Atrial septal defect closure: indications and contra-indications

Patent Foramen Ovale and Atrial Septal Defect

Patent foramen ovale (PFO) and atrial septal defects (ASDs) are two types of interatrial communications with unique clinical presentations and management strategies. The PFO is a normal part of fetal development that typically closes shortly after birth but may persist in as many as 25% to 30% of adults. The communication between atria may result in paradoxic embolism and embolic stroke. On the other hand, ASDs (anatomically defined as secundum, primum, sinus venosus, and coronary sinus in order of prevalence) typically result in right heart volume overload and are often associated with other congenital defects. The diagnostic methods, treatment options including surgical and percutaneous approaches, and potential complications are described. Both conditions underline the significance of precise diagnosis and appropriate management to mitigate risks and ensure optimal patient outcomes.

A Comparison of Long-Term Right Ventricular Functions in Children with Transcatheter and Surgically Closed Secundum Atrial Septal Defects (ASDs): A Strain Echocardiography Study

Background/Objectives: Secundum-type atrial septal defect (ASD) is one of the most common congenital heart defects, with an incidence of 5.64 per 10,000 live births worldwide. In our study, long-term follow-up results of children who underwent percutaneous ASD closure and patients who underwent surgical treatment were evaluated using right ventricular strain echocardiography and electrocardiography. Methods: 30 patients who underwent transcatheter ASD closure and 30 patients provided with surgical ASD closure were prospectively compared with 50 healthy children with similar demographic characteristics. ECG and transthoracic echocardiography were performed for all patients. The evaluated echocardiography variables are Tricuspid annular plane systolic excursion (TAPSE), 2D right ventricle (RV) and right atrium (RA) dimensions, right ventricular segmental longitudinal strain, and global longitudinal strain. ECG evaluation was performed especially in terms of QRS duration and its correlation with strain echo measurements. Results: The surgical treatment group has statistically significant ASD size compared to patients who underwent transcatheter closure (20 ± 3.6 and 14.87 ± 3.7 mm, p < 0.001). Patients who had surgical treatment have increased RA and RV diameters, and a statistically significant decrease was observed in right ventricular free-wall longitudinal strain and right ventricular four-chamber longitudinal strain compared to patients in transcatheter and the control group (p < 0.001). QRS durations were similarly normal in electrocardiography in the transcatheter and the control groups, and the QRS duration was observed as statistically significantly increased in the patients in the surgical treatment group (p < 0.001). Conclusions: Strain values of the patients who underwent surgical closure were lower, and the QRS values on the ECG were longer, compared to the transcatheter group, which is an indicator that a large ASD diameter has a negative effect on long-term right ventricular function. With this in mind, we argue that early surgical closure is an appropriate treatment option for children whose ASD is large for their age and who are not suitable candidates for transcatheter treatment.

Trans-thoracic echocardiographic findings after the closure of ostium secundum atrial septal defect: A six-month follow-up study

Introduction

Adults with an atrial septal defect (ASD) have the third most frequent congenital heart disease. We aimed to determine the echocardiography findings after the defect closure in patients with ostium secundum ASD.

Methods

We included patients who underwent the closure of ostium secundum ASD using trans-catheter or surgical procedures. All patients were subjected to transthoracic echocardiography at admission, one month, and six months following successful closure. The remaining shunt were measured using contrast echocardiography and none of our patients had the remaining shunt.

Results

We evaluated 28 patients with a mean age of 35.67±11.55 years. Twelve (42.85%) individuals had trans-catheter, and 16 (57.14%) patients had surgical closure of ASD. After ASD closure, the left ventricular (LV) ejection fraction (P=0.02), and LV end-diastolic diameter significantly increased while S'_TAPSE, right atrial (RA) area, RA volume, and pulmonary artery pressure (PAP) markedly diminished (P<0.001). During follow-up, RV size changes showed a significant decrease during one (17.93%) and six (25.78%) months (P<0.001 for both cases) and become normal following six months after the ASD closure. In addition, the RA/LA area ratio dropped by 24.31% during the first month and 33.17% after six months (P<0.001). In addition, the changes in measured echocardiographic parameters were not significantly different over time between the trans-catheter and surgical procedures. The decrease in S'_TAPSE was significantly greater in the surgical group than in trans-catheter closure.

Conclusion

Closure of ostium secundum ASD dramatically decreased right cardiac chamber size and PAP while enhancing LV diameter and LV ejection fraction.

Percutaneous atrial septal defect closure in limited-resource setting: a decade-long experience from Ethiopia

Introduction

Secundum Atrial septal defect (ASD) is the most common type of ASD. When it is large and hemodynamically significant, it can cause symptoms such as dyspnea, exercise intolerance, and palpitations. Following diagnosis confirmation, an ASD with hemodynamic significance should be closed electively. Percutaneous closure (PC) is an effective treatment option for ostium secundum ASD with adequate rims, despite the potential for several complications. This is the first study in Ethiopia and sub-Saharan Africa to report on percutaneous closure of secundum atrial septal defects (ASD) in children, adolescents, and adults. The study assessed the clinical characteristics, immediate and in-hospital outcomes, and complication rates following PC of secundum ASD.

Methodology

his follow-up study, conducted between October 2023 and January 2024, involved 99 patients who underwent percutaneous closure (PC) of ASD at the Cardiac Center of Ethiopia between January 2013 and January 2023. The patients were divided into two groups based on age: Group 1 included children and adolescents (≤18 years of age; n = 42), while Group 2 consisted of adults (>18 years of age; n = 57), at the time of device percutaneous closure. The median and interquartile range was used to describe continuous variables. The absolute frequency and percentages were used to describe the categorical variables. The data were shown using tables and graphs. Baseline characteristics of patients of ≤18 years vs. >18 years were compared using the Mann-Whitney U-test for continuous variables and the Chi-square or Fisher exact test for categorical data.

Results

There was a female predominance with female to male ratio of 1.3. Compared to Group 1 (children and adolescents of age ≤ 18 years), more patients in Group 2(adults of age > 18 years) experienced symptoms (p-value < 0.001). The most common symptoms in adults were easy fatigability and dyspnea (63.2% of adult patients), while the most common symptom in children was recurrent respiratory tract infections (23.8%). Patients in Group 2 had greater pulmonary artery systolic pressure than those in Group 1 (p-value < 0.001). Overall, 88.9% of patients attained immediate success; there was no statistically significant difference between the two groups in immediate success rate (p = 0.52; Group 1 85.7% vs. Group 2 91.2%). Overall, patients' median length of hospital stay was 2 days (IQR, 2-2.5 days). There was no statistically significant difference between the two groups' median hospital stays [Group 1: 2 (IQR, 2-2.5) and Group 2: 2.5 (IQR 2-2.5); P-value = 0.111]. 23.2% of patients experienced complications, with no significant difference between the two groups (Group 1 28.6% and Group 2 19.3%, p = 0.28). The most common complications for patients in Groups 1 and 2 were atrioventricular (AV) valve encroachment (4.8) and paroxysmal supraventricular tachycardia (SVT) (5.3%), respectively. The major complication rates in the two groups did not show a statistically significant difference. Group 1 had a rate of 4.8%, whereas Group 2 had a rate of 0% (p-value = 0.18). The length of stays significantly increased in both groups in the presence of complications (p-value < 0.001).

Conclusion

This study emphasized that Percutaneous Closure of ASD can be successfully performed in resource-limited settings with a high immediate success rate and minimal complications such as AV valve encroachment and paroxysmal SVT. Given that complications impact length of hospital stays, preventing them is crucial.

Morphological Characteristics of Interatrial Septum and Its Clinical Relevance

BACKGROUND

The development of new trans-septal transcatheter interventions for patients with structural heart disease necessitates a precise and comprehensive understanding of the anatomy of the interatrial septum (IAS). The scarcity of gross anatomical studies has triggered our interest in exploring the morphometry and morphology of IAS.

