Damien Kenny, MB, MD, Ziyad M. Hijazi, MD, MPH, FSCAI
Successive decades since the original description of percutaneous closure of secundum atrial septal defects by Terry King and Noel Mills in the early 1970s have provided up and downs for the perception of the procedure in relation to surgery. Following Mills and King’s groundbreaking approach, interest despite reasonable initial success waned. However the late 1980’s provided resurgence in interest despite the fact that early device design was suboptimal. The procedure was catapulted into the mainstream with development of the Amplatzer Septal Occluder by AGA Medical (now St Jude Medical) with studies in the early part of the new Millennium clearly demonstrating a lower morbidity with transcatheter versus surgical closure such that in over 80% of defects, transcatheter closure is now accepted as the appropriate option. A number of device designs followed as the market opened up.
However a cloud still hangs over the procedure with concerns regarding erosion related to the St Jude device. Although an alternative exists in the US with no reported erosion rates (Gore Helex Occluder, WL Gore and Associates, Flagstaff, AZ), this device has demonstrated suboptimal closure rates in defects larger than 18mms. And so the question begs, what to do in the case of a larger defect requiring closure with the St Jude device? Here are the facts:
- The reported incidence of erosion is between 0.1-0.3%.
- Although the causes are not clearly understood the reported mortality with erosion is approximately 0.005-0.01%.
- The mortality with erosion is still less that the reported mortality with surgical ASD closure.
So whilst the debate continues we need to ask ourselves, should we be offering our patients a less invasive procedure with significantly less morbidity and less mortality compared to surgery or is the longer-term risk of the unknown too great? Each physician needs to decide the burden they are willing to carry but whilst we work tirelessly on defining the contributing factors that lead to erosion and modify device design to counter these, surely we are obligated to provide the facts to our patients and allow them to be involved in the decision-making process.
Dr Damien Kenny, MB, MD is Assistant Professor of Pediatrics, Associate Director of the Cardiac Catheterization Hybrid Suite, Rush Center for Congenital and Structural Heart Disease in Chicago, Illinois.
Kazmouz S. Kenny D, Cao Q-L, Kavinsky CJ, Hijazi ZM. Transcatheter Closure of Secundum Atrial Septal Defects. J Invasive Cardiol 2013;25(5): 257-264
Other articles on atrial septal defects:
Ammar RI and Hegazy RA. Transcatheter Closure of Secundum ASD Using Occlutech Figulla-N Device in Symptomatic Children Younger Than 2 Years of Age. J Invasive Cardiol 2013;25(2): 76-79
Kumar SM, Bijulal S, Krishnamoorthy KM. Percutaneous Transjugular Device Closure of Postoperative Residual Atrial Septal Defect. J Invasive Cardiol 2013;25(4): E78-E80 (with video)
Zheng P, Zhu X-Y. Severe Thrombocytopenia Complicating Transcatheter Occlusion of a Patent Ductus Arteriosus. J Invasive Cardiol 2013;25(5): E88-E92
Webber MR, Stiles MK, Pasupati S. Percutaneous Repair of Aortic Puncture With Amplatzer Closure Device During Attempted Transseptal Puncture. J Invasive Cardiol 2013;25(5): E110-E113