Korean Circ J.  2010 Apr;40(4):191-196. 10.4070/kcj.2010.40.4.191.

Morphologic Characteristics and Relating Factors to the Need of Technical Modification in Transcatheter Closure of Large Atrial Septal Defect (> or =25 mm)

• Park SJ
• Kim NK
• Kim JO
• Yoo BW
• Choi JY
• Sul JH

• KMID: 2145556
• DOI: http://doi.org/10.4070/kcj.2010.40.4.191

Abstract

BACKGROUND AND OBJECTIVES
The rigid coupling between the delivery wire and the right atrial disk has been occasionally encountered during transcatheter closure of atrial septal defect (ASD). Therefore the device frequently makes a perpendicular angle, and the leading edge of left atrial disk slips through the defect and prolapses into right atrium (RA) before it is properly placed in the septum. The purpose of this study is to investigate relating factors to the need of technical modification in transcatheter closure of large ASD and to evaluate relevant morphologic characteristics of atrial septal rim in this situation. SUBJECTS AND METHODS: From July, 2003 to May, 2007, 312 patients underwent transcatheter occlusion of ASD with Amplatzer Septal Occluder(R) (ASO, AGA medical corporation, Golden Valley, MN, USA) at Yonsei Cardiovascular Center and among them 109 patients had large ASD (> or =25 mm) and these patients were enrolled in our study. Patients were divided into two groups according to the deploying methods of the device (Group I: standard method, Group II: modified methods). Assessments of the defects and its surrounding rims were made by echocardiography. RESULTS: There were no differences between 2 groups in age, body weight and height except for balloon-stretched diameter (stop-flow technique) and device size. Group II patients with modified methods showed larger balloon-stretched diameter and device size than group I patients with standard method. The mean length of anterosuperior (AS) rim in group II was significantly shorter than group I (p<0.05). As the size of the device used in procedure increased, there was a trend towards increase in the need of modified methods. CONCLUSION: This study shows that AS rim deficiency and the size of ASD may be the relating factors to the need of technical modification in transcatheter closure of ASD. Therefore, when the initial try with standard method is not successful in large ASD with deficient AS rim, we suggest that changing strategy of implantation may save time and efforts and possibly reduce the risk of complications associated with prolonged procedure.

Keyword

Atrial septal defect; Echocardiography; Amplatzer septal occluder; Congenital heart disease

MeSH Terms

Body Weight
Echocardiography
Heart Atria
Heart Septal Defects, Atrial
Humans
Prolapse
Septal Occluder Device

Figure

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  Fig. 1 Diagram showing the relationship between atrial septum and device. The prolapse of left atrial disk during deployment can be observed. SVC: superior vena cava, PV: pulmonary vein, IVC: inferior vena cava, CS: coronary sinus, AAo: ascending aorta, TV: tricuspid valve.

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  Fig. 2 Two dimensional echocardiography findings. A: diagram showing the measuring locations of septal rims. B, C and D: measurements of the rims with transesophageal echocardiography (TEE). Using the still images obtained by TEE, the rim lengths were measured in the modified 4 chamber view and the short axis view. E and F: measurements of the rims with intracardiac echocardiography (ICE). Using the still images obtained by ICE, the rim lengths were measured in the short axis view and the long axis view. SVC: superior vena cava, PS: posterosuperior rim, ASD: atrial septal defect, AS: anterosuperior rim, AAo: ascending aorta, PI: posteroinferio rim, AI: anteroinferior rim, CS: coronary sinus, IVC: inferior vena cava, LA: left atrium, LV: left ventricle, RV: right ventricle.

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  Fig. 3 Anatomical characteristics of defects according to deployment methods. A: in group I with standard method, 48 patients (65%) had central defect and 20 patients (27%) had anterosuperior (AS) defect. B: in group II with modified method, only 6 patients (17%) had central defect, whereas 22 patients (63%) had AS defect. PS: posterosuperior, AI: anteroinferior, PI: posteroinferior.

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  Fig. 4 The different deployment method in atrial septal defect (ASD) patients with central defect and anterosuperior (AS) rim defect. With sufficient rims, 87% of procedure was successfully performed by standard method and 13% needed modified technique, but with AS rim deficiency, modified techniques were needed in 53% of the procedure.

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  Fig. 5 The different deployment method according to employed device size. As the size of the device used in the procedure increased, there was a tendency towards increase in the frequency of use of modified methods.

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  Fig. 6 Modified techniques used in transcatheter closure of large astrial septal defect. A: left upper pulmonary vein technique. B: right upper pulmonary vein technique. C: dilator assisted technique (Wahab technique). D: balloon-assited technique.

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