Prevalence of deficient retro-aortic rim and its effects on outcomes in device closure of atrial septal defects

Sufficient versus deficient rims during percutaneous closure of ostium secundum type atrial septal defect: A systematic review and meta-analysis

BACKGROUND

The aim of this meta-analysis was to compare the efficacy and adverse events of percutaneous occlusion among patients with sufficient and deficient rims.

METHODS

A systematic review of all articles published in the Pubmed, MEDLINE and Google Scholar databases was performed. Odds ratio (OR) and 95% CI were used as a measure of effect of the combination of studies. I² with 95% CI was estimated to assess study heterogeneity. For the meta-analysis, a random effects model was used.

RESULTS

The systematic search identified ten studies which included 4355 patients; 2661 of those had sufficient rim and the remaining 1694 patients showed some rim deficiency. Implant failure rate was 4.13% CI 95% 3.53-4.72%. Compared to frequency of failures in the group with a deficient rim (5.43% CI 95% 4.35-6.50%), implant failure in patients with a sufficient rim was significantly lower (3.30% CI 95% 2.62-3.97%), OR 2.27 CI 1.34-3.83 (p 0.002). The combined adverse events were 5.19% CI 95% 4.22-6.35% vs 2.7% CI 95% 2.08-3.31% in the deficient vs sufficient rim groups respectively (OR 2.21 CI 0.93-5.29; p 0.07). Implant failures and adverse events were more frequent in patients with posterior inferior rim deficiency.

CONCLUSION

Patients presenting a posteroinferior rim deficiency are associated to both, an increased incidence of closure failure and a combined adverse events occurrence. More studies on posterior rim deficiency are necessary to ensure the feasibility and safety of the percutaneous approach.

Feasibility of transcatheter closure for absent aortic rim in patients with atrial septal defect

OBJECTIVES

This study aimed to assess the feasibility of transcatheter atrial septal defect (ASD) closure in patients with absent aortic rim.

BACKGROUND

The indication of transcatheter closure for ASD with absent aortic rim is controversial.

METHODS

We enrolled 547 patients with ASD who were scheduled for transcatheter closure. Morphologies of aortic rim were evaluated using transesophageal echocardiography (TEE).

RESULTS

Aortic rim of <5 mm was observed in 396 (72%) patients; 128 (23%) had absent aortic rim of 0 mm, and 268 (49%) had deficient aortic rim of >0 to <5 mm. Patients with absent aortic rim frequently had aortic rim absence at an angle of 0° on TEE and septal malalignment. Of the 128 patients with absent aortic rim, 126 (98%) successfully underwent transcatheter closure, while 2 (2%) failed transcatheter closure due to a large defect with severe septal malalignment. The success rate of transcatheter closure was similar between patients with absent aortic rim and those with deficient aortic rim (98% vs. 99%, p = .45). After the procedure, no patients had erosion or device embolization during a median follow-up of 24 months.

CONCLUSIONS

Transcatheter closure was successfully performed without adverse events in patients with absent aortic rim, as well as in those with deficient aortic rim. Our findings can be valuable to determine the indication of transcatheter closure in patients with ASD.

A novel three-dimensional echocardiographic method for device size selection in patients undergoing ASD trans-catheter closure

Background

Proper device size selection is a crucial step for successful ASD device closure. The current gold standard for device size selection is balloon sizing. Balloon sizing can be tedious, time consuming and increase fluoroscopy and procedure times as well as risk of complications. We aimed to establish a simple and accurate method for device size selection using three-dimensional echocardiographic interrogation of the ASD.This is a prospective observational study conducted over a period of 12 months. All patients underwent 2D TTE, three-dimensional echocardiographic assessment of the IAS and transesophageal echocardiogram. Comparison between echocardiographic variables was done using independent sample t test. Linear correlation was established between three dimensional echocardiographic variables and respective variables of device size and 2D TTE and TEE measurements.

Results

The study included 50 patients who underwent successful ASD device closure with properly sized device. There was no significant difference between 3D ASD maximum diameter and all diameters measured by TTE and TEE. There was a strong positive correlation between device size used for closure and both 3D measured ASD area (r = 0.907, P<0.0001) and 3D measured ASD circumference (r = 0.917, P<0.0001). Two regression equations were generated to determine proper device size where Device size = 10.8 + [3.95 x 3D ASD area] and Device size = [3.85 x 3D ASD circumference] -1.02

Conclusion

Three-dimensional echocardiogram can provide a simple and accurate method for device size selection in patients undergoing ASD device closure using either 3D derived ASD area or ASD circumference

