Efficacy and Safety of Transthoracic Echocardiography Alone in Transcatheter Closure of Secundum-Type Atrial Septal Defects in Adults

Comparison of the efficacy and safety of sedation protocols with the use of dexmedetomidine-remifentanil and propofol-remifentanil during percutaneous closure of atrial septal defects: a randomized clinical trial

Background

The study was aimed to compare the efficacy and safety of different sedation protocols of dexmedetomidine–remifentanil and propofol–remifentanil for percutaneous closure of atrial septal defects (ASD) under transthoracic echocardiography (TTE) guidance.

Material and methods

From March 2020 to January 2021, of 114 patients screened, 59 ASD patients scheduled for percutaneous closure under TTE guidance were randomly allocated into the dexmedetomidine–remifentanil (D–R) group (n = 29) and the propofol–remifentanil (P–R) group (n = 30). The incidence of hemodynamic and respiratory adverse events, arterial blood gas analysis, induction and recovery time, pain score, infusion rate of remifentanil, satisfaction of the surgeon and patient, additional sedatives were collected for analysis and comparison.

Results

The induction time was longer in the D–R group than that in the P–R group (17.66 ± 2.65 min vs 11.43 ± 1.48 min; difference, 6.22 min; 95% CI 5.10 to 7.35; P < 0.001). No differences were observed in the 2 groups in terms of the additional sedatives, infusion rate of remifentanil, pain score, recovery time (P > 0.05). There was no difference between the two groups regarding the incidence of cardiovascular adverse events (6 [20.7%] vs 4 [13.3%]; difference, 7.4%; 95% CI − 11.7 to 26.5%; P = 0.506). Respiratory adverse events occurred in 1 patient (3.4%) in the D–R group, and 8 patients (26.7%) in the P–R group (difference, 23.3%; 95% CI 6.2 to 40.5%; P = 0.026). The incidence of hypercapnia was significantly lower in the D–R group (4 [13.8%]) than in the P–R group (13 [43.3%]; difference, 29.5%; 95% CI 7.8 to 51.2%; P = 0.012).

Conclusions

Except for more rapid the induction time and higher the surgeon satisfaction score in the propofol–remifentanil protocol, the efficacy was similar between two sedation protocols. The hemodynamic stability was comparable, the dexmedetomidine–remifentanil protocol had superior airway security due to fewer hypercapnia and respiratory adverse events.

Midazolam for conscious sedation in transcatheter device closure of atrial septal defects guided solely by transthoracic echocardiography

OBJECTIVES

To investigate the safety and feasibility of midazolam for conscious sedation in transcatheter device closure of atrial septal defects guided solely by transthoracic echocardiography.

METHODS

A retrospective analysis was performed on 55 patients who underwent transcatheter device closure of atrial septal defects from October, 2019 to May, 2020. All patients received intravenous midazolam and local anesthesia with lidocaine to maintain sedation. A group of previous patients with unpublished data who underwent the same procedure with general anesthesia was set as the control group. The relevant clinical parameters, the Ramsay sedation scores, the numerical rating scale, and the post-operative satisfaction questionnaire were recorded and analyzed.

RESULTS

In the midazolam group, the success rate of atrial septal defect closure was 98.2%. Hemodynamic stability was observed during the procedure. None of the patients needed additional endotracheal intubation for general anesthesia. Compared with the control group, the midazolam group had no statistically significant differences in the Ramsay sedation score and numerical rating scale scores. Patients in the midazolam group experienced more post-operative satisfaction than those in the control group.

CONCLUSIONS

Conscious sedation using midazolam is a safe and effective anesthetic technique for transcatheter device closure of atrial septal defects guided solely by transthoracic echocardiography.

Transcatheter device closure of atrial septal defects guided completely by transthoracic echocardiography: A single cardiac center experience with 152 cases

Objective:

This study aimed to assess the safety and feasibility of transcatheter device closure of atrial septal defects (ASDs) guided completely by transthoracic echocardiography (TTE).

Methods:

A total of 152 patients underwent transcatheter device closure of ASDs guided completely by TTE in our center from September 2014 to June 2017. We used routine delivery sheaths during the procedure and then closed the ASDs by releasing a domestic occluder.

Results:

The closure was successful in 150 patients, and surgical repair was required in two patients. The size of the deployed occluder ranged from 10 mm to 38 mm (21.4±8.5 mm), and the procedure duration ranged from 30 to 90 min (38.2±21.4 min). No fatal complications were observed. Minor complications included transient arrhythmias (n=12) during the process of device deployment. The follow-up period was 3 months to 2 years, with no occluder dislodgment, residual fistula, or thrombus-related complications. In our comparative studies, no statistically significant differences were observed in success rates and complications.

