Atrial septal defect ostium secundum percutaneous closure: Difference between revisions

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==Overview==
==Overview==
Surgical closure is the commonest treatment method for [[atrial septal defect]] and has been the gold standard for many years. Many surgeons prefer more[[minimally invasive surgery|minimally invasive techniques]] over the conventional [[sternotomy]] to avoid potentials for additional complications. Special consideration must be taken into account for the age of the patient and the size of the defect involved. Surgical closure is indicated for patients with [[Atrial septal defect ostium primum|primum]], [[Atrial septal defect sinus venosus|sinus venosus]] and [[Atrial septal defect coronary sinus | coronary sinus]] type of[[atrial septal defect]]s. However, [[Ostium secundum atrial septal defects|ostium secundum]] [[atrial septal defect]]s are commonly treated by [[Percutaneous atrial septal defect|percutaneous closure]]. With uncomplicated [[atrial septal defect]], (without [[pulmonary hypertension]] and other comorbidities) the post-surgical mortality is as low as 1%


Percutaneous device closure is commonly performed to close an [[Atrial septal defect ostium secundum|ostium secundum]] type of [[atrial septal defect]] and [[Atrial septal defect patent foramen ovale | patent foramen ovale]]s. It is still not [[FDA]] approved for closure of other forms of atrial septal defects such as [[Atrial septal defect ostium primum|primum]], [[Atrial septal defect sinus venosus|sinus venosus]] and [[Atrial septal defect coronary sinus | coronary sinus]]. With proper patient selection at experienced centers, it has been found to be as successful, safe and effective as [[Atrial septal defect surgical closure | surgical closure]].  Additionally, it has been associated with fewer complications and a reduced length of stay compared to [[Atrial septal defect surgical closure | surgical closure]] <ref name="pmid12039500">{{cite journal| author=Du ZD, Hijazi ZM, Kleinman CS, Silverman NH, Larntz K, Amplatzer Investigators| title=Comparison between transcatheter and surgical closure of secundum atrial septal defect in children and adults: results of a multicenter nonrandomized trial. | journal=J Am Coll Cardiol | year= 2002 | volume= 39 | issue= 11 | pages= 1836-44 | pmid=12039500 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12039500  }} </ref>.
==Surgical Closure==
 
==Percutanous Closure==


===Mechanisms of Benefit===
===Mechanisms of Benefit===
In percutaneous closure of [[atrial septal defect]]s a self-expandable round disc is placed  around the defect that prevents the [[left-to-right shunt]]ing of blood across the lesion. The mechanical prevention of this shunting helps  improve the forward circulation in the heart, prevents shunting of blood, and prevents mixing of well exygenated blood with poorly oxygenated blood (shunting).  It is associated with excellent results, particularly among those patients who have not developed irreversible [[Pulmonary hypertension|pulmonary artery disease]] ([[(Eisenmenger's syndrome]]).


===Indications===
[[Atrial septal defect surgical closure | Surgical closure]] involves closing the defect either by putting a [[pericardial]] patch or via direct suture closure. The decision for suture closure or patch closure depends on the [[morphology]] and size of defect. The closure of the defect prevents the [[left-to-right shunt]]ing of blood across the [[atrium]] and thus improving the [[circulation]] in [[heart]]. It is not recommended that synthetic patches be used for primary closure.<ref name="pmid15172284">{{cite journal| author=Hopkins RA, Bert AA, Buchholz B, Guarino K, Meyers M| title=Surgical patch closure of atrial septal defects. | journal=Ann Thorac Surg | year= 2004 | volume= 77 | issue= 6 | pages= 2144-9; author reply 2149-50 | pmid=15172284 |doi=10.1016/j.athoracsur.2003.10.105 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15172284  }} </ref>.
The percutaneous closure of [[atrial septal defect]]s is currently only indicated for the closure of [[Atrial septal defect ostium secundum|ostium secundum atrial septal defects]] and [[Atrial septal defect patent foramen ovale | patent foramen ovale]] (patent formen ovale has inter-atrial communications but it is not a true [[atrial septal defect]] in sa far as there is a flap like piece of tissue). In patients with a [[Ostium secundum atrial septal defect|secundum defect]], there must be a sufficient rim of tissue around the defect for successful percutaneous closure.


