Right ventricular form and function after percutaneous atrial septal defect device closure

Development and Validation of a Nomogram of Persistent Pulmonary Hypertension in Adult Pretricuspid Shunts After Correction

BACKGROUND

Pretricuspid shunts have been associated with poorer survival rates in patients with Eisenmenger syndrome compared with postricuspid shunts and complex lesions. However, the risk stratification for persistent pulmonary hypertension (PH) in this population remains uncertain.

METHODS AND RESULTS

We retrospectively enrolled 103 patients with pretricuspid shunts with high total pulmonary resistance >4.5 Wood units (estimated pulmonary vascular resistance ≥3 Wood units). During a mean±SD follow-up of 20.95±24.84 months, 32 patients developed postoperative persistent PH after shunt correction. We identified 3 significant predictors of postoperative persistent PH, including mean pulmonary artery pressure after inhaled oxygen ≥40.5 mm Hg (odds ratio [OR], 7.78 [95% CI, 2.02-30.03]; P<0.01), total pulmonary resistance after inhaled oxygen ≥6.5 Wood units (estimated pulmonary vascular resistance ≥5 Wood units; OR, 12.23 [95% CI, 2.12-70.46]; P<0.01), and artery oxygen saturation at rest <95% (OR, 3.34 [95% CI, 1.07-10.44]; P=0.04). We established the prediction model with the C-statistics of 0.85 (95% CI, 0.77-0.93; P<0.01), and the C-statistic was 0.83 (95% CI, 0.80-0.86) after bootstrapping 10 000 times with a good performance of the nomogram calibration curve for predicting persistent PH.

CONCLUSIONS

Our study presents a multivariable risk stratification model for persistent PH after shunt correction in adults with pretricuspid shunts. This model, based on 3 hemodynamic predictors after inhaled oxygen, may assist in identifying individuals at higher risk of persistent PH after shunt correction.

Transcatheter closure of large ostium secundum atrial septal defects in symptomatic small children: A single-center retrospective study

Background

In general, the risks associated with transcatheter atrial septal defect (ASD) device closure are reported to be relatively low, but the evidence stems from trials involving adults and older children. Current guidelines do not recommend ASD device closure in children with defect sizes >20 mm due to limited data available in this group of patients. This retrospective study sought to determine the clinical and procedural characteristics of successful transcatheter ASD device closure in small children with large defects and assess the complication rates and reasons for unsuccessful device closure.

Methods

We retrospectively reviewed the data of all patients who underwent elective transcatheter closure of ostium secundum ASD in our department between September 2013 and February 2022. All children weighing <20 kg, requiring a device of size 20 mm or greater, were included. Major and minor complications were predefined and indications for referral were evaluated. Echocardiogram reports were reviewed from the time of referral, postcatheterization day 1, and at 1-year follow-up.

Results

We identified 40 patients meeting inclusion criteria with a median (interquartile range [IQR]) procedural age of 5 (4-7) years and median (IQR) weight of 14 (12-18) kg. Successful device closure was achieved in 39 patients with a success rate of 97.5%. The total complication rate was 2.5% (95% confidence interval: 0.44%- I2.8%) with only 1 major complication. All children had right heart enlargement and exertional dyspnea, 30% of patients had recurrent lower respiratory tract infections, and 10% had failure to thrive. At 1-year follow-up, a transthoracic echocardiogram showed a well-endothelialized device in a stable position in all the patients, and none of the patients had a residual shunt.

Conclusion

In experienced centers, percutaneous ASD closure of large defects in symptomatic small children can be done effectively and safely with a great degree of predictability and a low complication rate.

Echocardiography in Simple Congenital Heart Diseases: Guiding Adult Patient Management

This article provides comprehensive insights into the evaluation of simple congenital heart diseases (CHDs) in adults, emphasizing the pivotal role of echocardiography. By focusing on conditions such as congenital aortic stenosis, aortic coarctation, patent ductus arteriosus, atrial septal defects (ASDs), and ventricular septal defects (VSDs), the review underscores echocardiography's intricate contributions to precise clinical decision-making. Echocardiography serves as the primary imaging modality, offering high-resolution visualization of anatomical anomalies and quantification of hemodynamic parameters. It enables tailored therapeutic strategies through its capacity to discern the dimensions, spatial orientation, and dynamic shunt dynamics of defects such as ASDs and VSDs. Moreover, echocardiography's advanced techniques, such as tissue Doppler imaging and speckle tracking, provide detailed insights into atrial mechanics, diastolic function, and ventricular filling kinetics. Integration of echocardiographic findings into clinical practice empowers clinicians to create personalized interventions based on quantified ventricular function, which spans systolic and diastolic aspects. This approach facilitates risk stratification and therapeutic planning, particularly pertinent in heart failure management within the CHD patient population. In summary, echocardiography transcends its role as an imaging tool, emerging as a precision-guided instrument adept at navigating the complexities of simple CHD in adults. Its ability to expedite diagnosis, quantify hemodynamic impacts, and unravel multifaceted functional dynamics culminates in a comprehensive depiction of these conditions. The fusion of these insights with clinical expertise empowers clinicians to navigate the intricate pathways of CHD, crafting tailored therapeutic strategies characterized by precision and efficacy.

Machine learning for clustering and postclosure outcome of adult CHD-PAH patients with borderline hemodynamics

BACKGROUND

Patients with uncorrected isolated simple shunts associated pulmonary arterial hypertension (PAH) had increased mortality. Treatment strategies for borderline hemodynamics remain controversial. This study aims to investigate preclosure characteristics and its association with postclosure outcome in this group of patients.

METHODS

Adults with uncorrected isolated simple shunts associated PAH were included. Peak tricuspid regurgitation velocity<2.8 m/sec with normalized cardiac structures was defined as the favorable study outcome. We applied unsupervised and supervised machine learning for clustering analysis and model constructions.

RESULTS

Finally, 246 patients were included. During a median follow-up of 414days, 58.49% (62/106) of patients with pretricuspid shunts achieved favorable outcome while 32.22% (46/127) of patients with post-tricuspid shunts. In unsupervised learning, two clusters were identified in both types of shunts. Generally, the oxygen saturation, pulmonary blood flow, cardiac index, dimensions of the right and left atrium, were the major features that characterized the identified clusters. Specifically, mean right atrial pressure, right ventricular dimension, and right ventricular outflow tract helped differentiate clusters in pretricuspid shunts while age, aorta dimension, and systemic vascular resistance helped differentiate clusters for post-tricuspid shunts. Notably, cluster 1 had better postclosure outcome than cluster 2 (70.83% vs 32.55%, p < .001 for pretricuspid and 48.10% vs 16.67%, p < .001 for post-tricuspid). However, models constructed from supervised learning methods did not achieve good accuracy for predicting the postclosure outcome.

CONCLUSIONS

There were two main clusters in patients with borderline hemodynamics, in which one cluster had better postclosure outcome than the other.

