Original Research Received: July 4, 2013 Accepted after revision: August 28, 2013 Published online: November 21, 2013
Cardiology 2014;127:90–95 DOI: 10.1159/000355362
Application of the Defect Area in Transcatheter Closure of Atrial Septal Defect Jinyoung Song a I-Seok Kang a Sung-A Chang b June Huh a Seung Woo Park b Departments of a Pediatrics and b Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
Abstract Objectives: It was our aim to evaluate whether the defect area plays a crucial role in successful device closure of atrial septal defects (ASDs). Methods: The long and short diameters of the defect were measured on en-face images. The defect area was then measured by planimetry. The device size compared to the defect length and defect area was analyzed in each group. Results: There were 22 patients in the circular group and 45 patients in the noncircular group. The defect area did not differ between the groups (201.6 ± 107.1 vs. 245.6 ± 127.6 mm2). Although the length between the device size and the long diameter differed between the groups (3.4 ± 2.0 vs. 0.8 ± 3.7 mm; p = 0.003), there was no difference in the ratio of the device area compared to the defect area, which was constant even in the noncircular defect (1.73 ± 0.41 vs. 1.72 ± 0.53 mm2; p = 0.947). The device size was positively correlated with the defect area (p < 0.01). Conclusion: The defect area measured by planimetry on en-face images might be useful in selecting the device size for transcatheter closure of ASDs. © 2013 S. Karger AG, Basel
© 2013 S. Karger AG, Basel 0008–6312/14/1272–0090$39.50/0 E-Mail [email protected] www.karger.com/crd
Introduction
Transcatheter closure of atrial septal defect (ASD) with an Amplatzer septal occluder (ASO; AGA Medical, Golden Valley, Minn., USA) has gradually become a competitive alternative to surgery in selected patients and has demonstrated very good clinical outcomes [1–3]. For a successful device closure of ASD, detailed anatomic evaluation of the size, morphology and spatial relationship with the surrounding structures is crucial. The balloon occlusive diameter in ASD usually determines the device size as a standard method [1, 4]. However, in general, ASD presents with various shapes, including circular, ovoid and complex morphology [5–7]; therefore, one selected diameter from multiple 2-dimensional (2D) transesophageal echocardiography (TEE) may not represent the accurate morphology or the dimension of the defect. There have been various studies suggesting that real-time 3-dimensional (3D) TEE is very useful in evaluating the morphology of ASD and guiding device closure [6–10]. The use of en-face imaging has been evaluated for device closure of ASD and was found to be superior in visualizing the defect morphology [11–13]. We chose to extend this observation by investigating whether the defect area measured on en-face images might be more important for successful device closure than the diameter. I-Seok Kang, MD Department of Pediatrics, Cardiac and Vascular Center Samsung Medical Center, Sungkyunkwan University School of Medicine 50 Irwon-dong, Gangnam-gu, Seoul 135-710 (Republic of Korea) E-Mail amyjys @ naver.com
Downloaded by: HSC Library-Serials Dept., SUNY 129.49.5.35 - 10/30/2017 3:47:45 PM
Key Words Congenital heart disease · Atrial septal defect · Device closure · Imaging · Defect area
Therefore, we evaluated whether defect areas could play a crucial role in guiding the selection of the appropriate device size for successful transcatheter closure of ASD. From this evaluation, we aimed to investigate not only whether the en-face image of ASD could be helpful in understanding the exact defect morphology especially in the case of an asymmetric shape but also whether the defect area had a good correlation with the actual device size regardless of the morphology of the defect. Materials and Methods This is a retrospective study of patients who underwent percutaneous closure of ASD with ASO (AGA Medical) at the Samsung Medical center from January 2010 to September 2012. ASD was diagnosed by transthoracic echocardiography (TTE), and thereafter, cardiac CT or TEE was performed for further evaluation. Patients with multiple defects and whose en-face images could not be obtained or were too poor to be considered adequate were excluded. Criteria for the transcatheter closure of ASD with ASO were as follows: secundum ASD with evidence of right ventricular dilatation; absence of significant pulmonary arterial hypertension that was irreversible; no significant arrhythmia; no evidence of significant pathology in other organs, and presumptive appropriate rims for ASO implantation. The locally appointed ethics committee approved the research protocol and informed consent was waived. Morphology of ASD The long diameter (a) and the short diameter (b) were measured at the end-systolic phase from reconstructed en-face images
Defect Area in Device Closure of ASD
Device Selection and Procedure Balloon sizing for the choice of the device size and implantation of the device were applied under the guidance of intracardiac echocardiography only by one operator for all the patients. Balloon inflation was stopped at the moment that the shunt flow disappeared or at the moment that most of the shunt disappeared in spite of minimal shunt flow. Creating a waist in the sizing balloon on angiography was avoided due to oversizing. Usually the operator chose a device 0–2 mm larger than the occlusive balloon diameter. If successful implantation failed or oversizing was suggested, we changed the size of the device. A follow-up TTE was performed the following day and 6 months after the procedure to check for the presence of a residual shunt or other potential complications. It was recommended that all patients take 100 mg/day of aspirin for 6 months after implantation. Evaluation In addition to comparing the long diameter and the short diameter of the defect, the defect area was also evaluated and compared between the groups. The device size was defined as the diameter of the waist of the device, and the device area was defined as the calculated cross-sectional area of the waist of the device. The device size and area were compared with the long diameter of ASD and the defect area. The difference between the device size and the long diameter of the defect and the ratio of the device size to the long diameter of the defect were also compared between the two groups. Finally, the ratio of the device area to the defect area was evaluated and compared. Statistics Data are expressed as the mean ± standard deviation. To compare the results of the two groups, the parametric Student t test and χ2 test in SPSS 19.0 were used. Linear regression analysis was applied to prove the linear correlation of the device size with the defect area. A p value
