Original Scientific Articles
Journal of Structural Heart Disease, February 2016, Volume 2, Issue 1:15-32
Atrial Septal Defect: Step-by-Step Catheter Closure
1 Department of Cardiology, Glenmark Cardiac Center, Mumbai, Maharashtra, India
2 Jaslok Hospital and Medical Research Center, Mumbai, Maharashtra, India
Transcatheter device closure of ASD has come a long way since the first experimental closure in dogs by Kings and Mills in 1972. However, unlike earlier devices, the current generation is easier to deploy and retrieve. The secret to a successful procedure includes meticulous planning and execution. It involves comprehensive evaluation from the point of appropriate case selection, detailed pre- and intra-procedural imaging, knowledge of various techniques of device deployment, and anticipating complications and ways to deal with them. In this paper, we describe the step-by-step procedure for transcatheter closure of an atrial septal defect using the Amplatzer Septal Occluder.
Video 1Subcostal bicaval view, documenting adequacy of superior vena caval (SVC) and inferior vena caval (IVC) margins.
Video 2Skewed Apical 4 chamber view with color compare showing the atrio-ventricular (or mitral) margin and the posterior margin.
Video 3TEE at 0 degrees (4-chamber view), showing the AV valve (or mitral) and the posterior margins.
Video 4TEE at 40 degrees (aortic short axis view), depicting the retroaortic and the posterior margins.
Video 5TEE at 90 degrees (bicaval view) demonstrates the superior vena caval and inferior vena caval margins.
Video 6All the components of the delivery system are thoroughly flushed and wiped from outside with heparinized saline solution.
Video 7It is necessary to load the device after gently messaging it in heparinized saline so as to get rid of the air that might have been trapped in the Dacron patches. It is always a good habit to double check that the device is screwed onto the cable securely.
Video 8The ASO being slenderized within the loader followed by thorough flushing to get rid of the air within the system.
Video 9Crossing the defect with a right coronary artery catheter. The catheter tip is positioned in the left superior pulmonary vein (LSPV).
Video 10A floppy tip Amplatz SuperstiffTM guide wire (Boston Scientific, Marlborough, Massachusetts, USA) being placed in the LSPV.
Video 11An Amplatzer TorqVueTM 45° delivery sheath (St. Jude, Plymouth, MN, USA) being passed over the Superstiff wire into the mouth of the LSPV.
Video 12Corresponding TEE loop depicting the delivery sheath being positioned in the LSPV.
Video 13Delivery sheath being advanced over the dilator into the mouth of LSPV.
Video 14The delivery sheath positioned in the left atrium just outside the LSPV.
Video 15Corresponding TEE loop showing the sheath in the left atrium near the opening of the LSPV.
Video 16Dilator being removed from the sheath to allow back bleed and prevent air embolism.
Video 17Amplatzer septal occluder (ASO) being passed through the delivery sheath.
Video 18Left atrial disk of the ASO being extruded in the left atrium.
Video 19Corresponding TEE loop showing left atrial disk in the left atrium.
Video 20The left atrial disk of the ASO being pulled back against the interatrial septum.
Video 21Corresponding TEE loop depicting the same.
Video 22Delivery sheath “peeled” back over the loading cable to allow release of the waist and the right atrial disk and deployment of device.
Video 23Corresponding TEE loop depicting deployment of the ASO across the defect.
Video 24TEE loops at 0, confirming adequate capture of all margins before releasing the device from the loading cable
Video 25TEE loops at 45, confirming adequate capture of all margins before releasing the device from the loading cable
Video 26TEE loops at 90 degrees, confirming adequate capture of all margins before releasing the device from the loading cable
Video 27Release of the ASO from loading cable in left anterior oblique (LAO) view. Note the well-separated disks of the ASO in LAO view confirming a well-positioned device.
Video 28Final position of the device in anteroposterior projection; fluroscopic “fingerprinting” of the device.
Video 29TEE loops depicting a large ASD in a small child. The left atrium is relatively smaller compared to the right atrium.
Video 30TEE loops depicting a large ASD in a small child. The left atrium is relatively smaller compared to the right atrium.
Video 31TEE loops depicting a large ASD in a small child. The left atrium is relatively smaller compared to the right atrium.
Video 32TEE depicting the left atrial disk lying perpendicular to the atrial septum due to inability to accommodate the disk in the left atrium.
Video 33ASO being deployed via LSPV technique i.e. engaging the LA disk into LSPV. The LA disk disengagement was spontaneous.
Video 34Corresponding TEE loop depicting the LSPV technique.
Video 35A contrarian technique of pushing on the cable rather than pulling, to disengage the LA disk.
Video 36ASO being deployed with the left atrial disk being engaged into the right superior pulmonary vein. Loading cable is pushed to disengage the let atrial disk from the RSPV.
Video 37ASO being deployed with the left atrial disk engaged in the left atrial appendage. Similar to the previous case, the LA disk has been disengaged from the LA appendage by pushing the loading cable.
Video 38The delivery sheath has been positioned outside the right superior pulmonary vein instead of LSPV to prevent malalignment of the device disks with the interatrial septum.
Video 39The ASO device being deployed by this technique.
Video 40An Occlutech balloon is positioned in the right atrium and pushed against the interatrial septum over a Superstiff wire positioned in the LSPV.
Video 41The balloon is inflated followed by sequential release of the left atrial disk, waist and the right atrial disk.
Video 42The balloon is gradually deflated to allow deployment of the device across the ASD.
Video 43The balloon catheter being pulled back into the inferior vena cava before releasing the device.
Video 44The Superstiff wire now pulled back into the inferior vena cava before releasing the device.
Video 45Device position confirmed in left anterior oblique view and released.
Video 46ASO being retrieved from the descending thoracic aorta.
Video 47Absence of leak of contrast agent into the pericardial space after appearing in all the four cardiac chambers.
Cite this article as: Dalvi BL, Jain SA. Atrial Septal Defect: Step-by-Step Catheter Closure. Structural Heart Disease 2016;2(1):15-32. DOI: 10.12945/j.jshd.2016.007.14
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