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

Long term outcome after surgical ASD-closure at young age: Longitudinal follow-up up to 50 years after surgery

OBJECTIVES

To describe the clinical outcome and quality of life up to 50 years after surgical atrial septal defect (ASD) closure at young age. Primary outcome is defined as MACE (all-cause mortality, cardiac re-interventions, ischemic stroke, endocarditis, heart failure and symptomatic arrhythmia).

METHODS

Single-center, longitudinal cohort-study evaluating 135 consecutive patients who underwent ASD-closure before the age of 15 years between 1968 and 1980. Participants were invited for extensive cardiac evaluation and assessment of quality-of-life every 10 years.

RESULTS

Eighty patients (86%) of 93 eligible survivors were included in this study (mean age 52 ± 5 years (range 41-63), 40% male). Median follow-up since surgery was 45 years (range 40-51). Cumulative survival after 50 years was 86% and comparable to the normal Dutch population. Cumulative event-free survival after 45 and 50-years was 59% and 46% respectively (re-intervention in 6, symptomatic arrhythmia in 25, and pacemaker implantation in 10 patients). Right ventricular ejection fraction on CMR was diminished in 6%. Exercise capacity was normal in 77%. There was no pulmonary hypertension. NT-proBNP was elevated in 61%. Quality of life was comparable with the general population. No predictors for late events were identified.

CONCLUSION

Long-term survival after surgical ASD-closure in childhood is good and not statistically different at 50 years compared to the normal Dutch population. Re-intervention rate is low, there is no pulmonary hypertension. Right ventricular function was diminished in 6%, exercise capacity was good and stable over time with quality of life comparable to the general population. However, supraventricular tachycardia is common.

Safety and efficacy of the Amplatzer™ Trevisio™ intravascular delivery system: Post-approval study results

BACKGROUND

The Amplatzer™ Trevisio™ Intravascular Delivery System (Trevisio DS; Abbott Laboratories, Chicago, IL, USA) facilitates the delivery of Amplatzer™ Occluders and features an ultraflexible tip, which improves assessment of occluder position before release.

AIMS

To assess the safety and efficacy of the Trevisio DS for transcatheter closure of patent foramen ovale and atrial septal defect.

METHODS

The Amplatzer™ Trevisio™ Intravascular Delivery System Post-Approval Study was a prospective, postmarket, single-arm, multicentre, observational study of the Trevisio DS. Enrolled patients were indicated for transcatheter closure of patent foramen ovale or atrial septal defect. In all procedures, the Trevisio DS was used to deliver Amplatzer™ Occluders. Technical success was defined as successful deployment and release of at least one occluder. Device- or procedure-related serious adverse events were tracked until discharge or day 7, whichever occurred earlier.

RESULTS

The study enrolled 144 patients with patent foramen ovale and 107 patients with atrial septal defect at 22 European sites; 53 patients with atrial septal defect (49.6%) were aged<18years. The rate of technical success was 98.4% (97.2% for atrial septal defect, 99.3% for patent foramen ovale). There was one serious adverse event (0.4%), an acute periprocedural device embolization that occurred after occluder release in a patient with atrial septal defect; the device was retrieved percutaneously. This was determined by the implanter to be unrelated to the performance of the Trevisio DS.

CONCLUSIONS

The Trevisio DS exhibited a high rate of technical success and an excellent safety profile during transcatheter closure of patent foramen ovale and atrial septal defect.

Transcatheter Closure of Atrial Septal Defect with Carag Bioresorbable Septal Occluder™: First-in-Child Experience with 12-MonthFollow-Up

Background

Nowadays, transcatheter device closure of an atrial septal defect (ASD) is a standard approach in children. Potential early and long-term side effects or complications related to the metal framework of the devices are a known issue. A bioresorbable device such as the Carag Bioresorbable Septal Occluder™ (CBSO) could resolve such complications. Material and Results. The Carag Bioresorbable Septal Occluder™ (CBSO; Carag AG, Baar, Switzerland) is a self-centering double disk, repositionable, and retractable device with a bioresorbable framework (polylactic-co-glycolic acid), which is almost completely resorbed by 18-24 months postimplantation. This manuscript reports the four first-in-child ASD device closures using a CBSO. The patients' age was median (IQ1-IQ3), 4.5 years (4-7.25). Weight was 21.3 kg (17.6-32.7). We demonstrated procedural feasibility and safety. Effective defect closure with the device was 100%. Echocardiographic measurements of the thickness of the interatrial septum did not show any relevant increase over a 12-monthfollow-up period. There were no residual defects found after the procedure or later during the resorption process. The patients showed no evidence of any local or systemic inflammatory reaction.

