1. Trans-Catheter Management of Congenital Heart Disease: ASD device Closure
Balu Vaidyanathan, Sumantha Sekhar Padhi,
Ananthen KS, BRJ Kannan,
SR Anil, R Krishna Kumar
Pediatric Cardiology
Amrita Institute of Medical Sciences
Kochi, Kerala

2. Introduction
Catheter based treatment of Common forms of congenital heart disease is one of the most important advances in the field of Pediatric cardiology
Most forms of simple congenital heart lesions are now amenable to this form of therapy
In PDA, Ostium Secundum ASD, Valvar Pulmonic Stenosis etc catheter based treatment has become the preferred form of treatment over surgery
The major advantages of this form of therapy include avoidance of surgical scar, shorter hospital stay and earlier return to routine activities

3. Trans-catheter ASD closure
Only Fossa Ovalis ASDs are suitable
80% of patients with Fossa Ovalis ASD can be treated by this method
Can be safely performed in patients above 3 years
Long term results are comparable /better than surgical closure

4. Pre-Procedure Evaluation: AIMS Protocol
Clinical documentation of significant shunt
A thorough Echo evaluation( TTE & TEE in selected cases)
Size and adequacy of margins are assessed on echo
Defects measuring upto 33 mm on Echo are suitable

5. TEE assessment of ASD
Done routinely in all adults and in children with large defects
TEE much superior in identifying adequacy of rims
In adults TEE is done under local anesthesia while children require GA RA LA

6. The Device: Amplatzer Septal Occluder
Made of nitinol (nickel + titanium)
Double disc (LA > RA) joined by waist
Size of waist = size of ASD
Sizes ranging from 4 to 40 mm

7. Pre- procedure management
Admission on previous day evening
Routine blood investigations done
Children are kept fasting for 4 hours before procedure; adults fast overnight
Aspirin 3-5 mg/kg given from previous day
Peri-procedural antibiotics administered (Cefazolin and Gentamycin 1 dose before procedure)

8. Sedation for Procedure
Young Children
Ketamine bolus (1 mg/Kg) and infusion (0.5 mg/kg/min)
Midazolam (0.1 mg/kg)
Older Children and adults ( without TEE)
Pentazocine (1 mg/kg)
Phenergan (0.5 mg/kg)
Procedures under TEE
General Anesthesia

9. Delivery sheath being de-aired Deployed device as seen on TEE
STEPS IN ASD DEVICE CLOSURE( UNDER TEE)
Delivery sheath being de-aired
Deployed device as seen on TEE
Amplatz wire placed in the left upper PV
Catheter being introduced into the heart
Patient being extubated
Amplatzer septal occluder being prepared
Delivery Sheath being introduced
Preparation of the Sizing Balloon
Deployment of the device being performed
Vascular Access being Obtained
Minnesota Wiggle being performed
Sizing of the ASD being done
Device being loaded onto delivery system
Induction of General Anesthesia
Balloon Sizing as seen on TEE
TEE probe being introduced

10. Post-procedure management
Overnight stay in the hospital
Discharged on anti-platelet doses of Aspirin for 6 months
OAC in older patients, large device or h/o arrhythmia
Can resume normal work on the next day
Follow-up at 3 months, 1 year and then SOS

11. ASD Device Closure: AIMS Data
Total patients
301
Very large defects
(>25mm in diameter)
56; Largest Device deployed: 40 mm in 2
Procedural success
293 ( 97%)
Procedural complications
Device embolisation 3 requiring surgery in 2 ( all in the our early experience)
Failures/Backouts 6
Complications on Follow-up
Pulm embolism 1; TIA 1; atrial flutter: 3

12. Pediatric Trans-Catheter Therapy: AIMS Experience
One of the largest programs in the country at present
Largest single centre experience on PDA coil occlusions in the world
Pioneered the technique of Bioptome assisted multiple coil delivery for closure of large PDA (as an alternative for the more expensive Duct Occluder)
Country’s single largest experience on ASD device closure
A number of innovative procedures like ductal stenting in newborns with duct dependent CHD have been performed

13. Pediatric Cath Procedures at AIMS
Total Procedures: 2965 ( Sept 1998-May 2004)

14. AIMS Publications in Pediatric Trans-catheter Interventions
Kumar RK, Krishnan MN, Venugopal K, Anil SR, Sivakumar, Bioptome-assisted simultaneous delivery of multiple coils for closure of the large PDA, Catheterization and Cardiovascular Interventions 2001;54:95-100
Sivakumar K, Anil SR, Ravichandra M, Natarajan KU, Kamath P, Kumar RK. Emergency Transcatheter recanalization of acutely thrombosed Blalock Taussig shunts, Indian Heart Journal 2001;53:
Anil SR, Sivakumar K, Kumar RK. Coil occlusion of the small patent ductus arteriosus without arterial access, Cardiology in the Young 2002;12:51-56
Anil SR, Sivakumar K, Kumar RK, Bioptome assisted closure of coronary artery fistula Indian Heart Journal 2002;54:
Anil SR, Sivakumar K, Philip A, Francis E, Kumar RK, Management strategies for hemolysis after transcatheter closure of the patent arterial duct, Catheterization and Cardiovascular Interventions 2003;59:
Kannan BRJ, Anil SR, Sivakumar K, Kumar RK, Transcatheter closure of the very large atrial septal defects using the Amplatzer septal occluder, Catheterization and Cardiovascular Interventions 2003;59:
Francis E, Sivakumar K, Kumar RK, Transcatheter Closure of Fistula Between the Right Pulmonary Artery and Left Atrium Using the Amplatzer Duct Occluder, In press, Catheterization and Cardiovascular Interventions.
Kumar RK, Anil SR, Philip A, Sivakumar K, Bioptome-assisted coil occlusion of moderate-large patent arterial ducts in infants and small children, Catheterization and cardiovascular interventions 2004;62:
Kannan BRJ, Padhy SS, Anil SR, Kumar RK: Catheter closure of the patent ductus arteriosus in sick ventilated infants, In press, Indian Heart Journal

15. THANK YOU