Correction to: Multimodality imaging in takotsubo syndrome: a joint consensus document of the European Association of Cardiovascular Imaging (EACVI) and the Japanese Society of Echocardiography (JSE)

In the original publication of the article, the first and the second authors' names should be changed as follows.

Effect of PM2.5 for hospitalization of cardiovascular diseases and medical expenses by age group: a nationwide study from the Japanese Registry Of All cardiac and vascular Diseases (JROAD)

Introduction

Although particulate matter with an aerodynamic diameter less than or equal to 2.5 μm (PM2.5) exposure influences cardiovascular events, there is limited knowledge how PM2.5 exposure is associated with cardiovascular hospitalization in Japan.

Purpose

We tested the hypothesis that PM2.5 exposure was related to the number of cardiovascular hospitalizations, hospitalization period, and medical expenses.

Methods

We included 835,405 subjects who were admitted to acute care hospitals in Japan. We classified PM2.5 exposure concentration into quintile groups (from low to high in the order of “PM-1” to “PM-5” group). Multilevel mixed-effects Poisson and linear regression analysis were used to estimate the association of PM2.5 exposure concentration with the cardiovascular hospitalization events, duration and medical expenses. We also analyzed those factors classified by age.

Results

PM-2, 3, 4, 5 group were positively related to the number of cardiovascular hospitalization events compared with PM-1 group (Table 1). PM-3, 4, 5 group were positively associated with a 0.018, 0.029, and 0.029 (all p<0.001) of the difference of log cardiovascular hospitalization period compared with PM-1 group (p for trend <0.001). These groups were also positively associated with a 0.016, 0.023, and 0.021 (all p<0.001) of the difference of log medical expenses compared with PM-1 group (p for trend <0.001). Analyzed by age group, hospitalization duration was longer (p<0.05) and medical expenses was lower (p<0.05) significantly in super-aging group (over 90 years old) than the group under 64 years old (Figure 1).

Conclusions

PM2.5 exposure concentration has harmful effect on not only cardiovascular events but cardiovascular hospitalization period and medical expenses due to big-data in Japan. Medical costs were kept low in comparison with their hospitalization period in subjects over 90 years old.

Figure 1

Funding Acknowledgement

Type of funding source: None

Prognostic relevance of exercise pulmonary hypertension for new-onset atrial fibrillation in primary mitral regurgitation

Background/Introduction

New-onset of atrial fibrillation (AF) portends poor prognosis in patients with primary mitral regurgitation (MR). However less is known about prognostic indicator for new-onset AF.

Purpose

The purpose of this study was to identify the prognostic relevance of exercise pulmonary hypertension for the new-onset AF in patients with primary MR.

Methods

Total of 114 consecutive patients with primary MR who underwent symptom-limited exercise echocardiography using supine-cycle ergometer were followed for new-onset AF over mean follow-up time of 3.6±2.6 years. Those with prevalent AF and pulmonary hypertension (estimated systolic pulmonary artery pressure ≥50mmHg) prior to exercise echocardiography were excluded from our analysis. We defined exercise-induced pulmonary hypertension (ExPHT) as those with peak estimated systolic pulmonary artery pressure (SPAP) ≥60mmHg or delta SPAP defined as differences between rest and peak SPAP ≥20mmHg.

Results

The mean age was 61±15 years old and 70 (61%) were male. Of those, 8 (7.8%) had mild MR, 32 (31.1%) had moderate MR, and 63 (61.2%) had severe MR. 60 (52.2%) patients had ExPHT. A total of 27 cases of new-onset AF were found during follow-up where the ExPHT group had higher prevalence of new-onset AF than the non-ExPHT group (35% vs. 11%, p=0.002). Those with ExPHT had significantly stronger association with shorter event-free survival time of new-onset AF (log-rank p<0.001, Figure). When adjusted for age, sex, body surface area, the American Society of Echocardiography MR grade, left atrial dimension, peak systolic blood pressure and heart rate, the multivariable Cox regression analysis showed that those with ExPHT had a hazard risk of 3.1 ([95% CI 1.1–9.1], p=0.039) for new-onset of AF.

Conclusions

Exercise-induced pulmonary hypertension predicted incident of new-onset AF in those with primary MR. Exercise echocardiography is expected to play an important role in decision making with regards to the optimal timing for surgical intervention in primary MR.

