Atrial Septal Defect (ASD) device closure

 Atrial Septal Defect (ASD) Device Closure: A Comprehensive Overview

Case Presentation:

A 25-year-old female patient presented with complaints of shortness of breath on exertion and palpitations for the past 6 months. She had no significant past medical history and was not taking any medications.

Physical Examination:

- Vital signs: Blood pressure 120/80 mmHg, pulse rate 90 beats per minute, oxygen saturation 98% on room air.

- Cardiovascular examination: Revealed a systolic ejection murmur at the left upper sternal border, with fixed splitting of the second heart sound.

- Chest examination: Clear lungs, no peripheral edema.

Diagnostic Tests:

- Electrocardiogram (ECG): Showed sinus rhythm with right axis deviation and incomplete right bundle branch block.

- Chest X-ray: Revealed cardiomegaly with increased pulmonary vascular markings.

- Transthoracic echocardiogram (TTE): Demonstrated a secundum atrial septal defect (ASD) with left-to-right shunting, right ventricular enlargement, and normal left ventricular function.

- Transesophageal echocardiogram (TEE): Confirmed the presence of a 20-mm secundum ASD with adequate rims for device closure.

Management:

The patient was diagnosed with a secundum ASD and was considered a candidate for device closure. After discussing the risks and benefits of the procedure, the patient underwent ASD device closure using an Amplatzer Septal Occluder (ASO) device.

Procedure:

1. The procedure was performed under general anesthesia with fluoroscopic and TEE guidance.

2. Vascular access was obtained through the right femoral vein.

3. A catheter was advanced to the inferior vena cava, and a guidewire was placed in the left atrium through the ASD.

4. Balloon sizing was performed to determine the appropriate device size.

5. A 22-mm ASO device was deployed across the ASD under fluoroscopic and TEE guidance.

6. The device was positioned and released, and its stability was assessed.

Post-Procedure Care:

1. The patient was monitored in the hospital for 24 hours after the procedure.

2. Anticoagulation therapy with aspirin and clopidogrel was initiated to prevent thrombus formation.

3. Follow-up echocardiography was performed before discharge to assess device position and function.

Follow-up:

At 6-month follow-up, the patient reported significant improvement in symptoms, and echocardiography showed proper device position and function with no residual shunting.

Conclusion:

ASD device closure is a safe and effective procedure for treating secundum ASDs. With careful patient selection and precise device sizing, this procedure can significantly improve symptoms and quality of life for patients with ASDs.

Comprehensive Review: 

Atrial Septal Defect (ASD) device closure is a minimally invasive procedure used to treat a type of congenital heart defect where there's a hole in the wall (septum) between the heart's upper chambers (atria). This procedure has revolutionized the treatment of ASDs, offering a safe and effective alternative to open-heart surgery.

Indications for ASD Device Closure

1. Symptomatic patients: Patients experiencing symptoms like shortness of breath, fatigue, or palpitations due to significant left-to-right shunting.

2. Significant shunting: Patients with a Qp/Qs ratio ≥ 1.5:1, indicating significant left-to-right shunting.

3. Right heart enlargement: Patients with right ventricular enlargement or increased pulmonary blood flow.

4. Paradoxical embolism: Patients with a history of paradoxical embolism (stroke or transient ischemic attack) and a patent foramen ovale (PFO) or ASD.

Contraindications for ASD Device Closure

1. Severe pulmonary hypertension: Patients with severe pulmonary hypertension (pulmonary vascular resistance > 7 Woods units) may not benefit from ASD closure.

2. Small defect size: Patients with small defect sizes (< 5 mm) may not require device closure.

3. Multiple defects: Patients with multiple defects or complex anatomy may require surgical repair.

Procedure Steps

1. Preparation: Patients undergo general anesthesia or conscious sedation. Anticoagulation therapy (e.g., heparin) is administered to prevent thrombosis.

2. Vascular access: A catheter is inserted through the femoral vein, and a guidewire is advanced to the inferior vena cava.

3. Transseptal puncture: A transseptal needle or dilator is used to cross the atrial septum, and a guidewire is placed in the left atrium.

4. Balloon sizing: A sizing balloon is used to measure the defect size and determine the appropriate device size.

5. Device deployment: The selected device (e.g., Amplatzer Septal Occluder or Gore Cardioform ASD Occluder) is deployed across the defect under fluoroscopic and echocardiographic guidance.

6. Device positioning: The device is positioned across the defect, and its stability is assessed.

7. Release: The device is released, and its position is verified using echocardiography and fluoroscopy.

Devices Used

1. Amplatzer Septal Occluder (ASO): A self-expandable, double-disc device made of nitinol wire mesh.

2. Gore Cardioform ASD Occluder: A non-self-centering, conformable device made of a nickel-titanium alloy.

3. Other devices: Other devices, such as the Figulla Occlutech Septal Occluder or the Cocoon Septal Occluder, may be used depending on the patient's anatomy and the operator's preference.

Post-Procedure Care

1. Monitoring: Patients are monitored for complications, such as device embolization or thrombus formation.

2. Anticoagulation: Patients receive anticoagulation therapy (e.g., aspirin and clopidogrel) to prevent thrombus formation.

3. Follow-up: Patients undergo follow-up echocardiography to assess device position and function.

In conclusion, ASD device closure is a safe and effective procedure for treating atrial septal defects. With careful patient selection, precise device sizing, and meticulous procedural technique, this procedure can significantly improve symptoms and quality of life for patients with ASDs.