Atrial septal defect(ASD): Treatments
When there are atrial septal defects (ASD) in children, the following three considerations should be considered for treatment planning:
1) The possibility of ASD shutting down by itself
2) Size of ASD and amount of blood shunt
3) In the indication of ASD closure, whether to perform surgery or percutaneous transcatheter
Most ASD secundums are smaller than 6 mm in size, usually closed within 2 years and lasting up to 5 years. Therefore, if there is no symptom, it is not indications that the defect is prevented by the surgical procedure at a young age. If the size of the defect is moderate (6 to 8 mm) or large (> 8 mm), ASD secundum does not normally close on its own. However, since moderate, large ASD has the possibility of spontaneous closure, it is recommended to watch it until two years old on the assumption that there is no symptom.
The risk of embolism and the severity of the procedure should be considered by preventing ASD. However, the small size of less than 6mm did not prove the improvement of survival rate when the asymptomatic patients were prevented by surgery. If the size of the ASD is moderate or large, if it is not corrected, the child will grow and the size of the shunt will increase. The indications are as follows. Pulmonary flow (Qp) and systemic flow (Qs) ratios (Qp / Qs) of more than 2: 1 are indicative of surgical closure, but there are cases where the ratio is 1.7: 1 or 1.5: 1. Cardiac cathterization is the golden standard method of measuring Qp / Qs, but contrast MRI of skilled physicians can be an alternative.
Surgical methods and percutaneous transcatheter can be used to prevent defects in ASD. Before the procedure, size of defect, pulmonary hypertension should be excluded, and other cardiac types should be confirmed.
Surgery
Sinus venosus defects, coronary sinus defects, primum ASDs, and complex congenital lesions require surgical correction and are indications for surgical correction even in patients with large ASD secundum and heart failure. Surgical correction is usually performed using pericardial or Darcron patches. Closing a large defect with a suture can distort the atria and is not performed well. Cardiopulmonary bypass is necessary for surgery, and median sternotomy is required. Transesophageal echocardiography (TEE) can be used to determine the correctness of the procedure and whether the shunt remains. Postoperative complications include pericardial effusion, pleural effusion, arrhythmia, hemorrhage, pneumothorax, wound infection, and occur in 25-30% of patients. There was no significant difference in long term mortality with general children after surgery and long term morbidity of stroke, heart failure, heart block, and hypertension. One study found that symptomatic supraventricular tachyarrhythmia occurred in 6% of patients at 15 years post-operative f / u.
Percutaneous closure
Percutaneous closure is a trend to substitute surgical methods in small, moderate ASD because of the advantages of good results without cardiopulmonary bypass, thoracotomy, and atriotomy. Percutaneous closure is determined according to the position of the defect and the skill of the trachea. The defect in the large ASD secundum has been successfully treated with a percutaneous closure of up to 30 mm. Percutaneous closure can be performed only if there is adequate rim tissue around the defect to prevent coronary sinus, right pulmonary veins, vena cavae, and atrioventricular valves. By performing transesophageal echocardiography (TEE) or intracardiac echocardiography (ICE), the position and size of defects can be accurately identified to size and position the appropriate ASD closure device. It is also essential for the procedure because it can be observed simultaneously with the procedure. ICE does not require intubation or general anesthesia as compared with TEE, and it can be observed during the procedure, which shortens the procedure time and is used more widely than TEE. Side effects after the procedure include embolization, malpostion, and arrhythmia. Of 417 patients (mean age 27 ± 19) who underwent percutaneous insertion of the ASD device, 34 patients (8.6%) experienced side effects. Ten patients underwent surgical treatment due to the wrong position of the ASD device, and 7 patients had emboli in the device. The remaining 24 patients had side effects such as arrhythmia, pericardial effusion, and hematoma. One of the most serious complications is cardiac perforation, which may occur as early as 5 years after the first postoperative day, and may occur in the form of hemopericardium, pericardial effusion, cardiovascular collapse, or sudden death.
Data comparing surgery and percutaneous closure are relatively limited, but previous data showed similar or slightly better surgical outcome, but percutaneous closure significantly reduced postoperative side effects or hospital stay.
After surgery, aspirin, clopidogrel or other anticoagulants should be used for 6 months to avoid thrombus formation in the ASD device, and ASD device should be inserted and the activity should be avoided for one week. It is also recommended that amoxicillin be given as a prophylactic antibiotic when dental treatment or respiratory procedures are performed for 6 months after correction of ASD to prevent endocarditis, or if there is damage near the prosthetic device.