AIMS

To study the morphology, morphometry and variations of the interatrial septum in autopsied human hearts.

METHODS

The study was conducted on 97 autopsied fresh human hearts, in which we observed the position and shape of fossa ovalis (FOv), along with prominence of the limbus and its location. The diameter of FOv, thickness of its floor, redundancy and any variation in the IAS were noted.

RESULTS

In most cases (72.9%), the FOv was situated toward the inferior vena cava and was oval shaped (69.8%), with mean horizontal and vertical diameters of 17.21 ± 4.11 mm and 12.74 ± 3.78 mm, respectively. The limbus was prominent in 72.2% specimens, most commonly prominent all around (36.6%), followed by antero-superior (28.2%), antero-inferior (16.9%) and anterior (8.5%) prominence. The mean thickness of the floor of FOv was 0.71 ± 0.98 mm, and redundancy was observed in 47% of samples. Probe patency was seen only in 10.3% specimens. The right surface of the IAS showed more variations (71.1%) compared to the left (44.3%), in form of recesses, atrial septal pouches, fibrous strands, retinacular-type fibrous networks and combination of more than one type.

CONCLUSION

Variations in the location of FOv, the prominence of limbus and the common occurrence of anatomical variants of the IAS mandate the preprocedural imaging of the region to reduce the failure rate and complications.

Genetic Insights into Congenital Cardiac Septal Defects-A Narrative Review

Congenital heart diseases (CHDs) are a group of complex diseases characterized by structural and functional malformations during development in the human heart; they represent an important problem for public health worldwide. Within these malformations, septal defects such as ventricular (VSD) and atrial septal defects (ASD) are the most common forms of CHDs. Studies have reported that CHDs are the result of genetic and environmental factors. Here, we review and summarize the role of genetics involved in cardiogenesis and congenital cardiac septal defects. Moreover, treatment regarding these congenital cardiac septal defects is also addressed.

Transcatheter Closure of a Patent Foramen Ovale With a Small Adjacent Atrial Septal Defect and a Double Interatrial Septum Post Cryptogenic Stroke

The phenomenon of double interatrial septum (DIAS) represents a particularly rare subtype of atrial septal malformation, characterized by the presence of dual membranes separating the atria, resulting in a distinctive interatrial space. This unique anatomical structure has been linked to a paradoxical right-to-left shunt, potentially contributing to embolic ischemic strokes. Within this context, we report a rare case of a 34-year-old female who presented with a transient ischemic attack (TIA) and was diagnosed with patent foramen ovale (PFO) and a small adjacent atrial septal defect (ASD), along with the presence of a DIAS. The diagnosis was confirmed wit transoesophageal echocardiography and cardiac magnetic resonance imaging (MRI), and the condition was successfully treated with a transcatheter occluder device.

Surgical Treatment of Atrial Septal Defects

Atrial septal defects (ASDs) are among the most prevalent congenital cardiac malformations. Closure of the defect and repair of associated cardiac malformations are typically indicated if an ASD is hemodynamically significant or symptomatic. This narrative review aims to summarize key aspects of surgical ASD closures. A non-systematic literature review was conducted to cover surgically relevant aspects of (developmental) anatomy, morphology, and treatment. ASDs result from diverse developmental alterations, leading to subtype-specific associated cardiac malformations, meaning surgical therapy varies accordingly. Presently, surgical repair yields excellent outcomes for all ASD subtypes, with minimally invasive approaches, especially in adults, increasingly employed for ASD closure. Surgical ASD repair is safe with excellent results. However, familiarity with ASD subtypes and typically associated lesions is crucial for optimal patient management.

Perioperative Assessment and Clinical Outcomes of Percutaneous Atrial Septal Defect Closure with Three-Dimensional Transesophageal Echocardiography

BACKGROUND/OBJECTIVES

To close the atrial septal defect (ASD) with the transcatheter method, correctly defining the defect and selecting the appropriate closure device size are the most critical steps for the procedure's success. Although ASD can be successfully closed under the guidance of three-dimensional (3D) transesophageal echocardiography (TEE) and two-dimensional (2D) TEE, measurement comparisons between different types of defects are still needed.

METHODS

Our study was designed retrospectively. Sixty-one patients who underwent transcatheter ASD closure with 2D TEE and 3D TEE between 2020 and 2024 were included. The patients were divided into three groups according to the defect shape: circular, oval, and complex; and the measurement results, perioperative process, and clinical outcomes were compared in each group.

RESULTS

The average age of the patients was 35.05 ± 13.87 years, and 41 (67.2%) were women. The average follow-up period of the patients was 15.3 ± 9.18 months. No statistical significance was observed in the comparison of measurements obtained with 3D TEE and 2D TEE in the circular and oval defect groups. The differences between the minimum defect diameters of complex defects measured by 2D TEE and 3D TEE (p: 0.037), IVC rims (p < 0.001), aortic rims (p: 0.012), and the differences between implanted device dimensions and the maximum defect diameters measured by both methods were compared; statistical significance was observed (p: 0.025).

CONCLUSIONS

In circular and non-complex oval defects, it has been observed that the size of the closure device selected with 2D TEE or 3D TEE is optimal, and the procedure is practical and feasible. While the closure of complex ASDs with 3D TEE provides reliable and optimal results, using only 2D TEE in complex ASDs may lead to selecting a smaller-sized device.

Patent Foramen Ovale and Atrial Septal Defect

Patent foramen ovale (PFO) and atrial septal defects (ASDs) are two types of interatrial communications with unique clinical presentations and management strategies. The PFO is a normal part of fetal development that typically closes shortly after birth but may persist in as many as 25% to 30% of adults. The communication between atria may result in paradoxic embolism and embolic stroke. On the other hand, ASDs (anatomically defined as secundum, primum, sinus venosus, and coronary sinus in order of prevalence) typically result in right heart volume overload and are often associated with other congenital defects. The diagnostic methods, treatment options including surgical and percutaneous approaches, and potential complications are described. Both conditions underline the significance of precise diagnosis and appropriate management to mitigate risks and ensure optimal patient outcomes.

Iatrogenic Atrial Septal Defect After MitraClip Transcatheter Edge-to-Edge Repair: To Close or Not to Close?

The evolution of percutaneous procedures that use transseptal puncture to treat left-sided structural heart disease has led to the emergence of iatrogenic atrial septal defects as a potential complication. These defects can result in hemodynamic decompensation and worsening clinical outcomes. Some iatrogenic atrial septal defects require immediate closure, others do not. This case report presents 2 patients who underwent transcatheter edge-to-edge mitral valve repair with transseptal puncture and required iatrogenic atrial septal defect closure (1 immediate and 1 delayed). The goal of this report is to highlight iatrogenic atrial septal defect assessment and the possible need for closure after transseptal puncture.

Noninvasive Assessment of Left Ventricle Filling Pattern in Patient with Severe Tricuspid Regurgitation, Pulmonary Regurgitation, Atrial Septal Defect, and Pulmonary Embolism

Background

Severe tricuspid regurgitation (TR), pulmonic regurgitation (PR), large atrial septal defect (ASD), and large pulmonary embolism (PE) will lead to decreased left ventricular preload, and therefore, might alter left ventricle (LV) filling diastolic parameters. Significant LV preload reduction might preclude LV diastolic function assessment indeterminate.

Methods

This is a controlled study where patients with severe TR, PR, ASD, PE, and without significant LV disease were included in the study group. Stroke volume (SV), E-wave velocity, A-wave velocity, E/A, septal e', lateral e', average E/e', deceleration time, and isovolumic relaxation time (IVRT) were captured from the study group and the control group. The difference of mean of the diastolic parameters in both groups was evaluated as well as the correlation between the SV and the diastolic parameters of the pooled data from both groups.

