Journal of Cardiology 65 (2015) 1

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Monitoring tool of transcatheter atrial septal defect: Transesophageal echocardiography or transthoracic echocardiography?

The important point of transcatheter atrial septal defect (ASD) closure is the decision of indication and monitoring of device position during procedure. Transesophageal echocardiography (TEE) monitoring of transcatheter ASD closure began from the clamshell occluder procedure [1]. The early period of transcatheter ASD closure by clamshell occluder was done only by fluoroscopy monitoring. Device migration after implantation was experienced and lack of ASD rims was observed during surgical findings in those cases. Evaluation of detailed ASD anatomy by TEE and TEE monitoring began after those experiences. Success rates of the procedure were improved after this decision. TEE became the gold standard of transcatheter ASD closure monitoring after this episode. TEE was also used for another type of ASD occlusion devices for monitoring. Transcatheter ASD closure by AmplatzerTM Septal Occluder (St. Jude Medical, St. Paul, MN, USA) began from 2007 in Japan. This was the latest start of this procedure in the world. The evaluation of ASD anatomy and monitoring of procedure are very important. The most important part of ASD anatomical evaluation is accurate size of ASD and rims around ASD. Rim deficiency and hypoplastic rim are caused by device migration and erosion [2]. TEE or intracardiac echocardiography (ICE) is the main monitoring tool in the USA and Europe. The Society of Japan Pediatric Interventional Cardiology (JPIC) decided that TEE and ICE are the monitoring tools of procedures and transthoracic echocardiography (TTE) monitoring is not permitted [3]. However, TTE monitoring of transcatheter ASD closure is undertaken widely in Asian countries, because with TTE monitoring it is possible to perform ASD closure without general anesthesia. Small ASD closure is possible with TTE monitoring in my opinion. But, with TEE it is difficult to evaluate hypoplastic inferior rim and posterior rim, and superior rim defect. Only TTE monitoring of transcatheter ASD closures for hypoplastic rim cases or borderline cases increases the risk of erosion and device migration. But a limited number of institutions can do transcatheter ASD closure in China and one institute has much experience. They can detect high-risk cases from their rich experience [4]. But the number of institutions performing transcatheter ASD closure in Japan is large and the average number of procedures per institution is only 10 cases per year. Most new institutions have limited experience. In addition, a recent recommendation suggests that evaluation of aortic rim is important to prevent erosion [5]. In

particular, a wide area of aortic rim defect is at high risk of erosion. However, defective or hypoplastic aortic rim is common in ASD. Evaluation of rim defect area is not easy and Mallula and Amin [5] recommended TEE or ICE evaluation and not TTE. TEE or ICE evaluations are costly and time-consuming, but are safe and accurate. However, the value of information from TEE or ICE differs between experienced and inexperienced institutions. Careful and thoughtful observation and procedures are required. References [1] Hellenbrand WE, Fahey JT, McGowan FX, Weltin GG, Kleinman CS. Transesophageal echocardiographic guidance of transcatheter closure of atrial septal defect. Am J Cardiol 1990;66:207–13. [2] Amin Z, Hijazi ZM, Bass JL, Cheatham JP, Hellenbrand WE, Kleinman CS. Erosion of Amplatzer septal occluder device after closure of secundum atrial septal defects: review of registry of complications and recommendations to minimize future risk. Catheter Cardiovasc Interv 2004;63:496–502. [3] [12_TD$IF]Japanese Society of Pediatric Interventional Cardiology. [13_TD$IF]Facility standard and educational program regarding the use of Amplatzer septal occluder; 2014, Available from:[]FDI$T4_1 [in Japanese; cited 05.06.14]. [4] Xu XD, Ding XY, Liu SX, Bai Y, Zhao XX, Qin YW. Immediate- and medium-term effects of simultaneous percutaneous corrections of secundum type atrial septal defect combined with pulmonary valve stenosis in local anesthesia and without transesophageal echocardiography guidance. J Cardiol 2015;65:32–6. [5] Mallula K, Amin Z. Recent changes in instructions for use for the Amplatzer atrial septal defect occluder: how to incorporate these changes while using transesophageal echocardiography or intracardiac echocardiography? Pediatr Cardiol 2012;33:995.

Toshiki Kobayashi (MD)* Saitama Medical University, International Medical Center, Department of Pediatric Cardiology, Saitama, Japan *Correspondence to: Saitama Medical University, International Medical Center, Department of Pediatric Cardiology, 1397-1 Yamane, Hidaka-shi, Saitama 350-1298, Japan. Tel.: +81 42 984 4111; fax: +81 42 984 4586 E-mail address: [email protected] (T. Kobayashi).

DOI of original article: 0914-5087/ß 2014 Japanese College of Cardiology. Published by Elsevier Ltd. Open access under CC BY-NC-ND license.

5 June 2014 Available online 18 July 2014

Monitoring tool of transcatheter atrial septal defect: transesophageal echocardiography or transthoracic echocardiography?

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