Non-Surgical ASD Closure

By: Prof. Dr. Şükrü Akyüz

The heart has four chambers. Two chambers are on the left and two on the right. There is less oxygen in the blood in the right chambers and more in the left chambers. Thanks to the partitions (walls) separating the left from the right, the blood of the right and left sides does not mix. In some people, there are some developmental problems during the formation of the heart in the baby (foetus) in the mother’s womb and these compartments are not fully formed. Holes remain in the parts that cannot be formed. One of the most common of these holes is in the compartment between the right and left atria. This is called ASD (atrial septal defect) in medical language. It means “defect in the partition between the atria”.

ASD nedir

What are the types of ASD?

ASDs are named according to their location. In 3 out of 4 cases of ASD, the hole is located in the centre of the chamber between the atria of the heart and is called ostium secundum type ASD (letter B in the figure below).

atrial septal defekt

How does ASD affect the heart?

The hole, called ASD, causes some blood to leak from the left atrium into the right atrium. Because of the leak, the right side of the heart receives more blood than it needs and the workload increases. Over time, this additional blood volume causes the right side of the heart to enlarge. This ultimately impairs the functioning of the heart. These effects on the heart and lungs are closely related to the size of the hole; the larger the ASD, the more likely it is to cause problems and need treatment.

What are the symptoms of ASD?

Although ASD is present from birth, many people do not show signs (symptoms) until adulthood. Sometimes it may not be recognised until the age of 40 or 50. When it is recognised, fatigue and shortness of breath are most common. Small holes usually never cause any problems because they do not put too much work on the heart. Very large holes, on the other hand, can cause symptoms even in infants; loss of appetite, feeding difficulties and growth retardation may occur.

What are the complications of ASD?

  • Heart failure As the right side of the heart has to pump more blood than normal, it can become tired and weak over time, resulting in heart failure.
  • Disturbance of heart rhythm: Pathologically growing heart tissues may have difficulty maintaining electrical balance. Unnecessary impulses may be emitted from abnormal foci, resulting in irregular beating of the heart.
  • Leakage of the heart valves: When the heart enlarges, the parts that make up the valves move away from each other and the valves cannot close normally. As a result, blood leakage can occur, especially in the right valve (tricuspid valve).
  • Lung problems Leakage from the left side to the right side pumps blood into the lungs. In the lungs, increased blood flow can cause various problems (pneumonia, etc.).
  • Increased blood pressure in the pulmonary vein: High pressure caused by too much blood leaking from the left side to the right side. The medical name is pulmonary hypertension.
  • Stroke (paralysis): Sometimes, if a clot forms in the legs for any reason and this clot breaks off and travels through the veins to the heart, it can pass through this hole and pass to the left atrium. From there, it can go to a vein that feeds the brain as the heart pumps the blood. It may get stuck somewhere in the cerebral artery and cause a stroke by blocking the blood flow to that part.

What are the causes (risk factors) of ASD?

The cause of ASD is not known exactly. Genetic changes that occur before birth may be the cause. During pregnancy; alcohol, smoking, infections such as rubella, substance use (cocaine, etc.), diabetes, some diseases and medications may trigger these genetic problems.

How is ASD diagnosed?

  • ECHO (Echocardiography; heart ultrasound): It is the main test in the diagnosis of ASD. It is an instrument that works by using sound waves. It takes a film of the heart. The hole and the blood escaping through it can be seen directly in most cases.
  • TEE (ECHO through the oesophagus): The hole in the heart is not always visible on conventional chest ECHO, but there may be other findings that lead to suspicion that it is present. In this case, an ECHO through the oesophagus, which is neighbouring the heart, provides a clearer image. To do this, a flexible cable with the diameter of a pencil is inserted into the oesophagus. At the end of this cable there is a special mechanism that enables image acquisition. In this way, the size, shape and location of the hole are determined in detail. TEE is also used to guide doctors during the non-surgical closure of the hole.
  • MRI (Magnetic resonance imaging; MRI): This device takes a film of the heart using a magnetic field. It is preferred in cases where TEE cannot be diagnosed.
  • CT (computed tomography): This device takes a film of the heart using X-rays (radiation). This is preferred in cases where TEE cannot be diagnosed.

How is ASD treated?