Results

E wave velocity, E/A ratio, IVRT, deceleration time, septal and lateral e', and SV were significantly lower in the study group while E/e' was significantly higher in the study group. IVRT showed a strong positive correlation with SV. Lateral and septal e' showed a moderate positive correlation to SV while the average E/e' showed inverse correlation to SV.

Conclusion

Standard diastolic parameters should be interpreted with caution in assessing diastolic function in patients with severely decreased preload. However, a significant preload reduction might preclude diastolic function assessment indeterminate.

A 24-Year-Old Male Patient With an Ostium Secundum Complex Atrial Defect Secondary to a Perforated Aneurysm With Inferior Vena Cava Agenesis

The article describes a successful clinical outcome in the case of a 24-year-old male with a diagnosis of an ostium secundum atrial defect secondary to a perforated aneurysm associated with vena cava agenesis. During hospitalization, an echocardiogram revealed the presence of ostium secundum inter-atrial communication with a left to right shunt, a left ventricular ejection fraction (LVEF) of 60%, and mild pulmonary hypertension, measured at 40 mmHg. CT imaging showed anomalous dilation of the azygos vein (16.8 mm), associated with interruption of the vena cava in the intrahepatic and adrenal portion, continuing through the azygos system and draining into the superior vena cava. Open-heart surgery was performed with pericardium patch placement on the defect. Postoperative transthoracic echocardiography revealed a tracking of the interatrial septum, with adequate placement of the surgical patch and no evidence of residual short circuits. The postoperative recovery was favorable, and the patient was discharged five days after surgery. Outpatient monitoring at the first and third months showed no complications during physical examination and echocardiogram imaging.

Complications and Efficacies of Surgical Versus Transcatheter Closure for Pediatric Ostium Secundum Atrial Septal Defect: A Meta-Analysis

INTRODUCTION

The optimal approach for pediatric ostium secundum atrial septal defect (ASD) closure remains uncertain. This study aims to assess complications and efficacies of surgical and transcatheter closures.

METHODS

Systematic search in Medline, Cochrane, and EMBASE databases identified cohort studies until July 2023. Complications, length of hospital stay, and efficacy outcomes were evaluated. Subgroup analyses considered ethnicity, ASD size, age, and rim deficiency involvement.

RESULTS

Fourteen cohort studies involving 9695 patients were comprehensively analyzed. Regarding complications, the pediatric patients in the surgery group exhibited higher occurrences of cardiac arrhythmia (odds ratio [OR]: 1.87, 95% confidence interval [CI]: 1.22-2.87, p=0.004), pericardial effusion (OR: 14.80, 95% CI: 6.97-31.43, p<0.00001), and pulmonary complications (OR: 2.58, 95% CI: 1.73-3.85, p<0.00001) compared with those in the transcatheter group. However, no significant difference in fever incidence was observed (OR: 2.57, 95% CI: 0.90-7.34, p=0.08). Furthermore, length of hospital stay was notably shorter in the pediatric transcatheter group (mean difference [MD]: 4.00, 95% CI: 1.71-6.29, p=0.0006). Regarding efficacies, both groups demonstrated similar rates of successful closure (OR: 1.97, 95% CI: 0.56-6.92, p=0.29) and residual shunting (OR: 0.55, 95% CI: 0.17-1.77, p=0.31) in the pediatric cohort. Subgroup analyses revealed that surgical residual shunting was notably lower in the European pediatric population (OR: 0.18, 95% CI: 0.07-0.45, p=0.0002), in cases with ASD size exceeding 15 mm (OR: 0.19, 95% CI: 0.08-0.49, p=0.0006), and in pediatric patients younger than 8 years (OR: 0.33, 95% CI: 0.12-0.92, p=0.03). Interestingly, residual shunting involving complex ASD with rim deficiency was more pronounced in the surgery group (OR: 2.66, 95% CI: 1.33-5.32, p=0.006).

CONCLUSIONS

Both surgical and transcatheter closures are equally effective, with transcatheter closure showing significantly fewer complications.

CLINICAL IMPACT

This meta-analysis offers pivotal insights for clinicians grappling with the optimal approach to pediatric ostium secundum ASD closure. The observed higher incidence of cardiac arrhythmias, pericardial effusions, and pulmonary complications in surgical closures underscores the challenges associated with this modality. In contrast, transcatheter closure, with its comparable efficacy and shorter hospital stays, emerges as an appealing and less invasive alternative. These findings equip clinicians with evidence to make informed decisions, optimizing patient outcomes. Subgroup analyses further refine recommendations, emphasizing tailored considerations for European pediatric patients, larger ASDs, and those under 8 years old, ultimately fostering personalized and improved care strategies.

Surgical Correction of a Sinus Venosus Atrial Septal Defect with Partial Anomalous Pulmonary Venous Connections Using Cardiac Computed Tomography Imaging and a 3D-Printed Model

Sinus venosus atrial septal defects (SVASDs), concurrent with partial anomalous pulmonary venous connections (PAPVCs), are a rare congenital heart disease in dogs. Surgical correction is essential when clinical signs or significant hemodynamic changes are present. We aimed to report on the successful surgical correction of an SVASD with PAPVCs, using a computed tomography (CT)-based customized 3D cardiac model. A 10-month-old male poodle was referred for corrective surgery for an ASD. Echocardiography confirmed a hemodynamically significant left-to-right shunting flow through an interatrial septal defect and severe right-sided heart volume overload. For a comprehensive diagnosis, a CT scan was performed, which confirmed an SVASD with PAPVCs. A customized 3D cardiac model was used for preoperative decision-making and surgical rehearsal. The defect was repaired using an autologous pericardial patch under a cardiopulmonary bypass (CPB). Temporary pacing was applied for sinus bradycardia and third-degree atrioventricular block. The patient recovered from the anesthesia without further complications. The pacemaker was removed during hospitalization and the patient was discharged without complications 2 weeks post-surgery. At the three-month follow-up, there was no shunting flow in the interatrial septum and the right-sided volume overload had been resolved. The cardiac medications were discontinued, and there were no complications. This report indicates the validity of surgical correction under CPB for an SVASD with PAPVCs, and the advantages of utilizing a CT-based 3D cardiac model for preoperative planning to increase the surgical success rate.

Transcatheter Closure of Secundum Atrial Septal Defects in Pediatric Patients: A 15-Year Single-Center Experience

PURPOSE

Transcatheter closure is the first-line treatment option for hemodynamically significant secundum atrial septal defects (ASDs). This study examines our center's experience with this procedure over the last 15 years.

MATERIALS AND METHODS

Pediatric patients aged 0-18 years with secundum ASDs who were planned for transcatheter closure in our clinic between January 2007 and January 2023 were retrospectively evaluated.

RESULTS

Transcatheter secundum ASD closure was planned for a total of 334 patients during the study period: 191 girls (57.2%) and 143 boys (42.8%). Their mean age was 8.08±3.9 years, and their mean weight was 30±15.6 kg. Defect diameter measured transesophageally ranged from 5 to 35 mm, with a mean of 12.56±4.02 mm. Transesophageal echocardiographic examination revealed a single secundum ASD in 319 patients (95.5%) and multiple secundum ASDs in 15 patients (4.5%). In 11 patients (3.3%), the procedure was terminated before initiating transcatheter ASD closure because of insufficient vena cava rims or a very large or multi-fenestrated defect. The 323 patients (96.7%) who underwent transcatheter ASD closure had a mean pulmonary artery pressure of 15.1±4.0 mmHg and a mean Qp/Qs ratio of 1.97±0.56. The procedure failed in four patients (1.3%) because of device embolization (n=2) or the inability to properly position the device (n=2). Major complications other than device embolization observed during or after transcatheter closure included anesthetic-induced respiratory depression (n=1) and total atelectasis of the lung (n=1). No new major complications were detected during the patients' long-term follow-up.

