Atrial septal defect percutaneous closure
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Percutaneous closure
Percutaneous transcatheter closure is current only indicated for the closure of ostium secundum atrial septal defects. It should not be used in patients with sinus venosus, primum or patent foramen ovale atrial septal defects. In patients with a secundum defect, there must be a sufficient rim of tissue around the septal defect.
The Food and Drug Administration has authorized the following percutaenous transcatheters for usage:[1]
- Amplatzer septal occluder
- CardioSEAL
- HELEX septal occluder
- Sideris patch
The Ampltazer septal occluder (ASO) is the most commonly used device as it allows closure of large cavities, is easy to implant, and boasts high success rates. As an instrument, the ASO consists of two self-expandable round discs connected to each other with a 4-mm waist, made up of 0.004–0.005´´ nitinol wire mesh filled with Dacron fabric. Implantation of the device is relatively easy. The prevalence of residual defect is low. The disadvantages are a thick profile of the device and concern related to a large amount of nitinol (a nickel-titanium compound) in the device and consequent potential for nickel toxicity.
Evaluation
Prior to percutaneous closure, ostium secundum atrial septal defect patients undergo antiplatelet therapy such as aspirin or clopidogrel for a minimum of six months. This antiplatelet therapy protects patients against thrombus formation.
Secundum defects are assessed via echocardiographic monitoring to determine the anatomic viability of percutaneous closure. The ideal secundum defect is less than 30mm in diameter with an accompanying rim of tissue around the defect of at least 5mm. This rim of tissue serves to prevent impingement upon the superior vena cava (SVC), inferior vena cava (IVC), as well as the tricuspid or mitral valves.[2]
Benefits of percutaneous closure
Percutaneous closure is the method of choice in most centers.[3] Closure is associated with:
- Fewer complications
- Shorter hospital stays
- Reduced need for blood transfusions
- Symptomatic improvement
- Regression of positive airway pressure
- Positive changes in right ventricle performance
- Improved functional capacity
- Improved left atrial volume index
- Improved left ventricular myocardial performance index
- Improved right ventricular myocardial performance index
- Improved peak oxygen uptake
Complications of percutaneous closure
Complications associated with percutaneous closure include:
- Device embolization
- Malposition of device
- Device erosion
- Atrial fibrillation or supraventricular tachycardia
- Transient antrioventricular block/heart block
- Pericardial effusion
- Thrombus formation (on the left atrial appendage)
- Iliac vein dissection
- Groin hematoma
- Cardiac perforation
- Increased levels of cardiac tropnin I
- Residual shunts
Frequency of complications is low, manifesting in under 9% of all cases.[4] With experienced, skilled clinicians, the rate of complication may be as low as 1%.
References
- ↑ Schwetz BA (2002). "From the Food and Drug Administration". JAMA. 287 (5): 578. PMID 11829678.
- ↑ Ferreira SM, Ho SY, Anderson RH (1992). "Morphological study of defects of the atrial septum within the oval fossa: implications for transcatheter closure of left-to-right shunt". Br Heart J. 67 (4): 316–20. PMC 1024841. PMID 1389707.
- ↑ Bjørnstad P (2006). "Is interventional closure the current treatment of choice for selected patients with deficient atrial septation?". Cardiol Young. 16 (1): 3–10. PMID 16454871.
- ↑ Chessa M, Carminati M, Butera G, Bini RM, Drago M, Rosti L; et al. (2002). "Early and late complications associated with transcatheter occlusion of secundum atrial septal defect". J Am Coll Cardiol. 39 (6): 1061–5. PMID 11897451.