Long-term outcome of percutaneous closure of secundum-type atrial septal defects in adults

Comparative effectiveness of devices for transcatheter closure of atrial septal defects: Systematic review and network meta-analysis

Atrial septal defect is a common congenital heart disease, producing a left-to-right shunt in the atrial septum; the current preferred treatment is transcatheter device closure. The aim is to conduct a systematic review to synthesize information on the comparative effectiveness and safety of atrial septal defect closure devices. The methods used: a comprehensive search of Ovid MEDLINE®, Embase, and Cochrane Central databases was conducted. Studies comparing procedural and follow-up outcomes of atrial septal defect devices were included. Network meta-analyses were conducted to generate direct and indirect evidence for comparative effectiveness and safety outcomes between devices. The results are as follows: Twelve studies met our inclusion criteria and were compared in network meta-analyses. The meta-analyses evaluated contemporary devices: the AMPLATZER Septal Occluder; the GORE CARDIOFORM Septal Occluder; the Figulla Flexible II Occluder; the CeraFlex Septal Occluder; and the HELEX Septal Occluder. These studies represented 3998 patients. The primary safety and efficacy outcomes were device embolization and follow-up residual shunt, respectively. Secondary clinical outcomes included procedural success and major and minor complications. No differences were found between devices in terms of device embolization and secondary clinical outcomes. Follow-up residual shunt was higher with the HELEX Septal Occluder compared with the AMPLATZER Septal Occluder (odds ratio 2.92, 95% confidence interval 1.12-7.61). To conclude: although most outcomes were similar between devices, evidence was largely based on observational low-quality studies. There were inconsistencies in outcome reporting and definitions; this merits future studies, with head-to-head device comparisons and standardization of outcomes.

Atrial fibrillation following transcatheter atrial septal defect closure: a systematic review and meta-analysis

OBJECTIVE

The ostium secundum atrial septal defect (ASD) is among the most common congenital cardiac anomalies diagnosed in adulthood. A known complication of transcatheter ASD closure is the development of new-onset atrial fibrillation and flutter (AFi/AFl). These arrhythmias confer an increased risk of postoperative stroke, thrombus formation and systemic emboli. This systematic review examines the burden of de novo AFi/AFl in adults following transcatheter closure and seeks to identify risk factors for AFi/AFl development.

METHODS

Studies were identified by a search of MEDLINE, EMBASE and Cochrane databases from inception until 29 April 2020. A meta-analysis of AFi/AFl incidence was performed using a random-effects model.

RESULTS

A total of 31 studies met inclusion criteria, comprising 4788 adult patients without a history of AFi/AFl. Twenty-three studies were included in quantitative synthesis and demonstrated an overall incidence rate of 1.82 patients per 100 person-years of follow-up (I²=83%). In studies that enrolled only patients ≥60 years old, the incidence was 5.21 patients per 100 person-years (I²=0%). Studies with follow-up duration ≤2 years reported an incidence of 4.05 per 100 person-years (I²=55%) compared with a rate of 1.19 per 100 person-years (I²=85%) for studies with follow-up duration >2 years.

CONCLUSIONS

The incidence of new-onset AFi/AFl is relatively low following transcatheter closure of secundum ASDs. The rate of de novo AFi/AFl, however, was significantly higher in elderly patients. Shorter follow-up time was associated with a higher reported incidence of AFi/AFl.

Quality of Life in Adults Undergoing Percutaneous Device Closure of Atrial Septal Defect

To assess changes in the quality of life in adult patients undergoing percutaneous device closure of atrial septal defect (ASD).We used a standard Medical Outcome Study Short Form 36 (SF-36) that includes psychological and physiological aspects to assess and analyze the quality of life of 73 adult patients who underwent percutaneous device closure of ASD.Of the 73 patients who were investigated in this study, 67 completed questionnaires successfully. The following findings were revealed after analyzing the preoperative results and postoperative results. In some dimensions ( "physical functioning," "vitality," "general health" ), the postoperative perception was better than the preoperative status. Some differences were found in the quality of life feedback between the case group and the control group. Among the different subgroups, older patients scored lower than younger patients on most dimensions, and men seemed to perform better on "role-physical" factors than women. Unmarried people performed worse on "role-physical" and "bodily pain" than married people. Among people with different academic degrees, those with higher degrees demonstrated better scores on multiple dimensions ( "role-physical," "mental health," "social functioning," and "general health" ) than those with lower degrees.After percutaneous device closure of ASD, most adult patients feel that the quality of life is improved compared with that during the preoperative status. With the change of patients' own conditions, their quality of life seems to change differently. In order to better help patients integrate into life, psychological and physical support is still needed.

