Echocardiographic correlates of severe pulmonary hypertension in adult patients with ostium secundum atrial septal defect

Operability of atrial septal defect with borderline pulmonary vascular resistance index: A study in developing country

Background

Pulmonary arterial hypertension secondary to atrial septal defect (ASD) is an important determinant of morbidity and mortality in defect closure. We aimed to compare perioperative outcome between preoperative borderline and low pulmonary vascular resistance index (≥4 WU.m2 and <4 WU.m2, respectively) in surgical closure of secundum atrial septal defect with concomitant pulmonary arterial hypertension.

Methods and results

This was a single-center retrospective cohort study between January 2015 and January 2020. We classified patients with low and borderline PVRI who underwent ASD closure and recorded the perioperative outcomes.

Results

We analyzed a total of 183 patients with atrial septal defect and pulmonary arterial hypertension; 92 patients with borderline PVRI and 91 patients with low PVRI. Borderline pulmonary vascular resistance index was not associated with increased risk of postoperative mortality (p = 0.621; OR0.48, 95% CI 0.04–5.48), but associated with higher risk of overall morbidity in bivariate analysis (p = 0.002; OR3.28, 95% CI 1.5–6.72). Multivariate analysis showed positive association of borderline pulmonary vascular resistance index (p = 0.045; OR2.63, 95% CI 1.02–6.77) and preoperative tricuspid valve gradient ≥64 mmHg (p = 0.034; OR2.77, 95% CI 1.08–7.13) with overall morbidity.

Conclusion

There is no difference in incidence of in-hospital mortality between preoperative borderline and low pulmonary vascular resistance index patients. However, preoperative borderline pulmonary vascular resistance index and tricuspid valve gradient ≥64 mmHg are associated with increased overall morbidity after surgical closure in secundum atrial septal defect patients with pulmonary arterial hypertension.

Long-Term Outcomes in Adult Patients With Pulmonary Hypertension After Percutaneous Closure of Atrial Septal Defects

BACKGROUND

Pulmonary hypertension (PH), recently redefined as mean pulmonary arterial pressure >20 mm Hg (PH₂₀), may be observed in patients with atrial septal defects (ASD). We aimed to determine the effect of preprocedural PH₂₀ status on outcomes among patients undergoing ASD closure.

METHODS

Study population was selected from a retrospective registry of adult patients who underwent percutaneous ASD closure from 1998 to 2016 from a single center and had right heart catheterizations during the procedure. The clinical registry was linked to administrative databases to capture short- and long-term outcomes.

RESULTS

We included a total of 632 ASD closure patients of whom 359 (56.8%) had PH₂₀. The mean follow-up length was 7.6±4.6 years. Patients with PH₂₀ were older (mean age 56.5 versus 43.1 years, P<0.001) and a higher prevalence of comorbidities including hypertension (54.3% versus 21.6%, P<0.001) and diabetes (18.1% versus 5.9%, P<0.001) than those without PH. In a Cox proportional hazards model after covariate adjustment, patients with PH had a significantly higher risk of developing major adverse cardiac and cerebrovascular events (heart failure, stroke, myocardial infarction, or cardiovascular mortality), with hazards ratio 2.45 (95% CI, 1.4-4.4). When applying the prior, mean pulmonary arterial pressure ≥25 mm Hg (PH₂₅) cutoff, a significantly higher hazard of developing major adverse cardiac and cerebrovascular events was observed in PH versus non-PH patients.

CONCLUSIONS

ASD patients with PH undergoing closure suffer from more comorbidities and worse long-term major adverse cardiac and cerebrovascular events outcomes, compared with patients without PH. The use of the new PH₂₀ definition potentially dilutes the effect of this serious condition on outcomes in this population.

Preoperative coupling between right ventricle and pulmonary vasculature is an important determinant of residual symptoms after the closure of atrial septal defect

PURPOSES

The closure of atrial septal defect (ASD) is associated with a significant reduction in right ventricular (RV) overload and an improvement in functional capacity in most adults with ASD. However, a subset of patients remains symptomatic even after closure due to therapeutic delay. To date, no clinically robust preoperative predictor of postoperative residual symptoms has been clearly identified.

