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The success of transcatheter closure (TCC) in ostium secundum atrial septal defects (OS-ASD) is largely determined by the morphology of the defects. Modified techniques are being used for circumventing the anatomic complexities and increasing success. We planned a prospective study looking at different morphological features of complex ASD identified in TEE and their association with the outcome of TCC of ASD with such modified device delivery techniques after conventional techniques failed.
We prospectively looked at various morphological complexities associated with modified techniques of TCC of OS ASD and to study if these anatomic variables can predict the outcome of TCC by logistic regression analysis. Seven parameters, viz. defect size, an absence of aortic rim, septal aneurysm, septal malalignment, deficiency of posterior rim and deficient inferior vena caval rims were analyzed for the outcome. Size more than 44 mm and complete absence of inferior vena caval rim were exclusion criteria. We used balloon assistance in 72% cases and pulmonary vein deployment technique in 23%. In 5% cases, a modified sheath was used. In all these patients a conventional technique had failed.
TCC was successful in 84% (67 out of 80) of patients with modified techniques. Out of the seven parameters studied, mean defect size, absent aortic rim, septal aneurysm and multiple defects did not show any difference in the outcome. Mean defect size was 31.8 ± 3.2 mm (22.9-39.1) with success and 32.6 ± 4.5 mm (CI 23.1-39.7) with failure (P=0.06). Patients with malalignment had a high failure rate of 71.4% (P<0.001). The proportion of patients with deficient posterior rim was 44% (35/80). The success rate was 68.6% with deficient posterior rim vs. 95.6 with adequate posterior rim (P=0.019). The inferior vena caval rim was deficient in 19 (24%) and procedure failed in 52.6% of these patients (P<0.001). The odds ratio for procedural failure was 25.3 (4.3- 143.8) in patients with septal malalignment, 8.3 (1.4- 48.5) with deficient inferior caval rim and 4.1 (2.5-19) for a deficient posterior rim.
The modified techniques for device deployment offered good chances of success in TCC of OS ASD (84%) after a failed standard approach. Mean defect size and presence of a septal aneurysm did not affect an outcome as absent aortic rim. But a presence of septal malalignment, an absence of posterior and or inferior vena caval rim predicted failure of TCC with modified device delivery.