Reply to the letter to the editor by Dehgani, Collins, Horlick, and Benson, entitled “Sheath...
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Transcript of Reply to the letter to the editor by Dehgani, Collins, Horlick, and Benson, entitled “Sheath...
![Page 1: 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”](https://reader035.fdocuments.net/reader035/viewer/2022080306/5750033b1a28ab1148980580/html5/thumbnails/1.jpg)
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)
![Page 2: 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”](https://reader035.fdocuments.net/reader035/viewer/2022080306/5750033b1a28ab1148980580/html5/thumbnails/2.jpg)
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