CONCLUSION

With appropriate patient and device selection, transcatheter closure is a safe and effective treatment for secundum ASD and should be the first treatment of choice.

Amplatzer Vascular Plug closure of an iatrogenic interatrial tunnel-type communication

A 50-year-old woman who had atrial septal defect surgery at 11 months old underwent ascending aortic aneurysm resection and two attempts at closure of a residual atrial septal defect. Post-operatively, she had severe cyanosis. She was referred to our centre where a transesophageal echocardiogram and cardiac catheterisation showed an iatrogenic interatrial tunnel-type communication that was closed with an Amplatzer Vascular Plug.

Mid-Term Electrical Remodeling after Percutaneous Atrial Septal Defect Closure with GCO Device in a Pediatric Population

BACKGROUND AND AIM

The GORE® CARDIOFORM (GCO) septal occluder is an atrial septal defect/patent foramen ovale closure device with theoretical advantages over other commercialized devices thanks to its softness and anatomical compliance. Our aim was to evaluate the short- and medium-term electrocardiographic changes after percutaneous ASD closure with GCO in a pediatric population.

METHODS

We enrolled 39 patients with isolated ASD submitted to trans-catheter closure from January 2020 to June 2021. ECG was performed before, at 24 h and 6 months after the procedure. P wave dispersion, QTc and QTc dispersion were calculated. ECG Holter was recorded at 6 months after implantation.

RESULTS

Patients' age and body surface area (BSA) were 8.2 ± 4.2 years and 1.0 ± 0.3 m2 respectively. At the baseline, mean P wave dispersion was 40 ± 15 msec and decreased at 24 h (p < 0.002), without any further change at 6 months. At 24 h, PR conduction and QTc dispersion significantly improved (p = 0.018 and p < 0.02 respectively), while the absolute QTc value considerably improved after 6 months. During mid-term follow-up, QTc dispersion remained stable without a significant change in PR conduction. The baseline cardiac frequency was 88.6 ± 12.6 bpm, followed by a slight reduction at 24 h, with a further amelioration at 6 months after the procedure (87.3 ± 14.2, p = 0.9 and 81.0 ± 12.7, p = 0.009, respectively). After device deployment, two patients developed transient, self-limited junctional rhythm. One of them needed a short course of Flecainide for atrial ectopic tachycardia. No tachy/brady-arrhythmias were recorded at the 6-month follow-up. ASD closure resulted in a marked decrease in right heart volumes and diameters at 6 months after percutaneous closure.

CONCLUSIONS

Percutaneous ASD closure with the GCO device results in significant, sudden improvement of intra-atrial, atrio-ventricular and intraventricular electrical homogeneity. This benefit persists unaltered over a medium-term follow-up. These electrical changes are associated with a documented positive right heart volumetric remodeling at mid-term follow-up.

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.

Infective Endocarditis during Pregnancy-Keep It Safe and Simple!

The diagnosis of infective endocarditis (IE) during pregnancy is accompanied by a poor prognosis for both mother and fetus in the absence of prompt management by multidisciplinary teams. We searched the electronic databases of PubMed, MEDLINE and EMBASE for clinical studies addressing the management of infective endocarditis during pregnancy, with the aim of realizing a literature review ranging from risk factors to diagnostic investigations to optimal therapeutic management for mother and fetus alike. The presence of previous cardiovascular pathologies such as rheumatic heart disease, congenital heart disease, prosthetic valves, hemodialysis, intravenous catheters or immunosuppression are the main risk factors predisposing patients to IE during pregnancy. The identification of modern risk factors such as intracardiac devices and intravenous drug administration as well as genetic diagnostic methods such as cell-free deoxyribonucleic acid (DNA) next-generation sequencing require that these cases be addressed in multidisciplinary teams. Guiding treatment to eradicate infection and protect the fetus simultaneously creates challenges for cardiologists and gynecologists alike.

Sufficient versus deficient rims during percutaneous closure of ostium secundum type atrial septal defect: A systematic review and meta-analysis

BACKGROUND

The aim of this meta-analysis was to compare the efficacy and adverse events of percutaneous occlusion among patients with sufficient and deficient rims.

METHODS

A systematic review of all articles published in the Pubmed, MEDLINE and Google Scholar databases was performed. Odds ratio (OR) and 95% CI were used as a measure of effect of the combination of studies. I² with 95% CI was estimated to assess study heterogeneity. For the meta-analysis, a random effects model was used.

RESULTS

The systematic search identified ten studies which included 4355 patients; 2661 of those had sufficient rim and the remaining 1694 patients showed some rim deficiency. Implant failure rate was 4.13% CI 95% 3.53-4.72%. Compared to frequency of failures in the group with a deficient rim (5.43% CI 95% 4.35-6.50%), implant failure in patients with a sufficient rim was significantly lower (3.30% CI 95% 2.62-3.97%), OR 2.27 CI 1.34-3.83 (p 0.002). The combined adverse events were 5.19% CI 95% 4.22-6.35% vs 2.7% CI 95% 2.08-3.31% in the deficient vs sufficient rim groups respectively (OR 2.21 CI 0.93-5.29; p 0.07). Implant failures and adverse events were more frequent in patients with posterior inferior rim deficiency.

CONCLUSION

Patients presenting a posteroinferior rim deficiency are associated to both, an increased incidence of closure failure and a combined adverse events occurrence. More studies on posterior rim deficiency are necessary to ensure the feasibility and safety of the percutaneous approach.

The feasibility and safety of combining atrial septal defect/patent foramen ovale and left atrial appendage closure: A systematic review and meta-analysis

Introduction

Atrial Septal Defect/Patent Foramen Ovale (ASD/PFO) occlusion is performed to prevent paradoxical embolism and reduce the risk of recurrent ischemic stroke. Left atrial appendage (LAA) closure is used as an alternative to medical therapy of non-valvular atrial fibrillation for prevention of stroke. Multiple studies have examined performing LAA and ASD/PFO occlusion. However, the feasibility and safety of combined occlusion of the left atrial appendage and ASD/PFO are not clear, furthermore, these studies are limited by their small sample sizes and retrospective analysis. In this study, we aimed to systematically review and meta-analyze the feasibility and safety of combining left atrial appendage and ASD/PFO closure.

Methods

PubMed, Web of Science, CNKI, Cochrane Library, Embase, and WanFang database were searched up to April 2022 to identify peer-reviewed human studies on assessing the feasibility, safety, and efficacy of combining left atrial appendage and ASD/PFO closure. The primary outcome was calculated: procedural feasibility outcome and procedural safety outcome.

Results

A total of 10 articles, including 340 patients from multiple countries, were included in the analysis. The principal findings of our study are: compared with single LAA closure, (i) combining PFO/ASD occlusion and LAA closure had similar procedural success proportion (98.43%, 95% CI: 96.67-100.00%), (ii) similar safety event incidences developed (1.67%, 95% CI: 0.24-3.92%), subgroup analyzed safety event incidences in death was 0.00 (95% CI: 0.00-0.33%), cardiac tamponade was 0.87% (95% CI: 0.00-2.77%), device embolization was 0.00 (95% CI: 0.00-0.60%), major bleeding was 0.00 (95% CI: 0.00-0.33%), stroke was 0.00 (95% CI: 0.00-0.02%).

Conclusion

Although this systematic review and meta-analysis demonstrate the technical feasibility and safety of combining closure of PFO/ASD and LAA, further studies of sufficient sample size, long-term follow-up, and rigor endpoint criteria are yet needed to fully evaluate this combination procedure for its role in clinical outcomes.