Figure 1

Funding Acknowledgement

Type of funding source: None

Short-term effects of low-dose tolvaptan in acute decompensated heart failure patients with severe aortic stenosis: the LOHAS registry

Background

Tolvaptan exerts potent diuretic effects in heart failure patients without hemodynamic instability. Nonetheless, its clinical efficacy for acute decompensated heart failure (ADHF) due to severe aortic stenosis (AS) remains unclear. This study aimed to evaluate the short-term effects of tolvaptan in ADHF patients with severe AS.

Methods

The LOw-Dose Tolvaptan (7.5 mg) in Decompensated Heart Failure Patients with Severe Aortic Stenosis (LOHAS) registry is a multicenter (7 centers) prospective registry that assessed the short-term effects of tolvaptan in subjects hospitalized for ADHF with severe AS. A total of 59 subjects were enrolled between September 2014 and December 2017. The primary endpoints were changes in body weight and fluid balance measured daily from baseline up to 4 days.

Results

The median [interquartile range] patient age and aortic valve area were 85.0 [81.0–89.0] years and 0.58 [0.42–0.74] cm2, respectively. Body weight continuously decreased, and fluid balance was maintained from baseline to day 4 (p<0.001, p=0.194, respectively). Median serum B-type natriuretic peptide concentration significantly decreased from 910.5 to 740.0 pg/mL by day 4 (p=0.002). However, systolic blood pressure and heart rate were non-significantly changed (p=0.250, p=0.656, respectively). Hypernatremia (>150 mEq/L) and worsening renal function occurred in 2 (3.4%) and 4 (6.8%) patients, respectively.

Conclusions

Short-term treatment with low-dose tolvaptan is safe and effective, providing stable hemodynamic parameters in patients with ADHF and severe AS.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): This research was supported by Otsuka Pharmaceutical Co., Ltd.

Comparison in Clinical Outcomes Between Leadless and Conventional Transvenous Pacemaker Following Transcatheter Aortic Valve Implantation

OBJECTIVES

Atrioventricular block is a common complication of transcatheter aortic valve implantation (TAVI). Although conventional transvenous dual-chamber (DDD) pacemaker (PM) is ideal for atrioventricular block, leadless PM, which is less invasive, may be suitable for frail TAVI patients. Little is known about clinical outcomes of this newer device following TAVI.

METHODS

A total of 330 consecutive patients undergoing TAVI were reviewed. Of these, PM cases without atrial fibrillation were studied. Indication for leadless PM was based on heart team discussion.

RESULTS

PM implantations were performed in 30 patients (9.1%), and 24 patients (7.3%) had no atrial fibrillation. These 24 patients had 14 DDD-PMs and 10 leadless PMs, and formed the two study groups. Baseline characteristics were similar except for ejection fraction: median ages were 83.0 years (IQR, 81.0-87.0 years) vs 86.5 years (IQR, 83.5-90.3) (P=.18); 11 (78.6%) vs 8 (80%) were women (P=.67); Society of Thoracic Surgeons scores were 5.1% (IQR, 3.8%-5.9%) vs 5.3% (IQR, 3.4%-8.5%) (P=.82); and ejection fractions were 68.0% (IQR, 66.0%-70.5%) vs 59.0% (IQR, 52.8%-69.3%) (P=.049), for the DDD-PM and leadless PM groups, respectively. There was 1 case of atrial lead dislodgment in the DDD-PM group; otherwise, no complications related to the implantation procedure were found. The leadless PM group showed numerically shorter hospital stay: 12.5 days (range, 9.0-17.8 day) in the DDD-PM group vs 10.5 days (range, 7.8-15.3 days) in the leadless PM group (P=.44). Six-month follow-up revealed no significant differences in incidence of heart failure rehospitalizations or deaths: 2 (14.3%) in the DDD-PM group vs 2 (25%) in the leadless PM group (P=.47); and 2 (14.3%) in the DDD-PM group vs 0 (0%) in the leadless PM group (P=.39), respectively.

CONCLUSIONS

Patients with leadless PM following TAVI may have shorter hospital stays, and clinical outcomes can be comparable with DDD-PMs. Leadless PMs may therefore be a reasonable option for frail TAVI patients.