Outcomes in Patients with Pulmonary Arterial Hypertension Underwent Transcatheter Closure of an Atrial Septal Defect

Pulmonary arterial hypertension (PAH) related to an atrial septal defect (ASD) poses a challenge to transcatheter closure of an ASD (tcASD). We aimed to determine the predictors for remaining PAH (rPAH) post-tcASD. This retrospective study was conducted at a single tertiary university hospital. Adult patients with an ASD and PAH were divided into three groups according to pulmonary vascular resistance (PVR). Normalization of pulmonary atrial systolic pressure (PASP) was defined as an estimated right ventricular systolic pressure < 40 mmHg and was determined using transthoracic echocardiography. Among 119 patients, 80% showed PAH normalization post-tcASD. Normalization of PAH post-tcASD was observed in 100%, 56.2%, and 28.6% of patients in mild, moderate, and severe PVR groups, respectively. The patients’ New York Heart Association functional class improved. Multivariate logistic regression analysis showed that age and high PVR were significant risk factors for rPAH. A receiving operator curve analysis showed a PASP cutoff value > 67.5 mmHg to be predictive of rPAH post-tcASD, with an area under the curve value of 0.944 (sensitivity, 0.922; specificity 0.933). Most patients, including moderate-to-severe PAH patients, improved hemodynamically and clinically with tcASD. Since patients with severe PAH are at a risk of rPAH, tcASD should be performed by selecting the patient carefully based on pre-procedure medication, a vasoreactivity test, and a balloon occlusion test.

High-echoic line tracing of transthoracic echocardiography accurately assesses right ventricular enlargement in adult patients with atrial septal defect

Accurate measurement of right ventricular (RV) size using transthoracic echocardiography (TTE) is important for evaluating the severity of congenital heart diseases. The RV end-diastolic area index (RVEDAi) determined using TTE is used to assess RV dilatation; however, the tracing line of the RVEDAi has not been clearly defined by the guidelines. This study aimed to determine the exact tracing method for RVEDAi using TTE. We retrospectively studied 107 patients with atrial septal defects who underwent cardiac magnetic resonance imaging (CMR) and TTE. We measured the RVEDAi according to isoechoic and high-echoic lines, and compared it with the RVEDAi measured using CMR. The isoechoic line was defined as the isoechoic endocardial border of the RV free wall, whereas the high-echoic line was defined as the high-echoic endocardial border of the RV free wall more outside than the isoechoic line. RVEDAi measured using high-echoic line (high-RVEDAi) was more accurately related to RVEDAi measured using CMR than that measured using isoechoic line (iso-RVEDAi). The difference in the high-RVEDAi was 0.3 cm²/m², and the limit of agreement (LOA) was - 3.7 to 4.3 cm²/m². With regard to inter-observer variability, high-RVEDAi was superior to iso-RVEDAi. High-RVEDAi had greater agreement with CMR-RVEDAi than with iso-RVEDAi. High-RVEDAi can become the standard measurement of RV size using two-dimensional TTE.

Mid-term follow-up by speckle tracking and cardiac MRI of children post-transcatheter closure of large atrial septal defects

This is a case-control study of our experience of mid-term follow-up of 40 children who had a transcatheter closure of very large atrial septal defects group (1). All cases had an atrial septal defect device size more than 1.5 times their weight, a ratio considered a contraindication for trans catheter closure (TCC) in some previous reports. The aim of this study is to report the outcomes and mid-term follow-up of transcatheter closure of large atrial septal defects using two-dimensional conventional echocardiography, tissue Doppler imaging, and four-dimensional speckle tracking imaging, and as such to compare results of same echocardiographic examination of age-matched control group of 40 healthy children group (2). Cardiac MRI was performed on cases group (1) only to detect right ventricle and left ventricle volumes and function and early signs of complications. There was no difference between cases and matched healthy controls in terms of the assessment of left ventricle and right ventricle by two-dimensional echocardiography, tissue Doppler imaging, and four-dimensional speckle tracking imaging. Similarly, there was no statistically significant difference between four-dimensional echocardiography and cardiac MRI in their respective assessment of both left ventricle and right ventricle volumes and function. We also detected no complications by echo or by cardiac MRI after a median follow-up period of 2 years and recorded a complete remodelling of right ventricle volumes in all children studied. This points to the safety and efficiency of transcatheter closure of large atrial septal defects in children on mid-term follow-up.

Effectiveness and Safety of Transcatheter Atrial Septal Defect Closure in Adults with Systemic Essential Hypertension

Concomitant systemic essential hypertension (HTN) in adults with a secundum atrial septal defect (ASD) can unfavorably affect the hemodynamics and transcatheter ASD closure (ASDC) effects. This study aims to assess the effectiveness and safety of ASDC in adults with HTN in real-world clinical practice. Right ventricular (RV) reverse remodeling (RVR) and the lack of a left-to-right interatrial residual shunt (NoRS) in echocardiography 24 h and 6 months (6 M) post-ASDC, and ASDC-related complications within 6 M were evaluated in 184 adults: 79 with HTN (HTN+) and 105 without HTN (HTN−). Compared to HTN−, HTN+ patients were older and had a greater RV size and the prevalence of atrial arrhythmias, chronic heart failure, nonobstructive coronary artery disease, diabetes, hyperlipidemia, and left ventricular diastolic dysfunction. ASDC was successful and resulted in RVR, NoRS, and a lack of ASDC-related complications in the majority of HTN+ patients both at 24 h and 6 M. HTN+ and HTN− did not differ in ASD size, a successful implantation rate (98.7% vs. 99%), RVR 24 h (46.8% vs. 46.7%) and 6 M (59.4% vs. 67.9%) post-ASDC, NoRS 24 h (79% vs. 81.5%) and 6 M (76.6% vs. 86.9%) post-ASDC, and the composite of RVR and NoRS at 6 M (43.8% vs. 57.1%). Most ASDC-related complications in HTN+ occurred within 24 h and were minor; however, major complications such as device embolization within 24 h and mitral regurgitation within 6 M were observed. No differences between HTN+ and HTN− were observed in the total (12.7% vs. 9.5%) and major (5.1% vs. 4.8%) complications. Transcatheter ASDC is effective and safe in adults with secundum ASD and concomitant HTN in real-world clinical practice; however, proper preprocedural management and regular long-term follow-up post-ASDC are required.

Assessment of atria function after percutaneous closure of atrial septal defect using 2D speckle tracking echocardiography

BACKGROUND

Percutaneous occlusion of atrial septal defect (ASD) has recently become a standard therapeutic strategy, but little is known about atria function thereafter. Strain analysis by two-dimensional speckle tracking echocardiography (2D-STE) is considered to be a new tool to assess myocardial function.

METHODS

This study aimed to evaluate atria function by quantifying longitudinal strain in patients with chronic RV volume overload due to ASD before and after percutaneous closure using 2D-STE. 28 consecutive patients underwent percutaneous closure of ASD (18 female, 10 male) were examined, clinical and echocardiographic evaluation one day before, 1 day, and one month after percutaneous closure of ASD. Peak longitudinal systolic strain and strain rate of both atria were analyzed by 2D-STE.