Conclusions

The CBSO device system could offer a new treatment option for transcatheter ASD device closure in the pediatric and adult fields. In our first-in-child experience, it was effectively and safely implanted. During the first 12 months of follow-up, no complications occurred.

Comparative effectiveness of devices for transcatheter closure of atrial septal defects: Systematic review and network meta-analysis

Atrial septal defect is a common congenital heart disease, producing a left-to-right shunt in the atrial septum; the current preferred treatment is transcatheter device closure. The aim is to conduct a systematic review to synthesize information on the comparative effectiveness and safety of atrial septal defect closure devices. The methods used: a comprehensive search of Ovid MEDLINE®, Embase, and Cochrane Central databases was conducted. Studies comparing procedural and follow-up outcomes of atrial septal defect devices were included. Network meta-analyses were conducted to generate direct and indirect evidence for comparative effectiveness and safety outcomes between devices. The results are as follows: Twelve studies met our inclusion criteria and were compared in network meta-analyses. The meta-analyses evaluated contemporary devices: the AMPLATZER Septal Occluder; the GORE CARDIOFORM Septal Occluder; the Figulla Flexible II Occluder; the CeraFlex Septal Occluder; and the HELEX Septal Occluder. These studies represented 3998 patients. The primary safety and efficacy outcomes were device embolization and follow-up residual shunt, respectively. Secondary clinical outcomes included procedural success and major and minor complications. No differences were found between devices in terms of device embolization and secondary clinical outcomes. Follow-up residual shunt was higher with the HELEX Septal Occluder compared with the AMPLATZER Septal Occluder (odds ratio 2.92, 95% confidence interval 1.12-7.61). To conclude: although most outcomes were similar between devices, evidence was largely based on observational low-quality studies. There were inconsistencies in outcome reporting and definitions; this merits future studies, with head-to-head device comparisons and standardization of outcomes.

Minimally invasive versus transcatheter closure of secundum atrial septal defects: a systematic review and meta-analysis

BACKGROUND

Limited data exists demonstrating the efficacy of minimally invasive surgery (MIS) compared to transcatheter (TC) closure of atrial septal defects (ASD). This systematic review and meta-analysis aims to compare post-operative outcomes of MIS versus TC repair in ASD closure.

METHODS

PubMed, Medline and EMBASE were searched from inception until June 2018 for randomised and observational studies comparing post-operative outcomes for MIS and TC repair. The studies were reviewed for bias using the ROBINS-I Score and pooled in a meta-analysis using STATA (version 15).

RESULTS

Six observational studies, involving 1524 patients assessing three primary and five secondary outcomes were included. Evidence suggests TC repair yielded shorter hospital stay (MD = 3.32, 95% CI 1.04-5.60) and lower rates of transient atrial fibrillation (AF) (RR = 0.48, 95% CI 0.20-1.15). TC repair patients also had fewer pericardial effusions (RR = 0.27, 95% CI 0.05-1.54, I² = 0.0%) and pneumothoraxes (RR = 0.18, 95% CI 0.04-0.80, I² = 0.0%). However, TC repair results in more minor residual shunts (RR = 6.04, 95% CI 1.69-21.63 in favour of MIS, I² = 39.0%). No differences were found for incidences of strokes (RR = 1.58, 95% CI 0.23-10.91, I² = 19.3%), unexpected bleeding (RR = 0.44, 95% CI 0.19-1.04, I² = 0.0%) and blood transfusion (RR = 0.39, 95% CI 0.09-1.59, I² = 0.0%).

CONCLUSIONS

MIS closure for ASD has similar outcomes compared to TC repair. However, the lack of randomised literature related to MIS versus TC repair for ASD closure warrants further evidence in the form of RCTs to further support these findings.

