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How to close large and complex ASDs including multiple ASDs

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How to close large and complex
ASDs including multiple ASDs
Shakeel A Qureshi
Evelina Children’s Hospital
London, UK
Egyptian Paediatric Cardiac Society, Cairo, 2010
Limbus of
Fossa Ovale
Tricuspid
Valve
Secundum
ASD
Coronary
Sinus
Imaging is important in challenging
defects?
• Is the defect suitable for transcatheter
closure
• What type of device best suits the
particular defect
• What size device should be used
• Positioning and safe deployment of
the device
• Especially crucial in large defects
Ewert et al., Heart 2000
Difficult ASDs
• Device implantation may be difficult in cases with:
– No aortic rim, thin septum
– aneurysmal septum, floppy septum
– prominent Chiari malformation
– multi-fenestrated defect
– multiple defects
Device closure of atrial septal defects
Selection of patients

Weight above 10 kg

Age above 2-3 years

Atrial septal defect up to 36 mm stretched diameter

Reasonable rim around the defect (> 4mm, but not always)

Atria large enough to accommodate the selected device
Standard Approach
What are difficult ASDs?
•
Deficient aortic rim
•
Deficient posterior rim
•
Deficient aortic and posterior rims
•
Deficient IVC rim
•
Aneurysmal septum
•
Prominent Eustachian valve and Chiari malformation
•
Multi-fenestrated defect
•
Multiple defects
•
Any large ASD (balloon occlusion diameter > 30 mm) No aortic rim, thin
septum
These defects could be difficult to close
Balloon sizing
• Useful but not essential
• Balloons can overstretch the ASD and so result in
oversized device
• “Balloon-stretched diameter” needs to be avoided
• “Stop-flow technique”
– Inflate the balloon until no shunt seen on colour
– Deflate the balloon until shunt reappears
– Re-inflate to eliminate the shunt (stop-flow diameter of ASD)
Closure of Atrial Septal Defects
What are the solutions to the difficulties?
• Device approaches
•
Change the angle of approach
septum at incorrect
- use RUPV or roof of LA or
angle
balloon assisted method
• Part of device comes
through defect
•
RA, or within pulmonary veins
•
• Device unstable
• Device embolisation
Deploy device more in LA than
Pull device into sheath and try
a larger size
•
Retrieve device with snares
and big sheaths
Deficient aortic rim
Methods to deploy device:
• Catheter/dilator tip
• Device loaded over the wire
• Left upper pulmonary vein deployment
• Right upper pulmonary vein deployment
• Hausdorf-Lock sheath
• Balloon-assisted technique
Problems with absent aortic rim
Large ASD – poor device position
Device closure of difficult ASDs
Delivery near left atrial roof
Combined over the wire and LUPV
deployment
Left upper pulmonary vein technique
Device closure of difficult ASDs
Balloon in LUPV, device in LA
Device closure of difficult ASDs
Balloon in LUPV, device in LA
ASDs with aneurysms
• Challenging defects
• Stabilising the aneurysm will help
• Oversizing the device in relation to defect
ASD with aneurysmal septum
ASD with aneurysmal septum
ASD with aneurysmal septum
ASD with aneurysmal septum
Multiple ASDs
• Ensure guidewires are through appropriate
holes
• Balloons help (occlude one hole and cross the
other)
• Deliver small device first, then the larger one
ASD closed with 2 devices
ASD closed with 2 devices
Device closure of large secundum ASD with
deficient posterior and IVC rim
Device closure of large secundum ASD with
deficient posterior and IVC rim
Device closure of large secundum ASD with
deficient posterior and IVC rim
Device closure of large secundum ASD with
deficient posterior and IVC rim
Which defects cannot be closed?

Large ASDs >38mm diameter

Those with absent IVC rims

Those with absent rims in >2
areas

Those in which device is too
large to fit in the atria
Closure of difficult ASDs
• Standard deployment may not be adequate
• Different methods needed e.g
– Device deployed in R or LUPV
– Device loaded over a guidewire and deployed in a pulmonary
vein
– Device deployed with assistance from a dilator
– Device deployed with assistance from a balloon in R or LUPV
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