atrial septal defects and percutaneous closure · 2017-03-15 · atrial septal defect congenital...
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Atrial Septal Defects and Percutaneous
Closure
Salman Allana, MDInterventional CardiologistDirector Structural Heart DiseaseSentara Rockingham Memorial Hospital
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Atrial Septal Defects and Percutaneous
Closure
Introduction Embryology Pathophysiology Types of ASD Clinical presentation Diagnosis Treatment options
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What is an ASD?
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Atrial Septal Defect
Congenital defects of the atrial septum are common, accounting
for approximately 13 percent of congenital heart disorders, with a
reported birth prevalence of approximately 2 per 1000 live births
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Embryology of ASD
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Pathophysiology of ASD
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Types of ASD
Septum Primum ASD:
15-20% of ASDs
Lower portion of septum
Associated with other
heart defects, cleft mitral
valve
Down’s syndrome
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Types of ASD
Sinus Venosus ASD:
5-10% of ASDs
Near the orifice of superior
or inferior vena cava
Associated with
anomalous pulmonary
venous retrun
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Types of ASD
Coronary Sinus ASD:
1% of ASDs
Associated with persistent
left superior vena cava
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Types of ASD
Secundum ASD:
Most common type
70% of ASDs
Only type of ASD that can
be closed without surgery!
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Clinical Presentation: Spontaneous
closure
In a study of 200 children diagnosed at a mean age of five months
(range 0.1 months to 13.9 years) who were followed for a mean 3.5
years (range 0.5 to 9.4 years)
Spontaneous closure or a decrease in size <3 mm in diameter was
observed in:
• 69 of 81 patients (85 percent) with a 4 to 5 mm ASD
• In 36 of 56 patients (64 percent) with a 6 to 7 mm ASD
• In 15 of 41 patients (36 percent) with a 8 to 10 mm ASD
• In 22 patients with an ASD >10 mm there was no spontaneous resolution, but two had a defect that regressed to <3 mm
Hanslik A et al Pediatrics. 2006;118(4):1560
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Clinical Presentation
Age at presentation depends on how large the defect is
Left to right shunting increases with age
Symptoms
• Asymptomatic
• Recurrent respiratory infections
• Failure to thrive
• Migraine headaches with aura
• Atrial Fibrillation
• Heart failure
• Platypnea/Orthodeoxia
• Eisenmenger syndrome
• Paradoxical Embolism
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Eisenmenger Syndrome
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Important cardiac exam findings
Jugular venous pressure
Right ventricular heave
Fixed split S2 (A2 and P2)
Pulmonary systolic ejection murmur
Diastolic murmur
Holosystolic murmur tricuspid regurgitation
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ECG
Right axis
deviation
Right ventricular
enlargement
Left axis
deviation –
Ostium primum
defects
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Echocardiogram
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Indications for closure
Right Ventricular Enlargement with or without symptoms
? Qp/Qs >1.5
Paradoxical Embolism
Platypnea/Orthodeoxia syndrome
Scuba Divers
High altitude
When not to close?
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Percutaneous Closure Devices
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Methods of Closure
Only septum secundum ASDs can be closed percutaneously
<38 mm and with good rims of approximately 5 mm
Multiple ASDs/Frenestrated ASD
Surgical vs Percutaneous- Observations Studies
No difference in mortality rate
Procedural success is similar
Rate of early complications is lower with percutaneous closure
Recovery is quicker with percutaneous closure
5 year re intervention rate is higher with percutaneous closure
Butera G, Biondi-Zoccai G, Sangiorgi G, Abella R, Giamberti A, Bussadori C, Sheiban I, Saliba Z, Santoro T, Pelissero G, Carminati M, Frigiola A
SO
EuroIntervention. 2011 Jul;7(3):377-85.
Butera G et al. EuroIntervention. 2011 Jul;7(3):377-85
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Complications of percutaneous
closure
https://www.youtube.com/watch?v=fqiuGNrYAWc
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Other considerations
Device Erosion
Technical challenges (ASA)
Endocarditis prophylaxis
Unrepaired ASD
Repaired ASD
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https://www.youtube
.com/watch?v=P4zpi
ujNLX0
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Summary
ASDs are a common congenital heart defect
Most small ASDs close spontaneously
Septum Secundum ASD is the most common type
Indications of closure
Only Septum Secundum ASDs can be closed percutaneously.
Other ASDs require surgical closure
Both surgery and percutaneous closure have overall comparable
success and risk of complications
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Thanks You
Questions