Conclusion:

Transcatheter device closure of ASDs guided completely by TTE may be safe and effective and can be an alternative to traditional methods.

Cryptogenic Stroke: To Close a Patent Foramen Ovale or Not to Close?

A patent foramen ovale (PFO) has been shown to be highly prevalent in patients diagnosed with strokes of unknown cause, which are also called cryptogenic strokes (CSs). It has been a long-running controversy as to whether a PFO should be closed or not to prevent recurrent strokes in patients diagnosed with CS. A paradoxical embolism that is produced through a PFO is hypothesized to be a leading cause of CS, especially in younger patients with low risk factors for stroke. It remains controversial as to which anticoagulation therapy, defined as antithrombin or antiplatelet therapy, is better for patients with CS and a PFO. In addition, surgical and transcutaneous closure of a PFO has been proposed for the secondary prevention of stroke in patients with CS with PFO. Several randomized controlled trials have been conducted in recent years to test whether a PFO closure gives a significant benefit in the management of CS. Three earlier randomized controlled trials failed to show a statistically significant benefit for a PFO closure; thus, many investigators believed that a PFO was an incidental bystander in patients with CS. However, meta-analyses and more recent specific trials have eliminated several confounding factors and possible biases and have also emphasized the use of a shunt closure over medical therapy in patients with CS. Therefore, these latest studies (the CLOSE and REDUCE trials) can possibly change the treatment paradigm in the near future.

Safety and efficacy of transthoracic versus transesophageal echocardiography in transcatheter closure of atrial septal defects. Reporting a single center experience from Saudi Arabia

Objectives:

To assess the safety and effectiveness of transthoracic echocardiography (TTE) in monitoring transcatheter closure of atrial septal defect (ASD), in comparison with conventional technique using transesophageal echocardiography (TEE).

Methods:

A retrospective review of all cases of transcatheter closure of isolated ostium secundum ASDs operated from 2005 to 2015, at the Pediatric Interventional Cardiology Department, King Abdulaziz University Hospital, Jeddah, Kingdom of Saudi Arabia. Exclusion criteria included age ≤3 years at the time of the procedure and rim size ≤3 mm. Patients were divided into 2 groups: TTE and TEE group. Demographic and clinical baseline data, procedure data, and outcomes were compared between the 2 groups.

Results:

We included 77 cases: 45 in TTE group and 28 in TEE (mean ± standard deviation age=8.18 ± 5.85 versus 17.68 ± 14.88), with no significant difference in ASD size, rim adequacy, or other anatomical difficulties. All (100%) patients in TEE group underwent general anesthesia, versus 8.9% in TTE group. Device deployment was comparably successful (97.8% versus 92.9%, p=0.554); while procedure time (76.27 ± 31.80 versus 119.85 ± 19.90 minutes, p<0.001) and fluoroscopy time (11.29 ± 9.04 versus 18.73 ± 11.54 minutes, p=0.003) were significantly reduced in TTE versus TEE. Prevalence of postprocedural complications was comparable in the 2 groups.

Conclusion:

Transthoracic echocardiography has non-inferior efficacy in device deployment with reference to TEE and superior safety features including significant reduction of procedure and fluoroscopy times and lesser use of general anesthesia.

Comparative study of the transcatheter and transthoracic device closure treatments for atrial septal defect: A Chinese single-institution experience

The purpose of this study was to compare patient populations, safety, feasibility, complications, and total costs of the transcatheter and transthoracic device closure treatments for secundum atrial septal defect.From January 2014 to December 2014, we enrolled 155 patients with secundum atrial septal defects in our hospital. The patients were divided into 2 groups: the 70 patients in group A underwent transcatheter device closure, and the 85 patients in group B underwent transthoracic intraoperative device closure with a right lateral mini-thoracotomy.In group A, the total occlusion rate was 94.3% immediately after the operation, 100% at 3 months, and 100% at 12 months of follow-up; the group A results were not statistically different from the group B results (94.1%, 98.8%, 98.8%, respectively). There was a statistically significant difference in the minor complication rate (P < 0.05), and there were no reported deaths. There was a greater indicated scope using the transthoracic closure device to treat atrial septal defects. In our comparative study, the patients in group B had longer intensive care unit stays and hospital stays than group A (P < 0.05).Both of the device closure treatment options for secundum atrial septal defect are safe and feasible. The transcatheter device closure approach has the advantages of more cosmetic results, less trauma, and a shorter hospital stay than the transthoracic approach. On the contrary, the transthoracic closure device is an economical alternative choice, particularly for patients who are not eligible for the transcatheter closure device.