RESULTS

Mean age of the patients was 15.07 ± 8.39 years; mean diameter of ASD was 16.01 ± 2.78 mm; left atrium (LA) diameter significantly increased after ASD closure; and peak longitudinal strain of RA increased significantly one day and one month after ASD closure (48. 77 ± 4.40, vs.55.36 ± 3.70 and, vs. 62.13 ± 3.81%, p = 0.001). LA longitudinal strain significantly decreased after ASD closure (42.55 ± 4.57, vs. 34.79 ± 3.20%, p = 0.001). Furthermore, negative correlation was found between the size of the ASD and delta LA systolic strain and strain rate.

CONCLUSIONS

2D-STE can be considered a feasible and simple technique for assessment of atrial deformation in ASD patients, and it useful to assess the effect of percutaneous ASD closure on atrial reservoir function by measuring peak atrial longitudinal strain.

Crochetage sign may predict late atrial arrhythmias in patients with secundum atrial septal defect undergoing transcatheter closure

BACKGROUND

Atrial arrhythmias are well-known complications of atrial septal defect (ASD), and associated with substantial morbidity. After ASD closure, right atrial and ventricular enlargement regresses, however, the risk of atrial arrhythmia development continues. In this study, we aimed to investigate the relationship between the Crochetage sign, which is a possible reflection of heterogeneous ventricular depolarization due to long-term hemodynamic overload, and the development of late atrial arrhythmia after ASD closure.

METHODS

This retrospective study included a total of 314 patients (mean age: 39.5 (30-50) years; male: 115) who underwent percutaneous device closure for secundum ASD. The study population was divided into two groups according to the presence or absence of the Crochetage sign. The Crochetage sign was defined as an M-shaped or bifid pattern notch on the R wave in one or more inferior limb leads. Cox-regression analysis was performed to determine independent predictors of late atrial arrhythmia development.

RESULT

Fifty-seven patients (18.1%) presented with late atrial arrhythmia. Of these 57 patients, 30 developed new-onset atrial fibrillation/atrial flutter (AF/AFL), and 27 patients with pre-procedure paroxysmal AF/AFL had a recurrence of AF/AFL during follow-up. History of paroxysmal AF/AFL before the procedure (HR: 4.78; 95% CI 2,52-9.05; p < 0.001), the presence of Crochetage sign (HR: 3.90; 95% CI 2.05-7.76; p < 0.001), and older age at the time of ASD closure (HR: 1.03; 95% CI 1.01-1.06; p = 0.002) were found as independent predictors for late atrial arrhythmia.

CONCLUSION

The presence of Crochetage sign may be used to predict the risk of late atrial arrhythmia development after transcatheter ASD closure.

Comparison of the early cardiac electromechanical remodeling following transcatheter and surgical secundum atrial septal defect closure in adults

Background

Secundum atrial septal defect (ASD) closure leads to electrical and mechanical remodeling that occurs early after shunt disappearance. The relationship between electromechanical remodeling using electrocardiogram (ECG) and cardiac magnetic resonance (CMR) after percutaneous and surgical closure has not yet been recorded in prospective studies.

Objective

We thought to study right atrium (RA) and right ventricle (RV) changes by CMR 3 months after transcatheter and surgical closure and their comparison with electrical remodeling by ECG.

Results

We prospectively evaluated 30 consecutive adult patients with isolated secundum ASD who were referred for (transcatheter and surgical) ASD closure.

There was significant reduction in all of the electrical parameters within the same group as compared to the baseline values, except P wave dispersion (Pd). (P max was 97.33 ± 16.67 (pre closure) to 76 ± 15.49 (post closure) in the device group and 97.33 ± 12.79 (preclosure) to 73.33 ± 16.32 (post closure) in the surgical group, QRS complex was 104 ± 18.82 (preclosure) to 80 ± 18.51 (post closure) in the device group and 106.67 ± 14.47 (preclosure) to 86.67 ± 17.99 (post closure) in the surgical group. QTc maximum was 478.53 ± 36.79 (preclosure) to 412.53 ± 38.03 (post closure) in the device group and 470.53 ± 65.70 (preclosure) to 405.93 ± 63.08 (post closure) in the surgical group, and QTc dispersion was 70.33 ± 24.04 (preclosure) to 60.26 ± 28.56 (post closure) in the device group and 80.73 ± 30.38 (preclosure) to 60.27 ± 28.57 (post closure) in the surgical group).There was no significant difference between two groups indicating that transcatheter and surgical closure had led to equivalent value of electrical remodeling.

In CMR study, we measured RA maximal volume and right ventricle end diastolic volume (RVEDV), RA maximal volume decreased significantly as compared to the base line values post closure in both groups (P value < 0.001). The reduction in RA max volume was more in the transcatheter closure group; however, this difference was not statistically significant when compared with the surgical arm (P value = 0.5).RVEDV decreased significantly in both groups as compared to the baseline values (P value < 0.001). Transcatheter closure resulted in more significant reduction in the RVEDV than the surgical closure (P value = 0.03).

Conclusion

Our study showed early significant electromechanical reverse remodeling in most of the study parameters from the baseline values after ASD closure. We found no significant differences in all of the electrical and RA mechanical remodeling parameters with significantly better mechanical remodeling of RV in the device group.

Individualized Experience With Percutaneous Transcatheter Closure of Multiple Atrial Septal Defects: A Single-Center Study

Multiple atrial septal defects (ASDs) are one type of secundum ASD, most of which have an atrial septal aneurysm or long interdefect distance. In our retrospective single-center study, we reviewed different closure strategies for multiple ASDs. We analyzed 50 patients who underwent percutaneous transcatheter closure from May 2011 to July 2019. Information on the patients' characteristics, operation procedure, occluder selection, and complications was collected. According to the feature of the defects and device choice, multiple ASDs were divided into five groups. A successful operation was achieved in every patient. A total of 50 patients were implanted with 58 devices, with 26 patients implanted with a single standard ASD occluder (ASDO); six patients were implanted with double standard ASDOs, and only one patient was implanted with three standard ASDOs. There were 17 patients whose closure was made using the small-waist–big-edge ASDO. Seventy-six percent of the patients (38/50) had an immediate residual shunt. During the mean follow-up of 25.76 ± 22.53 months, the complete closure rate was 92%. Except for two patients with a transient atrioventricular block, individualized experience with percutaneous transcatheter closure for multiple ASDs was effective in a single-center study. After a mid- to long-term follow-up, the multiple ASDOs and small-waist–big-edge ASDO had no serious adverse events or complications.

Prevalence and outcomes of pulmonary hypertension after percutaneous closure of atrial septal defect: a systematic review and meta-analysis

BACKGROUND

Atrial septal defect (ASD) is a common form of congenital heart disease. Significant shunts may increase the risk of developing pulmonary hypertension (PH). We aimed to describe current PH definitions, evaluate PH prevalence and the effect of PH on outcomes in patients undergoing percutaneous ASD closure.

