At the China Heart Congress (CHC) held in early August at the China National Convention Center, Professor Shaobo Xie, Director of Cardiac Surgery at the First Affiliated Hospital of Guangzhou Medical University, introduced the “Atrial septal defect closure with adjustable curved sheath via the right internal jugular vein”, which drew an enthusiastic response from the experts in the audience. Those who have learned about the “right internal jugular vein adjustable curved sheath atrial septal defect closure” and those who have been treated with this procedure may be amazed by the simplicity and safety of this procedure. For this reason, AME interviewed Prof. Shaobo Xie, and let’s go into the revolution of ASD occlusion that is about to start! Xie Shaobo: chief physician, researcher, professor, master’s degree supervisor, director of cardiac surgery of Guangzhou Medical First Hospital. He is a member of the Standing Committee of the Cardiothoracic Surgery Branch of Guangdong Medical Association and a member of the Cardiothoracic Surgery Branch of Guangdong Medical Association. He has studied and worked for more than ten years at the Institute of Cardiovascular Diseases of Tongji Medical University, Fu Wai Cardiovascular Hospital of Chinese Academy of Medical Sciences, German Heart Center, Leipzig University Heart Center and other authoritative institutions at home and abroad. In the past 30 years of cardiac surgery, he has performed more than 4,000 cardiovascular surgeries such as infant and child predilection, complex predilection, heart valve replacement/plasty and coronary artery bypass grafting, with a success rate of 99%. In recent years, he has led the specialist team to actively participate in the Guangdong Red Cross Society’s “Heart Saving Action” and performed free surgery for more than 1,000 patients with congenital heart disease and rheumatic heart disease from poor families. In 2011, he was awarded the Zhuhai Model Worker and Zhuhai Moral Model Award, and in 2011, as the chief expert, he presided over the Guangdong Province “Heart Rescue Operation” and performed heart surgery for dozens of minority children, winning praise from many parties. In the first quarter of 2012, he was honored as one of the “Good People of Guangdong”. He was awarded the “Order of Fraternity” and the “Outstanding Contribution” award of the Heart Rescue Operation by the Red Cross Society of Guangdong Province. Prevalence and pathogenesis of ASD Before introducing this exciting and innovative procedure, Professor Xie Shaobo first introduced us to the prevalence and pathogenesis of congenital atrial septal defect (ASD) in China. “Congenital heart disease is the congenital malformation with the highest incidence, and its incidence reaches 6 to 8 per 1,000 in China, while atrial septal defect is one of the most common congenital heart diseases, accounting for roughly 15% of congenital heart diseases.” Regarding the pathogenesis of ASD, Professor Xie patiently explained, “The human heart has two atria, the left and the right, and they are separated by an atrial septum. The pressure in the left atrium and the right atrium are different, and the nature of the blood is also different, the left atrium is already oxygenated blood, and the right atrium is venous blood. Our whole body oxygen has been consumed blood back to the right atrium, then through the right ventricle, pulmonary artery oxygenation, and then back to the left atrium, left ventricle, and then supply the whole body, which is a complete cycle. Since the pressure of the left atrium and the right atrium are different and the nature of the blood is different, their blood should not be mixed. If the atrial septal defect causes the blood from the left and right atria to flow and the blood from the right atrium to perform pulmonary artery oxygenation, thus doing useless work. Moreover, the oxygen in the blood supplied to the whole body from the left atrium is also reduced (because of the mixing of venous blood from the right atrium), so that the atrial septal defect will cause an increased burden on the pulmonary circulation and a reduced supply of the body circulation, which will result in impaired development of the person, especially the heart itself will be a little weaker. The increased burden on the right atrium causes an increase in the volume of the pulmonary vascularz and a protective constriction of the pulmonary vasculature, resulting in pulmonary hypertension. The pressure in the pulmonary artery becomes higher and higher, and the pressure in the right atrium becomes higher and higher. Finally, if the pressure in the pulmonary circulation reaches a certain level, the blood pressure in the right atrium will be higher than the pressure in the left atrium, making no chance for blood oxygenation, and the patient will die quickly. That’s why larger atrial septal defects, if left