Operative Procedure
All surgeons with more than 5 years of experience. According to the edge length and toughness of the ASD, an occluder that was 2–6 mm larger than the ASD diameter was selected. Heparin 1 mg/kg was routinely administered before the operation with no postoperative protamine neutralization. Routine postoperative with aspirin (3–5 mg/kg) for 6 months.
The ASD diameter and atrial septum length were measured in several views (four-chamber view, parasternal short axis and double chamber section) by TEE. The distance from the puncture point to the third intercostal on the right side was measured, which was marked as the working distance. The right internal jugular vein was punctured with a 16G puncture needle using echo-guided, and the guidewire was placed through the puncture needle into the right atrium (about working distance length), the puncture needle was removed when the guidewire reached the superior vena cava edge of the ASD through TEE inspection, and the guidewire was kept in the right atrium. An adjustable bent sheath (Shenzhen LifeTech Scientifc Corporation) was prepared, which was able to adjust the head curvature from 0 to 900 for ASD. (Figure 1) The adjustable curved sheath (with inner core) entered the right atrium through the jugular vein along the guidewire. When the length reached the working distance, the guidewire and inner core were removed. Under the guidance of TEE, the sheath slowly entered the middle of the ASD parallel to the atrial septum. The manipulator was gently rotated clockwise to gradually bend the head of the sheath make the sheath passed through the ASD to the left atrium. The occluder with cable was delivered into the left atrium though sheath with the help of TEE detector.
The left side was released first, the cable was then pulled back to release the right side. TEE was used to observe the occlude position. This included whether it straddled the atrial septum, was parallel to the atrial septum, encircled the aortic root, and the residual edge of the atrial septum was located between the two plates. Also, whether there was residual shunt, whether the occluder affected the activity of the mitral valve, tricuspid valve, whether the occluder affected the return of the pulmonary vein and the superior and inferior vena cava. The occluder was released after a push-and-pull test if there was no residual shunting, no effect on surrounding tissue, and no arrhythmia. The manipulator was rotated to straighten the head of the adjustable bent sheath, the sheath was pulled out, and pressure was applied to the puncture point which was then bandaged. (Operative Procedure see Figure 2). The tracheal tube was removed in the operating room or intensive care unit (ICU), and all patients returned to the general ward after extubation.