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.