Left Atrial Function and Not Volume Predicts Mid-to-Late Atrial Fibrillation after Mitral Valve Repair

OBJECTIVES

Patients undergoing surgical mitral valve repair for degenerative mitral regurgitation are at risk of even late postoperative atrial fibrillation (AF). Left atrial (LA) functionhas been shown superior to LA volume in evaluating risk of AF in diverse cardiac conditions. We therefore investigated the prognostic value of LA function and volume in predicting mid-to-late postoperative AF after mitral valve repair (>30 days postoperatively).

METHODS

We retrospectively identified all patients who underwent mitral valve repair for degenerative mitral regurgitation between 2012-2019 at our institution. Exclusion criteria were preoperative AF, concomitant procedures, re-operations, missing or insufficiently processable preoperative echocardiograms, and missing follow-up. LA function and volume measurements were conducted using speckle-tracking strain echocardiographic analysis. Postoperative LA function was measured in a subgroup with sufficient postoperative echocardiograms.

RESULTS

We included 251 patients, of which 39 (15.5%) experienced AF in the mid-to-late postoperative period. Reduced LA strain parameters and more than mild preoperative tricuspid regurgitation were independently associated with mid-to-late postoperative AF. LA volume index had no association with mid-to-late postoperative AF in univariable analysis and did not improve performance of multivariable models. Patients with mid-to-late AF exhibited diminished improvement in LA function after surgery.

CONCLUSION

In mitral valve repair patients, LA function (but not volume) showed independent predictive value for mid-to-late postoperative AF. Including left atrial function into surgical decision making and approach may identify patients who will benefit from earlier intervention with the aim to prevent irreversible left atrial damage with consequent risk of postoperative AF.

Racial and Ethnic Differences in the Clinical Diagnosis of Aortic Stenosis

Background Racial and ethnic minority groups are underrepresented among patients undergoing aortic valve replacement in the United States. We evaluated the impact of race and ethnicity on the diagnosis of aortic stenosis (AS). Methods and Results In patients with transthoracic echocardiography (TTE)-confirmed AS, we assessed rates of AS diagnosis as defined by assignment of an International Classification of Diseases, Ninth Revision (ICD-9) and Tenth Revision (ICD-10) code for AS within a large multicenter electronic health record. Multivariable Cox proportional hazard and competing risk regression models were used to evaluate the 1-year rate of AS diagnosis by race and ethnicity. Among 14 800 patients with AS, the 1-year diagnosis rate for AS following TTE was 37.4%. Increasing AS severity was associated with an increased likelihood of receiving an AS diagnosis (moderate: hazard ratio [HR], 3.05 [95% CI, 2.86-3.25]; P<0.0001; severe: HR, 4.82 [95% CI, 4.41-5.28]; P<0.0001). Compared with non-Hispanic White, non-Hispanic Black (HR, 0.65 [95% CI, 0.54-0.77]; P<0.0001) and non-Hispanic Asian individuals (HR, 0.72 [95% CI, 0.57-0.90], P=0.004) were less likely to receive a diagnosis of AS. Additional factors associated with a decreased likelihood of receiving an AS diagnosis included a noncardiology TTE ordering provider (HR, 0.92 [95% CI, 0.86-0.97]; P=0.005) and TTE performed in the inpatient setting (HR, 0.72 [95% CI, 0.66-0.78]; P<0.0001). Conclusions Rates of receiving an ICD diagnostic code for AS following a diagnostic TTE are low and vary significantly by race and ethnicity and disease severity. Further studies are needed to determine if efforts to maximize the clinical recognition of TTE-confirmed AS may help to mitigate disparities in treatment.

Sex Differences and Similarities in Valvular Heart Disease

As populations age worldwide, the burden of valvular heart disease has grown exponentially, and so has the proportion of affected women. Although rheumatic valve disease is declining in high-income countries, degenerative age-related causes are rising. Calcific aortic stenosis and degenerative mitral regurgitation affect a significant proportion of elderly women, particularly those with comorbidities. Women with valvular heart disease have been underrepresented in many of the landmark studies which form the basis for guideline recommendations. As a consequence, surgical referrals in women have often been delayed, with worse postoperative outcomes compared with men. As described in this review, a more recent effort to include women in research studies and clinical trials has increased our knowledge about sex-based differences in epidemiology, pathophysiology, diagnostic criteria, treatment options, outcomes, and prognosis.