Endovascular Closure of Secondary Septal Defect in Children with Low Body Weight

The aim. To assess the effectiveness and safety of transcatheter closure of a secondary atrial septal defect (ASD) using an occluder in symptomatic children weighing ≤10 kg. Materials and methods. In the period from November 2014 to June 2021, on the basis of the National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine, closure of secondary ASD using an occluder was performed in 18 patients, among them 13 women (72.2%) and 5 men (27.8%). Th e mean age of the patients was 18.94±9.44 months (the youngest patient was 12 months, the oldest was 4 years). The mean weight was 9.294±1.170 kg (6.4 kg to 10 kg), the mean Z-score was -1.7±1.5 (-4.6 to 0.46), the mean height was 80 cm (71 cm to 88 cm). According to the measurements by transesophageal echocardiography (TEE), the average size of the defects was 13.7 mm±3.6mm (the largest 18.0 mm, the smallest 6.0 mm). Results and discussion. In our publication, the effectiveness of the method was 100% (18/18), while the world statistics show 94-95%. Th e frequency of complications was 5.6% (n=1). We suggest that this is associated with the use of a sizing balloon and careful selection of the device. When choosing treatment tactics for symptomatic children weighing ≤10 kg, the decisive factor was the determination of the presence of edges and the size of the defect. Defects were considered suitable for closure, according to TEE data, when all margins of the defect were ≥4 mm, except for the aortic margin. Although the total length of the interatrial membrane was taken into account, it was not of decisive importance, since for most occluders with the presence of all edges, the fields of the implant could not interfere with the work of the anatomical structures of the heart. To determine the real size of the defect, we recommend a measuring balloon under TEE control. The following devices were used to close the defect: MemoPart ASD occluder, Amplatzer Septal Occluder, LifeTech HeartR Occluder, LifeTech HeartR Multi-Fenestrated Atrial Septal Defect (MF-ASD) Occluder.   Conclusion. After the study, we are convinced that the endovascular method of closing a hemodynamically significant secondary ASD for the treatment of children with a body weight of ≤10 kg has proven to be an effective method, with successful implantation of the occluder in 100% of cases.

Mid-Term Outcome of Left Ventricle Reverse Remodeling After Atrial Septal Defect Closure: A Comparison Between Surgical and Device Groups

Right ventricular (RV) volume overload occurs in patients with significant atrial septal defect (ASD II) shunts, which can impair left ventricle (LV) filling, thus decreasing LV indices. However, after ASD II closure, the left ventricle regains near normal dimensions. The purpose of this study was to compare the long-term outcomes of LV reverse remodeling between device and surgical closure. We retrospectively reviewed the echocardiographic data of 222 patients with isolated ASD II who underwent surgical (95 patients) or device closure (127 patients) between January 2012 and December 2017. The ASD II was significantly larger in the surgical closure group (p < 0.001.) leading to a higher degree of paradoxical interventricular septal (IVS) movement. In contrast, the LV volume was larger in the device closure group (p < 0.001). After a median follow-up period of 19.5 months, the maximum LV systolic and diastolic volumes were reached at 1 year in the device closure group and 2 years in the surgical closure group. IVS motion normalized in 91% of the device closure group compared to 57% of the surgical closure group (p =  < 0.001). There was significant improvement in left ventricular indices and IVS motion after ASD II closure in both groups but more favorable in patients after device closure.

Transcatheter closure of "Surgical" ostium secundum atrial septal defects with GORE® Cardioform ASD Occluder

OBJECTIVE

To evaluate the GORE® Cardioform ASD Occluder (GCA)(WL Gore & Associates) device for closure of ostium secundum atrial septal defects (ASDs) with predicted indication for surgical correction.

BACKGROUND

Closure of large ASD in small children by transcatheter approach is still challenging. This study evaluated the results of GCA in this subset of patients in a tertiary referral center.

METHODS

Between January 2020 and March 2022, 97 children underwent transcatheter ASD closure at our Institution. Of them, 38 had a large defect (diameter/weight > 1.2 or diameter/body surface area > 20 mm/m² ), predicted suitable for surgery and underwent closure with GCA. Procedure results and midterm outcome are reported.

RESULTS

Patients' age and weight were 5.5 ± 1.5 years and 19.7 ± 4.7 kg, respectively. Absolute and relative ASD size was 21.5 ± 3.6 mm, 1.1 ± 0.2 mm/kg, and 27.7 ± 4.6 mm/m² , respectively, resulting in QP/QS of 2.0 ± 0.8. Three patients were sent to surgery after balloon sizing. Four of the remaining 35 patients who underwent device deployment, needed rescue or elective surgery due to device embolization (n = 1), device instability (n = 2) or new-onset tricuspid valve regurgitation (n = 1). Procedure feasibility was 88.6%. Major complications were recorded in two patients (5.7%). Minor complications were recorded in five patients (14.3%). Complete closure at discharge was 90.3% (28/31 pts) rising to 100% at the last follow-up evaluation. Wireframe fracture rate at the 6 months examination was 52%, without clinical and instrumental consequences.

CONCLUSIONS

Percutaneous treatment with GCA device is effective and safe in a high percentage of ASD children with predicted indications for surgical correction.

Cardiac remodeling after atrial septal defects device closure

BACKGROUND

Trans-catheter device closure of secundum type atrial septal defects (ASDs) has now become the treatment of choice. Device closure affects the hemodynamics and function of the heart. In the current study, we investigated the remodeling of the heart as assessed by advanced echocardiographic parameters following successful device closure.

METHODS

A prospective cohort study was conducted and 45 patients who were eligible for ASD device closure were evaluated for volumetric, functional, Doppler, strain, and strain rate data of left and right atrium and ventricle pre-procedural and 48 h post-procedure RESULTS: In a prospective cohort study 45 patients who were eligible for ASD device closure; atrial and ventricular volumetric, functional, Doppler, strain, and strain rate data were recorded and compared pre-procedurally and 48 h post-procedure.We found significant changes in the left ventricular (LV) end diastolic volume index (p-value = .03), right ventricular (RV) diameter (p-value = <.001), left atrial (LA) volume index (p-value = .05), right atrial (RA) volume index (p-value = .001), and right and left sided E/e' ratio with a p-value of .001 and .004, respectively. Our findings showed a significant reduction in the strains of the right and left atria and the right ventricular free wall after ASD device closure. LV global longitudinal strain decreased after the procedure but did not reach statistical significance.

CONCLUSION

ASD patients have impaired global strains compared to normal defined ranges. LA, RA, and RV strains show significant reduction after device closure. Decline in LA function following closure was greater in those with larger ASDs. In adult patients undergoing the procedure, abnormal LA function is a clinically relevant issue demanding pre and post- procedural precautions and treatment.

Limitations of Percutaneous Closure of a Complex Secundum Atrial Septal Defect

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Percutaneous closure of ASDs can be limited by size or shape of the defect.

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A 3D evaluation of ASDs is essential for proper sizing and procedural planning.

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Balloon sizing may help for large or irregularly shaped ASDs.

Percutaneous management of late occluder dislodgement: A case report

Percutaneous closure of ASD is nowadays preferred and more widely performed over surgical closure. The GORE® CARDIOFORM ASD occluder (GCA) is the latest generation of occluder with promising results as it performed well with high successful implant rates (96%) and showed high efficacy in challenging clinical and anatomical situations. We present the case of a 65 female with a 2.5 cm ASD, left atrial hypertension, deficient retroaortic rim, mobile septum primum and hypertrophied septum secundum. She underwent uncomplicated closure with a 44-mm GCA. However, the patient presented to the emergency room five weeks post procedure and was found to be in atrial fibrillation with rapid ventricular response at a rate of 158 bpm. Further workup showed a dislodged GCA device despite appropriate device placement and size selection based on the published instructions for use. We elected to not remove the 44-mm GCA given that it had become adherent to the septum primum but instead used the stiffer Amplatzer septal occluder to stabilize the GCA and occlude the residual defect. Finally, we highly recommend taking device destabilizing factors into consideration when selecting device size.