untreated, patients usually die before the age of 30, so this disease must be treated to be treated.” So, what is the traditional treatment for ASD? Professor Xie said that the traditional treatment is open-heart surgery, which means that the pericardium is opened and extracorporeal circulation is established to allow the heart to be repaired in a quiet and bloodless state. This traditional method is very effective and applicable to various diseases, but its biggest drawback is that it is more traumatic. In addition, it requires drawing blood outside the body and using an artificial heart-lung machine to temporarily replace the functions of the heart and lungs, so that the atrial septal defect can be repaired in a quiet state and then the heart can beat again and the lungs can work again. Since the blood has to be exposed to something artificial during this extracorporeal circulation process, it needs to be anticoagulated and diluted. This approach has no restrictions on the size and location of the atrial septal defect, no restrictions on the age of the patient, and better results for septal repair. However, it is more traumatic, the destruction of blood cells after extracorporeal circulation is greater, the inflammatory reaction is more serious, many patients need blood transfusion, and the recovery time is longer. And because the open chest scar is larger, it also has a greater psychological impact on the patient. So surgeons are doing some minimally invasive surgeries, such as small incision, lateral open chest, and thoracoscopy-assisted ones. However, these minimally invasive surgeries are not convenient to operate, and the small incisions increase the difficulty of the surgery, in addition, they require a lot of training and equipment, and such a procedure is not conducive to promotion. In 1995, a surgeon invented a blocker to seal the atrial septal defect, and after its successful clinical application, atrial septal defect sealing has been developed more and more rapidly for 20 years. The blocker is used to seal the septal defect with a double-sided umbrella structure. The incision is small and the blocker is inserted through a catheter, but it requires large equipment – an x-ray machine. Both the surgeon and the patient are exposed to X-rays during this procedure, and while the surgeon can wear a lead suit for protection, the patient cannot. As a result, there are many reports of increased incidence of tumors in many children later in life, as well as effects on fertility in women of childbearing age. Moreover, this type of occlusion is complicated and takes a long time to perform. Since the blood vessels are thin in younger patients, this operation can be done only after the patient has thicker blood vessels at a certain age. Therefore, it was later felt that there are some restrictions on this surgery, such as children after 3 years of age can do this surgery, and patients with too large defects and patients with some deviations of the defect location cannot do this surgery, which makes the application of this surgery is greatly limited. Therefore, in the last decade, a transthoracic occlusion procedure has been developed, which is not age-restricted and does not require X-ray, but can be performed under ultrasound guidance, thus avoiding radiation damage. This procedure has improved a lot, but it still requires an incision in the chest, is still traumatic, and still leaves a 1-2 cm scar. The birth of a new technique “Is there a way to combine the two (without either a chest opening or X-ray exposure)?” Professor Xie mused, “This is what we have been trying to figure out. The advantage of transthoracic occlusion is that you can enter this atrial septal gap vertically, but we are going in diagonally, and we can’t solve atrial septal defects with larger gaps. The second problem is that transthoracic occlusion has an incision. Then we wondered if we could enter through puncture like transthoracic occlusion but solve all the problems without an incision? We basically have a more perfect solution now, which is to use an adjustable curved sheath.” Note: The newly designed “adjustable curved sheath” by Prof. Shaobo Xie’s team (can you send us a picture of this “adjustable curved sheath” as well?) ”Such a thin sheath is empty in the middle, and then the blocker is put in. We go through the jugular vein, which is very close to the heart, and it goes in in one go. Once inside, it is also oblique, but the curvature of the sheath can be adjusted so that the sheath is perpendicular to the plane of the atrial septum and in the middle of the septum, so that it just covers the defect.” Professor Xie was pleased to say that with the adjustable bend sheath, we solved many problems: first, no large radiological equipment was needed, and damage from irradiation was avoided. Second, the jugular vein in small children is significantly thicker