METHODS

In this study, 120 adult patients with ASD and 39 controls were investigated. As an index of RV myocardial deformation, RV global longitudinal strain (RV-GLS) was evaluated. The degree of coupling between RV and pulmonary artery (PA) was quantified by the tricuspid annular plane systolic excursion (TAPSE) divided by the PA systolic pressure (PASP).

RESULTS

Compared to controls, baseline RV-GLS was significantly greater (- 27 ± 7 vs. - 23 ± 5%, P = 0.02) and TAPSE/PASP ratio was severely impaired (0.8 ± 0.3 vs. 2.1 ± 1.6 mm/mmHg, P < 0.01) in ASD patients. At 6 months after closure, 15 patients (12.5%) remained symptomatic. In patients without residual symptoms, TAPSE/PASP ratio significantly improved from 0.9 ± 0.3 to 1.0 ± 0.6 mm/mmHg (P = 0.02), and RV-GLS normalized (from - 28 ± 11 to - 24 ± 7%, P < 0.01) after closure. However, RV-GLS and TAPSE/PASP ratio showed no significant change in ASD patients with residual symptoms. On multivariate analysis, preoperative TAPSE/PASP ratio (odds ratio [OR] 0.034, 95% confidence interval [CI] 0.000-0.604, P = 0.03) and pulmonary vascular resistance index ([PVRI], OR 1.011, 95% CI 1.000-1.021, P < 0.05) were associated with the postoperative symptomatic status.

CONCLUSION

In terms of integrated assessment of the RV-PA unit, preoperative TAPSE/PASP ratio and PVRI were important determinants of residual symptoms after ASD closure.

How to diagnose heart failure with preserved ejection fraction: the HFA-PEFF diagnostic algorithm: a consensus recommendation from the Heart Failure Association (HFA) of the European Society of Cardiology (ESC)

Making a firm diagnosis of chronic heart failure with preserved ejection fraction (HFpEF) remains a challenge. We recommend a new stepwise diagnostic process, the 'HFA-PEFF diagnostic algorithm'. Step 1 (P=Pre-test assessment) is typically performed in the ambulatory setting and includes assessment for HF symptoms and signs, typical clinical demographics (obesity, hypertension, diabetes mellitus, elderly, atrial fibrillation), and diagnostic laboratory tests, electrocardiogram, and echocardiography. In the absence of overt non-cardiac causes of breathlessness, HFpEF can be suspected if there is a normal left ventricular ejection fraction, no significant heart valve disease or cardiac ischaemia, and at least one typical risk factor. Elevated natriuretic peptides support, but normal levels do not exclude a diagnosis of HFpEF. The second step (E: Echocardiography and Natriuretic Peptide Score) requires comprehensive echocardiography and is typically performed by a cardiologist. Measures include mitral annular early diastolic velocity (e'), left ventricular (LV) filling pressure estimated using E/e', left atrial volume index, LV mass index, LV relative wall thickness, tricuspid regurgitation velocity, LV global longitudinal systolic strain, and serum natriuretic peptide levels. Major (2 points) and Minor (1 point) criteria were defined from these measures. A score ≥5 points implies definite HFpEF; ≤1 point makes HFpEF unlikely. An intermediate score (2-4 points) implies diagnostic uncertainty, in which case Step 3 (F1: Functional testing) is recommended with echocardiographic or invasive haemodynamic exercise stress tests. Step 4 (F2: Final aetiology) is recommended to establish a possible specific cause of HFpEF or alternative explanations. Further research is needed for a better classification of HFpEF.

How to diagnose heart failure with preserved ejection fraction: the HFA-PEFF diagnostic algorithm: a consensus recommendation from the Heart Failure Association (HFA) of the European Society of Cardiology (ESC)