Most ASDs close spontaneously during childhood. Even if the ASD does not close spontaneously, if the hole is very small, it is usually not necessary to close it because it does not cause any problems. However, most ASDs that are not small need to be intervened at some point. The intervention is either surgical or non-surgical.

  • Surgical closure: Cardiac surgeons perform this operation. During the operation, a small incision is first made in the chest and the heart is accessed. A patch is preferred to close the hole in the heart. A fabric-like material or the patient’s heart membrane can be used for the patch. The operation is performed by stopping the patient’s heart and using a heart-lung pump. Usually, surgery can be performed through a small incision in the side of the chest. Rarely, robotic surgery may also be preferred.
ASD ameliyatı
Ameliyat ile Kapatma
  • Closure by non-surgical method: This operation is performed by interventional cardiologists or paediatric/ congenital cardiologists, not cardiac surgeons. Interventional cardiologists are doctors who perform procedures on patients over the age of 18. In the non-surgical method, the hole is closed with an umbrella-like device.
Şemşiye benzeri cihaz
ASD kapatma cihazı
ASd'nin ameliyatsız kapatılması
Ameliyatsız Yöntem ile Kapatma

Is it better to close the ASD surgically or non-surgically?

If possible, the non-surgical method is preferred because it is a safer method. Since there are no scars on the chest, it does not cause aesthetic concerns. However, ostium secundum type ASDs shown with the letter B in the figure above can be closed with the non-operative method; surgery is the only option in other ASD types (hole types shown with the letters A, C, D, E). In 90% of ostium secundum type ASD cases, it is suitable for closure; 10% require surgery either because the hole is too large or the ends to which the device will attach are anatomically inadequate.

When is the ASD switched off?

If the right ventricle of the heart starts to enlarge due to the blood flowing from left to right, the ASD should be closed. However, in very advanced cases, closing the ASD is unfortunately not beneficial; it may even cause harm.

How long does a person with ASD live?

Studies show that life expectancy is close to that of normal people if the ASD is closed in good time. However, if the ASD is closed too late, i.e. after the age of 40, life expectancy may be somewhat shorter. This is because by the time the hole is closed, the irreversible stage may have been reached over the years. This means that the right-sided heart failure and high blood pressure in the pulmonary arteries may have become permanent.

What is the success rate of ASD closure by non-operative method?

Overall, the technical success rate is >95%.

What are the risks of the ASD closure procedure?

Like any interventional procedure, this procedure is not without risks. However, these are very rare. Major complications, such as dislodgement of the device and clot formation on the device, occur in 1 in 100 people; death occurs in 1 in 1000 people.

I am concerned about these risks, what should I do?

You may be right to be concerned, but remember: These complications are very rare. The important question is whether the procedure is really necessary. If the decision is made in accordance with current scientific data and guidelines, avoiding this procedure means that you are exposing yourself to more significant risks (heart failure, etc.).

How long does the ASD closure process take?

Usually, 1 hour. However, this time may be shorter or longer depending on the anatomical features of the hole.

Is the procedure performed by stopping the heart, as in heart surgery?

No, it is not. There’s no need to stop the heart.

Will I feel pain during the procedure?

No, it is not. The procedure is performed either under sedation or under general anaesthesia. The difference is this: In general anaesthesia, a tube is inserted into the patient’s respiratory tract (intubation) and the patient is supplied with air by a respirator; in sedation, no breathing tube is inserted, the patient is not connected to a respirator, the patient is simply put to sleep and breathes on his/her own. In both techniques, drugs are given to prevent the patient from feeling pain during the procedure. General anaesthesia (intubation) is more comfortable for the patient.

How many days will I stay in hospital after the procedure?

Most patients are discharged the next day.

Will the ASD switch-off device move?

Although there have been cases reported in the literature where the device was found to have moved afterwards, this is very rare. It is not possible to move the device after it is covered with tissue within a few months.

Will I feel the device in my body?

No.

Will the device stay in my body for life?

Yes. It is not possible to remove the device.

Will I use blood thinners after ASD closure procedure?

Yes. Usually, two blood-thinning medicines are used together for the first 2-3 months. One of these is usually low-dose aspirin (Coraspin or Ecopirin) and the other is clopidogrel. After 2-3 months, one of these is stopped; the other is continued until the 6th month. After the 6th month, there is no need for blood thinners.