Surgical validation and implications for transcatheter closure of quantitative echocardiographic evaluation of atrial septal defect

Long-term prognosis of elderly patients undergoing atrial septal defect closure: Are we acting too late?

BACKGROUND

Atrial septal defects (ASD) often go unrecognized until very late in life. The impact of ASD closure on life expectancy in elderly patients remains unclear. This study compares the survival of patients≥65-years who underwent ASD closure with their average life expectancy (ALE).

METHODS

Single-centre retrospective study including all patients ≥65-years who underwent ostium secundum (OS) ASD closure (surgical/percutaneous) between 1998-2020. Baseline characteristics and the predicted peri-procedural ALE (as determined per pre-defined national ALE tables) for every given patient were assessed.

RESULTS

706 patients underwent OS ASD closure, 37 (5%) had ≥65 years-mean age 69±5 years, 62% presented with heart failure. Mean ASD size=21±9mm, 22% patients had severe tricuspid regurgitation, mean systolic pulmonary artery pressure (SPAP)=50±11mmHg. Five patients were treated surgically. At a mean follow-up of 9±5 years, mortality rate was 46%, occurring 8.8±5.3 years after the procedure. 25 (68%) outlived their predicted ALE. Overall, the mean age of death did not differ from the predicted ALE (79±6 vs. 84±1 years, p=0.304), however there was a 10-year absolute difference between patients who died prematurely vs. those who surpassed ALE (77±4 vs. 87±3 years, p<0.001). Patients who failed to reach ALE had higher SPAP (58±10 vs. 46±8mmHg, p=0.001) and a higher incidence of severe tricuspid regurgitation (42 vs. 12%, p=0.040).

CONCLUSION

Survival after late ASD closure was comparable to the expected ALE, though one-third of the patients died prematurely. Higher SPAP and severe tricuspid regurgitation were associated with premature death. ASD closure in elderly requires a thorough evaluation to ensure maximum benefit.

Feasibility of Transcatheter Closure of Secundum Atrial Septal Defect in Low Weight Infants Under 2-Year-Old from a 3-year Retrospective Cohort Study

We aimed to evaluate the feasibility of interventional treatment of atrial septal defect (ASD) in low weight infants under 2-year-old. Seven hundred and ninety-three secundum ASD patients were divided into 2 groups: 665 were above 2-year-old and 128 were under 2-year-old. The basic conditions before the operation, postoperative complications within 24 hours, and adverse outcomes during a three-year follow-up were compared between the 2 groups using multivariate analysis. There were significant differences in age, weight, and the diameter of the ASD between the 2 groups (p <0.001). The immediate success rate of the procedure was 96.7%. There were no significant differences in the success rate of the procedure, the incidence of residual shunt, arrhythmia, procedure-related arrhythmia, and occluder shedding between 2 groups (p >0.05). Similarly, we found no association between age ≤2-year-old and any adverse outcomes postprocedure within 24 hours, including procedure failure (OR = 0.35; 95%CI: 0.04 to 2.93), residual shunt (OR = 1.07; 95%CI: 0.54 to 2.14), arrhythmia (OR = 0.68; 95%CI: 0.32 to 1.43), or procedure-related arrhythmia (OR = 0.34; 95%CI: 0.04 to 2.87). In the follow-up data, we found no association between age ≤2-year-old and arrhythmia (HR = 0.95; 95%CI: 0.50 to 1.80) and procedure-related arrhythmia (HR = 0.96;95%CI:0.25 to 3.64). Kaplan-Meier survival curves indicated no significant difference in the occurrence of arrhythmia between the 2 groups (log-rank test: p = 0.776). In conclusion, percutaneous ASD closure in young and low weight infants has a high success and low complication rate, along with reliable effects.

Feasibility, Safety and Long-Term Follow-Up of Transcatheter Closure of Secundum Atrial Septal Defects with Deficient Rims

Objective: The aim of this work was to evaluate the feasibility and safety of transcatheter closure procedures for the treatment of atrial septal defects (ASDs) with insufficient rims. Methods: A total of 507 secondary ASDs were divided into two groups based on whether they had deficient rims or not (152 vs. 355 cases, respectively). Any complications, including residual shunt, heart arrhythmia, occluder translocation, etc., were followed up for 1-3 years. Results: There were no differences in gender, weight, exposure time, ECG states, pulmonary pressure, the intervention success rate, occurrence of residual shunt, the operation time and occurrence of residual shunt during follow-up between the two groups (p > 0.05). However, the occurrence of rhythm disorders was significantly different between the two groups; ASDs with deficient rims were at an elevated risk (p < 0.05). Specifically, there was a significantly higher incidence in the occurrence of arrhythmia in the deficient rims group at 24 h postoperation, but no differences in arrhythmia incidence at any of the other follow-up time points (1, 3, 6, 12 and 36 months; p > 0.05). Conclusions: Patients with deficient rims experience a high success rate of ASD intervention and low rate of complications when the procedures are performed by experienced operators.

