Cathlab Protocols: ASD Device Closure

ASD Device closure is an Interventional treatment to close the congenital atrial septal defect (ASD) in heart.

An atrial septal defect (ASD) is an abnormal opening in the wall (septum) between heart two upper chambers named atria. Every baby is born with a small opening there. The hole usually closes a few weeks or months after birth. A newborn may, however, be born with a bigger hole that does not close properly.

Hardware’s Required

1. Venous sheath   8 to 12F
2. Arterial sheath   5 to 6F
3. Multipurpose catheter (end hole)
4. 0.035 Terumo guide wire (150cm)
5. 0.035 Stiff exchange length guide wire (260cm) with 3-6cm floppy tip
6. Device delivery sheath with dilator
7. Device delivery system
8. Device Introducer
9. Sizing balloon

ASD Device Closure Procedure

• Introduce Venous and Arterial sheath and Heparinise with bolus of 5000 IU heparin

• A Diagnostic Multipurpose catheter with 0.035 Terumo guide wire need to be advanced into Pulmonary artery (IVC-RA-RV-PA) for baseline PA pressure measurement. Once PA pressure is recorded, the catheter can be pulled back to measure RV, RA pressures to complete the Right heart study, then the same catheter can be passed through the ASD into the left atrium

• Once the wire crossed the ASD and the guide is wire is directed to left upper pulmonary vein (Identified by wire passing out of cardiac borders), after confirming wire position by fluoroscopy advance the catheter with wire.

• Leave the catheter and remove 0.035 guide wire and exchange with  0.035 Stiff guide wire.

• Once wire is parked in satisfactory position on left superior pulmonary vein, Remove multipurpose catheter.

• If Sizing is needed introduce sizing balloon to confirm the size of device  

ASD Device Closure Sizing Balloon Preparation

1. Flush the Centre port of the Sizing balloon with heparinised saline and fill the balloon port with (1:5) diluted ionic Contrast.
2. Inject contrast into the balloon and hold upside down and aspirate (repeat it again). Put the syringe in negative with 3 way

• Now wipe the 0.035 exchange guide wire with wet gauze and introduce the balloon catheter through the wire till the distal marker crosses the ASD and into the LA

• Once the Balloon is in ASD, inflate it till the waist appears stretched then deflate the balloon

• Store Image and do length measurement on waist of balloon.

Steps to Measure Sizing balloon on Cathlab System

Step1: Enable Measure length option on Cathlab system 

Step2: Once Measurement curser appear, Measure the marker distance on Sizing balloon and give the reference value for system and click ok

Step3:  Now measure the waist length on stretched balloon, the value is the defect Diameter

Preparing the device delivery system

1. Long sheath with dilator (flush the sheath by keeping vertically)
2. Device introducer
3. Device delivery cable

Device Loading

• Pass the device delivery cable through the device introducer and screw it (anti clockwise) with device
• Pull the cable till the device comes into the introducer by keeping under saline
• Flush multiple time with introducer side-arm to make complete Air- free Septal Device

Long Sheath Positioning and De- Airing

• Introduce the long sheath into ASD through the Stiff wire parked in left superior pulmonary vein
• Once sheath is across the ASD into the left atrium, the sheath dilator must be removed very carefully to avoid air trap in left side of the heart and Coronary.
• In order to do this the sheath side arm port should be kept into a bowl of saline with its 3way open, once it’s completely inside the saline the sheath dilator alone can be pulled out slowly.
• Watch the Hemodynamics carefully during this process, If ST- Elevation noted, Administered high flow oxygen the ST – Elevation usually settle in 5min of time

Device Delivery

• Pass the device through sheath and advanced to the left atrium
• The sheath is then retracted allowing the distal portion of the device to unfold
• The whole unit is then pulled back until the distal device fits snugly against the defect in the left side of the inter atrial septum

• The sheath is further retracted allowing the proximal device to unfold in the mid right atrium Septum
• With the correct positioning of the device confirmed (under fluoroscopy as well as by echo), the device releases by turning delivery cable in clockwise direction and removes the delivery system
• If needed controlled angiogram is performed to confirm the closure of ASD

Once homeostasis is achieved, apply pressure dressing.

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