Reply to the letter to the editor by Dehgani, Collins, Horlick, and Benson, entitled “Sheath...
2
Letter to the Editor REBUTTAL Reply to the Letter to the Editor by Dehgani, Collins, Horlick, and Benson, entitled ‘‘Sheath Stabilizing Technique for Balloon Sizing of Large Atrial Septal Defects’’ I very much appreciate the comments by Dehgani et al. [1], regarding the recently published article Trans- catheter Closure of Secundum Atrial Septal Defects (ASD) [2]. The authors describe a novel technique to stabilize the sizing balloon across the atrial septum, for balloon sizing, prior to closing atrial septal defect. The tech- nique was used in two adult patients and to my knowl- edge has not been published previously. The ASD measured 20 and 27 mm, and 36 and 38 mm devices were deployed successfully. The authors emphasize the importance and usefulness of balloon sizing for opti- mal device selection. Their technique is innovative and seemed to have worked in these two patients. I concur with their comments that balloon sizing should be attempted and performed (where feasible) as long as it gives meaningful results. However, if balloon sizing over-stretches the defect, or if the long-axis of the balloon is not perpendicular to the atrial septum, the measurement of the defect will almost always be overestimated. Such is apparently the case in figure 3 of the authors’ case report. With large defects it is very difficult to keep the sizing balloon simultaneously across the atrial septum and perpendicular to it. The authors’ technique of keeping the balloon across the ASD is innovative, but unfortunately it may not main- tain the orientation of the balloon perpendicular to the atrial septum. One of the defects that measured only 20 mm actually was stretched to 36 or 38 mm (not clear what size device was used). In our recently pub- lished article, a balloon stretched defect that was more than 1.5 the static diameter of the defect, was a risk factor for hemodynamic compromise and other com- plications, such as pericardial effusion [3]. In the same article, we proposed using the stop-flow technique while balloon sizing. With stop-flow technique, it is not necessary to see a waist in the balloon. In my ex- perience, whenever a waist is seen in a balloon, the di- ameter being measured is not stop-flow diameter; it is rather balloon stretched diameter, which is against the current recommendations [3]. Lastly, my published statement [2] about proceeding with device closure, without balloon sizing was intended primarily for pediatric patients with large defects. Spe- cifically, my patients were less than 15 kg (p 780) with ASD greater than 20 mm in diameter. Balloon sizing in such patients does not yield any valuable information, and causes hemodynamic compromise. A short 12-mm sheath (as described by the authors) in such small patients, even when it can be introduced, risks vascular injury. I do agree that in adult patients this technique can work as long as the balloon can be kept perpendic- ular to the atrial septum and the defects are not stretched. The left atrial disc of the Amplatzer septal occluder (AGA Medical Corporation, Plymouth, MN) is 14 mm larger (16 mm for devices larger than 30 mm) and the right atrial disc is 10mm larger than the waist. Therefore, there is a good margin of safety as far as the potential of device embolization is concerned. So, in essence, the ‘‘waist’’ of the device does not have to be larger than the ASD; in fact our experience has shown that devices with the waist smaller than the defect can be used with excellent results. In summary, balloon sizing is an essential step for atrial septal defect closure [2]. In some instances, espe- cially when the defect is large with redundant atrial septal rims, stabilizing the balloon across the defect during balloon sizing can be difficult. The authors duly acknowledge that balloon sizing in these circumstances can be cumbersome and difficult. In my own experi- ence with small patients, it may compromise hemody- namics. As long as we know the risks and limitations *Correspondence to: Zahid Amin, University of Nebraska/Creighton University, Children’s Hospital of Omaha, 8200 Dodge Street, 4th floor, Health Care Pavilion, Omaha, NE 68114. E-mail: [email protected] Received 2 January 2007; Revision accepted 4 January 2007 DOI 10.1002/ccd.21112 Published online 22 June 2007 in Wiley InterScience (www.interscience. wiley.com). ' 2007 Wiley-Liss, Inc. Catheterization and Cardiovascular Interventions 70:158–159 (2007)
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Transcript of Reply to the letter to the editor by Dehgani, Collins, Horlick, and Benson, entitled “Sheath...
