Benson

When Not to Use a Device:
Characteristics of Atrial Septal Defects
Not Percutaneously Closed
Lee N. Benson, MD, FRCP(C), FACC, MSCAI
The Hospital for Sick Children
Toronto, Canada

Disclosures:
Proctor, consultant:
Medtronic Inc., Edwards Lifesciences

ASD Closure (a focus on the Secundum ASD)
• It’s a common, simple procedure so easily reproducible, a
1 st year fellow can do it,

ASD Closure (a focus on the Secundum ASD)
• It’s a common, simple procedure so easily reproducible, a
1 st year fellow can do it, -in fact your daughter can do it!

ASD Closure (a focus on the Secundum ASD)
• It’s a common, simple procedure so easily reproducible, a
1 st year fellow can do it, -in fact your daughter can do it!
• Procedural complications have been detailed, dissected,
& inferences have been drawn, although there remains
controversies over their etiology
• Everyone who has performed ASD closure feels as if
he/she is an expert because of procedural simplicity

However, not all atrial defects should be closed or
closed percutaneously
Objectives:
What are anatomical situations where a device
maybe inappropriate
Clinical characteristics of children whose defects
were not closed

Anatomical Considerations:
Understanding the components of the atrial septum & surrounding
structures is important to prevent short & long term complications & to
decide when not to close the defect: need of a big device, absence rims,
septal morphology

Ao rim absence may expose the device directly to the aorta

IVC and posterior rim absence
Device embolization due to poor stability
Evaluate the extent of deficiency: short segment may not
be significant

The maligned or spiral atrial septum
http://www.3dechocardiography.com/

Kijima et al. J Case Rep 2013

What is the profile of children deferred for device
closure?
Over an 8-year period, we evaluated the incidence,
morphological characteristics, & rationale for which
device closure was thought inappropriate

Surgery: age-5.7 (0.6–17.4) yr, wt-20.5 (5.6–73.3) kg & defect diam-22.9 (9–49) mm vs.
Device closure: age-8.2 (9 d to 21) yr, wt-30 kg (3.5–120) kg & defect diam-17.2 (5–39) mm

Demographics of Children Whose Defects Were Not Closed Percutaneously
Surgery was performed at a mean age of 5.7
years
(range: 0.6–17.4 years), weight of 20.5 kg
(range:
5.6–73.3 kg) and defect diameter of 22.9 mm
(range:
9–49 mm) versus device closure at a mean age
of 8.2
years (range: 9 days to 21 years), weight of 30
kg
(range: 3.5–120 kg) and defect diameter of
17.2 mm
(range: 5–39 mm)
Overall, children undergoing surgical closure had larger defects per
kilogram body weight, & more were

Indications for Referral Directly to Surgery
Surgery was performed at a mean age of 5.7
years
(range: 0.6–17.4 years), weight of 20.5 kg
(range:
5.6–73.3 kg) and defect diameter of 22.9 mm
(range:
1.50–3.69)
9–49 mm) versus device closure at a mean age
of 8.2
years (range: 9 days to 21 years), weight of 30
kg
(range: 3.5–120 kg) and defect diameter of
17.2 mm
(range: 5–39 mm)
D/W ratio of 1.83 (range: 0.47–3.69)
Two-thirds were

Indications for Deferred Implantation at Catheterization
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*
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Sufficient rims: D/W 1.64
(range: 0.95–2.42): 7

82 children referred directly to surgery, had uncomplicated closure,
mean LOS 3.1 days (range: 2–8 days)

82 children referred directly to surgery, had uncomplicated closure,
mean LOS 3.1 days (range: 2–8 days)

82 children referred directly to surgery, had uncomplicated closure,
mean LOS 3.1 days (range: 2–8 days)

82 children referred directly to surgery, had uncomplicated closure,
mean LOS 3.1 days (range: 2–8 days)

82 children referred directly to surgery, had uncomplicated closure,
mean LOS 3.1 days (range: 2–8 days)
43 (82%) subsequently underwent surgical closure without complication,
mean hospital LOS 3.2 days (range: 2–7 days).

What did we learn?
These observations support previous reports that the most
common reason deferring a transcatheter procedure was
insufficient or deficient rims, particularly the IVC or posterior
rims, as seen in just over 1/3 of the children
In 1/4 of the children the operator felt that the device would be
too large to be accommodated in the septum & interfere with
contiguous cardiac structures & a risk factor for erosion,
atrioventricular valve regurgitation, complete heart block, or
bradycardia
From this data, weight can be used to guide the largest device,
which could plausibly be implanted based on a D/W: in cases 1.5:1 was thought too large to be implanted

So When Not to Close
If the size fits:
in the small child D/W >1.5:1 if

Gracias
Thank You