Complications of trans-catheter closure of atrial septal defects

Trans-catheter device closure of atrial septal defects (ASD) is considered to be safe with minimal complications. But, there are certain complications that arise after these device closures which might require urgent or late surgical intervention. We have retrospectively analysed our experience. Out of 780 patients who underwent device closure, 11 (1.4%) patients required urgent surgical intervention to retrieve the embolized device. The size of the ASD, expertise of the cardiologist and the type of the device directly impacted the rate of device embolization. Early diagnosis and prompt surgical retrieval is paramount before any life threatening complications arise due to the embolized device. One patient developed infective endocarditis later, which required surgery. Regular long term follow up is needed after these procedures to diagnose the complications earlier so that prompt surgical intervention could be done.

A case of progressive dyspnea: Atrial septal device-related functional mitral regurgitation after myocardial infarction

Transcatheter device closure is a common treatment option of atrial septal defect. Mitral regurgitation has been reported with comorbid mitral valve prolapse and atrial septal defect. However there is no consensus regarding the pathogenesis of mitral regurgitation after closure. We are reporting a patient with functional mitral regurgitation associated with both an oversize closure device and wall motion abnormality after inferior myocardial infarction.

Renaissance of Cardiac Imaging to Assist Percutaneous Interventions in Congenital Heart Diseases:The Role of Three-Dimensional Echocardiography and Multimodality Imaging

Percutaneous interventions have completely refashioned the management of children with congenital heart diseases (CHD) and the use of non-invasive imaging has become the gold standard to plan and guide these procedures in the modern era. We are now facing a dual challenge to improve the standard of care in low-risk patients, and to shift our strategies from the classic open chest surgery to imaging-guided percutaneous interventions in high-risk patients. Such rapid evolution of ultrasound technologies over the last 20 years have permitted the integration of transthoracic, transesophageal and intracardiac echocardiography into the interventional workflow to improve image guidance and reduce radiation burden from fluoroscopy and angiography. Specifically, miniaturization of transesophageal probe and advances in three-dimensional (3D) imaging techniques have enabled real-time 3D image guidance during complex interventional procedure, In addition, multimodality and fusion imaging techniques harness the strengths of different modalities to enhance understanding of anatomical and spatial relationship between different structures, improving communication and coordination between interventionalists and imaging specialists. In this review, we aim to provide an overview of 3D imaging modalities and multimodal fusion in procedural planning and live guidance of percutaneous interventions. At the present times, 3D imaging can no longer be considered a luxury but a routine clinical tool to improve procedural success and patient outcomes.

Transcatheter versus surgical closure of atrial septal defects: a systematic review and meta-analysis of clinical outcomes

BACKGROUND

Atrial septal defects are a common form of CHD and dependent on the size and nature of atrial septal defects, closure may be warranted. The paper aims to compare outcomes of transcatheter versus surgical repair of atrial septal defects.

METHODS

A comprehensive electronic literature search was conducted. Primary studies were included if they compared both closure techniques. Primary outcomes included procedural success, mortality, and reintervention rate. Secondary outcomes included residual defect and mean hospital stay.

RESULTS

A total of 33 studies were included in meta-analysis. Mean total hospital stay was significantly shorter in the transcatheter cohort across both the adult (95% confidence interval, mean difference -4.05 (-4.78, -3.32) p < 0.00001) and paediatric populations (95% confidence interval, mean difference -4.78 (-5.97, -3.60) p < 0.00001). There were significantly fewer complications in the transcatheter group across both the adult (odds ratio 0.45, 95% confidence interval, [0.28, 0.72], p < 0.00001) and paediatric cohorts (odds ratio 0.26, 95% confidence interval, [0.14, 0.49], p < 0.00001). No significant difference in overall mortality was found between transcatheter versus surgical closure across the two groups, adult (odds ratio 0.76, 95% confidence interval, [0.40, 1.45], p = 0.41), paediatrics (odds ratio 0.62, 95% confidence interval, [0.21, 1.83], p = 0.39).

CONCLUSION

Both transcatheter and surgical approaches are safe and effective techniques for atrial septal defect closure. Our study has demonstrated the benefits of transcatheter closure in terms of lower complication rates and mean hospital stay. However, surgery still has a place for more complex closure and, as we have demonstrated, shows no difference in mortality.

Inappropriate shocks from a transvenous implantable defibrillator caused by atrial fibrillation and a missed atrial septal defect in a patient with a modified Bentall procedure

Background 

Inappropriate shocks have been reported in ∼1/3 of patients with implantable cardiac defibrillators (ICDs). We report an unusual case of inappropriate ICD shocks due to atrial fibrillation (AF) caused by a missed atrial septal defect (ASD) in a patient with a modified Bentall procedure.

Case summary 

A 67-year-old Caucasian male, with an ICD and a history of a modified Bentall procedure 24 years ago, reported to our outpatient clinic with recurrent inappropriate ICD shocks due to episodes of fast AF. The transthoracic echocardiographic exam revealed two large aneurysms at the ostia of the coronary arteries. We performed further evaluation with transoesophageal echocardiogram and computed tomography (CT) angiography. The aneurysms measured on CT were 3.14 cm × 2.29 cm on the right ostium and 1.9 cm × 0.99 cm on the left. A large secundum type ASD of 1.5 cm, missed in all previous echocardiographic studies, was revealed. The therapeutic options of surgical closure of the ASD and repair of the aneurysms or a more conservative approach with percutaneous closure of the ASD and closer follow-up were discussed with the patient. The patient declined the surgical option due to high complication risk, and closure of the ASD with an Amplatzer device was performed 3 months later. A 3-year follow-up was uneventful.

Conclusion 

It is of major importance to comprehensively and thoroughly assess patients before and after a surgical intervention to not miss other treatable conditions preoperatively and complications in the postoperative period.

GORE® Cardioform ASD Occluder experience in transcatheter closure of "complex" atrial septal defects

OBJECTIVE

To evaluate the GORE® Cardioform ASD Occluder (GCO) (WL Gore & Associates, Flagstaff, AZ) device for "complex" atrial septal defects (ASD) closure.

BACKGROUND

Transcatheter ASD closure is still challenging in "complex" clinical/anatomic settings. This study evaluated the results of GCO in closure of "complex" ASD in a tertiary referral center.

METHODS

Between January 2020 and March 2021, 72 patients with significant ASD were submitted to transcatheter closure with GCO at our Institution. Based on clinical/anatomic characteristics, they were classified as "complex" (n = 36, Group I) or "simple" (n = 36, Group II). We considered as "complex", defects with rim deficiency (< 5 mm) other than antero-superior, relatively large (diameter/patient weight > 1.2 or diameter/patient BSA > 20 mm/m² ) or within a multifenestrated septum. Procedure results and early outcome were compared between the groups.

RESULTS

Absolute and relative ASD size (20 ± 4 vs. 15 ± 3 mm, p < 0.0001; 0.9 ± 0.3 vs. 0.4 ± 0.2 mm/kg, p < 0.0001; 23 ± 7 vs. 12 ± 5 mm/m² , p < 0.0001), QP/QS (2.0 ± 0.8 vs. 1.4 ± 0.3, p < 0.001), procedure and fluoroscopy times (73 ± 36 vs. 43 ± 21 min, p < 0.0001; 16 ± 9 vs. 9 ± 4 min, p < 0.0001, procedure feasibility (94.4 vs. 100%, p < 0.0001) and overall complication rate (13.9 vs. 0%, p < 0.0001) were significantly different between the groups. Successful closure of "surgical" ASDs was achieved in 92% of cases. Complete closure at last follow-up evaluation did not significantly differ between the groups (97.1 vs. 100%, p = NS), as was wireframe fractures rate (49.1% in the overall population), without clinical, EKG and echocardiographic consequences.

CONCLUSIONS

Percutaneous treatment with GCO device is effective and safe in high percentage of "complex" ASDs.