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.

Characterization of atrial septal defect by simultaneous multiplane two-dimensional echocardiography

AIMS

The aim of this study was to assess the value of two-dimensional (2D) transthoracic simultaneous multiplane imaging (SMPI) in the evaluation of suitability for percutaneous atrial septal secundum defect (ASD) closure compared with the golden standard 2D transoesophageal echocardiography (TEE).

METHODS AND RESULTS

Twenty-nine patients with an ASD underwent both SMPI and TEE. Ten patients (34%) were male (age 41 ± 18 years, range 20-74). SMPI assessment of ASD size and rims included xPlane and I-rotate modes. Rims were defined as suitable for ASD percutaneous closure using a cut-off value of 5 mm. There were no significant differences between SMPI in xPlane mode and TEE regarding the sizes of the anterior-posterior dimension (13.7 ± 4.5 vs. 14.5 ± 5.2 mm) and superior-inferior dimension (13.5 ± 3.9 vs. 14.1 ± 5.0 mm, respectively). Agreement for the aortic, atrioventricular, inferior, right upper pulmonary vein, and superior rims was 100, 100, 100, 96, and 96%, respectively.

CONCLUSION

The SMPI technique can reliably assess the dimensions and rim size of a secundum ASD for pre-interventional selection when compared with TEE and has thus the potential to replace TEE.

Usefulness of Live Three-Dimensional Transthoracic Echocardiography in the Characterization of Atrial Septal Defects in Adults

In this report we present 12 adult patients in whom surgical or percutaneous intervention was considered for repair of atrial septal defect (ASD). Location, size, and surrounding atrial anatomy of the ASD were assessed prior to intervention in all patients with standard and live three-dimensional transthoracic echocardiography (3D TTE). In the four patients in whom intraoperative three-dimensional transesophageal echocardiographic reconstruction (3D TEE) was done, 3D TTE measurements of maximum dimension, maximum circumference, and maximum area of ASD agreed well with 3D TEE. In the seven patients who underwent transcatheter closure device insertion, live 3D TTE measurements of maximum dimension, maximum circumference, and maximum area of ASD agreed well with the sizing balloon. Additionally, since the sizing balloon measures a stretched diameter and area, a live 3D TTE stretched ASD diameter and area (derived from the actual live 3D TTE maximum circumference) were calculated and demonstrated improved agreement with the sizing balloon measurements. In all patients, > or =5 mm of atrial tissue was visualized surrounding the ASD. Further, with the addition of contrast enhancement, characterization of a small patent foramen ovale (<5 mm) was possible in one patient. Live 3D TTE accurately defined ASD location, size, and surrounding atrial anatomy in all patients studied by us. ASD characterization by live 3D TTE agreed well with 3D TEE and sizing balloon measurements.

Feasibility and clinical impact of live three-dimensional echocardiography in the management of congenital heart disease

BACKGROUND

Precise assessment of congenital heart lesions requires inferential evaluation from multiple two-dimensional echocardiographic images (2DE). The aim of our study was to assess the usefulness of transthoracic live three-dimensional echocardiography (3DE) in the evaluation of congenital heart disease.

METHODS

Eighty-two patients (from 4 months to 31 years, mean age 12 +/- 7.5, 38 males and 44 females), known to have congenital heart lesions, prospectively underwent both 2DE and 3DE. Conventional data acquisition by 2DE and "full volume" 3DE acquisition (apical four chambers, parasternal long and short axes, subcostal windows) were carried out by two independent and blinded operators. Data derived from 3DE were compared to 2DE, and 3DE results were graded into three categories: (A) new findings not seen on 2D echo studies, but not critical to therapeutic decision making; (B) additional anatomic information useful in therapeutic decision making; and (C) information equivalent to 2D echo studies.

RESULTS

Two out of 82 patients (2%) were excluded because of suboptimal 3DE images. In comparison with 2DE studies, 3DE was graded A in 23 patients (29%), B in 28 patients (35%), and C in 29 patients (36%). In the patients with group B results, atrial and ventricular septal defects, endocardial cushion defects, and l-transposition of great vessels were the most represented pathologies in which 3DE aided medical or surgical therapeutic options. While the new findings in group A did not influence therapy, they defined the whole spectrum of abnormalities in those patients. In patients who fell under group C results, 3DE provided a direct realistic display of the pathology detected by 2DE.

