Atrial Septal Defect repair

So, you've been referred for atrial septal defect closure. You were born with a hole in the heart, and this is genuinely a hole, the size of which will have been discussed with you in outpatients. So in an adult, the size of the septum, the diameter of it, in between the two collecting chambers is of the order of three and a half, four centimeters. So that will allow you to put into context the size of hole that you have. It may be small, less than a centimeter. It may be very large, more than three centimeters. will have been discussed with you in outpatients and your doctors have decided that you need to have that closed. They will have also discussed with you that you could have had it closed surgically, that's an open heart procedure, it requires you to go possibly on a heart-lung bypass machine to have a cut on your chest, which would require about a week in hospital and probably three or four weeks recovery period. They've chosen to have it done percutaneously, in other words, you will be asleep but there will be no large cuts on your skin. So what's going to happen on the day? Well, the anaesthetist will assess you, the doctor will consent you, and then you'll be put to sleep. The reason for being put to sleep is that we can then assess how we're going to deliver the device with a transesophageal echocardiogram. This swallowing echocardiogram that's a bit like an endoscopy, you will have had as part of your screening test. It's obviously going to make your throat slightly sore when you wake up. We're then going to puncture the vein in your groin to allow us to access your heart. The way we close it is we pass a wire all the way up from that vein across the hole and then usually do a balloon to size how big this hole actually is. Sometimes it's exactly as we measured it, sometimes it's a little bit bigger than we measured it. If we still feel it's suitable for closure, we're going to put what is a double umbrella device in. squashed up inside a small pipe, and as it pops out of the pipe, the first umbrella comes out on one side of the hole, and if it's sitting correctly, then the second umbrella goes on to the other side of the hole, and hey presto, your hole is no longer a hole, it's closed with this double umbrella device. Now of course, that's if everything has gone beautifully well. Sometimes a device does not sit correctly, and it may be that the doctor will take it out again and say no device sits well, it's better to have open heart surgery at a later date. Let's imagine that the device has sat correctly and you are now waking up from the procedure. You'll be a little sore from the groin and you'll be groggy from the anaesthetic and if you react badly to general anaesthetics, then you'll probably not react so well to this one. You may take a little longer to wake up and recover. You may feel a little nauseated afterwards, but we can cope with all of that, just let us know. So you will almost certainly be going home the same day. By that time, the leg will have recovered, there'll be no bleeding, you will have woken up, but I'd like you to go home with someone. If you haven't brought someone with you, your procedure is going to be cancelled because someone needs to take you home. Just as your safety manoeuvre, and someone needs to stay with you overnight in case something happens to you. Maybe you react late to the anesthetic, maybe the device decides to move at a later stage, maybe the groin bleeds. So what are the complications? I've mentioned some of them. During the procedure, bleeding from the leg can occur, internal bleeding as we poke wires inside the heart. We can set off a small heart attack or even a stroke as clot forms inside the heart. We thin the blood to try and avoid that happening, but thinning the blood means there's a bleeding risk associated with it. The device can move, usually we'll have done some safety checks to make sure the device is not going to suddenly spring off, but it can happen that with all the best intentions the device then moves. And if it does, you may feel nothing, that's happened before, or you may feel something very strange happening in your heart. Any odd feelings around your heart in the first week or two after the procedure should be reported immediately to the doctor. Hopefully, none of that will occur, and so when you get back home, you're not going to drive for a week, you're not going to go to work for a week, and because this is a reasonable sized device in a reasonable sized hole, I'd really like you to try and avoid any heavy lifting for the first month. Of course, you can pick up your six month old baby, but don't pick up your 12 year old child or a very heavy suitcase, so manual labor is out for the first three or four weeks. If you have a desk job, you can go back to work one week later. If you have a very heavy manual labor job, I'd advise you taking lighter duties for the first month. Your blood will also be thinned with aspirin and probably another drug, which is a bit like aspirin's big brother, to try and avoid clot forming on the device in that early phase. And of course, the doctors will be following you up with echocardiograms to see whether heart has responded well to the closure procedure that's actually been done. Very rarely do we find the device has suddenly disappeared and no one knew anything about it. It has happened but normally we're seeing that the device is in exactly the right place and the heart is now shrinking back to a more normal size because this hole and the shunt that it created moving blood in the wrong direction has been taken away and so in the long term you should feel much better. Your exercise tolerance may improve, even if you didn't even know you were limited in your exercise tolerance before. Occasionally people get palpitations in the longer term. If you do get them, then you should report that to the doctor. Usually it's part of the healing process and it will settle down. The evidence now is that we should probably follow you up in the longer term just to be sure that nothing is happening to your heart. And so you may be called back in a year's time, maybe a few years after that, and every couple of years have a further echo scan to make sure everything is fine. Whether that's absolutely necessary or not is a bit of a doubt in my mind beyond the first year, but the recent guidelines suggest we should be following you up, and so for the bigger devices at least, so if your device is more than 20 to 25 millimeters in size, we probably will be bringing you back in the longer term, just for a hello and a look-see with an echo cardiogram.