Integration of Functional Imaging, Cytometry, and Unbiased Proteomics Reveals New Features of Endothelial-to-Mesenchymal Transition in Ischemic Mitral Valve Regurgitation in Human Patients

Background: Following myocardial infarction, mitral regurgitation (MR) is a common complication. Previous animal studies demonstrated the association of endothelial-to-mesenchymal transition (EndMT) with mitral valve (MV) remodeling. Nevertheless, little is known about how MV tissue responds to ischemic heart changes in humans.

Methods: MVs were obtained by the Cardiothoracic Surgical Trials Network from 17 patients with ischemic mitral regurgitation (IMR). Echo-doppler imaging assessed MV function at time of resection. Cryosections of MVs were analyzed using a multi-faceted histology and immunofluorescence examination of cell populations. MVs were further analyzed using unbiased label-free proteomics. Echo-Doppler imaging, histo-cytometry measures and proteomic analysis were then integrated.

Results: MVs from patients with greater MR exhibited proteomic changes associated with proteolysis-, inflammatory- and oxidative stress-related processes compared to MVs with less MR. Cryosections of MVs from patients with IMR displayed activated valvular interstitial cells (aVICs) and double positive CD31+ αSMA+ cells, a hallmark of EndMT. Univariable and multivariable association with echocardiography measures revealed a positive correlation of MR severity with both cellular and geometric changes (e.g., aVICs, EndMT, leaflet thickness, leaflet tenting). Finally, proteomic changes associated with EndMT showed gene-ontology enrichment in vesicle-, inflammatory- and oxidative stress-related processes. This discovery approach indicated new candidate proteins associated with EndMT regulation in IMR.

Conclusion: We describe an atypical cellular composition and distinctive proteome of human MVs from patients with IMR, which highlighted new candidate proteins implicated in EndMT-related processes, associated with maladaptive MV fibrotic remodeling.

Sex Differences in Outcomes of Patients With Chronic Aortic Regurgitation: Closing the Mortality Gap

OBJECTIVE

To examine contemporary clinical differences between men and women with hemodynamically significant chronic aortic regurgitation (AR).

PATIENTS AND METHODS

We retrospectively identified 1072 consecutive patients with moderate to severe or severe AR diagnosed between February 21, 2004, and April 29, 2019. Echocardiographic data, aortic valve surgical intervention (AVS), and all-cause death were analyzed.

RESULTS

At baseline, the 189 women in the study group were older than the 883 men (mean ± SD age, 64±18 years vs 58±17 years), had more advanced symptoms, and had larger left ventricular end-systolic dimension index (LVESDi) (all P<.001) despite similar AR severity. An LVESDi of greater than 20 mm/m² was noted in 60 of 92 asymptomatic women (65%) vs 225 of 559 asymptomatic men (40%) (P<.001). Median follow-up was 5.6 years (interquartile range, 2.5 to 10.0 years). Female sex was associated with less AVS (P=.009), and overall 10-year survival was better in men (76%±2%) than in women (64%±5%) (P=.004). However, 10-year post-AVS survival was similar between the sexes (P=.86), and women had better left ventricular reverse remodeling than men regarding end-diastolic dimension (P=.02). Multivariable independent predictors of death were age, advanced symptoms, LVESDi, ejection fraction, and AVS (all P≤.03) but not female sex. When compared with the age-matched US population, women exhibited a 1.3-fold increased relative risk of death (P=.0383) while men had similar survival (P=.11).

CONCLUSION

In contemporary practice, women with AR continue to exhibit an overall survival penalty not related to female sex but to late referral markers, including more advanced symptoms, larger LVESDi, and less AVS. Nonetheless, women in our study exhibited outstanding post-AVS left ventricular remodeling and had good post-AVS survival, a step forward toward closing the sex-related mortality gap. The high percentage of LVESDi of 20 mm/m² or greater in asymptomatic women represents a window of opportunity for advanced-symptom prevention and timely AR surgical correction that may close the mortality gap.

Cost-effectiveness of coronary artery bypass grafting plus mitral valve repair versus coronary artery bypass grafting alone for moderate ischemic mitral regurgitation

OBJECTIVE

The Cardiothoracic Surgical Trials Network reported that left ventricular reverse remodeling at 2 years did not differ between patients with moderate ischemic mitral regurgitation randomized to coronary artery bypass grafting plus mitral valve repair (n = 150) or coronary artery bypass grafting alone (n = 151). To address health resource use implications, we compared costs and quality-adjusted survival.

METHODS

We used individual patient data from the Cardiothoracic Surgical Trials Network trial on survival, hospitalizations, quality of life, and US hospitalization costs to estimate cumulative costs and quality-adjusted life years. A microsimulation model was developed to extrapolate to 10 years. Bootstrap and deterministic sensitivity analyses were performed to address uncertainty.