Atrial Septal Defect Size and Rims on Transesophageal Echocardiogram

Background and aims:Rims and size of atrial septal defect (ASD) are crucial for the success of transcatheter ASD closure. The maximal diameter and dimensions of various rims of the ASD are essential for sizing and optimal placement of the device. We aimed to study the size and rims of ASD in our patients. Methods:This was a prospective study that was done at Shahid Gangalal National Heart Centre. All patients aged over 18 and referred to a unit IV in the Department of Cardiology for ASD device closure were included in the study. The study duration was six months, from April to September 2018. The size and rims of ASD were evaluated by transesophageal echocardiogram. Results:During the study, 173 patients underwent transesophageal echocardiogram. Most of them [122 (70.1%)] were women. Age ranged from 18 to 68 (mean, 35 years). The most common symptom was shortness of breath. Twenty-one (12.1%) patients were incidentally detected with ASDs. Sinus rhythm with right bundle branch block was present in 148 (85.5%) subjects. Right atrium and right ventricle were dilated in 162 (93.6%) patients. One patient had dextrocardia with situs inversus. More than half of all patients (54.9%) had mild tricuspid regurgitation. Mean tricuspid regurgitation pressure gradient was 39.5±16.8 mm Hg. More than one ASD was present in 11 (6.3%) patients. ASD size ranged from 2 mm to 43 mm in 4-chamber view, 2 mm to 44 mm in short axis view, and 2 mm to 47 mm in bicaval view. The mean ASD size was 18.6±7.7 mm in 4-chamber view, 19.6±8.5 mm in short axis view, and 18.7±8.0 mm in bicaval view. In only 11 (6.4%) patients, all rims were present and not floppy, while in other 11 (6.4%) subjects all rims were present, but floppy. With the exception of aortic rim, all other rims were present and good in 55 (33.9%) patients, while in 45 (27.7%) patients, other rims were present but floppy. Conclusion:Many ASD have absent, inadequate and floppy rims.

Should transcatheter closure of atrial septal defects with inferior-posterior deficient rim still be attempted?

Background

Transcatheter closure for atrial septal defect (ASD) with inferior-posterior rim deficiency has been scarcely reported with proper identification of the indications and limits. We aimed to assess the safety and feasibility of transcatheter closure of ASDs with deficient rims, paying particular attention to cases with inferior-posterior rim deficiency.

Methods

From January 2008 to January 2013, 241 patients underwent transcatheter ASD closure, including 50 cases (20.7%) with deficient rims, other than the anterior-superior one. Eighteen patients (12 females) presented inferior-posterior rim deficiency. Their median age was 8 (1.4-85) years and their median weight was 24 [9-97] kg. Transcatheter closure was performed in all cases under transesophageal echocardiography (TEE) guidance in children and intracardiac echocardiography (ICE) guidance in adults.

Results

Out of 18 patients with inferior-posterior rim deficiency, only 8 underwent successful immediate transcatheter closure. Four cases failed to be closed. Major complications occurred in 6 patients, including 4 device embolizations, 1 pericardial effusion and 1 complete atrioventricular block that resolved after surgical removal of the device. During a median follow up of 54±13 months, a residual right-to-left shunt was documented in 2 more cases, requiring surgery in one case because of cyanosis. Transcatheter closure was successfully performed in the rest of the 223 patients, including in the 32 cases with deficient rims other than inferior-posterior.

Conclusions

Transcatheter closure of ASDs with inferior-posterior rim deficiency cannot be recommended.

State-of-the-Art Atrial Septal Defect Closure Devices for Congenital Heart

This article describes current devices and indications for transcatheter device closure of atrial septal defect (TC-ASD) and patent foramen ovale in children and young adults. TC-ASD has a proven record of efficacy and safety, but device erosion raises questions about the relative safety of TC-ASD versus operative open heart surgical ASD closure. New devices for ASD closure with properties to reduce risk of erosion are being developed. Recent studies demonstrating superiority of patent foramen ovale device closure over medical therapy for cryptogenic stroke may lead to changes in practice for structural/interventional cardiologists. Care should be taken in extrapolating data to children and younger adults.

Closure of Secundum Atrial Septal Defects With the AMPLATZER Septal Occluder: A Prospective, Multicenter, Post-Approval Study

Background—

Prospective data on the medium-term safety and effectiveness of the AMPLATZER Septal Occluder in clinical practice are not available. The objective of this study was to prospectively evaluate the risk of hemodynamic compromise and obtain medium-term survival data on patients implanted with the AMPLATZER Septal Occluder for percutaneous closure of secundum atrial septal defects.

Methods and Results—

Subjects were enrolled prospectively at 50 US sites and followed for 2 years. Between 2008 and 2012, atrial septal defect closure with the AMPLATZER Septal Occluder was attempted in 1000 patients (aged 0.3–83.6 years, mean 21±22 years). Procedural closure occurred in 97.9%, with 1-month and 2-year closure 98.5% and 97.9%, respectively. Hemodynamic compromise occurred in 6 subjects (0.65%), because of dysrhythmia in 2, device embolization in 1, and cardiac erosion in 3. The rate of cardiac erosion was 0.3% (average 83, range 12–171 days from implant).