Making a firm diagnosis of chronic heart failure with preserved ejection fraction (HFpEF) remains a challenge. We recommend a new stepwise diagnostic process, the 'HFA-PEFF diagnostic algorithm'. Step 1 (P=Pre-test assessment) is typically performed in the ambulatory setting and includes assessment for heart failure symptoms and signs, typical clinical demographics (obesity, hypertension, diabetes mellitus, elderly, atrial fibrillation), and diagnostic laboratory tests, electrocardiogram, and echocardiography. In the absence of overt non-cardiac causes of breathlessness, HFpEF can be suspected if there is a normal left ventricular (LV) ejection fraction, no significant heart valve disease or cardiac ischaemia, and at least one typical risk factor. Elevated natriuretic peptides support, but normal levels do not exclude a diagnosis of HFpEF. The second step (E: Echocardiography and Natriuretic Peptide Score) requires comprehensive echocardiography and is typically performed by a cardiologist. Measures include mitral annular early diastolic velocity (e'), LV filling pressure estimated using E/e', left atrial volume index, LV mass index, LV relative wall thickness, tricuspid regurgitation velocity, LV global longitudinal systolic strain, and serum natriuretic peptide levels. Major (2 points) and Minor (1 point) criteria were defined from these measures. A score ≥5 points implies definite HFpEF; ≤1 point makes HFpEF unlikely. An intermediate score (2-4 points) implies diagnostic uncertainty, in which case Step 3 (F₁ : Functional testing) is recommended with echocardiographic or invasive haemodynamic exercise stress tests. Step 4 (F₂ : Final aetiology) is recommended to establish a possible specific cause of HFpEF or alternative explanations. Further research is needed for a better classification of HFpEF.

Impact of Pulmonary Hypertension on Survival Following Device Closure of Atrial Septal Defects

Pulmonary hypertension (PH), defined as mean pulmonary arterial pressure ≥25 mm Hg, may be a complication of a secundum atrial septal defect (ASD). This study sought to evaluate the impact of PH at time of ASD device closure on patient survival. A prospectively collected database of ASD closures was utilized. Patients were stratified by age above and below the cohort median (48 years). Survival was analyzed by preprocedural PH status, age cohort, and echocardiographic resolution of PH at 3 months postdevice closure. PH was present in 48 of 228 patients (21.1%) and was more common in the older cohort (31.3% vs 10.6%, p <0.01). ASD size was unrelated to the presence of PH (p = 0.33). Older patients had more medical co-morbidities including diabetes (p = 0.02), hyperlipidemia (p <0.01), and systemic hypertension (p <0.01) compared with younger patients. PH did not impact survival in patients ≤48 years, but PH was associated with fivefold increased risk of death in patients >48 years (p < 0.01). Patients with preprocedural PH and RVSP ≥40 mm Hg at 3-month follow-up continued to have an increased risk of mortality (p <0.01), whereas those with resolution of PH had similar survival to those without PH at time of closure. In conclusion, PH is common in adults with unrepaired ASDs and appears unrelated to defect size. PH in older adults and its persistence closure are strong predictors of a worsened clinical outcome. These patients may benefit from additional risk assessment and advanced medical therapies to mitigate this risk.

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.

Pathophysiology and natural history of atrial septal defect

Atrial septal defects are among the third most common types of congenital heart disease. This group of malformations includes several types of atrial communications allowing shunting of blood between the systemic and the pulmonary circulations. The nature of shunting across the defect in patients with atrial septal defect is of particular interest. Understanding the underlying mechanisms of interatrial shunts and their natural history will help selecting the best timing for closure, before irreversible cardiac and pulmonary injury occur. This review describes the different pathophysiologic mechanisms involved in the direction and magnitude of blood flow through atrial septal defects. The natural history of an individual born with an isolated atrial septal defect is then discussed, including the impact of a longstanding shunt on survival.

Pulmonary hypertension in congenital heart disease

Pulmonary hypertension is defined as a mean pulmonary arterial pressure ≥25 mmHg. We focus on its relevance in congenital heart disease, reviewing pathophysiology, diagnosis and management. Pulmonary hypertension is a relatively common complication of congenital heart disease, with adult prevalence between 5 and 10%. A multifactorial cause is recognized, relating to the size and nature of cardiac defect as well as environmental and genetic factors. More complex disease is increasingly recognized rather than pure Eisenmenger complex. Remodeling of the pulmonary vascular bed causes increased pulmonary vascular resistance diagnosed by a collection of investigations including echocardiography, exercise testing, cardiac catheterization, MRI and CT scanning. Management employs disease-modifying medications which are now used with increasing benefit.