1) The possibility of ASD shutting down by itself
2) Size of ASD and amount of blood shunt
3) In the indication of ASD closure, whether to perform surgery or percutaneous transcatheter
Most ASD secundums are smaller than 6 mm in size, usually closed within 2 years and lasting up to 5 years. Therefore, if there is no symptom, it is not indications that the defect is prevented by the surgical procedure at a young age. If the size of the defect is moderate (6 to 8 mm) or large (> 8 mm), ASD secundum does not normally close on its own. However, since moderate, large ASD has the possibility of spontaneous closure, it is recommended to watch it until two years old on the assumption that there is no symptom.
The risk of embolism and the severity of the procedure should be considered by preventing ASD. However, the small size of less than 6mm did not prove the improvement of survival rate when the asymptomatic patients were prevented by surgery. If the size of the ASD is moderate or large, if it is not corrected, the child will grow and the size of the shunt will increase. The indications are as follows. Pulmonary flow (Qp) and systemic flow (Qs) ratios (Qp / Qs) of more than 2: 1 are indicative of surgical closure, but there are cases where the ratio is 1.7: 1 or 1.5: 1. Cardiac cathterization is the golden standard method of measuring Qp / Qs, but contrast MRI of skilled physicians can be an alternative.
Surgical methods and percutaneous transcatheter can be used to prevent defects in ASD. Before the procedure, size of defect, pulmonary hypertension should be excluded, and other cardiac types should be confirmed.
Surgery
Sinus venosus defects, coronary sinus defects, primum ASDs, and complex congenital lesions require surgical correction and are indications for surgical correction even in patients with large ASD secundum and heart failure. Surgical correction is usually performed using pericardial or Darcron patches. Closing a large defect with a suture can distort the atria and is not performed well. Cardiopulmonary bypass is necessary for surgery, and median sternotomy is required. Transesophageal echocardiography (TEE) can be used to determine the correctness of the procedure and whether the shunt remains. Postoperative complications include pericardial effusion, pleural effusion, arrhythmia, hemorrhage, pneumothorax, wound infection, and occur in 25-30% of patients. There was no significant difference in long term mortality with general children after surgery and long term morbidity of stroke, heart failure, heart block, and hypertension. One study found that symptomatic supraventricular tachyarrhythmia occurred in 6% of patients at 15 years post-operative f / u.
Percutaneous closure
Percutaneous closure is a trend to substitute surgical methods in small, moderate ASD because of the advantages of good results without cardiopulmonary bypass, thoracotomy, and atriotomy. Percutaneous closure is determined according to the position of the defect and the skill of the trachea. The defect in the large ASD secundum has been successfully treated with a percutaneous closure of up to 30 mm. Percutaneous closure can be performed only if there is adequate rim tissue around the defect to prevent coronary sinus, right pulmonary veins, vena cavae, and atrioventricular valves. By performing transesophageal echocardiography (TEE) or intracardiac echocardiography (ICE), the position and size of defects can be accurately identified to size and position the appropriate ASD closure device. It is also essential for the procedure because it can be observed simultaneously with the procedure. ICE does not require intubation or general anesthesia as compared with TEE, and it can be observed during the procedure, which shortens the procedure time and is used more widely than TEE. Side effects after the procedure include embolization, malpostion, and arrhythmia. Of 417 patients (mean age 27 ± 19) who underwent percutaneous insertion of the ASD device, 34 patients (8.6%) experienced side effects. Ten patients underwent surgical treatment due to the wrong position of the ASD device, and 7 patients had emboli in the device. The remaining 24 patients had side effects such as arrhythmia, pericardial effusion, and hematoma. One of the most serious complications is cardiac perforation, which may occur as early as 5 years after the first postoperative day, and may occur in the form of hemopericardium, pericardial effusion, cardiovascular collapse, or sudden death.
Data comparing surgery and percutaneous closure are relatively limited, but previous data showed similar or slightly better surgical outcome, but percutaneous closure significantly reduced postoperative side effects or hospital stay.
After surgery, aspirin, clopidogrel or other anticoagulants should be used for 6 months to avoid thrombus formation in the ASD device, and ASD device should be inserted and the activity should be avoided for one week. It is also recommended that amoxicillin be given as a prophylactic antibiotic when dental treatment or respiratory procedures are performed for 6 months after correction of ASD to prevent endocarditis, or if there is damage near the prosthetic device.