METHODS

EMBASE, MEDLINE and Cochrane databases were systematically searched. Studies reporting PH prevalence or mean systolic pulmonary arterial pressure (sPAP) before and after percutaneous ASD closure in adults were included. We conducted meta-analyses to obtain summary estimates for PH prevalence and mean sPAP.

RESULTS

15 articles with a total of 1073 patients met the eligibility criteria. Studies applied variable PH definitions. PH prevalence and mean sPAP levels decreased in all studies after closure. The pooled PH prevalence decreased from 44% (95% CI 29-60%) to 18% (95% CI 8-27%). The overall standardised mean difference in sPAP was 1.12 (95% CI 0.81-1.44) and 1.62 (95% CI 1.00-2.23) in cohort and case-series studies respectively indicating a large decrease. The pooled standard mean difference among the younger and older patients were different, 1.25 (95% CI 0.78-1.71) and 0.91 (95% CI 0.56-1.27), respectively. A high degree of between-study heterogeneity was noted.

CONCLUSIONS

Both PH prevalence and mean sPAP decrease after ASD closure. Larger, prospective studies with consistent PH definitions using the recommended measurement modality are warranted.

Preoperative Threshold for Normalizing Right Ventricular Volume After Transcatheter Closure of Adult Atrial Septal Defect

BACKGROUND

The latest guidelines recommend early intervention in adult atrial septal defect (ASD) patients with signs of right ventricular (RV) enlargement. However, the criteria of RV enlargement for optimal intervention remain unclear. We investigated the preoperative determinants for normalizing the RV volume after transcatheter closure of ASD in adults.Methods and Results:We retrospectively analyzed 52 ASD patients who underwent transcatheter closure. Cardiac magnetic resonance imaging (CMR) measured RV volume before and 1 year after the closure. The patients were divided into normalized (postoperative RV end-systolic volume index [RVESVI] <47 mL/m²and end-diastolic volume index [RVEDVI] <108 mL/m²) and non-normalized (postoperative RVESVI ≥47 mL/m²or RVEDVI ≥108 mL/m²) groups. Preoperative RVESVI was significantly smaller (72 mL/m²vs. 80 mL/m²) and RVEF was higher (56% vs. 51%) in the normalized group compared with the non-normalized group. Receiver-operating characteristic analysis for the normalization of postoperative RV volume showed that the preoperative threshold value of RVESVI was 75 mL/m². In addition, multivariate analysis showed that preoperative RVESVI was an independent predictor for normalization of RV volume.

CONCLUSIONS

Preoperative RVESVI is an independent predictor for normalization of RV volume at 1 year after transcatheter closure of ASD in adults. Early intervention before RVESVI reaches 75 mL/m²may confer optimal timing for normalizing RV volume.

Elaborate evaluation of serial changes in electrocardiograms of atrial septal defects after transcatheter closure for a better understanding of the recovery process

Serial changes of electrocardiograms (ECG) could be used to assess their clinical features in atrial septal defects (ASD) after transcatheter closure together with other clinical parameters. We retrospectively studied 100 ASD patients who underwent transcatheter closure. Complications of persistent atrial fibrillation occurred in five ASD patients, and they were excluded. We divided the other 95 patients according to PQ intervals before closure (normal: < 200 ms, n = 51; prolonged: ≥ 200 ms, n = 44) to evaluate their clinical characteristics and parameters such as echocardiography, chest X-rays, and brain natriuretic protein (BNP) levels. Individuals in the prolonged PQ group were significantly older, had higher incidences of paroxysmal atrial fibrillation (PAF) and heart failure (HF) treated with more β-blockers and diuretics, and with a higher tendency of NYHA functional classification and BNP levels than the normal PQ group. The prolonged PQ group also had a significantly higher incidence of complete right bundle branch block, wider QRS intervals, and larger cardiothoracic ratios in chest X-rays accompanied by larger right atrial-areas and larger left atrial dimensions in echocardiograms. Furthermore, the prolonged PQ intervals with less PQ interval shortening after transcatheter closure revealed that the patients were the oldest at the time of closures and showed less structural normalization of the right heart and left atrium after ASD closure. PAF and HF also occurred more frequently in this subgroup. These results suggested that the ASD patients with prolonged PQ intervals with less PQ shortening were accompanied by more advanced clinical conditions. Together with other clinical parameters, detailed analyses of ECG and their changes after closure could elucidate the clinical characteristics and status of ASD patients with transcatheter closure and were useful for predicting structural normalization after transcatheter closure.

Velocity Vector Imaging Assessment of Functional Change in the Right Ventricle during Transcatheter Closure of Atrial Septal Defect by Intracardiac Echocardiography

The functional change of the right ventricle (RV) after atrial septal defect (ASD) via transcatheter closure is well known. We assessed the immediate RV functional change using velocity vector imaging (VVI) with intracardiac echocardiography (ICE). Seventy-four patients who underwent transcatheter closure of an ASD were enrolled. VVI in the “home view” of ICE showing the RV was obtained before and after the procedure. Velocity, strain, strain rate (SR), and longitudinal displacement were analyzed from VVI data, and the changes of these parameters before and after the procedure were compared. The velocity of the RV decreased after ASD transcatheter closure (3.97 ± 1.48 to 3.56 ± 1.4, p = 0.024), especially in the RV inlet and outlet. The average strain decreased (−19.21 ± 5.79 to −16.87 ± 5.03, p = 0.002), as did the average SR (−2.28 ± 0.64 to −2.03 ± 0.61, p = 0.006). The average longitudinal displacement did not differ. With the VVI technique, we could clearly observe RV functional change immediately after transcatheter closure of the ASD. RV functional change with regional difference may reflect the heterogeneity of volume reduction and suggest subclinical RV dysfunction. These findings can enhance our understanding of the physiologic changes in the RV during reverse remodeling.

Biventricular reverse remodeling and relationship with mitral valve prolapse after transcatheter closure of ASD secundum, a 3D echocardiographic study

Introduction: Mitral valve prolapse (MVP) is the most common anomaly of the mitral valve. Several studies have shown prevalence of MVP in atrial septal defect (ASD) especially secundum types (II). The aims of this study is to show the potential role of 3D echocardiography in improving the diagnosis of MVP and to depict the relationship between reverse remodeling of the right and left ventricles (RV, LV) and MVP after transcatheter closure of ASD II.

Methods: Sixty patients underwent transcatheter closure of ASD II and completed follow up by 2D and 3D echocardiography in Cairo University Children Hospital before the procedure and at 24 hours, 1 and 6 months after the procedure.

Results: 3D echocardiography was more accurate than 2D echocardiography in detecting MVP frequency in ASD II patients (75% vs. 50%). Maximum statistically significant remodeling was detected by 3D echocardiography 1 month after the procedure (RV: LV ratio by 3D echocardiography 1.9±0.03 24 hours after the procedure vs. 1.6±0.03 1 months after the procedure, P <0.01) while 2D echocardiography was delayed in detecting biventricular reverse remodeling. 3D derived RV: LV ratio was accurate in detecting MVP status with a sensitivity of 88%.