Cardiology 2014;127:90–95 DOI: 10.1159/000355362
Application of the Defect Area in Transcatheter Closure of Atrial Septal Defect Jinyoung Song a I-Seok Kang a Sung-A Chang b June Huh a Seung Woo Park b Departments of a Pediatrics and b Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
Abstract Objectives: It was our aim to evaluate whether the defect area plays a crucial role in successful device closure of atrial septal defects (ASDs). Methods: The long and short diameters of the defect were measured on en-face images. The defect area was then measured by planimetry. The device size compared to the defect length and defect area was analyzed in each group. Results: There were 22 patients in the circular group and 45 patients in the noncircular group. The defect area did not differ between the groups (201.6 ± 107.1 vs. 245.6 ± 127.6 mm2). Although the length between the device size and the long diameter differed between the groups (3.4 ± 2.0 vs. 0.8 ± 3.7 mm; p = 0.003), there was no difference in the ratio of the device area compared to the defect area, which was constant even in the noncircular defect (1.73 ± 0.41 vs. 1.72 ± 0.53 mm2; p = 0.947). The device size was positively correlated with the defect area (p < 0.01). Conclusion: The defect area measured by planimetry on en-face images might be useful in selecting the device size for transcatheter closure of ASDs. © 2013 S. Karger AG, Basel
© 2013 S. Karger AG, Basel 0008–6312/14/1272–0090$39.50/0 E-Mail [email protected] www.karger.com/crd
Introduction
Transcatheter closure of atrial septal defect (ASD) with an Amplatzer septal occluder (ASO; AGA Medical, Golden Valley, Minn., USA) has gradually become a competitive alternative to surgery in selected patients and has demonstrated very good clinical outcomes [1–3]. For a successful device closure of ASD, detailed anatomic evaluation of the size, morphology and spatial relationship with the surrounding structures is crucial. The balloon occlusive diameter in ASD usually determines the device size as a standard method [1, 4]. However, in general, ASD presents with various shapes, including circular, ovoid and complex morphology [5–7]; therefore, one selected diameter from multiple 2-dimensional (2D) transesophageal echocardiography (TEE) may not represent the accurate morphology or the dimension of the defect. There have been various studies suggesting that real-time 3-dimensional (3D) TEE is very useful in evaluating the morphology of ASD and guiding device closure [6–10]. The use of en-face imaging has been evaluated for device closure of ASD and was found to be superior in visualizing the defect morphology [11–13]. We chose to extend this observation by investigating whether the defect area measured on en-face images might be more important for successful device closure than the diameter. I-Seok Kang, MD Department of Pediatrics, Cardiac and Vascular Center Samsung Medical Center, Sungkyunkwan University School of Medicine 50 Irwon-dong, Gangnam-gu, Seoul 135-710 (Republic of Korea) E-Mail amyjys @ naver.com
Downloaded by: HSC Library-Serials Dept., SUNY 129.49.5.35 - 10/30/2017 3:47:45 PM
Key Words Congenital heart disease · Atrial septal defect · Device closure · Imaging · Defect area
Therefore, we evaluated whether defect areas could play a crucial role in guiding the selection of the appropriate device size for successful transcatheter closure of ASD. From this evaluation, we aimed to investigate not only whether the en-face image of ASD could be helpful in understanding the exact defect morphology especially in the case of an asymmetric shape but also whether the defect area had a good correlation with the actual device size regardless of the morphology of the defect. Materials and Methods This is a retrospective study of patients who underwent percutaneous closure of ASD with ASO (AGA Medical) at the Samsung Medical center from January 2010 to September 2012. ASD was diagnosed by transthoracic echocardiography (TTE), and thereafter, cardiac CT or TEE was performed for further evaluation. Patients with multiple defects and whose en-face images could not be obtained or were too poor to be considered adequate were excluded. Criteria for the transcatheter closure of ASD with ASO were as follows: secundum ASD with evidence of right ventricular dilatation; absence of significant pulmonary arterial hypertension that was irreversible; no significant arrhythmia; no evidence of significant pathology in other organs, and presumptive appropriate rims for ASO implantation. The locally appointed ethics committee approved the research protocol and informed consent was waived. Morphology of ASD The long diameter (a) and the short diameter (b) were measured at the end-systolic phase from reconstructed en-face images
Defect Area in Device Closure of ASD
Device Selection and Procedure Balloon sizing for the choice of the device size and implantation of the device were applied under the guidance of intracardiac echocardiography only by one operator for all the patients. Balloon inflation was stopped at the moment that the shunt flow disappeared or at the moment that most of the shunt disappeared in spite of minimal shunt flow. Creating a waist in the sizing balloon on angiography was avoided due to oversizing. Usually the operator chose a device 0–2 mm larger than the occlusive balloon diameter. If successful implantation failed or oversizing was suggested, we changed the size of the device. A follow-up TTE was performed the following day and 6 months after the procedure to check for the presence of a residual shunt or other potential complications. It was recommended that all patients take 100 mg/day of aspirin for 6 months after implantation. Evaluation In addition to comparing the long diameter and the short diameter of the defect, the defect area was also evaluated and compared between the groups. The device size was defined as the diameter of the waist of the device, and the device area was defined as the calculated cross-sectional area of the waist of the device. The device size and area were compared with the long diameter of ASD and the defect area. The difference between the device size and the long diameter of the defect and the ratio of the device size to the long diameter of the defect were also compared between the two groups. Finally, the ratio of the device area to the defect area was evaluated and compared. Statistics Data are expressed as the mean ± standard deviation. To compare the results of the two groups, the parametric Student t test and χ2 test in SPSS 19.0 were used. Linear regression analysis was applied to prove the linear correlation of the device size with the defect area. A p value