Transcatheter Closure of Atrial and Ventricular Septal Defects: JACC Focus Seminar

The field of congenital interventional cardiology has experienced tremendous growth in recent years. Beginning with the development of early devices for transcatheter closure of septal defects in the 1970s and 1980s, such technologies have evolved to become a mainstay of treatment for many atrial septal defects (ASDs) and ventricular septal defects (VSDs). Percutaneous device closure is now the preferred approach for the majority of secundum ASDs. It is also a viable treatment option for selected VSDs, though limitations still exist. In this review, the authors describe the current state of transcatheter closure of ASDs and VSDs in children and adults, including patient selection, procedural approach, and outcomes. Potential areas for future evolution and innovation are also discussed.

Recent developments in next-generation occlusion devices

Transcatheter closure has been widely accepted as a highly effective way to treat abnormal blood flows and/or embolization of thrombus in the heart. It allows the closure of four types of congenital heart defects (CHDs) and stroke-associated left atrial appendage (LAA). The four types of CHDs include atrial septal defect (ASD), patent foramen ovale (PFO), patent ductus arteriosus (PDA), and ventricular septal defect (VSD). Advancements in the materials and configurations of occlusion devices have spurred the transition from open-heart surgery with high complexity and morbidity, or lifelong medication with a high risk of bleeding, to minimally invasive deployment. A variety of occlusion devices have been developed over the past few decades, particularly novel ones represented by biodegradable and 3D-printed occlusion devices, which are considered as next-generation alternatives to conventional Nitinol-based occlusion devices due to biodegradability, customization, and improved biocompatibility. The aim here is to comprehensively review the next-generation occlusion devices in terms of materials, configurations, manufacturing methods, deployment strategies, and (if available) experimental results or clinical data. The current challenges and the direction of future work are also proposed. STATEMENT OF SIGNIFICANCE: Implantation of occlusion devices has become a widely accepted and highly effective treatment for occluding abnormal blood/thrombus flow within the heart. Due to the serious complications such as erosion and displacement of conventional Nitinol-based occluders, next-generation occluders with reduced risk of complications and improved biocompatibility has emerged. Here, we comprehensively review the next-generation occluders developed for atrial septal defect (ASD), patent foramen ovale (PFO), patent ductus arteriosus (PDA), ventricular septal defect (VSD), and left atrial appendage (LAA), with special emphasis on biodegradable occluders. Besides, intelligent materials (e.g., automatically deployable shape memory polymers) and rapid customized manufacturing methods (3D/4D printing) for the fabrication of occluders are also introduced. Lastly, the directions of future work are highlighted.

Antithrombotic Therapy for Stroke Patients with Cardiovascular Disease

Prevention of ischemic stroke relies on the use of antithrombotic medications comprising antiplatelet agents and anticoagulation. Stroke risk is particularly high in patients with cardiovascular disease. This review will focus on the role of antithrombotic therapies in the context of different types of cardiovascular disease. We will discuss oral antiplatelet medications and both IV and parental anticoagulants. Different kinds of cardiovascular disease contribute to stroke via distinct pathophysiological mechanisms, and the optimal treatment for each varies accordingly. We will explore the mechanism of stroke and evidence for antithrombotic therapy in the following conditions: atrial fibrillation, prosthetic heart values (mechanical and bioprosthetic), aortic arch atherosclerosis, congestive heart failure (CHF), endocarditis (infective and nonbacterial thrombotic endocarditis), patent foramen ovale (PFO), left ventricular assist devices (LVAD), and extracorporeal membrane oxygenation (ECMO). While robust data exist for antithrombotic use in conditions such as atrial fibrillation, optimal treatment in many situations remains under active investigation.

Antiplatelet and Antithrombotic Therapy After Patent Foramen Oval and Atrial Septal Defect Closure

Pathologies of the atrial septum include different interatrial communications varying from patent foramen ovale (PFO) to actual defects. Atrial septal defects (ASDs) may be localized within the fossa ovalis such as the secundum type ASD or outside the region of fossa ovalis, such as the ostium primum defect and sinus venosus defect. Over the last decades, the percutaneous closure of interatrial shunts has become a feasible and safe method. During these procedures, the delicate balance between thrombotic risk, device sealing process and bleeding risk is crucial. In this review, we sought to describe current available data on the antiplatelet and antithrombotic management of patients after percutaneous ASD or PFO closure.