===Contra-indications===
===Indication===
It should not be used in patients with [[Atrial septal defect ostium primum|primum]], [[Atrial septal defect sinus venosus|sinus venosus]] and [[Atrial septal defect coronary sinus | coronary sinus]] type of [[atrial septal defect]]s. Surgical closure of [[atrial septal defect ostium secundum|ostium secundum atrial septal defect]] can be done when a concomitant tricuspid valve repair is considered or when the anatomy of the defect doesn't favor a percutaneous device.
Surgical closure is indicated for patients with [[Atrial septal defect ostium primum|primum]], [[Atrial septal defect sinus venosus|sinus venosus]] and [[Atrial septal defect coronary sinus | coronary sinus]] type of [[atrial septal defect]]s. Whereas, [[Ostium secundum atrial septal defects|ostium secundum]] [[atrial septal defect]]s are commonly treated by percutaneous closure.


===Type of Occluders===
===Contraindications===
Surgery is contraindicated in patients with severe irreversible [[Pulmonary hypertension|pulmonary artery hypertension]], [[eisenmenger's syndrome]] and no evidence of a [[left-to-right shunt]]. Also, for uncomplicated cases with [[ostium secundum atrial septal defect|ostium secundum defects]] percutaneous closure is preferred.


The Amplatzer septal occluder (ASO) is currently the most widely used device because it is easy to implant and has high success rates. It first came to be used for human subjects in 1995. However, the device is still not approved for usage in percutaneous closure of [[Atrial septal defect ostium primum|primum]],[[Atrial septal defect sinus venosus|sinus venosus]] and [[Atrial septal defect coronary sinus | coronary sinus]] type of [[atrial septal defect]]s.
===General Considerations During Surgery===
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 [[Ampltazer septal occluder]] 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. The prevalence of residual defect is low. The [[Food and Drug Administration]] has authorized the following percutaenous transcatheters for usage:<ref name="pmid11829678">{{cite journal| author=Schwetz BA| title=From the Food and Drug Administration. |journal=JAMA | year= 2002 | volume= 287 | issue= 5 | pages= 578 | pmid=11829678 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11829678  }} </ref>.


*Amplatzer septal occluder
* Small to moderate defects with oval shape, can be closed with the help of sutures.
*CardioSEAL
*HELEX septal occluder
*Sideris patch


{{#ev:youtube|4c3CEgjj2PY}}
* Direct suture closure of large round defects may cause distortion of the [[atrium]] and aortic annulus. Thus, a patch closure is preferred in these cases.


===Pre-surgical Considerations===
* The patch can be made up of either natural (made out of the patient's [[pericardium]]) or artificial [[polytetrafluoroethylene]], ([[dacron]]).
* Other operations that are done for anomalies associated with atrial septal defects are [[tricuspid valve]] repair for significant [[tricuspid regurgitation]], repair for [[Total anomalous pulmonary venous connection|anomalous pulmonary venous drainage]], Warden procedure (translocation of the superior vena cava to the right atrial appendage) for sinus venosus ASD when the [[Total anomalous pulmonary venous connection|anomalous pulmonary venous drainage]] enters the mid or upper [[superior vena cava]] and [[maze procedure]] for intermittent/chronic [[atrial fibrillation]]/[[flutter]].


* Percutaneous device closure of [[atrial septal defect]], is currently approved only for [[Ostium secundum atrial septal defect|secundum defects]]. Prior to the procedure, the patient is started on [[antiplatelet]] therapy for 6 months to prevent [[thrombus]] formation. [[Transesophageal echocardiography]] along with stop-flow technique is used for determining the device size, position, and deployment.
* Considerations in an ostium primum repair:
:* Surgical closure is more complicated compared to other [[atrial septal defect]] repairs.  
:* The patch should be attached to the septum at the juncture of the [[mitral]] and [[tricuspid]] valves.  
:* Mitral valve repair, closure of the cleft mitral leaflet, annuloplasty and mitral valve replacement may be required to repair mitral insufficiency.