Long-Term Outcome After Transcatheter Atrial Septal Defect Closure in Adults: A Systematic Review and Meta-Analysis

AIMS

We performed a systematic review and meta-analysis of published studies to characterize the current literature and help determine the long-term outcomes after transcatheter ASD closure in adults.

METHODS AND RESULTS

Two investigators searched the manuscript databases for all eligible studies in accordance with the considered keywords. The pooled prevalence of each event according to the meta-analysis and considering the weight calculated for each study included 10.1% (for arrhythmia), 1.8% (for emboli), 2.3% (for stroke), 12.5% (for residual shunt), 1.8% (for erosion), and 2.5% (for death).

CONCLUSION

The present meta-analysis show high long-term successfulness of transcatheter ASD closure in adults.

Incidence and predictors of asymptomatic pericardial effusion after transcatheter closure of atrial septal defect

AIMS

Pericardial effusion (PE) without obvious periprocedural complications (e.g., cardiac perforation, device erosion) may occur after transcatheter closure of secundum atrial septal defects (ASD). The aim of the study was to investigate the incidence and predictors of PE unrelated to procedural complications.

METHODS AND RESULTS

We included all patients who had undergone successful percutaneous ASD closure from June 2009 to April 2014 (n=2,652) with no pre-existing PE or cardiac perforation or erosion. Transthoracic echocardiography (TTE) was performed during the procedure and one, three, and six months postoperatively. After device implantation, fifty patients (1.9%) developed new-onset PE (37 immediately, 13 during follow-up). These patients were asymptomatic, stable haemodynamically, and had no new arrhythmias. PE appeared mild (5.1±1.9 mm) and homogeneously echolucent by TTE. PE diminished spontaneously. Compared with 2,602 patients without PE, factors independently predicting asymptomatic PE were the device touching the atrial free wall, device size, patient age, and total defect size. Areas under the receiver operating characteristic curves were 0.78 (p<0.001), 0.66 (p<0.001) and 0.77 (p<0.001) for device size, patient age, and total defect size, respectively.

CONCLUSIONS

This is the first systematic report of a new type of PE. Our data provide new insights into new-onset PE after percutaneous ASD closure.

A passive beating heart setup for interventional cardiology training

Realistic training of cardiologic interventions in a heart catheter laboratory is hardly achievable with simple tools and requires animal experiments. Therefore, first a simple mock circuit connected to a porcine heart mimicking the natural heart motion was developed. In a second step the setup was duplicated to drive both sides of the heart independently to generate motion and physiologic pressures and flows. Using this simple setup cardiologic interventions (arterial and ventricular septal defects ASD/VSD closure) were performed successfully and allowed realistic training under the C-arm, echocardiography, placement of catheters and repair of ASD/VSD. With the second setup flows of up to 4 l/min were achieved in both sides of the heart at maximum left and right ventricular pressures of 80 mm Hg and 30 mm Hg respectively. This method is inexpensive and represents a realistic alternative to training in animal experiments.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Percutaneous closure of secundum type atrial septal defects: More than 5-year follow-up

AIM: To investigate long-term efficacy of two different devices more than five years after percutaneous atrial septal defect (ASD) closure in adults.

METHODS: All patients who underwent percutaneous closure of an ASD in the St. Antonius Hospital, Nieuwegein, The Netherlands, between February 1998 and December 2006 were included. Percutaneous closure took place under general anaesthesia and transesophageal echocardiographic monitoring. Transthoracic echocardiography (TTE) was performed 24 h post-procedure to visualize the device position and to look for residual shunting using color Doppler. All complications were registered. All patients were invited for an outpatient visit and contrast TTE more than 5-years after closure. Efficacy was based on the presence of a residual right-to-left shunt (RLS), graded as minimal, moderate or severe. The presence of a residual left-to-right shunt (LRS) was diagnosed using color Doppler, and was not graded. Descriptive statistics were used for patients’ characteristics. Univariate analysis was used to identify predictors for residual shunting.