Preliminary Experience With the New Amplatzer™ Trevisio™ Delivery System in Transcatheter Atrial Septal Defect Closures in Children

Objectives: To evaluate safety, efficacy, and technical advantages of Amplatzer™ Trevisio™ intravascular delivery system (ATIDS) in percutaneous atrial septal defect (ASD) closure in children. Background: The Trevisio™ is a novel delivery system designed for accurate and facilitated implantation of Amplatzer™ devices. There are no published clinical reports so far. Methods: During September 2020, 9 children with anatomically challenging ASDs underwent attempted transcatheter closure using ATIDS to deliver Amplatzer™ Septal occluders (ASO). All interventions were performed under general anesthesia, trans-esophageal echocardiography (TOE), and fluoroscopic guidance. Standard safety, immediate, and 60-days outcomes were prospectively assessed. Results: The median age was 8.1 (5.1-16.9) years and the median bodyweight was 30 (18-63) kg. Six patients had isolated secundum-type ASDs with absent anterosuperior rims including one with an aneurysmal septum. Three patients had unclassical defects associated with complex congenital heart anomalies. Eight devices were delivered from the femoral vein and the jugular vein was accessed in one patient with interrupted inferior caval vein and azygos continuation. All implantations were successful. The shape, position, and orientation of the ASO were identical before and after release on TOE and fluoroscopy. There was no device embolization or serious complication following closure. Complete shunt closure was confirmed on follow-up. Conclusions: We report the first clinical experience with ATIDS in transcatheter ASD pediatric closures. Safety and efficacy were witnessed in our case-series. The major advantage of reduced-tension deployment and reliable precision in device positioning is highly beneficial in challenging anatomies and unusual access.

Completed atrioventricular block induced by atrial septal defect occluder unfolding: A case report

BACKGROUND

An atrial septal defect is a common condition and accounts for 25% of adult congenital heart diseases. Transcatheter occlusion is a widely used technique for the treatment of secondary aperture-type atrial septal defects (ASDs).

CASE SUMMARY

A 30-year-old female patient was diagnosed with ASD by transthoracic echocardiography (TTE) 1 year ago. The electrocardiogram showed a heart rate of 88 beats per minute, normal sinus rhythm, and no change in the ST-T wave. After admission, TTE showed an atrial septal defect with a left-to-right shunt, aortic root short-axis section with an ASD diameter of 8 mm, a parasternal four-chamber section with an ASD diameter of 9 mm, and subxiphoid biatrial section with a diameter of 13 mm. Percutaneous occlusion was proposed. The intraoperative TTE scan showed that the atrial septal defect was oval in shape, was located near the root of the aorta, and had a maximum diameter of 13 mm. A 10-F sheath was placed in the right femoral vein, and a 0.035° hard guidewire was used to establish the transport track between the left pulmonary vein and the inferior vena cava. A shape-memory alloy atrial septal occluder with a waist diameter of 20 mm was placed successfully and located correctly. TTE showed that the double disk unfolded well and that the clamping of the atrial septum was smooth. Immediately after the disc was revealed, electrocardiograph monitoring showed that the ST interval of the inferior leads was prolonged, the P waves and QRS waves were separated, a junctional escape rhythm maintained the heart rate, and the blood pressure began to decrease. After removing the occluder, the elevation in the ST segment returned to normal immediately, and the sinus rhythm returned to average approximately 10 min later. After consulting the patient’s family, we finally decided to withdraw from the operation.

CONCLUSION

Compression of the small coronary artery, which provides an alternative blood supply to the atrioventricular nodule during the operation, leads to the emergence of a complete atrioventricular block.

Current practice in atrial septal defect occlusion in children and adults

INTRODUCTION

Atrial septal defect (ASD) is one of the most common congenital heart diseases (CHD) in children and adults. This group of malformations includes several types of atrial communications allowing shunting of blood between the systemic and the pulmonary circulations. Early diagnosis and treatment carries favorable outcomes. Patients diagnosed during adulthood often present with complications related to longstanding volume overload such as pulmonary artery hypertension (PAH), atrial dysrhythmias, and right (RV) and left (LV) ventricular dysfunction.

AREA COVERED

This article intended to review all aspects of ASD; anatomy, pathophysiology, clinical presentation, natural history, and indication for treatment. Also, we covered the transcatheter therapy in detail, including the procedural aspect, available devices, and outcomes.

