METHODS
This was a single-center, retrospective study. Between January 2014 and December 2019, all consecutive patients with ASD with chronic atrial fibrillation who were suitable for transcatheter occlusion were included in the study. Suitable subjects were defined as patients who had no significant coronary artery disease or cardiac pathology, which would otherwise obviate them from a transcatheter procedure. Patients with significant concomitant cardiac pathology may benefit from a cardiac surgery where all the pathologies can be treated in the same setting and hence, were excluded. All subjects underwent CHADS2, CHA2DS2-VAS and HAS-BLED score assessment to evaluate the risk of thrombotic strokes and bleeding on Warfarin prior to the procedure 2,4–6. Written consent was obtained before the procedures.
All procedures were performed under general anesthesia. A transesophageal echocardiogram was performed to assess the ASD for the adequacy of the interatrial septal rims, the normalcy of the pulmonary veins, the heart valves and the presence of the thrombi of the LAA. The LAA was profiled at 0o, 45o, 90o and 135o, where the size, the length and the morphology of the LAA were assessed. Once deemed suitable, the femoral vessels were canulated. The LAA was occluded via conventional method using Watchman device. The details of the technique and device selection were as previously described 6. After successful occlusion of the LAA, the subjects proceeded with the closure of the ASD. Saturation run was performed in routine fashion and the ASD occlusion was performed as previously described8. A 6 French pigtail catheter was positioned into the left ventricle to monitor the left ventricular end-diastolic pressure during the procedure. The ASDs were initially occluded with a sizing balloon while the left ventricular end-diastolic pressure is being monitored. A small fenestration was created onto the ASD occluder using the dilator of the long delivery sheath. Since the size of the delivery sheath corresponds to the size of the device, the size of the fenestration created was relative to the size of the atrial septal occluder (Figure 1). Post occlusion, the left ventricular end-diastolic pressure was measured to ensure that it did not exceed 20mmHg prior to releasing the septal occluder. All subjects had their ASD closed using Amplatzer or Amplatzer-like septal occluders.
In all patients, a transesophageal echocardiogram to assess the presence of residual flow around the devices, the formation of device-related thrombus and the stability of the atrial septal occluder was performed 45 days post procedure. If there was satisfactory occlusion of the LAA, which was defined as the presence of a residual flow of less than 5mm around the device, the Warfarin was stopped and replaced by dual anti-platelet therapy until 6 months after the initial LAA occlusion. Thereafter, the subjects were kept on Aspirin indefinitely.
The subjects were followed up at an interval of 45 days, 3 months, 6 months and yearly. Long term follow-up for device-related complications and the presence of stroke or transient ischemic attack (TIA) was carried out during which, a transesophageal echocardiogram was performed where indicated. The fenestration at the atrial septal occluder was also evaluated.