Venous drainage for minithoracotomy approach in an adult with interrupted inferior vena cava

For atrial septal defect closure via right minithoracotomy in an adult patient with infra-hepatic interruption of the inferior vena cava with azygos connection, an alternative venous cannulation strategy was applied. In addition to bicaval cannulations to the femoral vein and the internal jugular vein, a 20 Fr straight cannula draining the hepatic vein was added to the proximal IVC through the right atrium wall via a working port. A bloodless operative field in the right atrium was afforded with bicaval encircling. Preoperative imaging test of the continuity of the IVC was important planning cardiac surgery with peripheral cannulations.

Morphometric study of fossa ovale in human cadaveric hearts: embryological and clinical relevance

Atrial septal defect (ASD) is the 5th common congenital abnormality at birth. Secundum atrial defect and patent foramen ovale (PFO) are the most common atrial septal defects. In this setting, the anatomical functional characterization of the interatrial septum seems to be of paramount importance not only for device selection but also for therapeutic intervention. This study was carried out to evaluate the morphometric parameters of fossa ovale (FOv) in the human adult cadaveric hearts. For this study, 50 normal cadaveric human hearts available in the department of Anatomy over the period of 3 years were used where size, position, shape, nature of the FOv was noted. The size of the fossa was measured and prominence, location, and extent of the limbus fossa ovalis were observed. The probe patency of foramen ovale (FO) was confirmed. In most specimens, the fossa was oval (80%), the average transverse diameter was 24.21 mm, and the vertical diameter 26.84 mm. In 84% rim was raised. In 56% of cases, the fossa was present at the middle of the interatrial septum. The patency of foramen was observed in 3%. The findings of the present study provide pertinent information on the morphology of the FOv, which may be useful for device selection in treating ASDs and PFO. This would definitely help the clinicians in a deeper understanding of the region as very few cadaveric studies are available in the literature at present.

Atrio-aortic erosion caused by Amplatzer Atrial Septal Occluder - a case report

Background

In specialized centers, percutaneous closure using specific occluders is the first-choice treatment in atrial septal defects (ASD). Late complications after this intervention, such as erosion of the aorta or the atria, are rare and have not been sufficiently approached and dealt with in literature. In our clinic we have been faced with the problematic situation of diagnosing and treating such cases. That is why, we have decided to share our experience with other colleagues.

Case presentation

We present two cases of severe late complications after percutaneous closure of atrial septal defects (ASD). In both cases, the atrial septal occluder (Amplatzer™ Atrial Septal Occluder Device, Abbott, Chicago USA) caused the erosion between the left atrium and the aortic root. The atrio-aortic erosion led to acute cardiac tamponade with upper venous congestion and shock. As the bleeding source remained undetectable for any imaging tools, a diagnostical sternotomy remained the only solution.

The cause of the acute bleeding was discovered to be the erosion between the left atrium and the aortic root. The treatment consisted in the removal of the occluder, direct suturing of the perforated areas and the surgical closure of the remaining ASD. The patients fully recovered within the nine to fourteen days’ hospital stay. Six months after surgery both patients were well and able to recover their daily routine.

Conclusions

The atrio-aortic erosion after percutaneous closure of atrial septal defects is a surgical emergency. The more so, since it can be complicated by the absence of specific symptoms. A key-element in the diagnosis of this rare pathology remains the medical history of the patient, which the surgeon has to consider thoroughly and launch the diagnostic sternotomy without delay.

Preliminary Experience With the New Amplatzer™ Trevisio™ Delivery System in Transcatheter Atrial Septal Defect Closures in Children

Objectives: To evaluate safety, efficacy, and technical advantages of Amplatzer™ Trevisio™ intravascular delivery system (ATIDS) in percutaneous atrial septal defect (ASD) closure in children. Background: The Trevisio™ is a novel delivery system designed for accurate and facilitated implantation of Amplatzer™ devices. There are no published clinical reports so far. Methods: During September 2020, 9 children with anatomically challenging ASDs underwent attempted transcatheter closure using ATIDS to deliver Amplatzer™ Septal occluders (ASO). All interventions were performed under general anesthesia, trans-esophageal echocardiography (TOE), and fluoroscopic guidance. Standard safety, immediate, and 60-days outcomes were prospectively assessed. Results: The median age was 8.1 (5.1-16.9) years and the median bodyweight was 30 (18-63) kg. Six patients had isolated secundum-type ASDs with absent anterosuperior rims including one with an aneurysmal septum. Three patients had unclassical defects associated with complex congenital heart anomalies. Eight devices were delivered from the femoral vein and the jugular vein was accessed in one patient with interrupted inferior caval vein and azygos continuation. All implantations were successful. The shape, position, and orientation of the ASO were identical before and after release on TOE and fluoroscopy. There was no device embolization or serious complication following closure. Complete shunt closure was confirmed on follow-up. Conclusions: We report the first clinical experience with ATIDS in transcatheter ASD pediatric closures. Safety and efficacy were witnessed in our case-series. The major advantage of reduced-tension deployment and reliable precision in device positioning is highly beneficial in challenging anatomies and unusual access.

Atrial Septal Defect Closure Device-Related Infective Endocarditis in a 20-Week Pregnant Woman

With increasing atrial septal defect (ASD) repairs, more women of childbearing age will have ASD closure devices. Current ASD closure trials have excluded women planning pregnancy, making their management challenging. We present a pregnant woman, with a repaired ASD, who presented with device-related infective endocarditis. (Level of Difficulty: Beginner.).

Trans-catheter atrial septal defect closure with the new GORE® Cardioform ASD occluder: First European experience

BACKGROUND

This perspective, observational study evaluated safety and efficacy of the GORE® Cardioform ASD Occluder (WL Gore & Associates, Flagstaff, AZ), compliant and potentially innovative prosthesis recently approved for closure of ostium secundum atrial septal defects (ASD).

METHODS

Between January and June 2020, 43 unselected patients with -significant ASD were submitted to trans-catheter closure with GORE® Cardioform ASD Occluder at two high-volume Italian Pediatric Cardiology centers. Primary endpoints were procedural success and safety. Secondary endpoints were closure rate and clinical safety at 1-month follow-up.

RESULTS

Patients' age and weight were 8.2 ± 3.9 years (range 3-21, median 9.9) and 29.6 ± 15.3 kg (range 16-57, median 33.3), respectively. ASD diameter was 16.6 ± 4.5 mm (median 10), resulting in QP/QS of 1.7 ± 0.7 (median 1.6). Seventeen pts. (39.5%) were considered "surgical" candidates due to challenging septum morphology, ASD rim deficiency or ASD diameter/patient weight ratio ≥ 1.2. Device placement was successfully achieved in all but one patient (97.7%), in whom it embolized early after deployment, resulting in rescue surgical repair. No cross-over with different devices was recorded. Median procedure and fluoroscopy times were 40 and 6.8 min, respectively. Major adverse events were recorded in 7.0% (3 pts). Complete closure rate was 78.5% at discharge, rising to 92.9% (39/42 pts) at 1 month evaluation, without cardiac or extra-cardiac adverse events. "Challenging" procedures were more time-consuming but as effective and safe as the "simple" ones.

CONCLUSIONS

The GORE® Cardioform ASD Occluder device was highly effective and versatile in closure of ASDs with different anatomy and size, even in challenging settings.

A single atrial septal defect masquerading as multiple defects due to a refraction artifact – A cautionary note

Echocardiography is useful for making a diagnosis of atrial septal defect (ASD) by directly visualizing the shunt flow. Herein, we present a case in which a single ostium secundum type ASD masqueraded as multiple defects on color flow imaging by transthoracic echocardiography. We confirmed by transesophageal echocardiography that this patient actually had a single ASD. An echocardiographic refraction artifact was considered to be the cause of this phenomenon. We need to be aware of the existence of this artifact to avoid misdiagnosis.