RESULTS: In total, 104 patients (mean age 45.5 ± 17.1 years) underwent percutaneous ASD closure using an Amplatzer device (ASO) in 76 patients and a Cardioseal/Starflex device (CS/SF) in 28 patients. The mean follow-up was 6.4 ± 3.4 years. Device migration occurred in 4 patients of whom two cases occurred during the index hospitalization (1 ASO, 1 CS/SF). The other 2 cases of device migration occurred during the first 6 mo of follow-up (2 CS/SF). The recurrent thrombo-embolic event rate was similar in both groups: 0.4% per follow-up year. More than 12 mo post-ASD closure and latest follow-up, new-onset supraventricular tachyarrhythmia’s occurred in 3.9% and 0% for the ASO and CS/SF group, respectively. The RLS rate at latest follow-up was 17.4% (minimal 10.9%, moderate 2.2%, severe 4.3%) and 45.5% (minimal 27.3%, moderate 18.2%, severe 0%) for the ASO- and CS/SF groups, respectively. There was no residual LRS in both groups.

CONCLUSION: Percutaneous ASD closure has good long-term safety and efficacy profiles. The residual RLS rate seems to be high more than 5 years after closure, especially in the CS/SF. Residual LRS was not observed.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Atrioventricular block subsequent to intraoperative device closure atrial septal defect with transthoracic minimal invasion; a rare and serious complication

OBJECTIVES

Atrioventricular block (AVB) is a infrequent and serious complication after percutaneous ASD closure. In this study, we report on the incidence of AVB associated with intraoperative device closure of the ASD with transthoracic minimal invasion, and the outcomes of this complication in our center.

METHODS

Between May 2006 and January 2011, a total of 213 secundum-type ASD patients were accepted in our hospital for intraoperative and transthoracic device closure with a domestic occluder. All patients were assessed by real-time transthoracic echocardiography (TTE) and electrocardiograph (ECG).

RESULTS

All patients were occluded successfully under this approach. Immediate postprocedure third-degree AVB was observed in two patients. Since heart rates were in the range of about 50 to 55 beats per minute, no intervention was needed except for close observation for one patient. Another patient who recovered sinus rhythm intermittently during the operation was fitted with a temporary pacemaker. Approximately one week following glucocorticoid treatment, the AVB resolved spontaneously in these two patients. Mobitz type II AVB occurred in three patients during the procedure. Two patients developed post-operative cardiac arrest and were rescued successfully with cardiopulmonary resuscitation. One other patient changed to Mobitz type I AVB after three days. During the follow-up period, which ranged from six months to five years, no further occurrence of AVB was found.

CONCLUSIONS

Intraoperative and transthoracic device closure of secundum ASDs with domestic occluder resulted in excellent closure rate. AVB is an infrequent but serious complication during and after device closure of a secundum ASD. AVB is a complication that warrants greater attention and long-term follow-up.

Five-year follow-up of transcatheter intracardiac echocardiography-assisted closure of interatrial shunts

OBJECTIVE

We sought to prospectively evaluate long-term follow-up results of intracardiac echocardiography-aided transcatheter closure of interatrial shunts in adults.

BACKGROUND

Intracardiac echocardiography improves the safety and effectiveness of transcatheter device-based closure of interatrial shunts, but its impact on long-term follow-up is unknown.

METHODS

Over a 5-year period, we prospectively enrolled 258 consecutive patients (mean age 48 ± 19.1 years, 169 females) who had been referred to our centre for catheter-based closure of interatrial shunts. All patients were screened with transesophageal echocardiography before the operation. Eligible patients underwent intracardiac echocardiography study and attempted closure.

RESULTS

After intracardiac echocardiography study and measurements, 18 patients did not proceed to transcatheter closure due to unsuitable rims, atrial myxoma not diagnosed by preoperative transesophageal echocardiography or inaccurate transesophageal echocardiography measurement of defects more than 40 mm. The remaining 240 patients underwent transcatheter closure: transesophageal echocardiography-planned device type and size were modified in 108 patients (45%). Rates of procedural success, predischarge occlusion and complication were 100%, 94.2% and 5%, respectively. On mean follow-up of 65 ± 15.3 months, the follow-up occlusion rate was 96.5%. There were no cases of aortic/atrial erosion, device thrombosis or atrioventricular valve inferences.

CONCLUSIONS

Intracardiac echocardiography-guided interatrial shunt transcatheter closure is safe and effective and appears to have excellent long-term results, potentially minimizing the complications resulting from incorrect device selection and sizing.