Conclusions—

Closure of atrial septal defect with the AMPLATZER Septal Occluder is safe and effective. The rate of hemodynamic compromise and cardiac erosion is rare. The risk factors for cardiac erosion after device closure are not yet clear.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00650936.

Transcatheter device closure of atrial septal defects: more to think about than just closing the hole

PURPOSE OF REVIEW

To review current controversies in the transcatheter device closure of ostium secundum atrial septal defects (ASD).

RECENT FINDINGS

Transcatheter device closure of ASD (TC-ASD) has well established efficacy and safety. For most individual patients with suitable anatomy, TC-ASD is the preferred method for treating ASD. The availability of large multicenter data sets has made it possible to study practice patterns at a range of hospitals across the United States. These studies have revealed differences in practice that were not previously appreciated. Interpretation of the indications for TC-ASD, specifically the definition of right ventricular volume overload varies between hospitals. In response to concern about device erosion, an increasing proportion of patients are being referred for operative ASD closure. Over the last decade, the average age at which ASD closure occurs has decreased. These trends demonstrate previously underappreciated differences in opinion between cardiologists across the country and suggest that further research is necessary to address knowledge gaps limiting consistency of practice.

SUMMARY

As TC-ASD and congenital interventional cardiology mature as a field, studies of real-world practice provide increasingly valuable information about aspects of care in which there are disagreements about best practices and in which further research is necessary.

Increasing propensity to pursue operative closure of atrial septal defects following changes in the instructions for use of the Amplatzer Septal Occluder device: An observational study using data from the Pediatric Health Information Systems database

Concern for device erosion following transcatheter treatment of atrial septal defects (TC-ASD) led in 2012 to a United States Food and Drug Administration panel review and changes in the instructions for use of the Amplatzer Septal Occluder (ASO) device. No studies have assessed the effect of these changes on real-world practice. To this end a multicenter observational study was performed to evaluate trends in the treatment of ASD.

METHODS

A retrospective observational study was performed using data from the Pediatric Health Information Systems database of all patients with isolated ASD undergoing either TC-ASD or operative ASD closure (O-ASD) from January 1, 2007, to September 30, 2015, hypothesizing that the propensity to pursue O-ASD increased beginning in 2013.

RESULTS

A total of 6,392 cases from 39 centers underwent ASD closure (82% TC-ASD). Adjusting for patient factors, between 2007 and 2012, the probability of pursuing O-ASD decreased (odds ratio [OR] 0.95 per year, P = .03). This trend reversed beginning in 2013, with the probability of O-ASD increasing annually (OR 1.21, P = .006). There was significant between-hospital variation in the choice between TC-ASD and O-ASD (median OR 2.79, P < .0001). The age of patients undergoing ASD closure (regardless of method) decreased over the study period (P = .04). Cost of O-ASD increased over the study period, whereas cost of TC-ASD and length of stay for both O-ASD and TC-ASD was unchanged.

CONCLUSIONS

Although TC-ASD remains the predominant method of ASD closure, the propensity to pursue O-ASD has increased significantly following changes in instructions for use for ASO. Further research is necessary to determine what effect this has on outcomes and resource utilization.

Infective endocarditis after device closure of atrial septal defects: Case report and review of the literature

We report a case of late infective endocarditis in an 8-year-old boy 3 years after transcatheter closure of an atrial septal defect with the Amplatzer Atrial Septal Occluder Device. Echocardiography showed a very thick pannus lining the left atrial disc of the prosthesis, with some mobile elements. MRI showed several cerebral microemboli. The patient had dental caries and blood cultures found Staphylococcus aureus. Patient was treated with gentamicin and oxacillin before surgical removal of the prosthesis. Twenty-one cases of infective endocarditis after atrial defect device closure have been reported in the literature (13 ostium secundum ASD and 8 patent foramen ovale). Seven pediatric cases were reported. S. aureus was the most frequent bacterium. Antibiotics were administered in all cases and most patients (n = 18) underwent surgical removal of the device. Incomplete endothelialization of the prosthesis was a suggested mechanism. Two patients died after surgery. © 2016 Wiley Periodicals, Inc.

The influence of deficient retro-aortic rim on technical success and early adverse events following device closure of secundum atrial septal defects: An Analysis of the IMPACT Registry®

BACKGROUND

Concern regarding aortic erosion has focused attention on the retro-aortic rim in patients undergoing device closure of atrial septal defects (ASD), but its effect on early outcomes is not well studied.