* Prior to undergoing percutaneous closure, eligible [[atrial septal defect]] patients must undergo pharmacologic preparation therapy.
* Devices used are:
** Amplatzer septal occluder
** STARFlex septal occluder
** PFO Star
** HELEX


* Most therapy regimens include [[Antiplatelet Therapy to Support PCI (patient information)|antiplatelet drugs]] such as [[aspirin]] or [[clopidogrel]]for a minimum of six months to protect patients against [[thrombus]] formation.
===Steps During Surgery===
* [[Median sternotomy]] or right anterolateral submammary sub pectoral incision (preferred in females)
* [[Sternum]] is split in the midline.
* Direct arterial and double venous ([[superior vena cava]] and [[inferior vena cava]]) cannulation are performed.
* [[Cardiopulmonary bypass]] applied
* [[Aorta]] clamped
* [[Heart]] is arrested with a [[cardioplegia]] solution.
* [[Right atrium]] is opened.
* Defect repaired either by continuous [[prolene]] suture or with the use of patch
* Patch can be natural (autologus [[pericardium]]), bovine pericardium or artificial [[polytetrafluoroethylene]] (PTFE) or [[dacron]].


* [[Ostium secundum atrial septal defect|Secundum defects]] are assessed via [[Atrial septal defect echocardiography|echocardiographic monitoring]] to determine the anatomic viability of percutaneous closure.


* The ideal [[Ostium secundum atrial septal defect|secundum defect]] is less than '''30mm in diameter''' with an accompanying rim of tissue around the defect of at least '''5mm'''.


* The rim of tissue serves to prevent impingement upon the [[superior vena cava|superior vena cava (SVC)]], [[inferior vena cava|inferior vena cava (IVC)]], as well as the [[tricuspid valve|tricuspid]] or [[mitral valve|mitral]] valves.<ref name="pmid1389707">{{cite journal| author=Ferreira SM, Ho SY, Anderson RH| title=Morphological study of defects of the atrial septum within the oval fossa: implications for transcatheter closure of left-to-right shunt. |journal=Br Heart J | year= 1992 | volume= 67 | issue= 4 | pages= 316-20 | pmid=1389707 | doi= | pmc=PMC1024841 | url= }} </ref>
{{#ev:youtube|PbQhiv6OB0E}}


===Steps during Per-cutaneous Closure===
===Post Surgical Follow Up===
* The salient feature of the [[Atrial septal defect percutaneous closure | percutaneous closure]] are-
Due to the development of new [[Minimally invasive surgery|minimally invasive techniques]], [[Atrial septal defect percutaneous closure | percutaneous closure]]and improvement in [[Atrial septal defect surgical closure | surgical closure]], most patients with [[atrial septal defect]] can start eating and ambulating within the first or second postoperative days. Also, most patients with [[Atrial septal defect surgical closure | surgical closure]] are discharged by the third or fourth postoperative days and patients with [[Atrial septal defect percutaneous closure | percutaneous closure]], are generally discharged the next day. Surgical follow-up care is mostly for 1-2 months. Ideally, at least 1 follow-up [[echocardiogram]] to confirm complete closure of the [[atrial septal defect]] should be obtained. A cardiologist with good experience with heart defects should continue patient care. An yearly follow up to monitor development of complications like [[arrhythmia]]s should be arranged. Six months of [[aspirin]] with or without [[clopidogrel]] is recommended for prevention of [[thrombus]]formation.
 