Conclusion: MVP in ASD II may be related to Biventricular remodeling; 3D echocardiography is accurate in the detection of reverse remodeling as well as MVP in ASD II patients before and after device closure.

Venous flow patterns after percutaneous atrial septal defect closure: Does the mechanical device decrease right atrial compliance?

INTRODUCTION

Systemic venous flow patterns become abnormal and restrictive after surgical closure of ostium secundum atrial septal defect (ASD) but rarely studied after percutaneous device closure.

METHODS

From January 2017 to January 2018, systemic venous Doppler flow patterns were documented prospectively in 50 subjects who underwent percutaneous closure of ASD, prior to, after procedure, and at 6-month follow-up and correlated with defect size and device size.

RESULTS

In hepatic veins and superior venacava post device-closure closure, the velocity time integral (VTI) of forward flow in both systole (S) and diastole (D) increased. Overall S was higher than D, and D/S ratio was <1. The D/S ratio increased after device closure significantly reflecting that the improvement in atrial filling increase in diastolic flow more than the increase in systolic flow. Increase in flow velocities was more prominent at 6 months with further increase in D/S VTI ratios. When correlated with the defect size, in those with defect size less than 15 mm/sq.m (mean device size 13.05 ± 3.21 mm), the changes in S- or D-wave, D/S ratio were less prominent and statistically not significant, while in subjects with defect size ≥ 15 mm/sq.m (mean device size 23.02 (±4.77 mm), these changes were greater and statistical significant.

CONCLUSION

Residual filling defects with restriction of systolic venous flow were observed in subjects after device closure, correlating with larger device sizes, implying the compliance abnormality conferred by them which progresses at 6 months. Subjects with persistent abnormalities would need careful follow up for incomplete remodeling and increase in atrial size related arrhythmias.

Procedural, Early and Long-term Outcomes after Percutaneous Closure of Atrial Septal Defect: Comparison between Large and Very Large Atrial Septal Defect Groups

Background

This study aimed to compare procedural, early and long-term outcome of device closure of atrial septal defect (ASD) between large ASD patients and very large ASD patients.

Methods

We carried a retrospective study of adult large ASD (defined as ≥25 mm) treated by percutaneous closure using Amplatzer septal occluder during 12-year period (May 2003–February 2015) at a single tertiary center. A total of 269 patients were divided into 2 groups, according to the pre-procedural maximal ASD diameter; 25 mm≤ASD<35mm, group 1 (n=216) and 35 mm≤ASD, group 2 (n=53). We compared procedural parameters, early complications and long-term follow-up results between 2 groups.

Results

The need of modified implantation techniques (MITs) was higher group 2 (23.6% vs. 37.7%, p=0.034). Procedural success rate was considerably high in both groups (99.1% in group 1 vs. 100% in group 2, p=0.620). Major complications were occurred in 4 (1.5%) patients (1.4% vs. 1.9%, p=0.804). Minor complication rate was not different between 2 groups. During long-term follow-up (47.2±32.0 months, range, 6.0–135.5), there was one major complication (0.4%) of stroke. Most common long-term minor event was migraine headache (3.9%) followed by arrhythmias (1.9%) without statistical difference between 2 groups.

Conclusions

Although MIT was more frequently required in very large ASD groups, the procedural, early and long-term outcomes after percutaneous ASD closure were similar in both groups. This suggested that percutaneous ASD closure for very large ASD could be considered a good treatment option.

Risk Factors for Pulmonary Hypertension in Adults After Atrial Septal Defect Closure

Atrial septal defect (ASD) closure is performed to prevent pulmonary hypertension (PH), which is associated with poor outcome. This study investigated the prevalence of PH in adults before and after ASD closure and explored associations between patient characteristics and PH after ASD closure. Consecutive adult patients who underwent surgical or percutaneous ASD closure in the Erasmus MC, the Netherlands, were included (2000 to 2014). Echocardiograms before and after ASD closure were retrospectively assessed. Patients were categorized into 3 groups (no PH, possible PH, and PH) based on tricuspid regurgitation velocity (<2.9, 2.9 to 3.4, and ≥3.4 m/s) or mean pulmonary arterial pressure (<20, 20 to 24, and ≥25 mm Hg). Cox regression was performed to identify associations between patient characteristics and PH after ASD closure. Of the 244 eligible patients who underwent ASD closure, 198 (81%) had echocardiograms both before and median 15 (interquartile range 12 to 35) months after ASD closure (median age at closure 45 [interquartile range 30 to 57] years, 75% woman). The prevalence of PH was 13.1% (n = 26) before ASD closure and 5.0% (n = 10) after closure. New York Heart Association III to IV (hazard ratio [HR] 11.07, 95% confidence interval [CI] 3.12 to 39.29, p <0.001), pulmonary disease (HR 10.43, 95% CI 2.12 to 51.21, p = 0.004), cardiac medication use (HR 3.96, 95% CI 1.02 to 15.34, p = 0.047), right ventricular fractional area change (HR 0.87, 95% CI 0.81 to 0.93, p <0.001), and tricuspid annular plane systolic excursion (HR 0.75, 95% CI 0.59 to 0.95, p = 0.018) were significantly associated with PH. In conclusion, adult patients with low pulmonary pressures before ASD closure are not at risk of PH after closure. Nevertheless, PH remained prevalent in approximately 5% of patients. Especially those patients with high New York Heart Association functional class, presence of pulmonary disease, cardiac medication use and impaired RV function at baseline are at risk.

Electrical remodeling after percutaneous atrial septal defect closure in pediatric and adult patients

BACKGROUND

Several studies have reported changes in electrocardiographic variables after atrial septal defect (ASD) closure. However no temporal electro-and vectorcardiographic changes have been described from acute to long-term follow-up at different ages. We aimed to study electrical remodeling after percutaneous ASD closure in pediatric and adult patients.

METHODS

ECGs of 69 children and 75 adults (median age 6 [IQR 4-11] years and 45 [IQR 33-54] years, respectively) were retrospectively selected before percutaneous ASD closure and at acute (1-7 days), intermediate (4-14 weeks) and late (6-18 months) follow-up. Apart from electrocardiographic variables, spatial QRS-T angle and ventricular gradient (VG) were derived from mathematically-synthesized vectorcardiograms.

RESULTS

In both pediatric and adult patients, the heart rate decreased immediately post-closure, which persisted to late follow-up. The P-wave amplitude also decreased acutely post-closure, but remained unchanged at later follow-up. The PQ duration shortened immediately in children and at intermediate follow-up in adults. The QRS duration and QTc interval decreased at intermediate-term follow-up in both children and adults. In both groups the spatial QRS-T angle decreased at late follow-up. The VG magnitude increased at intermediate follow-up in children and at late follow-up in adults, after an initial decrease in children.

