Percutenous Closure of Large Secundum Atrial Septal Defect with the Amplatzer Septal Occluder Device Under TEE Guidance

- Operator : Young-Hui Kim

Percutenous Closure of Large Secundum Atrial Septal Defect with the Amplatzer Septal Occluder Device Under TEE Guidance

- Operator : Young-Hui Kim, MD, PhD, Korea
Case presentation
The patient was 24 year-old female and presented with asymptomatic cardiac murmur. EKG showed right axis deviation. Transthoracic echocardiography revealed paradoxical septal motion, mildly enlarged right ventricle, and large secundum atrial septal defect (ASD) with left to right shunt, and its size was measured 2.0cm in maximum length. Transesophageal echocardiography (TEE) also showed 2.0 x 2.5 cm sized ASD with left to right shunt (Figure 1).

After general anesthesia, an 8Fr sheath was inserted through right femoral vein. Intraprocedural TEE was used for guidance in the catheterization laboratory. Initially multipurpose catheter was advanced into left atrium through ASD. And then the multipurpose catheter was replaced with a 0.035inch J-tipped exchange length guidewire, the tip of which is preferably located in a left upper lobe pulmonary vein for stability. To size the defect, we used a Meditech sizing balloon (Boston Scientific, Watertown, MA) depending on estimated ASD size. The deflated balloon catheter is passed into the left atrium over the guidewire and inflated to a diameter of approximately 3cm (5 mm greater than estimated ASD diameter using saline). Under TEE guidance, the inflated balloon was gently pulled onto the atrial septum, at which step the balloon was slowly deflated until it popped through the defect into the right atrium. The diameter at which this occurred was 2.4 cm, which was measured on TEE (Figure 2). As a result of this measurement, we chose an 2.4 cm sized Amplatzer device. Selected Amplatzer device was loaded into the delivery tube. And then, delivery sheath, a long dilator, was inserted into left atrium over a 0.035inch guidewire. After which the prepared device was loaded into delivery sheath. The device was advanced until it reached the tip of the sheath. Once the device was at the tip of the sheath and the sheath was in the body of the left atium, the device should be slowly advanced while at the same time slightly withdrawing the sheath to ensure that the left atrial disk opened with the body of the left atrium. Advancing the device compensated for the device shortening as it was released from the sheath. Once the left atrial disk is fully opened in the left atrium, the sheath should be withdrawn further to allow the central waist portion of the device to open. The device and sheath are then both withdrawn to the septum as a unit, and once the resistance of the septum is encountered, the sheath is further withdrawn to allow the right atrial disk to open fully in the right atrium. As with the left atrial disk, the right atrial disk must be advanced to allow for the shortening as it is released. Therefore, it is important to apply the correct tension on the delivery cable to allow the right atrial disk to advance and open freely, yet not allow displacement through to the left atrium. Once the Amplatzer device has been fully opened, it is important to confirm by TEE that both atrial disks are flattened or nearly flattened and that the left atrial disk is entirely in the left atrium and the right atrial disk entirely in the right atrium (Figure 3). After the stability of the device has been confirmed, the delivery cable was released by counterclockwise rotation. As the atrial septum returns to its natural position, the device typically springs superiorly and leftward radiologically (Figure 4) and significant interatrial shunting through the device on TEE was eliminated on color Doppler (Figure 5).

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