery sheath is passed over the wire into the
mouth of the LSPV.

Delivery sheath is advanced over the dilator
into the mouth of LSPV

The delivery sheath positioned in the left atrium just
outside the LSPV

Amplatzer septal occluder (ASO) is being passed
through the delivery sheath

Left atrial disk of the ASO being extruded in
the left atrium

The left atrial disk of the ASO being pulled back
against the interatrial septum

Delivery sheath “peeled” back over the loading cable
to allow release of the waist and the right atrial disk

Release of the ASO from loading cable in left anterior
oblique (LAO) view

Final position of the device in anteroposterior projection;
fluroscopic “fingerprinting” of the device

To overcome accommodation problem
LADED technique[Left atrial disc engagement
disengagement]
To engage the LA disc till such time the waist
and RA disc can be delivered followed by
disengagement of LA disc.

Hausdorf, mullins sheath etc
Balloon assisted technique

Wahab technique (Dilator-assisted technique): Following deployment
of the left atrial disk, a long dilator is advanced into the left atrium,
holding the anterosuperior part of the left atrial disk to prevent it from
prolapsing

 The Amplatzer pivotal trial has described a MACE of 1.6 %
[7/442 patients].
Device embolization
Incidence varies from 0.55[Levi and Moore] to 0.62%
[Dibardino].
Retrieval can be done by surgery or percutaneous
method.

ASO embolized to the right
ventricle
ASO being retrieved
from the descending
thoracic
aorta

The collapse in the midpoint and the bulging at the
lateral edges (arrows) of the left atrial disc

Arrhythmia
Supraventriculr ectopic are noted in 63 % of patients
immediately after device closure.
6.2 % had a new onset or aggravation of preexisting
AV block.
Cardiac erosion
Occurs in less than 0.1 %
Higher risk in individuals with deficient aortic or
superior rim or use of oversized devices.

Others
Air embolism
Residual shunts
Perforation
Infective endocarditis
Device related thrombosis
Wire fracture
Haemopericardium, pericardial effusion
Cardiovascular collapse, and sudden cardiac death

Special considerations
Multifenestrated ASD
Most commonly seen along the posteroinferior portion of the
atrial septum.
If the fenestrated portion of the septum is > 7 mm away from
the primary defect, closure using multiple devices may be
needed.
While crossing the defect, operator should ensure that the
central defect is crossed and not one of he satellite lesions.
Non self centering devices like Amplatzer Cribriform device or
Helex device must be used.

Multicenter nonrandomized
• 29 pediatric cardiology centers from
• 442 patients enrolled in the device group
• 154 patients in the surgical group.
Complication rate:
•7.2% for the device group
•24% for the surgical group
•mortality = 0% for both groups
ASO Outcomes
The ASO pivotal study:
March
1998 to
March
2000

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