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Percutaneous trans-femoral technique for atrial septal defect closure under trans-esophageal echocardiographic guidance
Peng Ling, Ke Lin, Gan Chang ping, Liang Zhong lei, Ruan Wei qiang.
West china hospital of sichuan university, chengdu, China.

OBJECTIVE: A sequential therapy for artial septal defect (ASD) involves transcatherter closure, mini-thoracotomy peratrial device closure, minimally invasive endoscopic repair,and traditional median sternotomy approach. This retrospective study was aimed to introduce a percutaneous trans-femoral technique for ASD closure under trans-esophageal echocardiographic (TEE) guidance to supply the therapy strategy.
METHODS: Patients with isolated secundum ASD underwent percutaneous trans-femoral device closure between January to July 2015 were reviewed. The defects morphological characteristics and the size of an occluder were assessed by transthoracic echocardiography (TTE) and intraoperative TEE. Under TEE guidance, a guidewire was placed into the right atrium from the right femoral vein percutaneously and was replaced by a deliver sheath to deploy the occluder. (Fig.1) The procedure and special relationship between the device and neighboring structures were examined.
RESULTS: A total of 22 patients were enrolled, and their preoperative ECG revealed no significant abnormalities except one sinus rhythm with right bundle branch block. The diameter of defects was 19.3±8.6mm, and 5 patients presented with multiple defects. Finally, 95.55% (21/22) patients received closure successfully through this approach. The failed case was subsequently switched into a right anterior mini-thoracotomy device closure. The main reason for this failed one was that the atrial septum was weak and dilated and developed into a atrial septal aneurysm, which partially covered the defect and made it difficult for the deliver sheath to across. The size of occluder used was 24.6±5.7(12~32) mm,and deliver sheath was between 8F to 14F. No severe complications such as residual shunt, vascular dissection, embolism, occluder shift were observed during the 3 months follow-up.
CONCLUSIONS: It is feasible and safety to perform the percutaneous tran-femoral approach for ASD device closure by skilled surgeons. TEE can be used as a primary tool for assessment and guidance during the deployment which can avoids both patient's and surgeon's exposure to the radiation. Combined with previous approaches, percutaneous trans-femoral technique could be applied as an supplement to ASD sequential therapy strategy.

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