CONCLUSION

In both pediatric and adult ASD patients, electrocardiographic changes mainly occurred directly after ASD closure except for shortening of QRS duration and QTc interval, which occurred at later follow-up. Adults also showed late changes in PQ duration. At 6-to-18 month post-closure, the spatial QRS-T angle decreased, reflecting increased electrocardiographic concordance. The initial acute decrease in VG in children, which was followed by a significant increase, may be the effect of action potential duration dynamics directly after percutaneous ASD closure.

The prevalence of pulmonary arterial hypertension before and after atrial septal defect closure at adult age: A systematic review

BACKGROUND

The development or persistence of pulmonary arterial hypertension (PAH) after atrial septal defect (ASD) closure at adult age is associated with a poor prognosis. The objective of this review was to investigate the prevalence of PAH before and after ASD closure and to identify factors that are associated with PAH.

METHODS

EMBASE and MEDLINE databases were searched for publications until March 2017. All studies reporting the prevalence of PAH or data on pulmonary artery pressures both before and after surgical or percutaneous ASD closure in an adult population (≥16 years of age) were included. Papers were methodologically checked and data was visualized in tables, bar charts and plots.

RESULTS

A total of 30 papers were included. The prevalence of PAH ranged from 29% to 73% before ASD closure and from 5% to 50% after closure; being highest in older studies, small study cohorts, and studies with high rates of loss to follow-up. The pooled systolic pulmonary artery pressure (PAP) was 43±13 before ASD closure and 32±10 after closure. The overall mean PAP was 34±10 before closure and 28±8 after closure. Studies with a higher mean PAP before closure and a higher mean age of the study cohort reported greater PAP reductions.

CONCLUSIONS

The prevalence of PAH and mean pulmonary pressures decreased in all studies, regardless of the mean age or pulmonary pressures of the cohort. The reported prevalence of PAH after ASD closure is substantial, although widely varying (5%-50%), which is likely affected by selection of the study cohort.

Assessment of right atrial function with speckle tracking echocardiography after percutaneous closure of an atrial septal defect

INTRODUCTION

Speckle tracking echocardiography (STE) for two-dimensional (2D) strain analysis is a new tool to assess myocardial function. The aim of this study was to assess right atrial (RA) function using STE in patients with an atrial septal defect (ASD) before and one month after percutaneous closure.

METHODS

We prospectively examined 32 consecutive patients (nine male, 23 female) who underwent percutaneous transcatheter closure of a secundum ASD between June 2013 and December 2015. Echocardiography was performed on admission, prior to cardiac catheterization and then one month after ASD closure. Peak global RA longitudinal strain was analyzed by 2D-STE.

RESULTS

Patients' mean age was 34.6±8.2 years. The mean diameter of the occlusive devices was 18.5±7.5 mm. Right ventricular (RV) end-diastolic diameters were significantly increased but decreased significantly after ASD closure (43±5 vs. 38±4 mm, p<0.05). Left atrial (LA) diameters (40±8 vs. 37±6 mm, p<0.05) decreased significantly after the intervention, whereas left ventricular (LV) end-diastolic diameters (45±5 vs. 46±4 mm, NS) remained unchanged. Tricuspid annular plane systolic excursion increased significantly (17.6±5.4 vs. 22.3±8.1 mm, p<0.05). After closure of the defect, a significant increase was observed in longitudinal RA strain (26.5±9.6% vs. 35.3±10.5%, p<0.001).

CONCLUSIONS

After percutaneous transcatheter closure of a secundum ASD, there was an increase in RA longitudinal strain. 2D-STE strain analysis appears to be helpful for the assessment of RA function and of response to correction of volume overload after percutaneous transcatheter closure of a secundum ASD.

Right Ventricular Outflow Tract (RVOT) Changes in Children with an Atrial Septal Defect: Focus on RVOT Velocity Time Integral, RVOT Diameter, and RVOT Systolic Excursion

OBJECTIVE

Aim of the study was to determine the influence of right heart volume overload in children with atrial septal defect (ASD) on right ventricular outflow tract (RVOT) variables.

METHODS

A prospective study was conducted in 115 children (age range: 2 days-18.1 years) with a moderate to large ASD. We determined effects of age, body length (BL), body weight (BW), and body surface area (BSA) on the variables RVOT diameter, RVOT velocity time integral (VTI), and RVOT systolic excursion (SE), and tested the predictive value of published normal values for age, BW, BL, and BSA in our ASD patients.

RESULTS

In our pediatric ASD patients, the age-specific RVOT diameter (z-score: +2.2, 95% CI: 2.0-2.4, P < 0.001) was significantly increased compared to normal values with 54% of our ASD patients having a z-score >2.0. The age-specific RVOT VTI z-score (z-score: +3.6, 95% CI: 3.2-3.9, P < 0.001) was significantly increased compared to normal values with 81% of our ASD patients having a z-score >2.0. The age-specific RVOT SE z-score was not increased but slightly lower compared to normal values (z-score: -0.5, 95% CI: -0.7 to -0.3, P < 0.001) with 3% of our ASD patients having a z-score >2.0 while 12% of the patients had a z-score <-2.

CONCLUSION

In our study population, we show the RVOT VTI and diameter to be relevant predictors in identifying an enlarged RVOT size and flow in children with moderate to large ASD.

Contributors to and impact of residual shunting after device closure of atrial septal defects

BACKGROUND

The prevalence of residual shunt in patients after device closure of atrial septal defect and its impact on long-term outcome has not been previously defined.

METHODS

From a prospective, single-institution registry of 408 patients, we selected individuals with agitated saline studies performed 1 year after closure. Baseline echocardiographic, invasive hemodynamic, and comorbidity data were compared to identify contributors to residual shunt. Survival was determined by review of the medical records and the Social Security Death Index. Survival analysis according to shunt included construction of Kaplan-Meier curves and Cox proportional hazards modeling.

RESULTS

Among 213 analyzed patients, 27% were men and age at repair was 47 ± 17 years. Thirty patients (14%) had residual shunt at 1 year. Residual shunt was more common with Helex (22%) and CardioSEAL/STARFlex (40%) occluder devices than Amplatzer devices (9%; P = .005). Residual shunts were more common in whites (79% vs 46%, P = .004). At 7.3 ± 3.3 years of follow-up, 13 (6%) of patients had died, including 8 (5%) with Amplatzer, 5 (25%) with CardioSEAL/STARFlex, and 0 with Helex devices. Patients with residual shunting had a higher hazard of death (20% vs 4%, P = .001; hazard ratio 4.95 [1.59-14.90]). In an exploratory multivariable analysis, residual shunting, age, hypertension, coronary artery disease, and diastolic dysfunction were associated with death.

CONCLUSIONS

Residual shunt after atrial septal defect device closure is common and adversely impacts long-term survival.