EXPERT OPINION

There has been a remarkable improvement in the treatment strategy of ASD over the last few decades. Transcatheter closure of ASD is currently accepted as the treatment of choice in most patients with appropriately selected secundum ASDs. This review will focus on the most recent advances in diagnosis and treatment strategy of secundum ASD.

Analysis of the therapeutic effect of transesophageal echocardiography-guided percutaneous device closure of atrial septal defects via the right internal jugular vein in children

BACKGROUND

Traditional X-ray-guided transcatheter closure of atrial septal defects (ASDs) via the right femoral vein carries a risk of radiation damage, which is greatly exacerbated by age and vascular conditions. Transesophageal echocardiography (TEE) guidance for the closure procedure not only broadens the indications of interventional therapy for ASDs but also avoids radiation exposure.

PURPOSE

To assess the value of TEE-guided ASD device closure via the right internal jugular vein (RIJV) in children.

METHODS

Nineteen pediatric patients with secondary ASD underwent TEE-guided ASD device closure via the RIJV from July 22, 2015 to July 19, 2017. After the RIJV was successfully accessed, one Fustar curve-adjustable delivery sheath was inserted. The implant depth was adjusted, and the tip of the sheath was curved to facilitate passage through the ASD for the delivery and release of the occluder. TEE was used to guide the entire procedure.

RESULTS

In all 19 patients, the ASDs were successfully closed and the occluder was confirmed to have a stable position and good shape, with no residual shunt. During the follow-up period (2 months to 2 years), no pericardial effusion, thrombosis, tachyarrhythmia, atrioventricular block, or other complications were observed.

CONCLUSIONS

An adjustable delivery sheath can be used to treat ASD via the RIJV. This procedure has varied indications, and its advantages include a short operation path, procedural accuracy, minimal trauma, and quick recovery, especially for young patients with large ASDs and cases in which a femoral vein approach is difficult. The procedure has great clinical significance and merits attention.

Shape memory polymers and their composites in biomedical applications

As a kind of intelligent material, shape memory polymer (SMP) can respond to outside stimuli and possesses good properties including shape memory effect, deformability and biological compatibility, etc. SMPs have been introduced for medical applications such as tissue engineering, biological sutures, stents and bladder sensors. Due to the shape memory effect, the medical devices based on SMP can be implanted into body through minimally invasive surgery in contraction or folded state and recovered to their requisite original shapes at target position. In this paper, a review of SMPs utilized in biomedical applications and their actuation methods are listed. Various biomedical applications and potential applications based on the beneficial properties of SMP are also summarized.

Early to Mid-Term Follow-Up Outcomes of Percutaneous Closure of Atrial Septal Defects Using Recent Generation Devices: a Single-Center Experience

Background and Objectives

This study aimed to describe our early to mid-term experience with transcatheter atrial septal defect (ASD) closure using the Occlutech Figulla^® Flex II device (FSO), Gore^® Cardioform septal occluder (GSO), and Amplatzer^® septal occluder (ASO) after they were first approved in Korea in 2014, and to compare the three aforementioned kinds of ASD closure devices.

Methods

Between September 2014 and August 2016, 267 patients underwent transcatheter ASD closure in our institution. Baseline characteristics, hemodynamic features, comorbidities, and procedural success and complication rates were analyzed retrospectively. The unpaired Student t-test or variance analysis was used in the statistical analysis.

Results

The FSO was most commonly used (n=152, 56.9%), followed by the ASO (n=98, 36.7%) and GSO (n=17, 6.4%). Baseline characteristics and hemodynamic features were similar between the devices, except that the defect size and pulmonary flow-to-systemic flow ratio were lower in the GSO group than in the other groups. Overall, the procedural success rate remained at 100%, and major complication rate was <1%. No late complication occurred during the follow-up.

Conclusions

The FSO and GSO are feasible, safe options for use in transcatheter ASD closure, and they are comparable to the ASO.

Study of biodegradable occluder of atrial septal defect in a porcine model

Objective

To evaluate the safety and feasibility of a modified poly(l‐lactic acid) (PLLA) atrial septal defect (ASD) occluder.