New-Generation Transcatheter Aortic Valves in Patients With Small Aortic Annuli - Comparison of Balloon- and Self-Expandable Valves in Asian Patients

BACKGROUND

Asian patients have smaller aortic annuli. Although 20-mm balloon-expandable (BE) transcatheter heart valves (THV) are manufactured for transcatheter aortic valve implantation (TAVI) in these cases, the supra-annular design of self-expandable (SE) THV is considered more suitable; however, real-world comparative data are scarce.Methods and Results:Consecutive TAVI cases (n=330) in a single Japanese center were reviewed. Based on the cutoff for the new-generation 20-/23-mm BE-THV, a small aortic annulus was defined as <330 mm². A considerable number of patients had small annuli: 49/302 (16%). Of these, 33 BE-THV and 13 SE-THV using new-generation valves were compared. Although the SE-THV group had smaller annulus area (median 297 (interquartile range, 280-313) vs. 309 (303-323) mm²(P=0.022)), it had more favorable post-procedural parameters; for SE-THV and BE-THV, respectively, effective orifice area (EOA), 1.5 (1.3-1.6) vs. 1.1 cm²(0.9-1.3) (P=0.002); mean pressure gradient, 7.6 (5.6-11.0) vs. 14.2 mmHg (11.2-18.8) (P=0.001); and peak velocity, 1.8 (1.6-2.4) vs. 2.7 m/s (2.3-3.1) (P=0.001). Although new left bundle branch block was higher with SE-THV (24% and 62%, P=0.02), patient-prosthesis mismatch (PPM) ≥ moderate (indexed EOA <0.85 cm²/m²) was significantly less with SE-THV than with BE-THV (8% vs. 55%; P=0.04). Hemodynamic findings were consistent up to 1 year.

CONCLUSIONS

Small annuli are often seen in Asian patients, for whom SE-THV implantation results in favorable hemodynamics with less PPM.

Prognostic value of Mini Nutritional Assessment-Short Form with aortic valve stenosis following transcatheter aortic valve implantation

Aims

Older adults at risk for malnutrition are known to have a high mortality rate. This study aimed to investigate whether the Mini Nutritional Assessment—Short Form (MNA‐SF) could predict midterm mortality in patients undergoing transcatheter aortic valve implantation (TAVI).

Methods and results

We applied the MNA‐SF in 288 patients who had undergone TAVI from January 2016 to June 2019 at the St. Marianna University School of Medicine hospital. Using the MNA‐SF cut‐off value to indicate the risk of malnutrition, patients were divided into two groups, namely, those with an MNA‐SF score ≤11 (impaired MNA‐SF group) and those with an MNA‐SF score ≥12 (maintained MNA‐SF group). We used this value to investigate the association between the MNA‐SF and all‐cause mortality. Overall, 188 (65%) and 100 (35%) patients comprised the impaired MNA‐SF and maintained MNA‐SF groups, respectively, and 41 patients died after TAVI (mean follow‐up duration, 458 ± 315 days). Kaplan–Meier analyses showed that patients in the impaired MNA‐SF group had a significantly higher incidence of all‐cause mortality (hazard ratio 2.67; 95% confidence interval 1.29–6.21; P = 0.01). Multivariate Cox regression analyses showed that the MNA‐SF score was an independent predictor of all‐cause mortality after adjusting for the Society of Thoracic Surgeons risk score, Katz Index, and brain natriuretic peptide test results (hazard ratio 1.14; 95% confidence interval 1.01–1.28; P = 0.04).

Conclusions

The MNA‐SF was useful to screen for the risk of malnutrition in patients with TAVI and in predicting midterm prognoses in patients undergoing TAVI and could predict patient mortality after the procedure.

Multimodality imaging in takotsubo syndrome: a joint consensus document of the European Association of Cardiovascular Imaging (EACVI) and the Japanese Society of Echocardiography (JSE)

