Atrial septal defect and patent foramen ovale closure- complication profile of approved Gore Occluders

BACKGROUND

Patent foramen ovale and atrial septal defect are among the most common congenital heart diseases. When they are symptomatic, either pharmacologic or percutaneous/surgical treatment should be considered. The aim of this study was to investigate the post-approval complication profiles of the Gore Cardioform and Gore Helex devices based on the Manufacturer and User Facility Device Experience database.

METHODS

A search of the Manufacturer and User Facility Device Experience Database was performed to identify reports of complications following the closure of atrial septal defects with Gore devices. 401 reports met inclusion criteria, including 204 patients with Gore Cardioform Septal Occluder, 146 patients with Gore Cardioform ASD Occluder, and 51 patients with Gore Helex Septal Occluder.

RESULTS

The number of adverse events related to device problems contributed to 51.4 % of reported complications (n = 206), which mostly consisted of embolism of the device (n = 140). There were 3 reported cases of death, with 2 linked to device embolization. Most reports concerned devices sized 25 and 30 mm although only 313 reports (78.1 %) had information about size available. 54 cases of pericardial effusion and 14 cases of perforation were reported. Multiple postoperative arrhythmias were reported (n = 80), with the majority of them being atrial fibrillation (n = 39) or heart block (n = 18).

CONCLUSIONS

No cardiac erosions linked to Gore devices were found throughout our analysis, supporting earlier literature findings. The investigated devices and their sizes varied in terms of complication profiles.

Brazilian Guideline for Exercise Testing in Children and Adolescents - 2024

CLASSES OF RECOMMENDATION

LEVELS OF EVIDENCE

Impact of Gore Cardioform Atrial Septal Defect Occluder on Atrial and Ventricular Electromechanics in a Pediatric Population

Transcatheter closure is the first-line treatment for ostium secundum atrial septal defect (ASD). The GORE Cardioform ASD Occluder (GCA) is potentially innovative compared with other self-centering devices. This study aimed to compare the mechanic changes in atrial and ventricular properties before and after GCA implantation. All consecutive patients aged <18 years who underwent isolated ASD closure with a single GCA device were enrolled from 2 centers. Echocardiography and electrocardiogram were performed the day before, 24 hours, and 6 months after ASD closure. Between January 2020 and February 2021, 70 pediatric patients with ASD were enrolled. The mean age was 7.9 ± 3.9 years, and the mean defect diameter was 17.1 ± 4.5 mm. Global longitudinal strain analysis showed no change in left ventricular longitudinal function (T0 -23.2 ± 2.8%, 24 hours -23.0 ± 2.8%, and 6 months -23.5 ± 2.7%). An early and transient reduction in longitudinal strain was detected in the basal septal segments (T0 -19.8 ± 3.3%, 24 hours -18.7 ± 3.6%, and 6 months -19.2 ± 3.4%), left atrium (T0 41.4 ± 15.3%, 29.2 ± 1.4%, and 39.0 ± 12.9%), and right ventricle (-27.6 ± 5.4%, -23.6 ± 5.0%, and -27.3 ± 4.6) 24 hours after closure, secondary to hemodynamic changes because of flow redirection after ASD closure. Six months after the procedure, only the left atrium showed a mild global longitudinal strain reduction because of the presence of the device within the septum. GCA device had no impact on global and regional ventricular function. Atrial mechanics were preserved, except for the segments covered by the device. This is the first device demonstrating no impact on the left and right ventricular mechanics, irrespective of the device size.

Arrhythmic Risk and Treatment after Transcatheter Atrial Septal Defect Closure

Atrial septal defect (ASD) represents the most common congenital heart defect identified in adulthood. Atrial and ventricular geometric remodeling due to intracardiac shunt increase the risk of arrhythmias, especially atrial fibrillation (AF). Clinical, echocardiography, electrocardiogram, and device-related predictors may be used to assess the risk of atrial arrhythmias after ASD closure. The underlying mechanisms in these patients are complex and at least in part independent of the structural remodeling secondary to hemodynamic overload. Device closure of the ASD itself and its timing impact future arrhythmia risk, as well as posing a challenge for when transseptal puncture is required. Sudden cardiac death (SCD) risk is higher than in the general population and an implantable cardioverter-defibrillator (ICD) may be indicated in selected cases.

