Korean Circ J.  2015 May;45(3):216-224. 10.4070/kcj.2015.45.3.216.

Small Left Atrial Size Complicating Percutaneous Transcatheter Device Closure of Secundum Atrial Septal Defect with Conventional Approach

• Ko HK
• Kang SY
• Yu JJ
• Ko JK
• Kim YH

• KMID: 2389129
• DOI: http://doi.org/10.4070/kcj.2015.45.3.216

Abstract

BACKGROUND AND OBJECTIVES
Transcatheter device closure becomes the first option for treating secundum atrial septal defect (ASD), but the conventional method is sometimes unsuccessful even when the defect size indicates the closure to be feasible. To increase the success rate, modified methods have been introduced and used. This study aimed to find predictors for using the modified methods in the device closure of secundum ASDs.
SUBJECTS AND METHODS
Between October 2010 and December 2012, 92 patients with ASDs underwent the transcatheter device closure. We analyzed the sizes of the defect, the surrounding rims, and the ratios of the left atrium (LA) dimensions to the device size in the patients who underwent the procedure either using the conventional or modified methods.
RESULTS
Among the 88 successful cases (95.7%), 22 patients (25%) required modified methods (12 using pulmonary vein and 10 using balloon). The modified method group had the larger size of ASDs and smaller posterosuperior rim. The mean ratios of the LA anteroposterior diameter, width, and length to the device size were all significantly smaller in the modified methods group than in the conventional group (1.20 vs. 1.56, 1.32 vs. 1.71, and 1.61 vs. 2.07, respectively). We found that the risk factors for the modified methods were smaller retroaortic rim, larger ASD, and smaller LA dimension/device size.
CONCLUSION
In addition to larger defects and smaller retroaortic rim, the smaller ratios of the LA dimensions to the device size influenced the need for the application of modified methods in the transcatheter device closure of ASDs.

Keyword

Heart defect, congenital; Heart septal defects, atrial; Cardiac catheterization; Septal occluder device

MeSH Terms

Cardiac Catheterization
Heart Atria
Heart Defects, Congenital
Heart Septal Defects, Atrial*
Humans
Pulmonary Veins
Risk Factors
Septal Occluder Device

Figure

• 

  Fig. 1 Measurements of the LA diameters (A, B, C) and schematic diagram of the surrounding rims from the pre-interventional TTE (D). A: AP, anteroposterior diameter measured at the midline of the LA from a PLAX view during an end-systolic phase (red). B: parameters measured from an A4C view at an end systolic phase; W, width (blue); LA4C, length (yellow); AA4C, area measured from an A4C view (sky blue). C: parameters measured from an A2C at an end systolic phase; LA2C, length (yellow); AA2C, area measured from an A2C (sky blue). D: gray regions represent the surrounding rims measured from a subcoastal, an A4C, and a PSAX view. LA: left atrium, TTE: transthoracic echocardiography, PLAX: parasternal long axis, A4C: apical four chambers, A2C: apical two chambers, PSAX: parasternal short axis, FR: frame rate, C: compression rate, P: persistent grade, HGen: general harmony, BPM: beat per minute, ASD: secundum atrial septal defect, TV: tricuspid valve.

• 

  Fig. 2 Pulmonary vein method and schematic diagram. Angiographic film showed the approximation of the RA disc by pushing the cable while the LA disc was in the orifice of the right upper PV (A). Schematic diagram of the PV method (B). Modified balloon-assisted method and schematic diagram. Angiographic film showed both wings of the device were deployed before implantation by supporting the peripheral balloon (C). Schematic diagram of BA method (D). RA: right atrium, LA disc of the device was prevented from prolapsed into the RA by balloon (arrow head). LA: left atrium, PV: pulmonary vein, BA: balloon assisted.

• 

  Fig. 3 Flow chart of the strategy with treating ASD patients. All the patients started with the conventional method and then the modified methods were used; the BA method was the last approach after the PV method failed. If all three methods failed, surgical closure was indicated. ASD: secundum atrial septal defect, BA: balloon assisted; PV: pulmonary vein.

• 

  Fig. 4 Comparisons of the two groups in the ratios of the LA diameters (AP, width, and length) to the ASO size. A: ratio of LA AP diameter to ASO size. B: ratio of LA width to ASO size. C: ratio of LA length to ASO size. Pink box represented conventional group and blue box represented modified group. *Significant with p=0.001. LA: left atrium, AP: anteroposterior, ASO: Amplatzer septal occluder.

• 

  Fig. 5 ROC curve for the ratios of the LA AP diameter (red), LA width (blue), and LA length (yellow) to the ASO size. Areas under the curve were 0.719 (p=0.004), 0.716 (p=0.04), and 0.716 (p=0.004), respectively. ROC: receiveroperating characteristic, LA: left atrium, AP: anteroposterior, ASO: Amplatzer septal occluder, W: width, L: length

• 

  Fig. 6 Comparisons between the failed and successful cases in the modified methods group. A: ratio of LA AP diameter to ASO size. B: ratio of LA width to ASO size. C: ratio of LA length to ASO size. Black circle represented each of the failed cases and the blue circle represented each of the successful cases in the ratios of the LA diameters (AP, W and L) to the ASO size. LA: left atrium, AP: anteroposterior, ASO: Amplatzer septal occluder, W: width, L: length

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