Atrial Septal Defect: Step-by-Step Catheter Closure

Abstract

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.

Media

• Video 1

  

  Subcostal bicaval view, documenting adequacy of superior vena caval (SVC) and inferior vena caval (IVC) margins.

• Video 2

  

  Skewed Apical 4 chamber view with color compare showing the atrio-ventricular (or mitral) margin and the posterior margin.

• Video 3

  

  TEE at 0 degrees (4-chamber view), showing the AV valve (or mitral) and the posterior margins.

• Video 4

  

  TEE at 40 degrees (aortic short axis view), depicting the retroaortic and the posterior margins.

• Video 5

  

  TEE at 90 degrees (bicaval view) demonstrates the superior vena caval and inferior vena caval margins.

• Video 6

  

  All the components of the delivery system are thoroughly flushed and wiped from outside with heparinized saline solution.

• Video 7

  

  It 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 8

  

  The ASO being slenderized within the loader followed by thorough flushing to get rid of the air within the system.

• Video 9

  

  Crossing the defect with a right coronary artery catheter. The catheter tip is positioned in the left superior pulmonary vein (LSPV).

• Video 10

  

  A floppy tip Amplatz SuperstiffTM guide wire (Boston Scientific, Marlborough, Massachusetts, USA) being placed in the LSPV.

• Video 11

  

  An Amplatzer TorqVueTM 45° delivery sheath (St. Jude, Plymouth, MN, USA) being passed over the Superstiff wire into the mouth of the LSPV.

• Video 12

  

  Corresponding TEE loop depicting the delivery sheath being positioned in the LSPV.

• Video 13

  

  Delivery sheath being advanced over the dilator into the mouth of LSPV.

• Video 14

  

  The delivery sheath positioned in the left atrium just outside the LSPV.

• Video 15

  

  Corresponding TEE loop showing the sheath in the left atrium near the opening of the LSPV.

• Video 16

  

  Dilator being removed from the sheath to allow back bleed and prevent air embolism.

• Video 17

  

  Amplatzer septal occluder (ASO) being passed through the delivery sheath.

• Video 18

  

  Left atrial disk of the ASO being extruded in the left atrium.

• Video 19

  

  Corresponding TEE loop showing left atrial disk in the left atrium.

• Video 20

  

  The left atrial disk of the ASO being pulled back against the interatrial septum.

• Video 21

  

  Corresponding TEE loop depicting the same.

• Video 22

  

  Delivery sheath “peeled” back over the loading cable to allow release of the waist and the right atrial disk and deployment of device.

• Video 23

  

  Corresponding TEE loop depicting deployment of the ASO across the defect.

• Video 24

  

  TEE loops at 0, confirming adequate capture of all margins before releasing the device from the loading cable

• Video 25

  

  TEE loops at 45, confirming adequate capture of all margins before releasing the device from the loading cable

• Video 26

  

  TEE loops at 90 degrees, confirming adequate capture of all margins before releasing the device from the loading cable

• Video 27

  

  Release 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 28

  

  Final position of the device in anteroposterior projection; fluroscopic “fingerprinting” of the device.

• Video 29

  

  TEE loops depicting a large ASD in a small child. The left atrium is relatively smaller compared to the right atrium.

• Video 30

  

  TEE loops depicting a large ASD in a small child. The left atrium is relatively smaller compared to the right atrium.

• Video 31

  

  TEE loops depicting a large ASD in a small child. The left atrium is relatively smaller compared to the right atrium.

• Video 32

  

  TEE depicting the left atrial disk lying perpendicular to the atrial septum due to inability to accommodate the disk in the left atrium.

• Video 33

  

  ASO being deployed via LSPV technique i.e. engaging the LA disk into LSPV. The LA disk disengagement was spontaneous.

• Video 34

  

  Corresponding TEE loop depicting the LSPV technique.

• Video 35

  

  A contrarian technique of pushing on the cable rather than pulling, to disengage the LA disk.

• Video 36

  

  ASO 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 37

  

  ASO 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 38

  

  The 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 39

  

  The ASO device being deployed by this technique.

• Video 40

  

  An Occlutech balloon is positioned in the right atrium and pushed against the interatrial septum over a Superstiff wire positioned in the LSPV.

• Video 41

  

  The balloon is inflated followed by sequential release of the left atrial disk, waist and the right atrial disk.

• Video 42

  

  The balloon is gradually deflated to allow deployment of the device across the ASD.

• Video 43

  

  The balloon catheter being pulled back into the inferior vena cava before releasing the device.

• Video 44

  

  The Superstiff wire now pulled back into the inferior vena cava before releasing the device.

• Video 45

  

  Device position confirmed in left anterior oblique view and released.

• Video 46

  

  ASO being retrieved from the descending thoracic aorta.

• Video 47

  

  Absence of leak of contrast agent into the pericardial space after appearing in all the four cardiac chambers.