Methods

Forty‐five piglets were divided into two groups: an experimental group (n = 27) and a control group (n = 18). The experimental group underwent percutaneous implantation of a modified PLLA ASD device while the control group underwent percutaneous implantation of a widely used metal ASD device. X‐ray imaging, transthoracic echocardiography (TTE), electrocardiogram (ECG), histopathology and electron microscopic examination were performed at 7 days, 1, 3, 6, and 12 months after implantation.

Results

Twenty‐seven experimental piglets and 18 control piglets were all successfully implanted with modified biodegradable and metal ASD devices, respectively. While both devices exhibited very good occluding effects, the modified PLLA ASD devices were completely endothelialized at 3 months after implantation, and the endothelialization appeared to be more complete compared to the control group. Degradation of the PLLA devices was noted at 12 months follow‐up with no loss of integrity at the atrial septum.

Conclusion

This animal model with implanting of the occluders was effective and not associated with complications. The modified PLLA ASD devices are more controllable and practical than our previous devices. The implanted devices demonstrated good endothelialization and degradability in short and moderate term follow‐up. Long‐term studies are now underway to further evaluate the biodegradability of this novel device.

Transcatheter closure of atrial septal defect: principles and available devices

There has been a remarkable improvement in the treatment strategy of secundum atrial septal defect (ASD) over the last few decades. Indebted to the improvement in device technology and procedural techniques, transcatheter closure of ASD is currently accepted as the treatment of choice in most patients with secundum ASD. Recent generation devices enable easy and safe deployment of device with the properties of adequate flexibility, re-capturability and repositioning. Use of biocompatible materials with improved device design and refined equipment finish may promote re-endothelialization and reduce potential damage to nearby structures. Most of currently available devices show excellent efficacy and comparable outcome with its own advantages and disadvantages. In addition to improvement of device properties and performance, there has been distinct improvement in procedural technique from numerous experiences of device closure of ASD. Nowadays there are well established principles regarding patient selection, pre-procedural evaluation, step-by-step details of procedure as well as post-procedural follow-up. However, an operator may encounter pitfalls in closing complex lesions such as large defect, rim deficiencies and multiple defects, so every operator has to be familiar with each available device, general principle as well as special issues for complex lesions.

Atrial septal defect (ASD) device trans-catheter closure: limitations

Transcatheter closure is a widespread technique used to treat secundum atrial septal defects (ASDs). When compared to surgery, it provides a less invasive approach with quicker recovery and reduced physical and psychological impact. Nowadays, almost 85-90% of all secundum ASD can be closed by using a transcatheter approach. However, several limitations may have a significant impact on the feasibility and success of percutaneous ASD closure. Limitations can be grouped as: (I) anatomical; (II) device-related; (III) associated defects and natural history associated issues; (IV) physiological; (V) complications. Physician should be aware of potential limits of percutaneous ASD closure.

Changing Landscape of Congenital Heart Disease

Congenital heart disease is the most frequently occurring congenital disorder affecting ≈0.8% of live births. Thanks to great efforts and technical improvements, including the development of cardiopulmonary bypass in the 1950s, large-scale repair in these patients became possible, with subsequent dramatic reduction in morbidity and mortality. The ongoing search for progress and the growing understanding of the cardiovascular system and its pathophysiology refined all aspects of care for these patients. As a consequence, survival further increased over the past decades, and a new group of patients, those who survived congenital heart disease into adulthood, emerged. However, a large range of complications raised at the horizon as arrhythmias, endocarditis, pulmonary hypertension, and heart failure, and the need for additional treatment became clear. Technical solutions were sought in perfection and creation of new surgical techniques by developing catheter-based interventions, with elimination of open heart surgery and new electronic devices enabling, for example, multisite pacing and implantation of internal cardiac defibrillators to prevent sudden death. Over time, many pharmaceutical studies were conducted, changing clinical treatment slowly toward evidence-based care, although results were often limited by low numbers and clinical heterogeneity. More attention has been given to secondary issues like sports participation, pregnancy, work, and social-related difficulties. The relevance of these issues was already recognized in the 1970s when the need for specialized centers with multidisciplinary teams was proclaimed. Finally, research has become incorporated in care. Results of intervention studies and registries increased the knowledge on epidemiology of adults with congenital heart disease and their complications during life, and at the end, several guidelines became easily accessible, guiding physicians to deliver care appropriately. Over the past decades, the landscape of adult congenital heart disease has changed dramatically, which has to be continued in the future.