Prediction of arrhythmia after intervention in children with atrial septal defect based on random forest

BACKGROUND

Using random forest to predict arrhythmia after intervention in children with atrial septal defect.

METHODS

We constructed a prediction model of complications after interventional closure for children with atrial septal defect. The model was based on random forest, and it solved the need for postoperative arrhythmia risk prediction and assisted clinicians and patients' families to make preoperative decisions.

RESULTS

Available risk prediction models provided patients with specific risk factor assessments, we used Synthetic Minority Oversampling Technique algorithm and random forest machine learning to propose a prediction model, and got a prediction accuracy of 94.65 % and an Area Under Curve value of 0.8956.

CONCLUSIONS

Our study was based on the model constructed by random forest, which can effectively predict the complications of arrhythmia after interventional closure in children with atrial septal defect.

Percutaneous secundum atrial septal defect closure for the treatment of atrial arrhythmia in the adult: A meta-analysis

BACKGROUND

Atrial arrhythmias are common in patients with atrial septal defects (ASD) but the effects of percutaneous closure on atrial arrhythmia prevalence is unclear. We investigated the effects of ASD device closure and the impact of age at time of closure on prevalent atrial arrythmia.

METHODS

Meta-analysis of studies reporting atrial arrhythmia prevalence in adult patients before and after percutaneous closure was performed. Primary outcomes were prevalence of 'all atrial arrhythmia' and atrial fibrillation alone post closure. Sub-group analysis examined the effects of closure according to age in patients; <40 years, ≥40 and ≥ 60 years. 25 studies were included.

RESULTS

Meta-analysis of all studies demonstrated no reduction in all atrial arrhythmia or atrial fibrillation prevalence post-closure (OR 0.855, 95% CI 0.672 to 1.087, P = .201 and OR 0.818, 95% CI 0.645 to 1.038, P = .099, respectively). A weak reduction in all atrial arrhythmia and atrial fibrillation was seen in patients ≥40 years (OR 0.77, 95% CI 0.616 to 0.979, P = .032 and OR 0.760, 95% CI 0.6 to 0.964, P = .024, respectively) but not ≥60 years (OR 0.822, 95% CI 0.593 to 1.141, P = .242 and OR 0.83, 95% CI 0.598 to 1.152, P = .266, respectively). No data were available in patients <40 years. This, and other limitations, prevents conclusive assessment of the effect of age on arrhythmia prevalence.

CONCLUSIONS

Overall, percutaneous ASD closure is not associated with a reduction in atrial arrhythmia prevalence in this meta-analysis. A weak benefit is seen in patients ≥40 years of age, not present in patients ≥60 years.

Persistent atypical atrial flutter after device closure of the atrial septal defect in a young man

Atrial flutter is uncommon in young patients with uncorrected atrial septal defect (ASD). Although rare, it has been reported in the younger population following device closure of ASD/patent foramen ovale. We describe a case of persistent atypical atrial flutter following device closure of ASD in a young man and discuss the management strategy given the various underlying dilemmas.

"One-stop shop": safety and efficacy of combining atrial septal defect occlusion and left atrial appendage closure for patients with atrial septal defect and atrial fibrillation

Background

One-stop occlusion, which is defined as the combination of atrial septal defect [ASD] or patent foramen ovale [PFO] occlusion and left atrial appendage [LAA] closure, in patients with ASD/PFO and atrial fibrillation (AF) has not yet been investigated systematically. This study aimed to evaluate the safety and efficacy of one-stop occlusion in the treatment of adult patients with ASD/PFO and AF.

Methods

Inpatients with AF and ASD/PFO were recruited between August 2014 and April 2019. Preoperatively, transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) were conducted to identify the ASD/PFO size and margin, presence of thrombus in the LAA, and LAA orifice width and depth at 0°, 45°, 90°, and 135°. After confirmation of the indications of LAA closure (LAAC) and ASD/PFO occlusion, the procedures were performed simultaneously under general anesthesia. Oral anticoagulants were administered for 45–60 days, followed with regular evaluation of TTE and TEE.