Takotsubo syndrome (TTS) is a complex and still poorly recognized heart disease with a wide spectrum of possible clinical presentations. Despite its reversibility, it is associated with serious adverse in-hospital events and high complication rates during follow-up. Multimodality imaging is helpful for establishing the diagnosis, guiding therapy, and stratifying prognosis of TTS patients in both the acute and post-acute phase. Echocardiography plays a key role, particularly in the acute care setting, allowing for the assessment of left ventricular (LV) systolic and diastolic function and the identification of the typical apical-midventricular ballooning pattern, as well as the circumferential pattern of wall motion abnormalities. It is also useful in the early detection of complications (i.e. LV outflow tract obstruction, mitral regurgitation, right ventricular involvement, LV thrombi, and pericardial effusion) and monitoring of systolic function recovery. Left ventriculography allows the evaluation of LV function and morphology, identifying the typical TTS patterns when echocardiography is not available or wall motion abnormalities cannot be properly assessed with ultrasound. Cardiac magnetic resonance provides a more comprehensive depiction of cardiac morphology and function and tissue characterization and offers additional value to other imaging modalities for differential diagnosis (myocardial infarction and myocarditis). Coronary computed tomography angiography has a substantial role in the diagnostic workup of patients with acute chest pain and a doubtful TTS diagnosis to rule out other medical conditions. It can be considered as a non-invasive appropriate alternative to coronary angiography in several clinical scenarios. Although the role of nuclear imaging in TTS has not yet been well established, the combination of perfusion and metabolic imaging may provide useful information on myocardial function in both the acute and post-acute phase.

"Avulsion Injury" of the Artery by a Suture-Mediated Closure System During Transcatheter Aortic Valve Implantation

We describe a cut-down method that is useful in cases with calcification restricted to the region surrounding the puncture site in transcatheter aortic valve implantation patients with severe aortic stenosis.

Calcified Nodule Protruding Into the Lumen Through Stent Struts: An In Vivo OCT Analysis

We observed a calcified nodule (CN) protruding into the coronary lumen through the stent struts of an in-stent restenosis (ISR) lesion in detail using optical coherent tomography (OCT). The patient was a 56-year-old Japanese male on regular hemodialysis for his end-stage renal disease who had multiple coronary risk factors. He previously underwent percutaneous coronary intervention (PCI) for the middle left anterior descending artery and a drug-eluting stent was implanted. OCT showed a CN in the culprit lesion. He underwent coronary angiography 9 months later, and an ISR lesion was observed. Re-PCI was done, and a drug-coated balloon was used. OCT showed a CN protruding into the coronary lumen through the stent struts in the ISR lesion. Although this phenomenon was previously reported in a pathological study, the observation of a CN protruding through stent struts by in vivo OCT has been rarely demonstrated previously. The present study provides support for the previous pathological report, and demonstrates a useful application of OCT imaging that can help in the treatment of ISR lesions.

Impact of Board-Certified Cardiologist Characteristics on Risk of In-Hospital Mortality

Background: This study examined the influence of board-certified cardiologist characteristics on the in-hospital mortality of patients with cardiovascular disease.

Methods and Results: Data were collected between 2012 and 2014 from a nationwide database of acute care hospitals in Japan. Overall, there were 1,422,703 patients, of whom 883,746 were analyzed. The primary outcome was all-cause in-hospital mortality. The association between board-certified cardiologist characteristics and in-hospital mortality was estimated using multilevel mixed-effect logistic regression modeling. Median age of cardiologists in a hospital was not related to in-hospital mortality (OR, 1.003; 95% CI: 0.998–1.008, P=0.316), but a greater cardiologist age range was associated with a lower risk of in-hospital mortality (OR, 0.992; 95% CI: 0.988–0.995 per 1-unit increment in age range, P<0.001). Meanwhile, the average years of experience of the board-certified cardiologists in a hospital was not associated with a lower risk of in-hospital mortality (OR, 1.002; 95% CI: 0.996–1.007, P=0.525), but a greater range of years of experience was (OR, 0.986; 95% CI: 0.983–0.990 per 1-unit increment in range of years of experience, P<0.001).

Conclusions: Median board-certified cardiologist age/experience at an institution is not related to in-hospital mortality, but a greater range in age/experience is associated with a lower risk of mortality.

Association between the number of board-certified cardiologists and the risk of in-hospital mortality: a nationwide study involving the Japanese registry of all cardiac and vascular diseases

OBJECTIVES

Although there are 14 097 board-certified cardiologists in Japan, it is unknown whether the number of institutional board-certified cardiologists is related to the prognosis of cardiovascular disease patients.

DESIGN

Cross-sectional analysis.

SETTING

Data were collected from the nationwide database of acute care hospitals in Japan (2371 hospitals) between 2012 and 2013.