Incomplete RV Remodeling After Transcatheter ASD Closure in Pediatric Age

Published data showing the intermediate effect of transcatheter device closure of atrial septal defect (ASD) in the pediatric age-group are scarce. The objective of the study was to assess the effects of transcatheter ASD closure on right and left ventricular functions by tissue Doppler imaging (TDI). The study included 37 consecutive patients diagnosed as ASD secundum by transthoracic echocardiography and TEE and referred for transcatheter closure at Cairo University Specialized Pediatric Hospital, Egypt, from October 2010 to July 2013. Thirty-seven age- and sex-matched controls were selected. TDI was obtained using the pulsed Doppler mode, interrogating the right cardiac border (the tricuspid annulus) and lateral mitral annulus, and myocardial performance index (MPI) was calculated at 1-, 3-, 6- and 12-month post-device closure. Transcatheter closure of ASD and echocardiographic examinations were successfully performed in all patients. There were no significant differences between two groups as regards the age, gender, weight or BSA. TDI showed that patients with ASD had significantly prolonged isovolumetric contraction, relaxation time and MPI compared with control group. Decreased tissue Doppler velocities of RV and LV began at one-month post-closure compared with the controls. Improvement in RVMPI and LVMPI began at 1-month post-closure, but they are still prolonged till 1 year. Reverse remodeling of right and left ventricles began 1 month after transcatheter ASD closure, but did not completely normalize even after 1 year of follow-up by tissue Doppler imaging.

Fate of Mitral Regurgitation After Transcatheter Closure of Atrial Septal Defect in Adults

Although the volume overload of pulmonary circulation improves after atrial septal defect (ASD) closure, the increasing left ventricular preload may contribute to mitral regurgitation (MR) deterioration. We aimed to evaluate the impact of MR after transcatheter ASD closure on clinical outcomes in adults. A total of 288 consecutive patients who underwent transcatheter ASD closure were enrolled. Changes in MR were assessed at 1 month after the procedure. The end point was defined as cardiovascular events. After the procedure, MR ameliorated in 3 patients and unchanged in 253, whereas MR deteriorated in 32. During a median follow-up of 24 months, patients with MR deterioration had no cardiovascular events, and the event-free survival rate was not different between patients with MR deterioration and those with MR amelioration or no-change (p = 0.355). Even in patients with MR deterioration, the New York Heart Association functional class improved after the procedure, with no cases of worsening functional class. Multivariate logistic regression analysis showed that MR deterioration was independently related to advanced age and female gender. The degree of enlargement of mitral valve annulus diameter after the procedure was greater in patients with MR deterioration than in those with MR amelioration or no-change, and it was correlated with the degree of MR deterioration. In conclusion, MR deterioration occurs in a minority of adult patients after transcatheter ASD closure; however, it is not linked with adverse outcomes. MR deterioration may be provoked by geometric changes in mitral valve annulus, especially in women with advanced age.

The benefit of atrial septal defect closure in elderly patients

Objective

Closure of an atrial septal defect in elderly patients is controversial. The aim of the study was to evaluate the outcomes of transcatheter closure of secundum atrial septal defects (ASDs) in elderly patients.

Patients and methods

From a total of 488 patients with ASDs who underwent transcatheter closure, 75 patients aged over 60 years (45 female, 30 male) with a mean age of 65.3±15.7 (60–75) years were analyzed. All patients had an isolated secundum ASD with a mean pulmonary blood flow:systemic blood flow of 2.84±1.9 (1.5–3.9). Symptom-limited treadmill exercise tests with respiratory gas-exchange analysis and transthoracic color Doppler echocardiographic study, as well as quality of life measured using the Short Form (36) Health Survey (SF-36) were repeated in all patients before the procedure and after 12 months of follow-up.

Results

The atrial septal device was successfully implanted in all patients (procedure time 37.7±4.5 [13–59] minutes, fluoroscopy time 11.2±9.9 [6–40] minutes). There were no major complications. The defect echo diameter was 17.7±15.8 (12–30) mm. The mean balloon-stretched diameter of ASDs was 22.4±7.9 (14–34) mm. The diameter of the implanted devices ranged from 16 to 34 mm. Significant improvement of exercise capacity was noted at 6 and 12 months after the procedure. Exercise time within 6 months of ASD closure was longer (P<0.001) compared to baseline values, and also oxygen consumption increased (P<0.001). Seven quality-of-life parameters (except mental health) improved at 12-month follow-up compared to baseline data. The mean SF-36 scale increased significantly in 66 (88%) patients, with a mean of 46.2±19.1 (5–69). As early as 1 month after the procedure, a significant decrease of the right ventricular dimension and the right atrium dimension was observed (P<0.001). The right ventricular dimension decreased in 67 patients (89.3%).

Conclusion

Closure of ASDs in elderly patients caused significant clinical and hemodynamic improvement after percutaneous treatment, which was maintained during long-term follow-up, justifying this procedure in old age.

Electrocardiographic differences between COPD patients evaluated for lung transplantation with and without pulmonary hypertension

INTRODUCTION

Pulmonary hypertension (PH) is an indicator of poor prognosis in COPD patients; particularly in those with mean pulmonary artery pressure ≥ 40 mm Hg. Electrocardiography (ECG) might be useful for screening of this condition.

METHODS

Retrospective study of COPD patients evaluated for lung transplantation in whom we analyzed the 12-lead ECG performed closest to the time of right heart catheterization.

RESULTS

We included 142 patients. PH was present in 90 patients (63%) and 16 (11%) had a mean PAP ≥ 40 mmHg. The PR interval was longer in PH patients (151 (29) versus 139 (22) ms, p = 0.01) and T wave axis had a left shift (56.9 (32) versus 68.7 (19) degrees, p = 0.006). PR interval was longer (178.5 (35) versus 142.2 (23) ms, p = 0.001), T wave axis had a leftward deflection (63.6 (24) versus 42.8 (46) degrees, p = 0.005) and S wave in lead I was larger (0.19 (0.13) versus 0.12 (0.12) mV, p = 0.03) in patients with mean PAP ≥ 40 mmHg. A PR interval > 137 ms and S wave in DI > 0.02 mV had a sensitivity of 100% and a specificity of 59.5% to identify COPD patients with a mean PAP ≥ 40 mmHg.

CONCLUSION

There are significant ECG differences between advanced COPD patients with and without PH; however the ECG is an inadequate tool to differentiate between the groups. A prolonged PR interval suggests the presence of severe PH.

Is it worth closing the atrial septal defect in patients with insignificant shunt?

Introduction

Closure of the atrial septal defect in patients with insignificant shunt is controversial.

Aim

To evaluate the outcomes of transcatheter closure of atrial septal defect (ASD) in symptomatic patients with borderline shunt.

Material and methods

One hundred and sixty patients (120 female, 40 male) with a mean age of 30.1 ±16.2 (20–52) years with a small ASD who underwent transcatheter closure were analyzed. All patients had a small ASD with Qp: Qs ratio ≤ 1.5, mean 1.2 ±0.9 (1.1–1.5) in echo examination. Cardiopulmonary exercise tests, clinical study, transthoracic echocardiographic study as well as quality of life (QoL) (measured using the SF36 questionnaire (SF36q)) were repeated in all patients before and after the procedure.

