Closure of Patent Foramen Ovale and Atrial Septal Defects

Airway: ETT
Access: 18G
Pain: Minimal
Position: Supine
Time:
Blood loss:
Special:

  • TOE required
  • Low volume, high respiratory rate

Percutaneous closure of atrial septal defects can be performed for:

Primum ASD are not amenable to percutaneous closure due to the lack of safe landing zone for an occlusion device against the AV margin.

Surgical Stages

  • Groin access
  • Transeptal puncture
    Guidewire passed through the fossa ovalis into the LA.
    • Needle “tenting” (if passing through septal tissue) is assessed under echocardiography
      • First in the superior-inferior (bicaval) position
      • Second in the aortic short axis position (for anterior-posterior position)
      • The four chamber can be used to determine height above the MV annulus
  • Defect sized
    • Sizing balloon passed over guidewire into defect and inflated
    • Septum indents the balloon, appearing as a ‘waist’ on fluoroscopy and echocardiography
    • Measurement of the waist in orthogonal planes sizes the closure device
  • LA disc deployed and positioned
  • RA disc deployed and positioned
  • Occlusion assessed
  • Deployment mechanism removed

Optimal “tenting” position depends on the procedure:

    Procedure
 Superior–inferior axis (bicaval view) Anterior–posterior axis (AV short-axis view)
PFO closure Superior Anterior
LAA occlusion Inferior Posterior
Ablation procedures Middle Middle
Paravalvular leak closure Mid to superior Mid to posterior
MV valvotomy Mid to superior Mid to posterior
MV repair Mid to superior
Ideally 4-5cm above grasping zone.		 Mid to posterior

Preoperative

Assessment:

  • Cryptogenic stroke
  • Right heart volume overload
    • Right heart dysfunction
    • Pulmonary hypertension
    • Clinical right heart failure
  • Preoperative echocardiography
    • Presence of atrial septal aneurysm
    • Chiari network
    • Atrial thrombi
      Contraindication until cleared.

Consultation:

Optimisation:

Premedication:

Explain/Consent:

Intraoperative

Preparation:

Induction:

Maintenance:

Echocardiography:

  • 2D imaging typically provides higher temporal and spatial resolution of the thin and mobile septum
  • 3D imaging may be helpful for defining the shape of the defect and relationship to surrounding structures, and for confirming the device has captured the margins
Transeptal Puncture

  • Exclude atrial thrombi
  • Conduct critical measurements
    Defect should be <35mm diameter, with margins ideally >5mm.
    • AV Short Axis
      For anterior-posterior position.
      • Posterior margin
      • Anterior margin
        At aortic valve. Commonly <5mm.
    • Bicaval
      For superior-inferior position.
      • Inferior margin
        At IVC.
      • Superior margin
        At SVC.
    • MO 4-chamber
      For position in relation to the MV annulus.
  • Closure device sizing
  • LA position assessment
    2D and 3D.
  • RA position assessment
  • Closure device position
    • Small amount of residual flow is common, and may persistent until endothelialised
    • Assess stability
    • Assess interference with:
      • SVC
      • Aorta
      • PV
      • AV
    • Rule out pericardial collection

Emergence:

Postoperative

Disposition:

Referrals/Review:

Analgesia:

Fluids:

Thromboprophylaxis:

Specific: