Transcatheter closure of atrial-septal defects and patent foramen ovale in adults: optimal anatomic adaptation of occlusion device

Historical developments of atrial septal defect closure devices: what we learn from the past

INTRODUCTION

Since King and Mills' pioneering work in percutaneous closure devices of secundum atrial septal defects (ASD) four decades ago, developments in device shape, material and implantation technique led to adoption of percutaneous ASD closure as current treatment of choice. Not only was the feasibility of such a percutaneous procedure tested altogether, but pursuing the ideal device in terms of safety and efficacy became priority.

AREAS COVERED

In this review we present the historical development of ASD devices in design, material and technique with clinical data, and provide the future perspectives in percutaneous ASD closures.

EXPERT OPINION

An 'ideal device' requires complete defect closure with negligible risk of complications using a safe, straightforward delivery technique with repositioning and retrieving properties. Some of the devices currently at hand come close to fulfilling these criteria, however none seem to provide those prerequisites completely. By understanding how challenges in device development were overcome in the past, new insights into future improvements are given.

Percutaneous closure with Amplatzer device is a safe and efficient alternative to surgery in adults with large atrial septal defects

BACKGROUND

In adults with atrial septal defect (ASD) and large right-to-left shunt, closure of the defect is recommended. Percutaneous closure is still rarely used in this population. This study presents the results of transcatheter closure with the Amplatzer occluder in such patients.

METHODS AND RESULTS

We studied 44 consecutive adult patients with a secundum ASD and 2 of the 3 following criteria: QP/QS >/=2 by oximetry, echocardiographic right ventricle overload, and ASD size >20 mm. Forty-two patients had a successful implantation. In 1 patient an unstable device was withdrawn; in another one, the device embolized in the pulmonary artery. At 6-month median follow-up, 95% had a complete closure; 2 patients with an additional defect had a small residual shunt. Major complications were the aforementioned embolization and a cerebrovascular accident in a patient with atrial fibrillation treated with aspirin. Others were minor and transitory: premature atrial beats in 3 patients, and paroxysmal atrial fibrillation and pulmonary edema in 1 patient each.

CONCLUSIONS

Transcatheter closure of large ASDs with the Amplatzer device is efficient with less morbidity than surgical closure.

Transcatheter closure of atrial septal defect using Amplatzer septal occluder in Chinese adults

Amplatzer septal occluder (AGA Med. Co., USA) is a novel device for occlusion of atrial septal defect. We present our experience of transcatheter closure of atrial septal defects using Amplatzer septal occluder in 45 adult Chinese patients (age range 18-69 years). The size of atrial septal defect varied from 14-28 (23 +/- 4) mm. Cardiac catheterization revealed a pulmonary-to-systemic shunt ratio ranging from 1.4-2.8 (mean 2.0 +/- 0.4). The procedure was successful in 44 (98%) patients. Displacement of the device requiring surgical removal occurred in one (2%) patient and minor wound complication occurred in two (4%) patients. Total procedure time was 67 +/- 16 minutes and the fluoroscopy time was 25 +/- 8 min. Immediate post-procedure and pre-discharge echocardiography revealed complete abolition of shunt in 42 (93%) and trivial residual shunt in 3 (7%) patients. The average follow-up period was 16 +/- 6 months (range 2 months to 3 years) months. None of the patients had developed other major complication at follow-up. Cathet Cardiovasc Intervent 2001;52:373-377.

Interventional catheterization

Several investigations have been performed to evaluate the mid-term results of coil embolization for patent ductus arteriosus. Excellent results were obtained with coils if the minimum diameter of the ductus was less than 4 mm. Balloon dilation of native coarctation and recoarctation may be associated with complications such as aneurysm formation. Stent placement may solve some of the problems of balloon dilation, but the stents currently available are not perfect. Results of transcatheter closure of atrial septal defect using new devices have been were reported. The self-expanding nitinol double-disk device (Amplatzer septal occluder) (AGA Medical Corporation, Golden Valley, Minnesota) is becoming popular because it is easy to implant, is easy to retrieve before its release, can occlude a relatively large defect, and has a low rate of residual leak. Although the immediate results with this device were excellent, surgical closure is still the standard treatment and we need to see the long-term results of transcatheter closure.