CONCLUSIONS

Our study demonstrates that live 3DE, easily performed at the bedside, provides incremental information on patients with a variety of congenital heart lesions. In the clinical scenario, it clarifies the pathology in all its dimensions, particularly in complex lesions with the incremental information having impact on therapeutic decision making.

Usefulness of three-dimensional echocardiographic reconstruction of the Amplatzer septal occluder in patients undergoing atrial septal closure

Eighty-eight patients referred for transcatheter closure of atrial septal or patent foramen ovale defects underwent 3-dimensional transesophageal echocardiography to correlate preclosure anatomy with the morphology and positioning of the atrial septal occluder. Despite the effectiveness of the trancatheter closure and absence of complications, 2 linear indentations of the aortic root by the 2 discs of the device were clearly demonstrated in 16 cases, suggesting caution in the choice of very large occluders.

Atrial septal defects in pediatric patients: noninvasive sizing with cardiovascular MR imaging

PURPOSE

To evaluate phase-contrast magnetic resonance (MR) imaging for sizing of secundum atrial septal defects (ASDs) and inflow MR angiography for detection of associated venous anomalies in pediatric patients with inconclusive transthoracic echocardiographic (TTE) results.

MATERIALS AND METHODS

Sixty-five children (mean age, 5.4 years +/- 2.7 [SD]) with ASD and inconclusive TTE results underwent phase-contrast MR imaging. Defect size and rim distances measured on MR imaging sections obtained in the ASD plane and from the defect to the venae cavae, aortic root, and atrioventricular valves were compared with transesophageal echocardiographic (TEE) findings (n = 30) during transcatheter closure or surgical measurements (n = 40) by using Bland-Altman analysis. Inflow MR angiography was compared with invasive cine angiocardiography for detection of associated venous anomalies.

RESULTS

For ASD size, mean differences were less than 1 mm between MR imaging and TEE measurements (with upper and lower limits of agreement between 2.3 and -3.3 mm) and were between 1.2 and -1.6 mm between MR imaging and surgical measurements (with upper and lower limits of agreement between 4.7 and -5.2 mm). Septal rim measurements at MR imaging agreed fairly well with TEE and surgical results. Septal length was overestimated at MR imaging versus TEE (mean difference, 3.0 mm; upper and lower limits of agreement, between 8.0 and -2.8 mm), but MR imaging septal length measurements agreed with surgical results. Rim distance to coronary sinus was difficult to assess. MR imaging enabled referral of 25 of 30 patients for successful transcatheter closure; five patients were found to have too large defects after balloon sizing. Multiple ASDs and/or associated vascular anomalies in 17 of 65 patients were clearly identified at MR imaging, compared with results of TEE, surgery, and cardiac catheterization.

CONCLUSION

In children with ASD and inconclusive TTE results, MR imaging can enable determination of defect size, rim distances to adjacent structures, and venous connections.

Comparison of transcatheter closure of secundum atrial septal defect using the Amplatzer septal occluder associated with deficient versus sufficient rims

To evaluate the feasibility of transcatheter closure of secundum atrial septal defects (ASDs) associated with deficient rims (<5 mm) using the Amplatzer septal occluder (ASO), 23 patients (median age 10.7 years) underwent an attempted transcatheter closure. The patients had a deficient anterior rim of 0 to 4 mm (n = 20), an inferior rim of 2 mm (n = 2), or a posterior rim of 4 mm (n = 1) as assessed by transesophageal echocardiography (TEE) or intracardiac echocardiography (ICE). Forty-eight patients with sufficient rims (>5 mm) who underwent closure served as controls. There were no differences between the 2 groups in ASD stretched diameter and device size (p >0.05). Of 23 patients with deficient rims, 17 (74%) had immediate complete closure compared with 44 of 48 patients (92%) with sufficient rims (p <0.05). At 24-hour and 6-month follow-up, the complete closure rates were not significantly different between the 2 groups (91% for patients with deficient rims vs 94% for patients with sufficient rims at 24 hours and 100% vs 93% at 6 months, respectively). The fluoroscopic time and procedure time were longer in patients with deficient rims (13 +/- 7 and 72 +/- 26 minutes, respectively) compared with those with sufficient rims (10 +/- 4 and 61 +/- 22 minutes, respectively). No major complications were encountered either during or after the closure procedure in both groups. Thus, transcatheter closure of ASDs associated with small anterior, inferior, or posterior rims is feasible using an ASO. Long-term follow-up data are still needed to assess long-term safety and efficacy.