PARTICIPANTS

A total of 1 422 703 consecutive patients were initially included in this study, but 518 610 patients were excluded due to age <18 years, missing data or prior hospitalisations; therefore, 896 171 patients comprised the final sample population.

MAIN OUTCOME MEASURES

The primary outcome was in-hospital mortality due to any cause. For the per-hospital analysis, Poisson regression models were used to estimate the association of board-certified cardiologists with in-hospital mortality, adjusted for hospital facilitation. For the per-patient analysis, hierarchical logistic regression models were used to estimate the ORs of the number of institutional board-certified cardiologists, adjusted for patient demographics, diagnoses, therapies and hospital facilities.

RESULTS

The regression model of the per-hospital analysis indicated that the number of board-certified cardiologists was associated with a lower rate ratio of in-hospital mortality (rate ratio, 0.988; 95% CI 0.983 to 0.993; p<0.01). The per-patient analysis indicated that the median age was 73 years and the in-hospital mortality rate was 11.7%. The regression model indicated that the presence of more board-certified cardiologists was associated with a lower risk of in-hospital mortality (OR, 0.980; 95% CI 0.975 to 0.986; p<0.01) after adjustments for hospital facilities, patient characteristics and treatments.

CONCLUSIONS

Among cardiovascular disease patients admitted to acute care hospitals in Japan, the presence of more board-certified cardiologists was associated with a lower risk of in-hospital mortality. These results have implications for national and institutional strategies for determining the required number of board-certified cardiologists.

P304Prognostic significance of transvalvular flow rate during exercise in asymptomatic patients with aortic stenosis

Background

The optimal management of asymptomatic aortic stenosis (AS) remains controversial. The aim of this study is to investigate the prognostic value of exercise stress echocardiography (ESE) in asymptomatic patients with AS.

Purpose

To investigate the additive value of ESE in asymptomatic patients with AS.

Methods and results

We retrospectively enrolled 109 consecutive patients (mean age 73±13 years, 55 men) with AS (aortic valve area ≤1.5cm2) who underwent ESE. Of these, 10 patients referred for aortic valve replacement without symptoms were excluded; finally, 99 conservatively managed patients were enrolled. During the mean follow-up period of 14±11 months, 23 patients (23%) suffered from AS related events. Although no differences in mean pressure gradient at rest and during exercise were found between the patients with and without adverse events, transvalvular flow rate during exercise (Ex-FR) was lower in patients with adverse events than those without adverse events (236±55 ml/sec vs 274±64 ml/sec, P=0.01). Using multivariate Cox regression analysis, low Ex-FR (<270 ml/sec) was an independent predictor for adverse events in patients with asymptomatic AS (hazard ratio: 3.53, P<0.01). The Kaplan–Meier analysis showed that Ex-FR was clearly stratified the event-free survival (Figure, log-rank P<0.01).

K-M curve according to Ex-FR

Conclusion

These results suggested that Ex-FR measured by ESE should play crucial roles in risk stratification in asymptomatic patients with AS.

P1493Prognostic significance of right ventricular function during exercise in patients with non-obstructive hypertrophic cardiomyopathy

Background

Hypertrophic cardiomyopathy (HCM) is a heterogeneous condition that may present crucial complication including life-threatening arrhythmia and sudden cardiac death. However, the risk stratification of HCM without left ventricular outflow tract (LVOT) obstruction had not been fully elucidated. Moreover, although recent studies have revealed the right ventricle (RV) involvement of HCM, the prognostic importance of RV function during exercise is unclear.

Purpose

To investigate the prognostic significance of RV function in patients with non-obstructive HCM using exercise stress echocardiography (ESE).

Methods and results

This study conducted on 100 HCM patients (age 62.9±13.6 years, 63% men) with preserved left ventricular ejection fraction who underwent ESE using semi-supine bicycle ergometer. Ten patients with significant LVOT obstruction (≥30mmHg) were excluded and 9 were also excluded because of the inadequate imaging quality or insufficiency of data. Among remaining 81 non-obstructive HCM patients, 9 patients suffered from HCM related cardiac events including cardiac death, unexpected hospitalization, life-threatening arrhythmias, and new-onset of syncope during the mean follow up period of 2.6±1.6 years. A multivariate Cox Hazard analysis revealed that low tricuspid annular plane systolic excursion during exercise (Ex-TAPSE, cut-off: 24mm) was an independent predictor of cardiac events. (hazard ratio: 18.66, 95% confidence interval: 3.66–338.46, P<0.001) The estimated cumulative cardiac event free survival using the Kaplan-Meier method was significantly lower in patients with reduced Ex-TAPSE (<24mm) than those with preserved Ex-TAPSE (Log-rank, P<0.01).