===Complications===
* Device is placed via [[femoral vein]]
In some patients, surgical intervention may result in developing complications such as:
 
*[[Atrial fibrillation]]
* Best results are for centrally located [[Ostium secundum atrial septal defect|secundum defects]].  
*[[Infective endocarditis]] (primarily within the first 6 months post-surgery)
 
*[[Congestive heart failure]]
* Static diameter of the defect is assessed by using [[transesophageal echocardiography]]
*[[Arrhythmia]]
 
*[[Pulmonary hypertension]]
* [[Transesophageal echocardiography]] used for determining the device size, position, and deployment
*[[Cyanosis]]
 
*[[Atrial septal defect paradoxical emboli|Paradoxical emboli]]
* A stop-flow  technique is used to select the proper diameter of the device
*[[Stroke]]
 
* In the stop flow technique, the sizing balloon is inflated until no flow is visible through the defect using [[transesophageal echocardiography]].
 
* The margins of the defect must be '''≤5 mm''' to accommodate the edges of the device.
 
{{#ev:youtube|Gros-u7YCTk}}
 
===Benefits of Percutaneous closure===
Among treatment options,  percutaneous closure  is the method of choice for [[Atrial septal defect ostium secundum|ostium secundum]] patients. Many patients experience positive improvements in quality of life such as fewer complications, shorter hospital stays, and overall symptomatic improvement.
 
The  percutaneous closure of ostium secundum is the method of choice in many centers.<ref>{{cite journal | author = Bjørnstad P | title = Is interventional closure the current treatment of choice for selected patients with deficient atrial septation? | journal = Cardiol Young | volume = 16 | issue = 1 | pages = 3-10 | year = 2006 | id = PMID 16454871}}</ref><ref name="pmid10525508">{{cite journal| author=Dhillon R, Thanopoulos B, Tsaousis G, Triposkiadis F, Kyriakidis M, Redington A| title=Transcatheter closure of atrial septal defects in adults with the Amplatzer septal occluder. | journal=Heart | year= 1999 | volume= 82 | issue= 5 | pages= 559-62 | pmid=10525508 | doi= |pmc=PMC1760778 | url= }} </ref>. The benefits that can be associated with the closure are as follow:
 
====Disease Related Benefits====


*Fewer complications compared to surgical closure
===Post Surgical Prognosis===
*Reduced need for [[blood transfusion]]s
Post-surgical prognosis depends on type of defect, amount of shunting, age at surgery and pulmonary pressure. Early mortality is approximately 1% in the absence of [[pulmonary hypertension]] or other major comorbidities. Long-term follow-up is excellent, and preoperative symptoms decrease or abate. The incidence of[[atrial fibrillation]]/[[flutter]] is reduced when concomitant [[antiarrhythmic]] procedures (eg, [[Maze]]) are performed; however, atrial arrhythmias may occur de novo after repair.The need for reoperation of residual/recurrent [[ASD]] is uncommon. [[Superior vena cava]] stenosis or [[pulmonary vein]] stenosis may occur after closure of [[Sinus venosus atrial septal defect|sinus venosus]] [[ASD]].
*Symptomatic improvement
*Regression of [[positive airway pressure]]
*Positive changes in right ventricle performance
*Improved functional capacity <ref name="pmid15708694">{{cite journal| author=Salehian O, Horlick E, Schwerzmann M, Haberer K, McLaughlin P, Siu SC et al.|title=Improvements in cardiac form and function after transcatheter closure of secundum atrial septal defects. | journal=J Am Coll Cardiol | year= 2005 | volume= 45 | issue= 4 | pages= 499-504 | pmid=15708694 | doi=10.1016/j.jacc.2004.10.052 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15708694  }} </ref>
**Improved left atrial volume index
**Improved left ventricular myocardial performance index
**Improved right ventricular myocardial performance index
**Improved peak oxygen uptake


====Other Benefits====
====Age at Surgery and Pulmonary Pressure====
* '''Age ≤ 25 years'''- Survival rates comparable to age and sex-matched control subjects.