RESULTS

In-hospital costs were $59,745 for coronary artery bypass grafting plus mitral valve repair versus $51,326 for coronary artery bypass grafting alone (difference $8419; 95% uncertainty interval, 2259-18,757). Two-year costs were $81,263 versus $67,341 (difference 13,922 [2370 to 28,888]), and quality-adjusted life years were 1.35 versus 1.30 (difference 0.05; -0.04 to 0.14), resulting in an incremental cost-effectiveness ratio of $308,343/quality-adjusted life year for coronary artery bypass grafting plus mitral valve repair. At 10 years, its costs remained higher ($107,733 vs $88,583, difference 19,150 [-3866 to 56,826]) and quality-adjusted life years showed no difference (-0.92 to 0.87), with 5.08 versus 5.08. The likelihood that coronary artery bypass grafting plus mitral valve repair would be considered cost-effective at 10 years based on a cost-effectiveness threshold of $100K/quality-adjusted life year did not exceed 37%. Only when this procedure reduces the death rate by a relative 5% will the incremental cost-effectiveness ratio fall below $100K/quality-adjusted life year.

CONCLUSIONS

The addition of mitral valve repair to coronary artery bypass grafting for patients with moderate ischemic mitral regurgitation is unlikely to be cost-effective. Only if late mortality benefits can be demonstrated will it meet commonly used cost-effectiveness criteria.

Clinical features and prognosis of patients with isolated severe aortic stenosis and valve area less than 1.0 cm2

OBJECTIVE

Current guidelines define severe aortic stenosis (AS) as an aortic valve area (AVA)≤1.0 cm², but some authors have suggested that the AVA cut-off be decreased to 0.8 cm². The aim of this study was, therefore, to better describe the clinical features and prognosis of patients with an AVA of 0.8-0.99 cm².

METHODS

Patients with isolated, severe AS and ejection fraction ≥55% with an AVA of 0.8-0.99 cm² (n=105) were compared with those with an AVA<0.8 cm² (n=155) and 1.0-1.3 cm² (n=81). The endpoint of this study was a combination of death from any cause or aortic valve replacement at or before 3 years.

RESULTS

Patients with an AVA of 0.8-0.99 cm² group comprised predominantly normal-flow, low-gradient (NFLG) AS, while high gradients and low flow were more often observed with an AVA<0.8 cm². The frequency of symptoms was not significantly different between an AVA of 0.8-0.99 cm² and 1.0-1.3 cm². The combined endpoint was achieved in 71%, 52% and 21% of patients with an AVA of 0.8 cm², 0.8-0.99 cm²and 1.0-1.3 cm², respectively (p<0.001). Among patients with an AVA of 0.8-0.99 cm², NFLG AS was associated with a lower hazard (HR=0.40, 95% CI 0.23 to 0.68, p=0.001) of achieving the combined endpoint with outcomes similar to moderate AS in the first 1.5 years of follow-up. Patients with high-gradient or low-flow AS with an AVA of 0.8-0.99 cm² had outcomes similar to those with an AVA<0.8 cm². The sensitivity for the combined endpoint was 61% for an AVA cut-off of 0.8 cm² and 91% for a cut-off of 1.0 cm².

CONCLUSIONS

The outcomes of patients with AS with an AVA of 0.8-0.99 cm² are variable and are more precisely defined by flow-gradient status. Our findings support the current AVA cut-off of 1.0 cm².

Two-Year Outcomes of Surgical Treatment of Moderate Ischemic Mitral Regurgitation

BACKGROUND

In a trial comparing coronary-artery bypass grafting (CABG) alone with CABG plus mitral-valve repair in patients with moderate ischemic mitral regurgitation, we found no significant difference in the left ventricular end-systolic volume index (LVESVI) or survival after 1 year. Concomitant mitral-valve repair was associated with a reduced prevalence of moderate or severe mitral regurgitation, but patients had more adverse events. We now report 2-year outcomes.

METHODS

We randomly assigned 301 patients to undergo either CABG alone or the combined procedure. Patients were followed for 2 years for clinical and echocardiographic outcomes.

