Transcatheter closure of atrial septal defect: does age matter?

Abstract

Atrial septal defect (ASD) is the most common type of common congenital heart disease (CHD) in adults. During the last decade, there has been a remarkable change in the treatment strategy of ASD, shifting the therapeutic gold standard from surgery to transcatheter closure, along with refinements and the evolution of device technology. Reports on the outcome of transcatheter ASD closure have shown an excellent efficacy as well as a low complication rate. However, the procedural details and/or outcomes of this procedure may be influenced by several factors including morphologic characteristics of the defect, co-morbid diseases, as well as individual factors including age and weight of the patient. Because the risk-benefit relationship in both the very young and the elderly subsets of the patients has not been clearly defined yet, closure of an ASD with device may be potentially subtracted from the treatment option in these patient groups. In this article, we will review the basis for device closure in small children and elderly patients with ASD and provide an overview of the frequently encountered problems.

Keywords: Aged; Atrial septal defect; Child; Septal occluder device.

Fig. 1

Discrepancy in the left atrial disc and waist ratio (a/b). This figure shows that in 32 mm ASO, the (a) and (b) ratio is 1.44, but in a 12 mm ASO, the (a) and (b) ratio is 2.17. Relative large rim of LA disc in smaller devices may encroach to adjacent cardiac structures which prevent safe device closure. In reality, these are entirely different devices, when considering the structure and shape. Therefore, the discrepancy maximizes as the device gets smaller. LA disc is marked. a: left atrial disc, b: waist of device. A: anterior-posterior view of 32 mm ASO demonstrates the relationship of left atrial disc and waist size. B: anterior-posterior view of 12 mm ASO reveals that left atrial disc occupies large area in smaller device. ASO: Amplatzer septal occluder.

Fig. 2

The pathophysiologic mechanisms in elderly patients with atrial septal defect. Longstanding left to right shunt in the atrial level results in progressive right heart dilatation, significant TR and subsequent increase in RA pressure. Left heart may also be influenced by chronic volume underload, increased atrial pressure as well as co-morbid diseases. Lt: left, Rt: right, RAE: right atrial enlargement, RVE: right ventricular enlargement, LV: left ventricle, HTN: hypertension, IHD: ischemic heart disease, CO: cardiac output, PAH: pulmonary arterial hypertension, TR: tricuspid regurgitation, RAP: right atrial pressure, LAP: left atrial pressure, LAE: left atrial enlargement, A Fib: atrial fibrillation, A Flut: atrial flutter.

Fig. 3

Different protocols for the detection and management of high risk patients. If left ventricle restriction is detected, both protocols recommend several days of medical therapy including diuretics, inotropic agents and afterload reducing therapy, and if the patient is refractory to medical therapy on a subsequent balloon occlusion test, they recommend using a fenestrated device. LAP: left atrial pressure, ASD: atrial septal defect.

Fig. 4

Self-fabricated fenestrated device. Fabrication of the device by creating fenestration (white arrow) in both discs and connecting waist can be achieved using various sized dilators. Ties using non-absorbable suture materials (black arrow head) ensures the maintenance of fenestration.