1. Atrial Septal Defect Closure
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 Closure
St. George’s experience
Presentation in adults
Indications for closure
Techniques for closure

5. RV RA LA
RUPV

6. Atrial Septal Defect Closure

8. RA RA LA LA
Fig 9

9. Atrial Septal Defect and Patent Foramen Ovale Closure
St. George’s Hospital 7 Year Experience
1st October 1998 – 31st January 2007
414 procedures
174 ASDs : 114 female, 60 male
240 PFOs : 115 female, 125 male

10. Atrial Septal Defect Closure
Age at referral :
Males : years, Range years
Females : years, Range years

11. Atrial Septal Defect Closure
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. Atrial Septal Defect Closure Devices Used

13. Atrial Septal Defect Closure Amplatzer ASO Sizes (mm)

14. Atrial Septal Defect Closure
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 Closure
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 Closure
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 Closure
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 Closure
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 Closure
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 Closure
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
66 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 Closure
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 Closure
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 Closure
Atrial septal defect – Devices
Amplatzer Helex

24. Atrial Septal Defect Closure
Atrial septal defect – Devices
Cardioseal StarFlex

25. Atrial Septal Defect Closure
Atrial septal defect – Devices
Biostar

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

27. Atrial Septal Defect Closure
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 Closure
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. Atrial Septal Defect Closure
Intracardiac Echo

30. Atrial Septal Defect Closure
Atrial septal defect – Fenestrated defect

31. Atrial Septal Defect Closure
Atrial septal defect – Fenestrated defect

32. Atrial Septal Defect Closure
Atrial septal defect – Fenestrated defect

33. Atrial Septal Defect Closure
Device deployment

34. Atrial Septal Defect Closure
Atrial septal defect – Cribriform device

35. Atrial Septal Defect Closure
Atrial septal defect – Cribriform device

36. Atrial Septal Defect Closure
Atrial septal defect – Cribriform device

37. Atrial Septal Defect Closure
Atrial septal defect – Cribriform device

38. Atrial Septal Defect Closure
Atrial septal defect – Multiple defects

39. Atrial Septal Defect Closure
Atrial septal defect – Multiple defects

40. Atrial Septal Defect Closure
Atrial septal defect – Multiple defects

41. Atrial Septal Defect Closure
Atrial septal defect – Multiple defects

42. Atrial Septal Defect Closure
Atrial septal defect – Multiple defects

43. Atrial Septal Defect Closure
Atrial septal defect – Multiple defects

44. Atrial Septal Defect Closure
Atrial septal defect – Multiple defects

45. Atrial Septal Defect Closure
Atrial septal defect – Multiple defects

46. Atrial Septal Defect Closure
Atrial septal defect – Multiple defects

47. Atrial Septal Defect Closure
Atrial septal defect – Multiple defects

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