Results

Forty-nine patients (age, 65.6 ± 9.6 years) were recruited in this study, including 24 patients with ASD and 25 patients with PFO. They were treated with LAAC and ASD/PFO occlusion successfully. The mean ASD size and mean diameter of the ASD occluders were 14.2 ± 7.7 and 25.4 ± 8.5 mm, respectively. The mean PFO size was 3.5 ± 0.4 mm. The mean maximal LAA orifice width and depth were 20.5 ± 3.4 and 28.3 ± 3.6 mm, respectively. All patients were implanted with a Watchman device (diameter, 27.1 ± 2.9 mm). Postoperatively, all patients took anticoagulants orally for 45–60 days, and their mean postoperative follow-up duration was 29.0 ± 12.1 months. Postoperative TEE showed that all had normal positioning of the LAA and ASD/PFO occluders. At 45–60 days after operation, TEE showed that the LAA and ASD/PFO occluder were in the normal position; however, two patients who took warfarin and novel oral anticoagulants, respectively, have developed occluder thrombosis. After adjusted anticoagulant therapy, TEE showed that the thrombus disappeared at 6 months after operation.

Conclusion

One-stop occlusion is safe and effective for the treatment of adult patients with ASD/PFO and AF. It is also feasible to administer warfarin or novel oral anticoagulants after operation.

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.

Microtransesophageal Echocardiographic Guidance during Percutaneous Interatrial Septal Closure without General Anaesthesia

Objective

To study the safety and efficacy of microtransesophageal echocardiography (micro-TEE) and TEE during percutaneous atrial septal defect (ASD) and patent foramen ovale (PFO) closure.

Background

TEE has proven to be safe during ASD and PFO closure under general anaesthesia. Micro-TEE makes it possible to perform these procedures under local anaesthesia. We are the first to describe the safety and efficacy of micro-TEE for percutaneous closure.

Methods

All consecutive patients who underwent ASD and PFO closure between 2013 and 2018 were included. The periprocedural complications were registered. Residual shunts were diagnosed using transthoracic contrast echocardiography (TTCE). All data were compared between the use of TEE or micro-TEE within the ASD and PFO groups separately.

Results

In total, 82 patients underwent ASD closure, 46 patients (49.1 ± 15.0 years) with TEE and 36 patients (47.8 ± 12.1 years) using micro-TEE guidance. Median device diameter was, respectively, 26 mm (range 10–40 mm) and 27 mm (range 10–35 mm). PFO closure was performed in 120 patients, 55 patients (48.6 ± 9.2 years, median device diameter 25 mm, range 23–35 mm) with TEE and 65 patients (mean age 51.0 ± 11.8 years, median device diameter 27 mm, range 23–35 mm) using micro-TEE. There were no major periprocedural complications, especially no device embolizations within all groups. Six months after closure, there was no significant difference in left-to-right shunt after ASD closure and no significant difference in right-to-left shunt after PFO closure using TEE or micro-TEE.

Conclusion

Micro-TEE guidance without general anaesthesia during percutaneous ASD and PFO closure is as safe as TEE, without a significant difference in the residual shunt rate after closure.

Impact of additional annuloplasty on tricuspid valve and cardiac functions after atrial septal defect closure in adults

BACKGROUND

Surgical indications for moderate to severe tricuspid regurgitation (TR) during atrial septal defect (ASD) closure are still unclear. Additional tricuspid valve annuloplasty (TVP) can be beneficial to avoid postoperative persistent TR. Therefore, we compared the results of surgical ASD closure with or without additional TVP in patients who presented with moderate-to-severe TR.

METHODS

Between November 2009 and June 2016, 103 patients with ASD and moderate-to-severe TR underwent surgical ASD closure without (n = 76, group 1) and with additional TVP (n = 27, group 2). Clinical outcomes and echocardiographic data were analyzed.

RESULTS

There was no mortality. Postoperative outcomes were similar despite significantly longer aortic clamping time in group 2 (P = .003). Mean TR grade, right atrial diameter, right ventricular end-diastolic diameter, pulmonary artery pressure, and Qp/Qs ratio decreased significantly in both groups (P < .05). Mean follow-up time was 5.3 months (range: 1 month-6.2 years) in group 1 and 6.1 months (range: 1 month-4.1 years) in group 2 (P = .66). Echocardiography results showed significant decrease in TR grade in both groups (P = .93). The incidence of persistent moderate to severe TR was higher in isolated ASD closure group (14.4% vs 3.7%, P = .086). Additional TVP provided greater regression in TR grade (-1.49 ± 0.9 vs -1.89 ± 0.8, P = .041).