Letter to the Editor
REBUTTAL
Reply to the Letter to the Editorby Dehgani, Collins, Horlick,and Benson, entitled ‘‘SheathStabilizing Technique forBalloon Sizing of Large AtrialSeptal Defects’’
I very much appreciate the comments by Dehganiet al. [1], regarding the recently published article Trans-catheter Closure of Secundum Atrial Septal Defects(ASD) [2].The authors describe a novel technique to stabilize
the sizing balloon across the atrial septum, for balloon
sizing, prior to closing atrial septal defect. The tech-
nique was used in two adult patients and to my knowl-
edge has not been published previously. The ASD
measured 20 and 27 mm, and 36 and 38 mm devices
were deployed successfully. The authors emphasize the
importance and usefulness of balloon sizing for opti-
mal device selection. Their technique is innovative and
seemed to have worked in these two patients.I concur with their comments that balloon sizing
should be attempted and performed (where feasible) aslong as it gives meaningful results. However, if balloonsizing over-stretches the defect, or if the long-axis ofthe balloon is not perpendicular to the atrial septum,the measurement of the defect will almost always beoverestimated. Such is apparently the case in figure 3of the authors’ case report. With large defects it isvery difficult to keep the sizing balloon simultaneouslyacross the atrial septum and perpendicular to it. Theauthors’ technique of keeping the balloon across theASD is innovative, but unfortunately it may not main-tain the orientation of the balloon perpendicular to theatrial septum. One of the defects that measured only20 mm actually was stretched to 36 or 38 mm (notclear what size device was used). In our recently pub-lished article, a balloon stretched defect that was morethan 1.5 the static diameter of the defect, was a riskfactor for hemodynamic compromise and other com-plications, such as pericardial effusion [3]. In the same
article, we proposed using the stop-flow techniquewhile balloon sizing. With stop-flow technique, it isnot necessary to see a waist in the balloon. In my ex-perience, whenever a waist is seen in a balloon, the di-ameter being measured is not stop-flow diameter; it israther balloon stretched diameter, which is against thecurrent recommendations [3].Lastly, my published statement [2] about proceeding
with device closure, without balloon sizing was intendedprimarily for pediatric patients with large defects. Spe-cifically, my patients were less than 15 kg (p 780) withASD greater than 20 mm in diameter. Balloon sizing insuch patients does not yield any valuable information,and causes hemodynamic compromise. A short 12-mmsheath (as described by the authors) in such smallpatients, even when it can be introduced, risks vascularinjury. I do agree that in adult patients this techniquecan work as long as the balloon can be kept perpendic-ular to the atrial septum and the defects are notstretched. The left atrial disc of the Amplatzer septaloccluder (AGA Medical Corporation, Plymouth, MN)is 14 mm larger (16 mm for devices larger than 30mm) and the right atrial disc is 10mm larger than thewaist. Therefore, there is a good margin of safety as faras the potential of device embolization is concerned.So, in essence, the ‘‘waist’’ of the device does not haveto be larger than the ASD; in fact our experience hasshown that devices with the waist smaller than thedefect can be used with excellent results.In summary, balloon sizing is an essential step for
atrial septal defect closure [2]. In some instances, espe-cially when the defect is large with redundant atrialseptal rims, stabilizing the balloon across the defectduring balloon sizing can be difficult. The authors dulyacknowledge that balloon sizing in these circumstancescan be cumbersome and difficult. In my own experi-ence with small patients, it may compromise hemody-namics. As long as we know the risks and limitations
*Correspondence to: Zahid Amin, University of Nebraska/Creighton
University, Children’s Hospital of Omaha, 8200 Dodge Street, 4th
floor, Health Care Pavilion, Omaha, NE 68114.
E-mail: [email protected]
Received 2 January 2007; Revision accepted 4 January 2007
DOI 10.1002/ccd.21112
Published online 22 June 2007 in Wiley InterScience (www.interscience.
wiley.com).
' 2007 Wiley-Liss, Inc.
Catheterization and Cardiovascular Interventions 70:158–159 (2007)
of balloon sizing, and can perform balloon sizing with-out stretching the defect, I believe we should continueto do so.
Zahid Amin,* MD, FSCAI, FAAP, FACCJoint Division of Pediatric CardiologyUniv. of Nebraska/Creighton UniversityChildren’s Hospital of Omaha, Omaha, Nebraska
REFERENCES
1. Dehgani P, Collins N, Horlick E, Benson L. Sheath stabilization
technique for balloon sizing of larger atrial septal defects.
2. Amin Z. Transcatheter closure of secundum atrial septal defects.
Catheter Cardiovasc Interv 2006;68:778–787.
3. Amin Z, Hijazi ZM, Bass JL, Cheatham JP, Hellenbrand W,
Kleinman C. Erosion of Amplatzer septal occluder device after
closure of atrial septal defects: Review of registry of complica-
tions and recommendations to minimize future risks. Catheter
Cardiovasc Interv 2004;63:496–502.
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd.Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
Rebuttal 159
