Centers of Excellence in Interventional Cardiology and Radiology

Congenital Heart Disease

Atrial / Ventricular Septal Defect -ASD / VSD

The procedure performed by team of specialists from abroad!

We have opened the first section for Percutaneous Closure of Congenital Heart Diseases in Romania!

The most modern equipped angiography room , an exceptional medical team

We have the most famous abroad specialists! Team from Romania, Israel, Greece and Germany!

We have the largest experience. The youngest child was treated at the age of 5 days! Call now us!

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Generalities

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Atrial septal defect (ASD), a cardiac congenital malformation, is an abnormal communication between the two atria (the two small chambers at the top of the heart).

Ventricular septal defect (VSD) is a congenital cardiac malformation representing an abnormal communication between the two ventricles (the two larger chambers at the bottom of the heart).

Left chamber (left atrium and left ventricle) pressure is higher than right chamber (right atrium and right ventricle) pressure. Thus, an atrial septal defect permits an abnormal flow of blood from the left chambers of the heart to the right chambers of the heart (left-to-right shunt).

The volume of blood passing from the left side of the heart to the right side of the heart depends on the size of the septal defect and the pressure difference between the chambers. This leads to the increase in the volume of the right side of the heart and in the lungs, and to left ventricle overload. The flow increase in the right ventricle and in the lungs make the right ventricle work harder and consequently dilate. Subsequently, the right ventricle can no longer effectively pump the blood to the lungs, leading to pooling of the blood in the abdomen and the lower extremities (the so-called right heart failure).

The increased blood flow in the lungs leads to the occurence of structural changes leading to pulmonary hypertension and, in the end, the right chambers pressure becomes higher than the left chambers pressure, and shunt reversal occurs (reversal of the left-to-right shunt to a right-to-left shunt).

These defects are innate, and the patient may be symptom free for a long period of time (depending, as mentioned above, on the size of the shunt, the pressure difference between the left cavities). Over time, symptoms appear – such as failure to thrive in infants, exertional dyspnea, recurrent pulmonary infections, palpitations, fatigue, cyanosis of the skin (bluish coloration indicating deoxygenation of the arterial blood), leg edema.

Atrial septal defects are categorized as follows:

Ostium primum type – located in the lower portion of the interatrial septum, almost always accompanied by an anomaly of the mitral or tricuspid valve; because of the complexity of this malformation, its closure is made surgically.

Ostium secundum type – located in the central part of the septum separating the right atrium from the left atrium. This is the most frequent type of ASD, its central location making possible the closure by percutaneous procedures.

Sinus venosus defects – occur at the cardiac junction of the superior vena cava.

Coronary sinus septal defects – the coronary sinus is the most important vein taking the blood from the heart muscle. Coronary sinus septal defects arise from an opening of its wall with the left atrium, allowing left-to-right atrial shunting.67

There are many types of ventricular septal defects as well, depending on the location: membraneous type (70-80%) –most frequently in adults, located in the vicinity of the tricuspid valve; muscular type (5-20%) –most frequently in newborns, usually closes spontaneously ; infundibular type (5-7%) located in the antero superior area of the interventricular septum, and may complicate with aortic valve insufficiency.

Inlet type (5-8%) – located beneath the tricupsid valve.

Small atrial septal defects close almost always spontaneously durimg childhood.

Large atrial septal defects can lead to the following complications:

Pulmonary hypertention – as mentioned above.

Eisenmenger syndrome – because of structural changes of the pulmonary arteries, pulmonary hypertension develops over years, and a reversal of flow from the right cavities to the left cavities. Cyanosis occurs by stimulation of red cell production, in order to increase the delivery of oxygen to peripheral tissues, and erythrocytosis occurs with its complications.

Right heart failure – the inability of the right ventricle to pump the blood, with blood pooling in the abdomen (leading to bloating, loss of appetite, nausea, vomiting) and in the lower extremities (leading to edema).

Cardiac arrhythmias – atrial fibrillation, atrial flutter, atrial tachycardia, sinus node disease.

Stroke – migration of a blood clot arising for example in the lower limbs – through a large ASD – to the brain.

The complications of ventricular septal defects are:

Frequent respiratory infections.

Heart failure.

Infectious endocarditis – due to bacteria entering the circulation and colonizing the heart, frequently the right ventricle side of the septal defect.

Stroke.

Arrhythmias.

Eisenmenger syndrome – its occurence is a contraindication to defect closure.

