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Ann Thorac Surg 2008;85:695. doi:10.1016/j.athoracsur.2007.06.100
© 2008 The Society of Thoracic Surgeons
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Correspondence

The Experience of Occluding Secundum Atrial Septal Defect

Liang Tao, MDa, Xiang Jun Zeng, MDa, Xiao Jing Ma, MDa, Yan Hong Luo, MDa, Yeong Phang Lim, FRCSb, Yeow Leng Chua, FRCSb

a Cardiac Surgical Department and Echocardiography Department, Wuhan Asia Heart Hospital, JingHan Ave, #753, Wuhan 430022, China
b Department of Cardiothoracic Surgery, National Heart Centre, Singapore

(Email: zengxiangjun{at}sohu.com; xiangjunzeng{at}163.com; yeongphanglim{at}yahoo.com).

To the Editor:

We write in reply to the comments raised by Dixit and colleagues [1]. All the patients who underwent this procedure were ruled out from having transcutaneous device closure by our cardiology colleagues. The reasons for not considering these patients for transcutaneous closure were (1) size of defect exceeding 25 mm, (2) presence of a deficient rim (especially a deficient aortic rim), and (3) complicated or fenestrated atrial septal defect (ASD). One of the key advantages of this method is the ability to implant large devices for large ASDs regardless of femoral vessel size.

As these patients were not candidates for transcutaneous closure, the second point raised by Dixit and colleagues [1] is not valid.

We believe that the advantages of this approach are:

1 The ability to implant large devices; the largest device we have implanted using this approach is 46 mm (waist) in diameter. We have recently moved away from implanting very large devices in smaller right atriums as we believe that we can not adequately test for device stability by pulling on the device as the right atrium (RA) disc usually ends up being incompletely folded and we are unable to "tug" on the left atrium (LA) disc directly.
2 This approach is easy to perform and has a short learning curve. The device is easily guided through the ASD into the left atrium under intraoperative transesophageal echocardiographic (TEE) guidance. There is little maneuvering required for this step.
3 There is no exposure to radiation in this procedure.
4 Stability of device position is better assessed in this approach, because the device is pulled directly in the axis of the ASD when testing for stability.
5 Fenestrated ASDs can be easily closed using this method by deploying more than one device. To date, we have closed approximately seven fenestrated ASDs in more than 100 patients in our series.
6 There is an added element of safety compared with the transcutaneous route, because the procedure is performed in the operating room with cardiopulmonary bypass facilities readily available in short notice and any complications can be dealt with expediently.
7 The occlusion device we use has few differences in comparison with the Amplatzer device (Long Teng Xing Kong Medical Inc, Beijing, China), which can also be used. The LA disc has a smooth surface to minimize thrombogenicity. The RA disc has no screw head and we only use a suture to pull on the device to test for stability. The RA and LA discs are closer together to form a tighter seal. Therefore, we only prescribe aspirin for 3 months post-procedure and we have not had any thrombotic events in our patients. It was discovered that some patients forgot to take the postoperatively prescribed aspirin, but these patients did not have any thrombotic events.

The relative disadvantage of this approach is that it still involves an incision in the chest wall and pericardium, albeit a small one; therefore, it has the potential for wound complications such as hemorrhage, infections, and pericarditis. Fortunately we have not experienced any wound complications in our series.

We have been able to close defects with deficient margins by using an oversized device. In our experience there have not been any incidences of residual shunt or device instability using this strategy. It is precisely the presence of deficient margins that made some of the patients unsuitable for device closure, as mentioned earlier. One of the problems is that estimating the size of the deficient rim is often inaccurate, especially in patients with a deficient rim around the inferior vena cava; therefore, we have recently opted not to use this approach for these patients. We have no hesitation in performing ASD closure using conventional means if we deem that closure by the previously described approach is too risky.

In our experience to date, using this method in approximately 100 cases of ASD closure we have found that as long as the overlap of the device with the anterior mitral leaflet is less than one third its length, then there is minimal mitral regurgitation. If the overlap is more than one third, even if there is minimal mitral regurgitation, we would still perform conventional ASD repair under cardiopulmonary bypass.


   References
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 References
 

  1. Dixit MD, Pradeep KK, Gan M, Dayal A. Problems in perioperative secundum atrial septal defect device closure: our experience Ann Thorac Surg 2007;83:1580.[Free Full Text]



This article has been cited by other articles:


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X. Wei, W. Yi, X. Xu, J. Zhang, J. Li, S. Yu, and D. Yi
Transthoracic occlusion for secundum atrial septal defects unsuitable for transcatheter occlusion approach
J. Thorac. Cardiovasc. Surg., July 1, 2011; 142(1): 113 - 119.
[Abstract] [Full Text] [PDF]

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