Transcatheter atrial septal defect closure: Modified balloon sizing technique to avoid overstretching the defect and oversizing the Amplatzer septal occluder

Abstract

The objective of this study was to evaluate a new technique of sizing atrial septal defects (ASDs) for transcatheter device closure. ASD closure using the Amplatzer septal occluder (ASO) device is commonly performed. Complications, including arrhythmias, pericardial effusions, and perforations, may be related to oversizing ASDs and choosing larger devices. Two methods were used to size ASDs using a compliant balloon. In some patients, the balloon was inflated until a waist was visible [(+)waist]; in others, only until no shunting was demonstrable by echocardiogram [echo; (-)waist]. The device was selected and implanted using standard procedure and echo guidance. One hundred seventeen patients underwent secundum ASD closure with an ASO device. There were 43 patients in the (-)waist group and 74 in the (+)waist group. All devices were implanted successfully. The initial echo ASD diameter was larger in the (-)waist group compared to the (+)waist group (P = 0.01). There was a smaller difference between the initial echo and balloon-sized ASD diameters in the (-)waist group (P < 0.02). ASO device size implanted (in mm greater than echo ASD diameter) was smaller in the (-)waist group (P < 0.01). There were 0/43 complications in the (-)waist group and 5/74 in the (+)waist group. The complete closure rate was the same in both groups. Sizing an ASD by inflating a compliant balloon just until shunting is eliminated, and not until a waist is visible, results in less overstretching of the ASD and selection of a smaller ASO device, achieving similar closure rates and potentially fewer complications.

The relation between atrial septal defect shape, diameter, and area using three-dimensional transoesophageal echocardiography and balloon sizing during percutaneous closure in children

“…25 Some studies suggest that balloon calibration techniques oversize the defect. 9 Modified BS techniques have been developed to avoid overstretching. 9,25 In this study, a modified BS technique using the pull-through technique was also applied.…”

“…9 Modified BS techniques have been developed to avoid overstretching. 9,25 In this study, a modified BS technique using the pull-through technique was also applied. Despite this technique being believed to decrease overstretching of the rims, an overestimation of the ASD diameters by BS compared with 3D-TEE, particularly in round ASDs was found.…”

“…8 However, BS could also lead to an overestimation of ASD size by overstretching the rims. 9 Its necessity in current practice is debatable and alternative techniques such as 3D echocardiography are being used more frequently. Using an 'en face' view, the recently introduced 3D-TEE technology allows the visualization of the number, the shape and the rims.…”

Stretched Size of Atrial Septal Defect Predicted by Intracardiac Echocardiography

“…3,12,14,15) This is because most ASD have pliable and redundant rim tissues. Although some authors have suggested that the balloon stretched size overestimates the real size, 16) balloon stretch size is still A B being adopted as a gold standard until a new consensus is reached in the future. In this study, we found that the balloon stretched size may be 22 to 34% larger than the size measured by echocardiography.…”

Device Closure of Atrial Septal Defect

“…To avoid oversizing with respect to avoiding erosion, the stop-flow method was used for measurement in every patient. 13 Deployment of the device was performed by an approach from either the left upper pulmonary vein or right pulmonary vein. A Hausdorff sheath was used in 14 cases of relatively large defects compared with body size.…”