* Less invasive no need for [[cardiopulmonary bypass]]
* '''Age 25-40 years''' - Surgical survival reduced compared to surgical repair ≤ 25 years
* Successful implantation rates of more than 96%.  
** [[Pulmonary hypertension|Pulmonary artery pressures]] are normal- survival comparable with surgery done at ≤ 25 years.  
* Established practice (done in most hospital these days)
** Pulmonary artery pressure ≥40 mm Hg- Late survival 50% less than control rates
* Cost-effective
* Shorter hospital stays


===Post Surgical Follow Up===
Due to the development of new [[Minimally invasive surgery|minimally invasive techniques]], percutaneous closure and improvement in surgical closure, most patients with [[atrial septal defect]] can start eating and ambulating within the first or second postoperative days. Also, most patients with surgical closure are discharged by the third or fourth postoperative days and patients with  percutaneous closure, are generally discharged the next day. Surgical follow-up care is mostly for 1-2 months. Ideally, at least 1 follow-up [[echocardiogram]] to confirm complete closure of the [[atrial septal defect]]should be obtained. A cardiologist with good experience with heart defects should continue patient care. An yearly follow up to monitor development of complications like [[arrhythmia]]s should be arranged. Six months of [[aspirin]] with or without [[clopidogrel]] is recommended for prevention of [[thrombus]] formation.


===Complications===
* '''Age ≤ 45 years''' + no comorbidities like heart failure, pulmonary artery pressures ≤60 mm Hg.  - Mortality rate post surgery ≤1%.


As with any invasive treatment,  percutaneous closure could be associated with potential complications. Common complications include issues with device functional integrity such as [[embolization]] around the device or erosion of the materials and malpositioning. Other complications include potential for development of serious circulatory conditions such as [[atrial fibrillation]], [[heart block]], and [[thrombus]]formation.The disadvantages are a thick profile of the device and concerns related to a large amount of nitinol (a nickel-titanium compound) in the device and consequent potential for [[nickel]] toxicity.
* '''Age ≥ 60 years''' + no serious comorbidities - [[Atrial septal defect]] should be closed as early as possible as [[surgery]] can cause an improvement in symptoms


The frequency of complications with percutaneous closure is low, manifesting in under 9% of all cases. With experienced, skilled clinicians, the rate of complication may be as low as 1%.<ref name="pmid11897451">{{cite journal| author=Chessa M, Carminati M, Butera G, Bini RM, Drago M, Rosti L et al.| title=Early and late complications associated with transcatheter occlusion of secundum atrial septal defect. | journal=J Am Coll Cardiol | year= 2002 | volume= 39 | issue= 6 | pages= 1061-5 | pmid=11897451 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11897451  }} </ref>. Complications associated with percutaneous closure include:
* Life expectancy in surgically treated older patients is better than that of medically treated patients.


====Device Related====
* Patient's age at time of surgical closure is a good predictor of development of atrial [[arrhythmias]] as complications.


*Device embolization
* [[Atrial fibrillation]], [[stroke]],  and [[heart failure]] common after surgical repair in adult.
*Malposition of the device
*Device erosion


====Medical Complications====


*[[Atrial fibrillation]] or [[supraventricular tachycardia]]
====Post-surgical Arrhythmias====
*Transient [[atrioventricular block]] / [[heart block]]
*[[Pericardial effusion]]
*[[Thrombus]] formation in the [[left atrial appendage]]
*Iliac vein dissection
* Groin hematoma
* Cardiac perforation
*Increased levels of cardiac tropnin I
* Residual shunts
*There can be migration or erosion of the device so follow-up is warranted.


===Prognosis===
* Surgical closure during childhood - Late onset [[supraventricular arrhythmias]]. The reason for these could be:
The prognosis of percutaneous repair of [[atrial septal defect]] is generally good. However, the prognosis varies and depends on some factors like age at [[surgery]], size of defect, amount of blood [[shunting]] and other associated co-morbidities at the time of repair. Some complications like [[pulmonary hypertension]],[[eisenmenger’s syndrome]], [[right sided heart failure]], [[arrhythmia]]s ([[atrial fibrillation]], [[atrial flutter]]) and [[stroke]] can occur after the repair. However, these are common in older patients(>40years) compared to younger patients.
** Patchy fibrosis of the right [[atrium]] secondary to dilatation
** [[SA node]] dysfunction


