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Transcatheter ASD closure, sans X-rays

Transcatheter ASD closure, sans X-rays. Peter Ewert MD Robert Beekman MD. Transcatheter closure of ASD’s without fluoroscopy. Current transcatheter methods of defect closure require fluoroscopy with radiation exposure.

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Transcatheter ASD closure, sans X-rays

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  1. Transcatheter ASD closure, sans X-rays Peter Ewert MD Robert Beekman MD

  2. Transcatheter closure of ASD’swithout fluoroscopy • Current transcatheter methods of defect closure require fluoroscopy with radiation exposure. • A recent study (Ewert et al.) demonstrates effectiveness of diagnostic, sizing and implantation procedures using echographic guidance, performed without fluoroscopy. • 19 of 22 patients underwent successful defect closure without fluoroscopy. • All procedures were uneventful with the exception of one case of atrial flutter during diagnostic catheterization, cardioverted to sinus rhythm before implantation. Ewert P, et al. Circulation 2000;101:847-849

  3. Transcatheter closure of ASD’swithout fluoroscopy • In the absence of fluoroscopy, the diagnostic procedure still requires oxymetry of shunt volumes and pressure recordings from PA and RV using a Swan-Ganz catheter. • Defect is crossed with a multipurpose catheter (inner lumen 1.5 mm, length 65-70 cm). • An inner Fogarty balloon catheter is inflated and gently pulled back to precisely locate tip of first guidewire. • The sizing maneuver is performed over the wire. Ewert P, et al. Circulation 2000;101:847-849

  4. Diagnosis • Legend • LA left atrium • RA right atrium • RAA right atrial appendage • VCS superior caval vein • ASD atrial septal defect Transesophageal long axis view. A diagnostic catheter is placed in the VCS to draw a blood sample for oxymetry.

  5. Sizing • Legend • LAA left atrial appendage • PV pulmonary vein • LV left ventricle • * sizing balloon The sizing balloon has been inflated in front of the orifice of the left upper PV. The sizing catheter is guided over a wire in the left upper PV.

  6. Transcatheter closure of ASD’swithout fluoroscopy • Defect closure is performed with the Amplatzer septal or PFO occluder device. • The Amplatzer occluder device has been the one device used for closure under echo guidance without fluoroscopy due to its rotational symmetry (no difficulties with obtaining the correct echo slice). • This device also has a relatively high metal content and is more uniformly echodense. Ewert P, et al. Circulation 2000;101:847-849

  7. Implantation (i) • Legend • LA left atrium • PV pulmonary vein • LAA left atrial appendage * occluder device An occluder has been advanced through a long sheath inserted into the left upper PV. Here, the sheath is pulled back with the occluder held in place. The distal end of the device begins to unfold.

  8. Implantation (ii) • Legend • LA left atrium • AO aortic root * occluder device The left atrial disc is configured behind the aortic root and can now be pulled back into the defect.

  9. Implantation (iii) • Legend • LA left atrium • RA right atrium • AO aortic root * occluder device The occluder is completely configured inside the defect but yet connected to the delivery cable. Pulling reveals a stable position.

  10. Transcatheter closure of ASD’swithout fluoroscopy • One disadvantage to this technique is the fact that the operator sees only echo slices of the catheter rather than the shadow of the catheter as would be seen under fluoroscopy. • The operator must become accustomed to this procedure and should be very disciplined, moving the catheter only when it is seen under imaging. • Transesophageal echo might be required for a longer period of time during the procedure. Ewert P, et al. Circulation 2000;101:847-849

  11. Comparisons between study and control groups Study group n = 22 18 (2-66) 9/13 9 (6-26) 88 (35-135) 9.9 (3.2-19.2) Control group n = 131 34 (1-78) 54/77 11 (4-26) 100 (45-150) 5.6 (2.6-21.2) p value NS NS NS NS 0.002 • Age, years • PFO vs ASD • Defect size, mm • Procedure time, min • Propofol, mg/kg • PFO patent foramen ovale • ASD atrial septal defect Ewert P, et al. Circulation 2000;101:847-849

  12. Transcatheter closure of ASD’swithout fluoroscopy • Septal closures without fluoroscopy should not be performed outside the cath lab, and fluoroscopy should remain readily available if complications arise. • Closure under echo guidance alone should be restricted to experienced centers, and operators should be well trained under echo guidance with backgrounds in the fluoroscopic approach. Ewert P, et al. Circulation 2000;101:847-849

  13. Transcatheter closure of ASD’swithout fluoroscopy • “One of [our surgical colleagues’] major concerns about what we have to offer is the radiation exposure. So I think that you have probably convinced them that catheter therapy is clearly the treatment of choice for these defects.” • Dr Robert BeekmanDirector, Division of CardiologyChildren's Hospital Medical CenterCincinnati, OH

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