than the femoral vein, so it can generally be done in children over 3 kg, so it is also applicable for younger patients. Third, it is not limited by the size and location of the atrial septal defect. It is also easier to operate for large defects because after the adjustable curved sheath enters the atrium vertically, the sheath tube can be adjusted to be located in the center of the septum and sealed well under ultrasound surveillance. So we have done nearly 20 cases now, and the patients have good results, and there is no incision, just a puncture of about 2mm, which will not leave any scar. Fourth, the operation is flexible and simple, the operation distance is short, the operation time is also short, and the safety is very good, and the success rate is high. In our fastest one, it only took more than 5 minutes in total from puncture to putting the blocker in place, and the core operation only took more than 2 minutes. Moreover, compared with open-heart surgery, this procedure does not bleed a drop. Fifth, the learning curve is very short and the surgeon does not necessarily need to be very experienced. Because this operation is very simple, anyone can do it as long as they have this adjustable bending sheath and learn a little. Sixth, it can be done in any general operating room as long as it is sterile, and if there is any problem that requires an open chest, it is very simple and can be done immediately. In addition, the cost of the procedure is low. Because there is no need for large irradiating instruments, irradiating agents, etc., the cost of the operation is greatly reduced, and currently a case of such an operation costs less than 30,000 RMB. In general, “ultrasound-guided atrial septal defect closure with adjustable curved sheath via right internal jugular vein” is a great breakthrough in terms of indications, and there are almost no restrictions on patient’s age, weight, size and location of atrial septal defect. This procedure perfectly solves the limitations of several existing methods and should be the best choice for the treatment of atrial septal defect. However, there has never been any international report on this “ultrasound-guided atrial septal defect closure via adjustable curved sheath of the right internal jugular vein”. The story behind this new procedure,” says Professor Xie, “is that we have been exploring it for a year. The “atrial septal defect closure with adjustable curved sheath through the right internal jugular vein” is the result of repeated research, simulation and operation, and many improvements before it is applied in practice, so it is more mature and faster to use, and the results achieved in clinical practice are also very good.” Professor Xie has now performed the procedure on more than 20 patients from Fujian, Guangxi, Northeast China and other regions. Professor Xie also shared with us the reaction of many patients’ families to the procedure, “Many patients’ parents can’t quite believe that the child has just entered the operating room, and then they go out to buy something and come back, and in less than half an hour, the child is already out of the surgery. Today into the hospital, tomorrow the child can be discharged.” The Future and Prospects There is no gold, and no one is perfect. Although the “ultrasound-guided atrial septal defect closure via the adjustable curved sheath of the right internal jugular vein” is undoubtedly the best choice for the treatment of ASD compared to the previous methods, the procedure is not only the best choice for the treatment of ASD, but also the best for the treatment of ASD. When asked whether this procedure needs further improvement, Prof. Xie gave a lot of advice: In the case of “ultrasound-guided atrial septal defect closure via the right internal jugular vein with adjustable curved sheath”, we need to continue to standardize and develop an operation specification in the process of operation. For patient selection, we are also currently doing a statistical study. For example, how thick the vessel is and how large the sheath can be, we need to have a precise positioning so that the operation is more convenient and safe. Currently, the “ultrasound-guided atrial septal defect closure with an adjustable curved sheath through the right internal jugular vein” is only used for atrial septal defects, but it may be used in other areas in the future. This technique and the adjustable curved sheath need to be improved for different diseases and should have different designs. As the pioneer of this “ultrasound-guided atrial septal defect occlusion with adjustable curved sheath via right internal jugular vein”, Prof. Shaobo Xie expressed his vision for this new technique: “Although this new technique is in the process of exploration, it has shown a very good prospect. We hope that it will be widely popularized and more patients will benefit from it!”