===Supportive Trial Data===
* Surgical closure in adults -
====Trials Comparing Percutaneous Versus Surgical Closure====
** [[Atrial fibrillation]] may continue post surgery and require [[cardioversion]] and [[antiarrhythmic]]s treatment.  
* In a multicenter, non-randomized study performed in 29 pediatric cardiology centers, the patients were allotted to either the percutaneous closure or the surgical closure group depending on their preference. The success rate of the surgery was similar in the percutaneous closure and the surgical closure. However, the complication rates were more in the surgical groups (24%) compared to the percutaneous groups (7.2%). Also, the mean hospital stay was 3 days in [[Atrial septal defect surgical closure | surgical group]] compared to 1 day in the percutaneous device group. Additionally,  surgical closure required [[sternotomy]] and [[cardiopulmonary bypass]]. With appropriate patient selection, device closure could be very successful. Also, it is safe and effective compared to other modalities <ref name="pmid12039500">{{cite journal| author=Du ZD, Hijazi ZM, Kleinman CS, Silverman NH, Larntz K, Amplatzer Investigators| title=Comparison between transcatheter and surgical closure of secundum atrial septal defect in children and adults: results of a multicenter nonrandomized trial. | journal=J Am Coll Cardiol | year= 2002 | volume= 39 | issue= 11 | pages= 1836-44 | pmid=12039500 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12039500  }} </ref>.  
** Age at surgery ≥40 years- 1/2 patients with preoperative normal [[sinus rhythm]] will develop postoperative atrial fibrillation.  


* A study done on 45 subjects (15 with percutaneous closure, 15 with surgical correction and 15 control) to evaluate the left and right atrial function after transcatheter [[atrial septal defect]] closure compared with surgically treated [[ASD]], using strain (epsilon) and epsilon rate imaging (SR) techniques, found that in the  surgical corrected groups the peak systolic epsilon and SR values were significantly reduced compared to device and control group. Thus, it could be concluded that percutaneous closure helps in conserving both the atrial regional myocardial properties <ref name="pmid16153516">{{cite journal| author=Di Salvo G, Drago M, Pacileo G, Rea A, Carrozza M, Santoro G et al.| title=Atrial function after surgical and percutaneous closure of atrial septal defect: a strain rate imaging study. | journal=J Am Soc Echocardiogr | year= 2005 | volume= 18 | issue= 9 | pages= 930-3 | pmid=16153516 | doi=10.1016/j.echo.2005.01.029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16153516  }} </ref>.
*Common in the [[Atrial septal defect sinus venosus|sinus venosus]] type than in the [[Ostium secundum atrial septal defects|ostium secundum]] type.


====Trials Testing the Efficacy and Safety of Device Closure====
==2008 ACC/AHA Guidelines for the Management of Adults With Congenital Heart Disease (DO NOT EDIT)<ref name="pmid19038677">{{cite journal| author=Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA et al.| title=ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal=J Am Coll Cardiol | year= 2008 | volume= 52 | issue= 23 | pages= e1-121 | pmid=19038677 | doi=10.1016/j.jacc.2008.10.001 | pmc=|url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19038677  }} </ref> ==
===Recommendations for Postintervention Follow-Up (DO NOT EDIT)<ref name="pmid19038677">{{cite journal| author=Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA et al.| title=ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal=J Am Coll Cardiol | year= 2008 | volume= 52|issue= 23 | pages= e1-121 | pmid=19038677 | doi=10.1016/j.jacc.2008.10.001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19038677  }} </ref>===