RESULTS

At 2 years, the mean (±SD) LVESVI was 41.2±20.0 ml per square meter of body-surface area in the CABG-alone group and 43.2±20.6 ml per square meter in the combined-procedure group (mean improvement over baseline, -14.1 ml per square meter and -14.6 ml per square meter, respectively). The rate of death was 10.6% in the CABG-alone group and 10.0% in the combined-procedure group (hazard ratio in the combined-procedure group, 0.90; 95% confidence interval, 0.45 to 1.83; P=0.78). There was no significant between-group difference in the rank-based assessment of the LVESVI (including death) at 2 years (z score, 0.38; P=0.71). The 2-year rate of moderate or severe residual mitral regurgitation was higher in the CABG-alone group than in the combined-procedure group (32.3% vs. 11.2%, P<0.001). Overall rates of hospital readmission and serious adverse events were similar in the two groups, but neurologic events and supraventricular arrhythmias remained more frequent in the combined-procedure group.

CONCLUSIONS

In patients with moderate ischemic mitral regurgitation undergoing CABG, the addition of mitral-valve repair did not lead to significant differences in left ventricular reverse remodeling at 2 years. Mitral-valve repair provided a more durable correction of mitral regurgitation but did not significantly improve survival or reduce overall adverse events or readmissions and was associated with an early hazard of increased neurologic events and supraventricular arrhythmias. (Funded by the National Institutes of Health and Canadian Institutes of Health Research; ClinicalTrials.gov number, NCT00806988.).

Two-Year Outcomes of Surgical Treatment of Severe Ischemic Mitral Regurgitation

BACKGROUND

In a randomized trial comparing mitral-valve repair with mitral-valve replacement in patients with severe ischemic mitral regurgitation, we found no significant difference in the left ventricular end-systolic volume index (LVESVI), survival, or adverse events at 1 year after surgery. However, patients in the repair group had significantly more recurrences of moderate or severe mitral regurgitation. We now report the 2-year outcomes of this trial.

METHODS

We randomly assigned 251 patients to mitral-valve repair or replacement. Patients were followed for 2 years, and clinical and echocardiographic outcomes were assessed.

RESULTS

Among surviving patients, the mean (±SD) 2-year LVESVI was 52.6±27.7 ml per square meter of body-surface area with mitral-valve repair and 60.6±39.0 ml per square meter with mitral-valve replacement (mean changes from baseline, -9.0 ml per square meter and -6.5 ml per square meter, respectively). Two-year mortality was 19.0% in the repair group and 23.2% in the replacement group (hazard ratio in the repair group, 0.79; 95% confidence interval, 0.46 to 1.35; P=0.39). The rank-based assessment of LVESVI at 2 years (incorporating deaths) showed no significant between-group difference (z score=-1.32, P=0.19). The rate of recurrence of moderate or severe mitral regurgitation over 2 years was higher in the repair group than in the replacement group (58.8% vs. 3.8%, P<0.001). There were no significant between-group differences in rates of serious adverse events and overall readmissions, but patients in the repair group had more serious adverse events related to heart failure (P=0.05) and cardiovascular readmissions (P=0.01). On the Minnesota Living with Heart Failure questionnaire, there was a trend toward greater improvement in the replacement group (P=0.07).

CONCLUSIONS

In patients undergoing mitral-valve repair or replacement for severe ischemic mitral regurgitation, we observed no significant between-group difference in left ventricular reverse remodeling or survival at 2 years. Mitral regurgitation recurred more frequently in the repair group, resulting in more heart-failure-related adverse events and cardiovascular admissions. (Funded by the National Institutes of Health and Canadian Institutes of Health Research; ClinicalTrials.gov number, NCT00807040.).

Standard transthoracic echocardiography and transesophageal echocardiography views of mitral pathology that every surgeon should know

The mitral valve is the most commonly diseased heart valve and the prevalence of mitral valve disease increases proportionally with age. Echocardiography is the primary diagnostic imaging modality used in the assessment of patients with mitral valve disease. It is a noninvasive method which provides accurate anatomic and functional information regarding the mitral valve and can identify the mechanism of mitral valve pathology. This is especially useful as it may guide surgical repair. This is increasingly relevant given the growing trend of patients undergoing mitral valve repair. Collaboration between cardiac surgeons and echocardiographers is critical in the evaluation of mitral valve disease and for identification of complex valvular lesions that require advanced surgical skill to repair. This article will provide an overview of transthoracic and transesophageal assessment of common mitral valve pathology that aims to aid surgical decision making.

Surgical treatment of moderate ischemic mitral regurgitation

BACKGROUND

Ischemic mitral regurgitation is associated with increased mortality and morbidity. For surgical patients with moderate regurgitation, the benefits of adding mitral-valve repair to coronary-artery bypass grafting (CABG) are uncertain.

METHODS

We randomly assigned 301 patients with moderate ischemic mitral regurgitation to CABG alone or CABG plus mitral-valve repair (combined procedure). The primary end point was the left ventricular end-systolic volume index (LVESVI), a measure of left ventricular remodeling, at 1 year. This end point was assessed with the use of a Wilcoxon rank-sum test in which deaths were categorized as the lowest LVESVI rank.

