Balloon Interrogation of Intervening Tissue: A Novel Method to Decide Strategy for Closing Multiple Atrial Septal Defects.

Balloon Interrogation of Intervening Tissue: A Novel Method to Decide Strategy for Closing Multiple Atrial Septal Defects.

Dalvi B, Bhalgat P. Circ Cardiovasc Interv. 2022 Sep;15(9):e012048. doi:10.1161/CIRCINTERVENTIONS.122.012048. Epub 2022 Sep 20.PMID: 36126135 Free article.

Take Home Points: 

  • Balloon interrogation of patients with two secundum atrial septal defects beyond the typical “stop-flow” and “balloon stretch” techniques allow for determination of candidacy for a single-device approach to percutaneous device closure.
  • If balloon interrogation of one of two ASDs does not result in intervening tissue impingement and cessation of flow through the 2nd defect, it is important to separately interrogate the 2nd defect to determine if that is a single-device candidate.

Commentary from Dr. Arash Salavitabar (Columbus, OH, USA), section editor of Congenital Heart Disease Interventions Journal Watch: 

The authors report on an approach to a challenging dilemma of performing device closure of two separate ostium secundum atrial septal defects (ASDs). The clinical decision of whether to use a single device to cover both defects and/or use multiple devices can be a difficult judgement call.  This was a prospective study of 20 patients (age range 3-67 years, weight range 11-71 kg) with 2 secundum ASDs who underwent device closure.

In these patients, an Amplatzer sizing balloon was inflated across one of the defects until flow through that defect stopped completely. This was then further inflated to determine whether the intervening tissue between the ASDs demonstrated enough mobility to also stop flow through the 2nd defect. A “successful balloon interrogation” was if this technique stopped flow through both defects and the diameter at which flow stopped through both defects was referred to as the “balloon interrogated diameter” (Figure 4).

If flow did not cease in the 2nd defect, that additional defect was crossed separately from the contralateral femoral vein and balloon interrogation was performed using the same technique to determine if a single device could be utilized within that defect (Figure 5). An “unsuccessful” balloon interrogation resulted in a 2-device strategy. When a single device was used, 1-2mm were added to the balloon-interrogated diameter, whereas in the 2-device approach, 1-2mm were added to each balloon-stretched diameter. When deploying 2 devices, the smaller device was delivered first, followed by the larger device.

A single device was implanted successfully and without residual shunt in 15/20 patients. Four of the 15 patients had an initially unsuccessful balloon interrogation but was subsequently successful when performed in the 2nd defect. The remaining 5 patients received 2 devices. Although statistical analysis was not reported, the authors found that successful single-device approach was more likely if the smaller defect was <10 mm in diameter, that the width of tissue separating defects was shorter in patients who received a single device, as compared with 2 devices (5.2±2.4 mm for 1 versus 8±1.1 mm for 2). Successful single-device strategy also tended to be in younger patients. Importantly, the single-device strategy required use of a significantly larger (35±14%) device and the Amplatzer Septal Occluder was used in all of these single-device cases.

This study provides a logical, stepwise approach to interrogation and decision-making in percutaneous treatment of two secundum atrial septal defects. The authors provide a small cohort with success using this strategy of triaging patients who are candidates for a single-device approach. Given that a larger device is needed to perform this single-device strategy, it will be important to have subsequent follow-up data regarding device-related complications, such as erosion.