*In a study done on 236 patients with [[Ostium secundum atrial septal defects|ostium secundum]] ([[ASD]]), to evaluate the safety and efficacy oftranscatheter closure with the amplatzer septal occluder, the device was found to be very efficient.  It causes [[atrial septal defect]] closure in 84.7% of the treated patient population. During a median follow up of 2.3 years complete closure was documented in 94%, with a residual shunt only in 12 patients. Two of the treated patients were reported to have procedure related complications like [[retroperitoneal bleeding]] and [[air embolism]].<ref name="pmid12527678">{{cite journal| author=Fischer G, Stieh J, Uebing A, Hoffmann U, Morf G, Kramer HH| title=Experience with transcatheter closure of secundum atrial septal defects using the Amplatzer septal occluder: a single centre study in 236 consecutive patients. | journal=Heart | year= 2003 | volume= 89 | issue= 2 | pages= 199-204 | pmid=12527678 | doi= | pmc=PMC1767528 | url= }} </ref>
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Early postoperative symptoms of undue [[fever]], [[fatigue]], [[vomiting]], [[chest pain]], or [[abdominal pain]] may represent postpericardiotomy syndrome with [[tamponade]] and should prompt immediate evaluation with [[echocardiography]].  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Annual clinical follow-up is recommended for patients postoperatively if their ASD was repaired as an adult and the following conditions persist or develop: <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''a.''' [[PAH]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''b.''' Atrial arrhythmias. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''c.''' [[RV dysfunction|RV]] or [[LV dysfunction]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''d.''' Coexisting valvular or other cardiac lesions. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' Evaluation for possible device migration, erosion, or other complications is recommended for patients 3 months to 1 year after device closure and periodically thereafter. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' Device erosion, which may present with [[chest pain]] or [[syncope]], should warrant urgent evaluation.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}


==References==
==References==
{{reflist|2}}
{{Reflist|2}}


[[Category:Cardiology]]
[[Category:Cardiology]]

Revision as of 19:03, 4 January 2013

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Risk calculators and risk factors for Atrial septal defect ostium secundum percutaneous closure

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Priyamvada Singh, M.B.B.S. [2]; Cafer Zorkun, M.D., Ph.D. [3] Assistant Editor(s)-In-Chief: Kristin Feeney, B.S. [4]

Overview

Surgical closure is the commonest treatment method for atrial septal defect and has been the gold standard for many years. Many surgeons prefer moreminimally invasive techniques over the conventional sternotomy to avoid potentials for additional complications. Special consideration must be taken into account for the age of the patient and the size of the defect involved. Surgical closure is indicated for patients with primum, sinus venosus and coronary sinus type ofatrial septal defects. However, ostium secundum atrial septal defects are commonly treated by percutaneous closure. With uncomplicated atrial septal defect, (without pulmonary hypertension and other comorbidities) the post-surgical mortality is as low as 1%

Surgical Closure

Mechanisms of Benefit

Surgical closure involves closing the defect either by putting a pericardial patch or via direct suture closure. The decision for suture closure or patch closure depends on the morphology and size of defect. The closure of the defect prevents the left-to-right shunting of blood across the atrium and thus improving the circulation in heart. It is not recommended that synthetic patches be used for primary closure.[1].

Indication

Surgical closure is indicated for patients with primum, sinus venosus and coronary sinus type of atrial septal defects. Whereas, ostium secundum atrial septal defects are commonly treated by percutaneous closure.

Contraindications

Surgery is contraindicated in patients with severe irreversible pulmonary artery hypertension, eisenmenger's syndrome and no evidence of a left-to-right shunt. Also, for uncomplicated cases with ostium secundum defects percutaneous closure is preferred.

General Considerations During Surgery

  • Small to moderate defects with oval shape, can be closed with the help of sutures.
  • Direct suture closure of large round defects may cause distortion of the atrium and aortic annulus. Thus, a patch closure is preferred in these cases.
  • Considerations in an ostium primum repair:
  • Surgical closure is more complicated compared to other atrial septal defect repairs.
  • The patch should be attached to the septum at the juncture of the mitral and tricuspid valves.
  • Mitral valve repair, closure of the cleft mitral leaflet, annuloplasty and mitral valve replacement may be required to repair mitral insufficiency.
  • Devices used are:
    • Amplatzer septal occluder
    • STARFlex septal occluder
    • PFO Star
    • HELEX