CONCLUSION

Despite TVP being associated with longer ischemic time, postoperative outcomes were comparable to ASD closure alone. Both approach demonstrated an effective decrease in TR, but TVP provided greater regression and lower incidence of persistent TR. Therefore, additional TVP should be considered in patients undergoing ASD closure with moderate-to-severe TR.

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.

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.

Strengths, Limitations, and Geographical Discrepancies in the Eligibility Criteria for Sport Participation in Young Patients With Congenital Heart Disease

OBJECTIVE

Benefits of physical activity has been shown in children with congenital heart disease (CHD). In several forms of CHD, the risk of sudden death remains a major concern both for parents and clinicians, who in turn will have to consider the risk-benefit ratio of sport participation versus restriction.

DATA SOURCE

A literature search was performed within the National Library of Medicine using the keywords: Sport, CHD, and Eligibility. The search was further refined by adding the keywords: Children, Adult, and Criteria.

MAIN RESULTS

Fifteen published studies evaluating sport eligibility criteria in CHD were included. Seven documents from various scientific societies have been published in the past decade but which of them should be adopted remains unclear. Our research highlighted accuracy and consistency of the latest documents; however, differences have emerged between the US and European recommendations. Eligibility criteria were consistent between countries for simple congenital heart defects, whereas there are discrepancies for borderline conditions including moderate valvular lesions and mild or moderate residual defects after CHD repair. Furthermore, some of the more severe defects were not evaluated. Multiple recommendations have been made for the same CHD, and cut-off values used to define disease severity have varied. Published eligibility criteria have mainly focused on competitive sports. Little attention was paid to recreational activities, and the psychosocial consequences of activity restriction were seldom evaluated.

CONCLUSIONS

Comprehensive consensus recommendations for sport eligibility evaluating all CHD types and stages of repair are needed. These should include competitive and recreational activities, use standardized classifications to grade disease severity, and address the consequences of restriction.

Value of the Ratio of Occluder Versus Atrial Septal Length for Predicting Arrhythmia Occurrence after Transcatheter Closure in Children with Ostium Secundum Atrial Septal Defect

Background:

Transcatheter occlusion has been applied to treat ostium secundum atrial septal defect (OS ASD) since 1997. During the clinical practice, several postoperative complications including arrhythmia have been reported. This study aimed to evaluate the value of the ratio of atrial septal occluder (ASO) versus atrial septal length (ASL) for predicting arrhythmia occurrence after transcatheter closure in children with OS ASD.

Methods:

Six hundred and fifty-one children diagnosed with OS ASD underwent occlusion procedures after completing routine examinations. The onsets and types of arrhythmia both during and after the occlusion procedures were monitored. Treatments were given based on the individual types of arrhythmia. The binary logistic regression analysis and receiver-operating characteristic (ROC) curve were used in the analysis of value of the ratio of ASO/ASL for predicting postoperative arrhythmia occurrence.

Results:

Transcather occlusions were conducted in 651 children, among whom 7 children had different types and degrees of arrhythmia, with an incidence of 1.1%. The types of arrhythmia included sinus bradycardia, atrial premature beats, bundle branch block, and different degrees of atrioventricular block. Normal electrocardiograph findings were resumed in these 7 patients following active therapies such as corticoids, nutrition, and surgeries. The binary logistic regression and ROC analysis suggested that the ratio of ASO/ASL exhibited an intermediate predictive value for predicting arrhythmia occurrence after occlusion procedures. A cut-off value of 0.576 in the ratio provided a sensitivity of 87.5% and a specificity of 76.2% with an area under the ROC curve of 0.791 (95% confidence intervals, 0.655–0.926; P < 0.05) in predicting arrhythmia occurrence after the closure procedures.

Conclusions:

The ratio of ASO/ASL might be a useful index for predicting arrhythmia occurrence after closure procedures in children with OS ASD.

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.