〈Learning objective: Echocardiography is useful for making a diagnosis of atrial septal defect (ASD). We present the case with a single ostium secundum type ASD which masqueraded as multiple defects on color flow imaging due to a refraction artifact. Refraction artifacts can make multiple false flow signals on color imaging. This case emphasizes the importance of an understanding of the existence of this artifact in not only B mode imaging but also color Doppler imaging.〉

Atrial Septal Defect

Atrial septal defects are common congenital heart defects, characterized by insufficient/absent tissue at the interatrial septum. An unrepaired defect may be associated with right heart volume overload, atrial arrhythmia or pulmonary arterial hypertension. The 3 major types of atrial septal defect are: ostium secundum defect, ostium primum defect, and sinus venosus. Characteristic physical findings include a midsystolic pulmonary flow or ejection murmur, accompanied by a fixed split-second heart sound. Small defects may spontaneously close; larger defects may persist and result in hemodynamic and clinical sequelae requiring percutaneous or surgical intervention. Severe pulmonary arterial hypertension is a contraindication to closure.

Autopsy in adults with congenital heart disease (ACHD)

The adult congenital heart diseases (ACHD) population is exceeding the pediatric congenital heart diseases (CHD) population and is progressively expanding each year, representing more than 90% of patients with CHD. Of these, about 75% have undergone surgical and/or percutaneous intervention for palliation or correction. Autopsy can be a very challenging procedure in ACHD patients. The approach and protocol to be used may vary depending on whether the pathologists are facing native disease without surgical or percutaneous interventions, but with various degrees of cardiac remodeling, or previously palliated or corrected CHD. Moreover, interventions for the same condition have evolved over the last decades, as has perioperative myocardial preservations and postoperative care, with different long-term sequelae depending on the era in which patients were operated on. Careful clinicopathological correlation is, thus, required to assist the pathologist in performing the autopsy and reaching a diagnosis regarding the cause of death. Due to the heterogeneity of the structural abnormalities, and the wide variety of surgical and interventional procedures, there are no standard methods for dissecting the heart at autopsy. In this paper, we describe the most common types of CHDs that a pathologist could encounter at autopsy, including the various types of surgical and percutaneous procedures and major pathological manifestations. We also propose a practical systematic approach to the autopsy of ACHD patients.

Minimally Invasive Surgery vs Device Closure for Atrial Septal Defects: A Systematic Review and Meta-analysis

Device closure is the first-line treatment for most atrial septal defects (ASDs). Minimally invasive cardiac surgery (MICS) has been found safe and effective for ASD closure with comparable mortality/morbidity and superior cosmetic results compared to conventional median sternotomy. Our goal was to compare percutaneous versus MICS of ASDs. A systematic review was performed using PubMed and the Cochrane Library (end-of-search date on May 22, 2019). Meta-analyses were conducted using fixed and random effects models. In the present systematic review, we analyzed six studies including 1577 patients with ASDs who underwent either MICS (n = 642) or device closure (n = 935). Treatment efficacy was significantly higher in the MICS (99.8%; 95% CI 98.9-99.9) compared to the device closure group (97.3%; 95% CI 95.6-98.2), (OR 0.1; 95% CI 0.02-0.6). Surgical patients experienced significantly more complications (16.2%; 95% CI 13.0-19.9) compared to those that were treated with a percutaneous approach (7.1%; 95% CI 5.0-9.8), (OR 2.0; 95% CI 1.2-3.2). Surgery was associated with significantly longer length of hospital stay (5.6 ± 1.7 days) compared to device closure (1.3 ± 1.4 days), (OR 4.8; 95% CI 1.1-20.5). Residual shunts were more common with the transcatheter (3.9%; 95% CI 2.7-5.5) compared to the surgical approach (0.95%; 95% CI 0.3-2.4), (OR 0.1; 95% CI 0.06-0.5). There was no difference between the two techniques in terms of major bleeding, hematoma formation, transfusion requirements, cardiac tamponade, new-onset atrial fibrillation, permanent pacemaker placement, and reoperation rates. MICS for ASD is a safe procedure and compares favorably to transcatheter closure. Despite longer hospitalization requirements, the MICS approach is feasible irrespective of ASD anatomy and may lead to a more effective and durable repair.

Normalization of the right heart and the preoperative factors that influence the emergence PAH after surgical closure of atrial septal defect

BACKGROUND

Surgical closure of atrial septal defect (ASD) is contraindicated in the condition with severe pulmonary arterial hypertension (PAH), whereas ASD closure in an effective intervention to normalize the structure and function of the right heart after previously experiencing volume overload due to shunting from the defect. This study aimed to evaluate normalization of the right heart and emergence of PAH after surgical closure of ASD.

METHODS

This retrospective study was carried out in 45 patients over 18 years who had undergone surgical closure of ASD. The study has the aim to evaluate the morphological and functional parameters before and after the surgical approach and the preoperative factors that influenced the development of pulmonary arterial hypertension (PAP) after the ASD closure.

RESULTS

The majority of subjects were female (73.3%) although there were no significant differences between males and females from the various parameters. The average of mPAP in the group that experienced PAH was higher than non-PAH group after ASD closure (p = 0.019, 31.23 ± 12.70 mmHg vs 24.07 ± 13.08 mmHg). Significant differences were found in the Right Atrium (RA) dimension, Right Ventricle (RV) dimension, Tricuspid Regurgitation Velocity (TRV) and Tricuspid Annular Plane Systolic Excursion (TAPSE) between before and at 6 months after ASD closure (p = 0.000, p = 0.000, p = 0.000, p = 000, respectively). The sensitivity of the predictive model to estimate PAH at 6 months after surgical closure of ASD was 58%, with a specificity of 62.5%.

CONCLUSION

Structural and functional normalization of the right heart occurs at 6 months after surgical closure of ASD with the decrease of RA and RV dimensions and improvement from tricuspid regurgitation. Emergence of PAH after ASD closure was influenced by higher mPAP before surgical approach.

The role of 'halo sign' for the accurate quantification of atrial septal defect size with 3D TEE

In patients undergoing percutaneous closure of secundum atrial septal defect, the device selection is decided based on three-dimensional transesophageal echocardiography (3D TEE) measurements and two-dimensional balloon stretched diameter measurements; more importantly balloon sizing. The purpose of the study was to assess whether in patients with "halo-sign", defined as increased tissue thickness at the edge of the ASD rims, there is an agreement between 3D TEE and 2D balloon stretched diameter aiming to avoidance of balloon sizing. Forty consecutive patients who underwent closure of a single, without complex anatomy ASD were included. 3D and 2D TEE datasets were acquired and analyzed offline. Planimetry was used to calculate circumference derived diameter of ASD from 3D datasets. Patients were classified according to the presence of the "halo sign" and the agreement between circumference derived diameter and balloon stretched diameter was examined. Forty consecutive patients who underwent closure of a single, without complex anatomy ASD were included. 3D and 2D TEE datasets were acquired and analyzed offline. Planimetry was used to calculate circumference derived diameter of ASD from 3D datasets. Patients were classified according to the presence of the "halo sign" and the agreement between circumference derived diameter and balloon stretched diameter was examined. Higher correlation and lower median absolute difference between 3D TEE measurements and 2D stretched balloon diameter was found in patients with "halo sign". In patients with the "halo sign" mean diameter difference was non-significant. On the contrary statistically significant difference was found in patients without the "halo sign". Significant difference was also found when comparing mean difference in the two patient groups. ASD sizing by 3D echocardiography, is accurate in patients with halo sign and it correlates well with the balloon sizing method. This study justifies further investigation concerning the reliability of 3D imaging for the selection of the ASD device size with a view to avoid balloon sizing, decrease procedural time and thus simplify the procedure.