Atrial septal defect ostium secundum percutaneous closure
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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
Percutaneous device closure is commonly performed to close an ostium secundum type of atrial septal defect and patent foramen ovales. It is still not FDA approved for closure of other forms of atrial septal defects such as primum, sinus venosus and coronary sinus. With proper patient selection at experienced centers, it has been found to be as successful, safe and effective as surgical closure. Additionally, it has been associated with fewer complications and a reduced length of stay compared to surgical closure [1].
Percutanous Closure
Mechanisms of benefit
In percutaneous closure of atrial septal defects a self-expandable round disc is placed around the defect that prevents the left-to-right shunting 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 artery disease ((Eisenmenger's syndrome).
Indications
The percutaneous closure of atrial septal defects is currently only indicated for the closure of ostium secundum atrial septal defects and 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 secundum defect, there must be a sufficient rim of tissue around the defect for successful percutaneous closure.
Contra-indications
It should not be used in patients with primum, sinus venosus and coronary sinus type of atrial septal defects. Surgical closure of 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.
ACC/AHA recommendations
Video: Types of occluders
Video: Percutaneous closure
Benefits
Post-surgical follow up
Complications
Prognosis
Supportive trial data
Trials comparing percutaneous versus surgical closure
1) 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 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 [1].
2) 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 [2].
Trials testing the efficacy and safety of device closure
1) In a study done on 236 patients with ostium secundum (ASD), to evaluate the safety and efficacy of transcatheter 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.[3]
References
- ↑ 1.0 1.1 Du ZD, Hijazi ZM, Kleinman CS, Silverman NH, Larntz K, Amplatzer Investigators (2002). "Comparison between transcatheter and surgical closure of secundum atrial septal defect in children and adults: results of a multicenter nonrandomized trial". J Am Coll Cardiol. 39 (11): 1836–44. PMID 12039500.
- ↑ Di Salvo G, Drago M, Pacileo G, Rea A, Carrozza M, Santoro G; et al. (2005). "Atrial function after surgical and percutaneous closure of atrial septal defect: a strain rate imaging study". J Am Soc Echocardiogr. 18 (9): 930–3. doi:10.1016/j.echo.2005.01.029. PMID 16153516.
- ↑ Fischer G, Stieh J, Uebing A, Hoffmann U, Morf G, Kramer HH (2003). "Experience with transcatheter closure of secundum atrial septal defects using the Amplatzer septal occluder: a single centre study in 236 consecutive patients". Heart. 89 (2): 199–204. PMC 1767528. PMID 12527678.