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-VASc 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.