Results

The devices were successfully implanted in all patients. After 12 months of ASD closure, all the patients showed a significant improvement of exercise capacity (oxygen consumption – 21.9 ±3.1 vs. 30.4 ±7.7, p > 0.001). The QoL improved in 7 parameters at 12-month follow-up. The mean SF36q scale increased significantly in 141 (88.1%) patients of mean 43.2 ±20.1 (7–69). A significant decrease of the right ventricular area (20.3 ±1.3 cm² vs. 18.3 ±1.2 cm², p < 0.001) and the right atrial area (15.2 ±1.9 cm² vs. 12.0 ±1.6 cm², p < 0.001) was observed at 12-month follow-up.

Conclusions

Closure of ASD in the patients with insignificant shunt resulted in significant durable clinical and hemodynamic improvement after percutaneous treatment.

Atrial septal defects

Atrial septal defects are the third most common type of congenital heart disease. Included in this group of malformations are several types of atrial communications that allow shunting of blood between the systemic and the pulmonary circulations. Most children with isolated atrial septal defects are free of symptoms, but the rates of exercise intolerance, atrial tachyarrhythmias, right ventricular dysfunction, and pulmonary hypertension increase with advancing age and life expectancy is reduced in adults with untreated defects. The risk of development of pulmonary vascular disease, a potentially lethal complication, is higher in female patients and in older adults with untreated defects. Surgical closure is safe and effective and when done before age 25 years is associated with normal life expectancy. Transcatheter closure offers a less invasive alternative for patients with a secundum defect who fulfil anatomical and size criteria. In this Seminar we review the causes, anatomy, pathophysiology, treatment, and outcomes of atrial septal defects in children and adult patients in whom this defect is the primary cardiac anomaly.

Amplatzer occluder versus CardioSEAL/STARFlex occluder: a meta-analysis of the efficacy and safety of transcatheter occlusion for patent foramen ovale and atrial septal defect

OBJECTIVE

Percutaneous transcatheter occlusion has benefited thousands of patients suffering from patent foramen ovale and atrial septal defect. However, no general agreement has been reached on the superiority among occluders. Thus, a meta-analysis between the two most commonly adopted types of occluders was conducted.

METHODS

The literature review has identified relevant studies up to May, 2011 in the databases of PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, and World Health Organization clinical trials registry centre. Meta-analysis was performed in a fixed/random effects model using Revman 5.1.1. Information on complications and outcomes was extracted.

RESULTS

Analysis from included studies reports an outcome in favour of the Amplatzer. The Amplatzer has proven its superiority in efficacy with a significantly lower risk of early (95% confidence interval = 0.09-0.34) and long-term (95% confidence interval = 0.14-0.97) residual shunt rate for atrial septal defect occlusion, although no significant difference in performance has been reported for patent foramen ovale. In addition, the Amplatzer has also remarkably reduced the risk of embolisation by the device (95% confidence interval = 0.07-0.45) for atrial septal defect and new-set atrial fibrillation (95% confidence interval = 0.18-0.48) for patent foramen ovale. On evaluation of recurrent thrombotic events, it was found that the Amplatzer greatly lowered the rate of thrombus formation on the device (95% confidence interval = 0.02-0.21) for patent foramen ovale; however, no statistical difference was found on atrial septal defect evaluation. However, the result indicated no statistically significant difference between the two kinds of occluders in stroke and transient ischaemic attack of patent foramen ovale.

CONCLUSION

The meta-analysis has proven the Amplatzer to be the superior occluder, serving better prognosis with more fluent procedure and less complications.

Enlarged right ventricular size at 11 years' follow-up after closure of secundum-type atrial septal defect in children

BACKGROUND

The fate of right ventricular dimensions after surgical closure of secundum-type atrial septal defects remains unclear. The objectives of this study were to assess ventricular dimensions, exercise capability, and arrhythmias of patients operated for secundum-type atrial septal defect and compare the results with those in healthy references.

METHODS

A total of 78 consecutive patients underwent surgical closure for a secundum-type atrial septal defect between 1990 and 1995. In all, 42 patients were included and underwent a cross-sectional evaluation including echocardiography, magnetic resonance imaging, exercise testing, and 24-hour ambulatory electrocardiography. Patients were matched with healthy controls for gender, body surface area, and age.

RESULTS

The mean age at surgery was 4.6 plus or minus 2.8 years, and the mean age at follow-up was 16 plus or minus 3 years. There were no residual intracardiac lesions. The mean right ventricular endsystolic volume was significantly larger in patients (142 ± 26 millilitres) than in references (137 ± 28 millilitres; p = 0.04). In 25% of the patients, right ventricular end-systolic volume was larger than the 95th percentile for references. No relevant arrhythmias were detected. Exercise testing did not reveal differences with healthy references: maximal power (169 ± 43 Watt patients versus 172 ± 53 controls; p = 0.8), maximal oxygen uptake (38 ± 8 versus 41 ± 13 millilitres per minute per kilogram; p = 0.1).

COMMENT

After surgical closure of secundum-type atrial septal defect, right ventricular end-systolic volume is increased. These findings have no impact on rhythm status or exercise capacity at this stage of follow-up, but may have implications for the timing of surgery or the technique of closure if confirmed in longer follow-up.

Comparative effects of surgical and percutaneous repair on P-wave and atrioventricular conduction in patients with atrial septal defect--ostium secundum type

Both surgical and percutaneous closures of atrial septal defects have been successful in reversal of atrial dilatation. We compared the effects of surgical and percutaneous transvenous device closure of atrial septal defect on post-operative changes of P-wave duration, PR segment, and PR interval. Electrocardiographic data were prospectively collected from 30 patients following either surgical (n equal to 16) or percutaneous (n equal to 16) repair of atrial septal defects between 2004 and 2010. A cardiologist blinded to the closure technique performed the electrocardiographic analyses. P-wave duration (98.5 plus or minus 15.4 to 86.4 plus or minus 13.2 milliseconds, p-value less than 0.05) and PR interval (162.9 plus or minus 18.5 to 140.6 plus or minus 15.2 milliseconds, p-value less than 0.05) were reduced after percutaneous transvenous device closure. P-wave duration (104.5 plus or minus 24.7 versus 83.2 plus or minus 13.3 milliseconds, p-value less than 0.05) and PR interval (173.2 plus or minus 38.7 versus 144.3 plus or minus 32.0 milliseconds, p-value less than 0.05) were also reduced after surgical closure. PR segment in the percutaneous group was significantly reduced (63.4 plus or minus 14.5 to 52.1 plus or minus 10.8 milliseconds, p-value less than 0.05), but not in the surgical group (68.6 plus or minus 18.7 versus 61.1 plus or minus 24.7 milliseconds). However, the difference in PR segment changes between the two groups was not significant (-11.3 plus or minus 15.0 versus -7.6 plus or minus 20.5 milliseconds, p-value equal to 0.18). Our analysis demonstrates that the changes between the two groups were not different and that both closure techniques reduce P-wave duration, PR segment, and PR interval within 6 months.