Steps During Surgery


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Post Surgical Follow Up

Due to the development of new minimally invasive techniques, percutaneous closureand improvement in surgical closure, most patients with atrial septal defect can start eating and ambulating within the first or second postoperative days. Also, most patients with surgical closure are discharged by the third or fourth postoperative days and patients with percutaneous closure, are generally discharged the next day. Surgical follow-up care is mostly for 1-2 months. Ideally, at least 1 follow-up echocardiogram to confirm complete closure of the atrial septal defect should be obtained. A cardiologist with good experience with heart defects should continue patient care. An yearly follow up to monitor development of complications like arrhythmias should be arranged. Six months of aspirin with or without clopidogrel is recommended for prevention of thrombusformation.

Complications

In some patients, surgical intervention may result in developing complications such as:

Post Surgical Prognosis

Post-surgical prognosis depends on type of defect, amount of shunting, age at surgery and pulmonary pressure. Early mortality is approximately 1% in the absence of pulmonary hypertension or other major comorbidities. Long-term follow-up is excellent, and preoperative symptoms decrease or abate. The incidence ofatrial fibrillation/flutter is reduced when concomitant antiarrhythmic procedures (eg, Maze) are performed; however, atrial arrhythmias may occur de novo after repair.The need for reoperation of residual/recurrent ASD is uncommon. Superior vena cava stenosis or pulmonary vein stenosis may occur after closure of sinus venosus ASD.

Age at Surgery and Pulmonary Pressure

  • Age ≤ 25 years- Survival rates comparable to age and sex-matched control subjects.
  • Age 25-40 years - Surgical survival reduced compared to surgical repair ≤ 25 years
    • Pulmonary artery pressures are normal- survival comparable with surgery done at ≤ 25 years.
    • Pulmonary artery pressure ≥40 mm Hg- Late survival 50% less than control rates


  • Age ≤ 45 years + no comorbidities like heart failure, pulmonary artery pressures ≤60 mm Hg. - Mortality rate post surgery ≤1%.
  • Age ≥ 60 years + no serious comorbidities - Atrial septal defect should be closed as early as possible as surgery can cause an improvement in symptoms
  • Life expectancy in surgically treated older patients is better than that of medically treated patients.
  • Patient's age at time of surgical closure is a good predictor of development of atrial arrhythmias as complications.


Post-surgical Arrhythmias

2008 ACC/AHA Guidelines for the Management of Adults With Congenital Heart Disease (DO NOT EDIT)[2]

Recommendations for Postintervention Follow-Up (DO NOT EDIT)[2]

Class I
"1. Early postoperative symptoms of undue fever, fatigue, vomiting, chest pain, or abdominal pain may represent postpericardiotomy syndrome with tamponade and should prompt immediate evaluation with echocardiography. (Level of Evidence: C) "
"2. Annual clinical follow-up is recommended for patients postoperatively if their ASD was repaired as an adult and the following conditions persist or develop: "
"a. PAH. (Level of Evidence: C) "
"b. Atrial arrhythmias. (Level of Evidence: C)"
"c. RV or LV dysfunction. (Level of Evidence: C)"
"d. Coexisting valvular or other cardiac lesions. (Level of Evidence: C)"
"3. Evaluation for possible device migration, erosion, or other complications is recommended for patients 3 months to 1 year after device closure and periodically thereafter. (Level of Evidence: C)"
"4. Device erosion, which may present with chest pain or syncope, should warrant urgent evaluation.(Level of Evidence: C)"

References

  1. ↑ Hopkins RA, Bert AA, Buchholz B, Guarino K, Meyers M (2004). "Surgical patch closure of atrial septal defects". Ann Thorac Surg. 77 (6): 2144–9, author reply 2149-50. doi:10.1016/j.athoracsur.2003.10.105. PMID 15172284.
  2. ↑ 2.0 2.1 Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA; et al. (2008). "ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". J Am Coll Cardiol. 52 (23): e1–121. doi:10.1016/j.jacc.2008.10.001. PMID 19038677.

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