METHODS

A multicenter retrospective cohort study of patients undergoing device occlusion of ASD between 1/2011-10/2014 was performed, using data from the IMproving Pediatric and Adult Congenital Treatment Registry. Subjects were divided between those with retro-aortic rim <5 and ≥5 mm. Primary outcomes were technical failure and major early adverse events. Case times were measured as surrogates of technical complexity. The effect of deficient retro-aortic rim on primary outcomes was assessed using hierarchical logistic regression, adjusting for other suspected covariates and assessing whether they represent independent risk factors RESULTS: 1,564 subjects (from 77 centers) were included, with deficient retro-aortic rim present in 40%. Technical failure occurred in 91 subjects (5.8%) and a major early adverse event in 64 subjects (4.1%). Adjusting for known covariates, the presence of a deficient retro-aortic rim was not significantly associated with technical failure (OR: 1.3, 95% CI: 0.9-2.1) or major early adverse event (OR: 0.7, 95% CI: 0.4-1. 2). Total case (P = 0.01) and fluoroscopy time (P = 0.02) were greater in subjects with deficient rim, but sheath time was not significantly different (P = 0.07). Additional covariates independently associated with these outcomes were identified.

CONCLUSION

Deficient retro-aortic rim was highly prevalent but not associated with increased risk of technical failure or early adverse events. Studies with longer follow-up are necessary to assess other outcomes, including device erosion. © 2016 Wiley Periodicals, Inc.

Cost comparison of transcatheter and operative closures of ostium secundum atrial septal defects

BACKGROUND

Clinical outcomes for transcatheter and operative closures of atrial septal defects (ASDs) are similar. Economic cost for each method has not been well described.

METHODS

A single-center retrospective cohort study of children and adults<30 years of age undergoing closure for single secundum ASD from January 1, 2007, to April 1, 2012, was performed to measure differences in inflation-adjusted cost of operative and transcatheter closures of ASD. A propensity score weight-adjusted multivariate regression model was used in an intention-to-treat analysis. Costs for reintervention and crossover admissions were included in primary analysis.

RESULTS

A total of 244 subjects were included in the study (64% transcatheter and 36% operative), of which 2% (n = 5) were ≥18 years. Crossover rate from transcatheter to operative group was 3%. Risk of reintervention (P = .66) and 30-day mortality (P = .37) were not significantly different. In a multivariate model, adjusted cost of operative closure was 2012 US $60,992 versus 2012 US $55,841 for transcatheter closure (P < .001). Components of total cost favoring transcatheter closure were length of stay, medications, and follow-up radiologic and laboratory testing, overcoming higher costs of procedure and echocardiography. Professional costs did not differ. The rate of 30-day readmission was greater in the operative cohort, further increasing the cost advantage of transcatheter closure. Sensitivity analyses demonstrated that costs of follow-up visits influenced relative cost but that device closure remained favorable over a broad range of crossover and reintervention rates.

CONCLUSION

For single secundum ASD, cost comparison analysis favors transcatheter closure over the short term. The cost of follow-up regimens influences the cost advantage of transcatheter closure.

Accuracy of Transthoracic Echocardiography in Assessing Retro-aortic Rim prior to Device Closure of Atrial Septal Defects

OBJECTIVE

Deficient retro-aortic rim has been identified as a risk factor for device erosion following trans-catheter closure of atrial septal defects (ASDs). Transthoracic echocardiography (TTE) is the primary screening method for subjects for possible device closure of ASD, but its reliability in measuring retro-aortic rim size has not been assessed previously.

DESIGN

A single-institution cross-sectional analysis of children and adults referred for trans-catheter device closure of single ostium secundum ASD from January 1, 2005 to April 1, 2012 with reviewable TTE and trans-esophageal echocardiogram images was performed. Inter-rater reliability of measurements was tested in a 24% sample. Accuracy of TTE measurement of retro-aortic rim was assessed using a Bland-Altman plot with trans-esophageal echocardiogram measurement as the gold standard. Test characteristics of TTE detection of deficient retro-aortic rim were calculated. Risk factors for misclassification of deficient retro-aortic rim were assessed using receiver operator characteristic curves. Risk factors for measurement error were assessed through multivariate linear regression.

RESULTS

In total, 163 subjects of median age 5 years (range: 0.3-46 years) were included. Trans-thoracic echocardiography had 90% sensitivity, 84% specificity, 90% positive predictive value, and 83% negative predictive value to detect deficient retro-aortic rim. Bland-Altman plot demonstrated no fixed bias (P = .23), but errors in measurement increased on average as the aortic rim increased in size (P < .001). Prespecified patient level risk factors did not affect receiver operator characteristic curve area under the curve, nor were any patient-level risk factors independently associated with increased measurement error on TTE.

CONCLUSIONS

TTE is a sensitive and specific screening test for deficient retro-aortic rim across a range of patient ages and sizes.