Discussion
ASD is a common type of congenital heart defect in children and careful selection of treatment is important for those who are unlikely to self-heal. The aim of this study was to retrospectively analyze the safety and effectiveness of trans-jugular transcutaneous closure of ASD with an adjustable curved sheath under echocardiography guidance. We, therefore, present the clinical data from 156 patients treated in our department. The procedure was effective and safety.The first cases of transcatheter closure ASD were described in1974 (14). The traditional transcatheter treatment had little trauma, the patients recovered quickly, they could get out of bed as soon as possible, return to work, with short hospitalization time. This saved time and economic cost; there was no surgical incision, a good cosmetic effect; no bleeding, and complications related to blood transfusion were avoided. Houeijeh reported their study of transcatheter closure of large ASD in symptomatic children (15). This method has become preferred for the treatment of secondary ASD (16,17). However, there are some risks with the use of radiation and contrast media may cause allergy and renal insufficiency (2,3). Most of these treatments also need use expensive catheterization room or hybrid operating room. In recent years, the use of echocardiography instead of radiation for interventional therapy has become an important method. Ewert showed that transcutaneous ASD occlusion guided by TEE alone was feasible (4). Schubert reported 1605 cases of transcutaneous ASD occlusion, which showed that TEE guided transcutaneous ASD occlusion can achieve the same safety and effectiveness as a radiation-guided method (5). Seol(6), Sharfi(7), Lu(8), Snijder(9), and Zhang(12), have all reported transcutaneous close ASD under echocardiography guidance. At present, transcutaneous ASD occlusion under echocardiography guidance is commonly through the femoral vein (4-9). But this method has a long operation path and needs long bedrest after femoral vein puncture.
We transcutaneous closure of ASD with an adjustable curved sheath under echocardiography guidance though jugular vein which no need femoral vein puncture or lower-limb braking. It has been suggested that this method can reduce bedrest and significantly increase patient comfort(10, 11). It may also reduce the risk of vein thrombosis, and bleeding of puncture point may reduce because of a relative decrease of jugular venous pressure after the operation. All 156 patients in this study had no bleeding at the point of puncture. Especially for infants, the diameter of the jugular vein is larger than that of the femoral vein (18). Transcutaneous interventional therapy via the jugular vein can relax the restrictions of the vascular conditions on the type of the transport sheath, which makes it possible to treat young patients with relatively large ASD.
The operation time(From puncture right internal jugular vein to leaving the operating room )was 46.6 ±30.9 min in this study, The intracardiac operation time is significantly less. A comparative analysis of the duration of the procedure from when the operators started to use it versus when they were considered experiente, could show differences. The operation time of 56 patients in the first two years was 60.7 ±37.6 min, and The operation time of the next 100 cases was significantly reduced 43.6 ±21.3 min(P<0.01)
, and a range of 25 to 30 minutes(10.11) in other studies that used a similar approach. So, this method has a relatively short operation time when compared to transcutaneous ASD occlusion under the guidance of echocardiography through the femoral vein which Shubert showed had a median procedure time of 50 min with a range of 20-170 min(5). The safety of the method was shown by no complications occurring during the procedure of during follow-up. This was also similar to previous studies with similar methods(10, 11).
Our experience of trans-jugular transcutaneous closure of ASD with adjustable curved sheath under echocardiography yielded the following conclusions
1. The preoperative ultrasound diagnosis is clear, and the cooperation of experienced ultrasound doctors is important. During the operation, multiple sections of TEE are needed to evaluate the ASD size and each edge situation. The operator needs to have certain ultrasound knowledge, if the defect edge is tough, even if only 3mm closure can be tried; the operation is easier under the guidance of a double chamber view. The movement of the adjustable sheath into the left atrium should be gentle to avoid damaging left atrium.
2. Select the appropriate occlude. We choose to use a double chamber view, four chamber view and aortic short axis view to measure the maximum diameter of the ASD, and take the average value as the ASD size. We then added 2-6mm to the find the correct occluder size, if the edge was tough, we chose a relatively small occluder, if the quality was soft, we chose a relatively large occluder.
3. After the right disk of the occluder is released, due to a certain angle traction at the head of the transport sheath, TEE shows the occluder may be unnatural in shape; at this time, multiple views are needed to check if the atrioventricular valve rim, inferior vena cava rim, superior vena cava rim, posterior rim and aortic rim are ”stuck” between the left and right disk of the occluder, the occluder can be released. In general, the shape will become very natural after the occluder is released.
4. The operation needs a team of doctors with experience in minimally invasive procedures. If transcutaneous closure is unsuccessful, it can then be directly changed to transthoracic minimally invasive closure or cardiopulmonary bypass close ASD.
Our study has some limitations. The retrospective analysis method is likely to have patient selection bias. More studies that directly compare this method with other methods are needed to confirm that this method can be recommended.