ASD closure can be performed :

– either interventionally, by placing an umbrella device at the level of the ASD, thus closing the abnormal communication between the two atria, the best results being obtained in ostium secundum-type atrial septal defects located in the central portion of the septum.

– or surgically – in the case of atrial septal defects which cannot be closed percutaneously.

VSD closure can be performed :

– surgically under CBP (extracorporeal circulation) by suturing the margins of the septal defect or by the implantation of a synthetic patch,

– or interventionally – the insertion of an umbrella-type device covering the defect. Not all types of VSD can be closed by this technique, which is most suitable for muscular-type ventricular septal defects situated at a distance from the tricuspid or aortic valve.

Indications

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Some simple cardiac malformations may close spontaneously (small ostium secundum ASD, small muscular-type VSD). However, most of the defects need either interventional or surgical closure before the development of Eisenmenger syndrome.

Closure of an ASD is recommended in the presence of symptoms, persistence of a left-to-right shunt before the development of a fixed pulmonary hypertension, in the presence of right ventricular dilation, or the occurence of a stroke following the passage of a blood clot through the ASD in the systemic circulation.

As mentioned previously, the interventional closure procedure cannot be performed for all defects. It will not be performed if there are other cardiac malformations requiring surgical intervention, if the placement of the umbrella device affects the function/structure of the surrounding structures (valves, aorta), if the defect is too large, or if the veins through which the catheters are advanced are too small.

Procedure

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The procedure is performed using a technique similar to angiography.

It is done under general anesthesia. Thus, after anesthesia, a small inguinal incision is made. Through this incision, the physician will introduce a small narrow tube, then through this tube a catheter will be introduced which will reach the heart. The physician will then introduce over the catheter the umbrella device (at this time the device is folded) which will be placed at the level of the defect. Once in the desired position (the correct position is controlled both by radiological images and transesophageal echocardiography), the umbrella, which has two components resembling two discs attached in the central portion, will be opened and will obstruct the defect. Initially, this device will be maintained at the level of the defect by the pressure differences between the left and right chambers, then, with time, it will be incorporated in the interatrial septum. Thus, immediately postprocedurally, small defects may persist at the margins of the disc, which will then disappear.

Is it painful?

No, the intervention is performed under general anesthesia.

How long does it take?

The duration of the procedure is about 1-2 hours and takes place in the cardiac catheterization laboratory.

Risks

The complications are rare; the complications are reduced by the proper preparation and the continuous surveillance of the patient. Potential complications:

Allergic reactions to administered substances

Reactions to anesthetic compounds

Arteriovenous fistulas at the vascular puncture site.

Minor bleeding at the vascular puncture site.

Fever.

Headache, migraine.

Infection.

Gaseous embolism.

Cardiac arrythmia.

Extremely rare – cardiac perforation and cardiac tamponade (perforation of the cardiac wall and bleeding in the pericardial sac, which compresses the heart)

Embolization or umbrella migration

Cardiac muscle erosion at the contact with the prosthesis

Stroke

Hemolysis

Before procedure

The preoperative assessment will establish if the closure of the defect can be done percutaneously or there is an indication of surgical closure of the defect. Physical examination and echocardiography are key elements which help making a decision.

Prior to the intervention, the interventional cardiologist must be prevented about any history of allergic reactions. Blood tests are taken including hemoglobin level, coagulation, renal function, and other specific tests.

The patient is admitted the day before the intervention, and he/she should not eat before the procedure.

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After procedure

Since the procedure is minimally invasive, the postprocedural recovery is usually very fast. The majority of patients can leave the hospital the following day. Indications about recovery and postprocedural treatment will be clearly specified to all patients. Treatment with aspirin must be administered 6 months post intervention in order to prevent blood clot formation within the umbrella device. After 6 months it is considered that the umbrella is completely incorporated in the septum by the formation of epithelial tissue, and the risk of blood clot formation disappears.

Also, in the first six months the prevention of infectious endocarditis is mandatory – antibiotic treatment (unique dose of amoxicilin, ampicilin, or clindamicin in case of pennicilin allergy) before any dental procedure carrying a risk of microbial translocation into the bloodstream. Infectious endocarditis prophylaxis is also needed in other several situations, which will be explained by ourphysician.

Important!

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The percutaneous closure of septal defects is a revolutionary procedure which avoids the risks and complications of an open heart surgery. However, even though many lesions can be treated percutaneously, if there are other associated cardiac malformations, or the defect is eccentric, surgical intervention is recommended. The recovery is rapid. The physician must be informed of any complications in the postintervention period.

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Sună Mesaj