K-M curve according to Ex-TAPSE

Conclusion

Ex-TAPSE had a strong predictive value of clinical outcomes in non-obstructive HCM patients. Right ventricular function during exercise may have crucial role in the risk stratification of non-obstructive HCM.

Novel Device-Based Algorithm Provides Optimal Hemodynamics During Exercise in Patients With Cardiac Resynchronization Therapy

BACKGROUND

An adaptive cardiac resynchronization therapy (aCRT) algorithm has been described for synchronized left ventricular (LV) pacing and continuous optimization of cardiac resynchronization therapy (CRT). However, there are few algorithmic data on the effect of changes during exercise.Methods and Results:We enrolled 27 patients with availability of the aCRT algorithm. Eligible patients were manually programmed to optimal atrioventricular (AV) and interventricular (VV) delays by using echocardiograms at rest or during 2 stages of supine bicycle exercise. We compared the maximum cardiac output between manual echo-optimization and aCRT-on during each phase. After initiating exercise, the optimal AV delay progressively shortened (P<0.05) with incremental exercise levels. The manual-optimized settings and aCRT resulted in similar cardiac performance, as demonstrated by a high concordance correlation coefficient between the LV outflow tract velocity time integral (LVOT-VTI) during each exercise stage (Ex.1: r=0.94 P<0.0008, Ex.2: r=0.88 P<0.001, respectively). Synchronized LV-only pacing in patients with normal AV conduction could provide a higher LVOT-VTI as compared with manual-optimized conventional biventricular pacing at peak exercise (P<0.05).

CONCLUSIONS

The aCRT algorithm was physiologically sound during exercise by patients.

Cardiogenic shock following balloon post-dilatation in transcatheter aortic valve implantation: first case report of all three stuck leaflets

Background

A stuck leaflet and frozen cusp are reported complications following transcatheter aortic valve implantation (TAVI). These complications are rare but can drastically change haemodynamics and be potentially life-threatening; thus, their awareness during TAVI is indispensable. Leaflet malfunction generally presents in one of the three leaflets of a prosthetic valve; however, we encountered a case where all three leaflets were simultaneously stuck.

Case Summary

A 94-year-old woman was referred to our cardiology department with severe aortic stenosis. She underwent transfemoral TAVI. After a 20 mm balloon was inflated, a 23 mm Sapien 3 valve was deployed. Since the delivery balloon slipped into the ventricle, the valve top was not fully expanded. Post-dilatation using a 23 mm balloon was performed, which led to cardiogenic shock. Immediate cardiopulmonary resuscitation and venoarterial extracorporeal membrane oxygenation were provided. Since aortography and haemodynamics indicated severe aortic regurgitation and transoesophageal echocardiography depicted no leaflets inside the Sapien 3, we confirmed that all leaflets were stuck. The valve-in-valve procedure using the second 23 mm valve was successfully performed, and her haemodynamics dramatically improved. The patient was discharged 20 days later.

Discussion

Only a handful of cases have been reported on a stuck leaflet following post-dilatation. Root rupture is a major concern of the abrupt change after post-dilatation, but a stuck leaflet should also be considered even when the new-generation balloon-expandable valve, Sapien 3, is used. Here we report the first case in which all three leaflets were stuck.

Endothelialization of an Amplatzer Septal Occluder Device 6 Months Post Implantation: Is This Enough Time? An In Vivo Angioscopic Assessment

The current guidelines recommend a minimum of 6 months of antithrombotic and antibiotic prophylaxis following septal occluding device placement for transcatheter closure of atrial septal defect. Full neoendothelialization is thought to be completed within 6 months of device implantation; however, there is no method available that can assess the level of neoendothelialization in vivo. This report therefore evaluates endothelialization in vivo and demonstrates that 6 months of postimplantation prophylactic therapy may not provide sufficient time for adequate endothelialization. Further investigations are warranted to determine the optimal duration of these treatments after atrial septal defect closure.