Fig. 33.1
Percutaneous closure of large ASD in adult. (a) Large ASD with significant left-to-right shunt at color Doppler analysis. (b) LV end-diastolic pressure before ASD temporary occlusion. (c) Dynamic ASD balloon occlusion test performed from the right atrium. (d) No change in LV end-diastolic pressure during balloon inflation is recorded
Pulmonary artery pressures are evaluated during and after balloon testing in subjects with high baseline values.
In patients with chronic atrial fibrillation, percutaneous ASD closure may be followed by DC shock conversion and prophylactic anti-arrhythmic therapy, hoping that a favorable long-term atrial remodeling might maintain sinus rhythm over long-term follow-up.
If needed, fenestration is created in the device.
Fenestration is obtained by perforating a self-centered occluding device using a Seldinger technique with 10–12 Fr femoral sheath, so creating a 3–4 mm hole within the device. If needed, the hole can be further increased “in vitro” by using a 6–8 mm peripheral angioplasty balloon.
Inhaled 100 % oxygen, via a rebreathing mask, was the most commonly used agent to test pulmonary artery vasoreactivity. It is now more common that acute vasodilator testing be performed using short-acting vasodilators such as inhaled nitric oxide, intravenous administration of epoprostenol, or adenosine. An acute reduction of mean pulmonary arterial pressure as high as >10 mmHg, with resultant mean pulmonary arterial pressure drop to less than 40 mmHg without fall in cardiac output, is considered as positive vasoreactivity response.
33.1.3 Follow-Up
ASD closure is expected to abolish systemic-to-pulmonary shunt, reduce pulmonary artery pressure, and significantly increase systemic output, thereby resulting in steadily and progressively clinical and functional improvement also in elderly. However, arrhythmic risk of these patients does not seem to change over time, although a favorable atrial remodeling might halt the trend toward atrial instability. Mortality and morbidity of percutaneous ASD closure in elderly are not significantly different from younger age but pharmacologic long-term therapy with pulmonary vasodilators or anti-congestive drugs might be advisable in patients with borderline pulmonary hypertension or LV compliance, respectively. In subjects with a fenestrated device, the fate of fenestration is usually spontaneous closure within a few months.
33.2 ASD Closure in Pulmonary Atresia with Intact Ventricular Septum
ASD or patent foramen ovale (PFO) is almost invariably present in the setting of pulmonary atresia with intact ventricular septum (PA-IVS) submitted to right chamber unloading by percutaneous or surgical valvotomy. RV hypoplasia and abnormal compliance almost always burden on long-term pathophysiology of this malformation [2, 3].
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