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PERCUTANEOUS CLOSURE of ASD's and PFO'S

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					PERCUTANEOUS CLOSURE
   of ASD’s and PFO’S



 LESSONS I HAVE LEARNED

       JEFF HARRISBERG

   Sunninghill Clinic & WSPCCA
PERCUTANEOUS ASD CLOSURE
PERCUTANEOUS CLOSURE OF
     ASD SECUNDUM


 Patient selection.

 Visualisation of the ASD.

 Sizing of the defect.

 Tips and tricks for the procedure.
         THE MODERN DEVICES
 Various devices with different mechanisms of occlusion
  and deployment are used

CardioSeal /StarFlex
                                         Amplatzer

          Helex
         THE MODERN DEVICES

 To date, the Amplatzer has been shown to be the

  most versatile and practical to use.

 Can close defects up to 40mm via low-profile delivery

  sheaths with minimal complications.
          PATIENT SELECTION
                               EXCLUSIONS:
   Primum ASD’s
   Sinus venosus defects
   IVC types                   Unsuitable for percutaneous closure.


   The ideal secundum defect is one with adequate and firm margins
    to:


              the mitral valve
              the base of the aorta
              the orifices of the vena cavae
              the coronary sinus
              the pulmonary veins
PATIENT SELECTION


             SVC




                         AO

              ASD




  IVC
        CS
                    TV
At what age should ASD’s be
          closed?
     At what age should ASD’s be
               closed?
 Small defects may close spontaneously, but defects over +/-

  8mm tend to become larger with somatic growth and result

  in RV volume overload.

 As a guide, ASD’s are closed at a weight of +/- 15kg when

  the septal length and LA dimensions are sufficient to

  accommodate the device adequately.
           SIZING THE ASD

 Transthoracic echocardiography +
 TEE +
 Balloon sizing.
        STANDARD TRANSTHORACIC ECHO VIEWS


                                           SUPRASTERNAL

                              PARASTERNAL SAX

SUBCOSTAL
                APICAL 4 CH
             TRANSTHORACIC ECHO EVALUATION


     Septal length

        LA

RA                                  LA
                                                  LA
                     RA
                             LA

                                         RA



 4 Chamber                Short axis    Subcostal

Defect size + 14mm = estimated device size
                                 (un-stretched)
                   ASD “en face” view 2-D




Changing size of
  ASD in the
 cardiac cycle
              Rejection with TEE

 Rim deficiency:          Too close to pulmonary veins, mitral
  valve, coronary sinus.

 Too large.        (>35mm un-stretched)

 Unfavourable anatomy.

 IVC type. (deficient inferior rim)
Rejection with TEE
    Unsuitable anatomy
Rejection with TEE
 Too large with insufficient rims
Rejection with TEE
         ASD: deficient IVC rim




IVC
Rejection with TEE

 ASD: close to coronary sinus
BALLOON SIZING

                  Stop-Flow
                    only




           Sizing plate
              Tip: Balloon sizing

 The diameter of the defect with
 the catheter thru it, often duplicates the
 balloon stretched diameter quite
 accurately – making balloon sizing
 unnecessary.

  Guide: (If balloon sizing not used)
  Device size = TEE unstretched (mm) + 2mm if no rim absent
  Device size = TEE unstretched (mm) + 4mm if rim deficiency
ANGIOGRAPHY




 NO   LA


RA
  TECHNIQUE OF ASD CLOSURE

 Most cases of percutaneous closure are

  performed under GA using TEE for guidance in the

  cath lab.

 An alternative would be the use of intracardiac

  echo (ICE) which would obviate the need for a GA.

 Flouroscopy is not essential during implantation
Device delivery
                      LA Disc




                     RA Disc




                  Post release
                Tips and Tricks
                 Large ASD’s

 Almost all large ASD’s have aortic (anterior) rim
  deficiency.

 The device tends to align itself perpendicularly
  with the septum and prolapse.
            Hausdorf sheath




Amplatzer                     Hausdorf
sheath                        sheath
         Tips and tricks
Implanting devices in large ASD’s




       LA disc
       in LPV                Second
                             sheath
    Avoid air embolism.
De-air the sheath in the IVC.
   Amplatzer Erosion
  44 yr old female with 22mm device

 18 hours post implantation
    ASO device erosion
                           2006




 80,000 devices implanted

 44 cases of erosion.

                                 Risk = 1 in 1,818               (0,05%)

 4 deaths.

                                 Risk = 1 in 20,000               (0,005%)


      Zahid Amin et al Catheterisation and cardiovasc interventions 63: 496 – 502 (2004)
             Cardiac erosion /Perforation

                       Oversizing of the defect
 Implanted device size > 1.5 times the native diameter of the
  defect




         Zahid Amin et al Catheterisation and cardiovasc interventions 63: 496 – 502 (2004)
                  Summary
 Know which patients not to do!
 Sizing is crucial- [avoid over-sizing].
 Angiographic sizing – waste of time.
 De-air the delivery sheath carefully [IVC].
 TEE guidance during the delivery- NB!
 Flouroscopy not essential during delivery.
 Intra-cardiac echo (ICE)- attractive
  alternative.
PERCUTANEOUS PFO CLOSURE
PERCUTANEOUS PFO CLOSURE




Do we need to close all PFO’s ?


Did our creator get it wrong ?
  PERCUTANEOUS PFO CLOSURE


 Patient selection / indications for closure.

 Diagnosing the PFO.

 Contrast echo study.

 Implantation.
   Devices used in catheter closure of
                  PFO’s




  CardioSEAL / STARflex              HELEX




Amplatzer PFO occluder    Premere   Cardia Star
   Devices used in catheter closure of
                  PFO’s




Occlutech    RF closure       BioStar
                                             Solysafe




Amplatzer PFO occluder    Premere   Cardia Star
Transoesophageal Echocardiography
    Bubble test / contrast Echo
Positive   (10cc agitated saline)   Negative
                    Demographics of the PFO

            27% of the population (1.9 billion) have a PFO

                                               majority

+ve bubble test
? 1% (19 million)
                                         -ve bubble test
? 10% (190 million)




   A PFO is not a disease but merely a facilitator
   of paradoxical embolisation (clot/fat/gas).
     PFO variation and clinical application

 Anatomy and shunt at rest             Bubble test

PFO. No shunt.   probe patent only.   -ve


PFO with spontaneous L-R shunt.       -ve

PFO with spontaneous L-R shunt.       +ve with valsalva

PFO with spontaneous R-L shunting. +ve without valsava
                    Patient selection:
   Previous TIA / stroke.

   Failed or contra-indication to medical Rx.

   Congenital heart defect with R-L shunting

                  (eg Ebstein’s or PA IVS p/o).

   Any scuba diver with unexplained DCS.

   Commercial / technical divers.

   Thrombotic disorders

   Platypnoea orthodeoxia

   Planned major surgery with increased risk of fat or air embolism.

   ?Migraines with aura
           Screening for PFO

 Transthoracic echo. Low yield

 Transcranial doppler. High sensitivity

 Trasnsoesphageal echocardiogram.

            Invasive but added benefits
 Transoesophageal Echcardiography

PFO left to right shunting and effect of catheter
               through the defect

                               LA
     LA


                             RA
RA
Transoesophageal Echocardiography

       PFO with spontaneous R-L shunting



                                       LA



  LA



                                            RA




 RA
Transcranial Doppler
Trans-cranial Doppler
                PFO Diagnosis
               TCD versus TEE
 TCD is safer and less invasive than TEE.

 TCD sensitivity is higher than TEE but lower
  specificity (PFO vs pulmonary A-V fistulae).

 No discomfort / no sedation.

 TEE is poorly tolerated by patients.

 TEE sedation limits the ability to perform Valsalva
  maneuver.
              TCD vs TEE


 TCD is effectively used to:
  Diagnose the existence of PFO.

  Follow up after closure device implantation.
                   TCD vs TEE
 TEE offers greater anatomical delineation.
    Size of defect (ASD continuous flow vs PFO intermittent

     flow)

    Number of defects

    Shape of defect (flap vs tunnel)

    Intracardiac thrombi

    Septal anatomy (aneurysm vs not)

    Quality control of the bubble test.

    Other pathology
Two defects and an atrial septal
          aneurysm
        Screening and Rx of PFO

               History, Exam +/- TTE


              TCD and bubble test


 Positive                                 Negative


                      TEE +ve bubble    No further Rx


                   Device closure

              F.U. TCD and bubble test
     Balloon interrogation of PFO
 Not readily done.
 But may be used to delineate the tunnel type PFO’s
  and to assist in determining which device to select.


              Size             Device (Amplatzer)
              <8mm         25mm PFO occluder
             8-11mm        35mm PFO Occluder
              >11mm        Septal occluder


      Exp Clin Cardiol. 2008 Spring; 13(1): 42–46.   J Alibegovic, RF Bonvini, et al
RA side               3-D TEE guided PFO closure        LA side




                                              Sept primum



          Sept secundum
3-D TEE guided PFO closure
                   Summary

 The number of different PFO occluders on
 the market bears testimony to the fact
 that PFO closures have become
 “big business”.
                   Summary

                    However

 We need to establish strong scientific, trial

  driven, medical indications for closure of

  PFO’s and avoid outright hysteria to correct

  something just because we can.
Thank you

				
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