RESULTS

At 1 year, the mean LVESVI among surviving patients was 46.1±22.4 ml per square meter of body-surface area in the CABG-alone group and 49.6±31.5 ml per square meter in the combined-procedure group (mean change from baseline, -9.4 and -9.3 ml per square meter, respectively). The rate of death was 6.7% in the combined-procedure group and 7.3% in the CABG-alone group (hazard ratio with mitral-valve repair, 0.90; 95% confidence interval, 0.38 to 2.12; P=0.81). The rank-based assessment of LVESVI at 1 year (incorporating deaths) showed no significant between-group difference (z score, 0.50; P=0.61). The addition of mitral-valve repair was associated with a longer bypass time (P<0.001), a longer hospital stay after surgery (P=0.002), and more neurologic events (P=0.03). Moderate or severe mitral regurgitation was less common in the combined-procedure group than in the CABG-alone group (11.2% vs. 31.0%, P<0.001). There were no significant between-group differences in major adverse cardiac or cerebrovascular events, deaths, readmissions, functional status, or quality of life at 1 year.

CONCLUSIONS

In patients with moderate ischemic mitral regurgitation, the addition of mitral-valve repair to CABG did not result in a higher degree of left ventricular reverse remodeling. Mitral-valve repair was associated with a reduced prevalence of moderate or severe mitral regurgitation but an increased number of untoward events. Thus, at 1 year, this trial did not show a clinically meaningful advantage of adding mitral-valve repair to CABG. Longer-term follow-up may determine whether the lower prevalence of mitral regurgitation translates into a net clinical benefit. (Funded by the National Institutes of Health and the Canadian Institutes of Health Research; ClinicalTrials.gov number, NCT00806988.).

Ischemic (functional) mitral regurgitation

Mitral regurgitation (MR) is a frequent complication of myocardial infarction and coronary artery disease that is associated with adverse prognosis. The main mechanism of ischemic MR relates to distortion of the spatial relationships between the mitral valve and papillary muscles secondary to ventricular remodeling. The evidence that treatment of ischemic MR improves long-term survival still remains unclear, and further studies are needed to determine whether correcting ischemic MR will improve survival and/or symptoms.

Mitral-valve repair versus replacement for severe ischemic mitral regurgitation

BACKGROUND

Ischemic mitral regurgitation is associated with a substantial risk of death. Practice guidelines recommend surgery for patients with a severe form of this condition but acknowledge that the supporting evidence for repair or replacement is limited.

METHODS

We randomly assigned 251 patients with severe ischemic mitral regurgitation to undergo either mitral-valve repair or chordal-sparing replacement in order to evaluate efficacy and safety. The primary end point was the left ventricular end-systolic volume index (LVESVI) at 12 months, as assessed with the use of a Wilcoxon rank-sum test in which deaths were categorized below the lowest LVESVI rank.

RESULTS

At 12 months, the mean LVESVI among surviving patients was 54.6±25.0 ml per square meter of body-surface area in the repair group and 60.7±31.5 ml per square meter in the replacement group (mean change from baseline, -6.6 and -6.8 ml per square meter, respectively). The rate of death was 14.3% in the repair group and 17.6% in the replacement group (hazard ratio with repair, 0.79; 95% confidence interval, 0.42 to 1.47; P=0.45 by the log-rank test). There was no significant between-group difference in LVESVI after adjustment for death (z score, 1.33; P=0.18). The rate of moderate or severe recurrence of mitral regurgitation at 12 months was higher in the repair group than in the replacement group (32.6% vs. 2.3%, P<0.001). There were no significant between-group differences in the rate of a composite of major adverse cardiac or cerebrovascular events, in functional status, or in quality of life at 12 months.

CONCLUSIONS

We observed no significant difference in left ventricular reverse remodeling or survival at 12 months between patients who underwent mitral-valve repair and those who underwent mitral-valve replacement. Replacement provided a more durable correction of mitral regurgitation, but there was no significant between-group difference in clinical outcomes. (Funded by the National Institutes of Health and the Canadian Institutes of Health; ClinicalTrials.gov number, NCT00807040.).

Long-Term Survival After Surgical Revascularization for Moderate Ischemic Mitral Regurgitation

BACKGROUND

We sought to characterize patient survival and degree of late mitral regurgitation (MR) in patients undergoing surgical revascularization with moderate ischemic MR.

METHODS

We retrospectively reviewed 251 patients undergoing coronary artery bypass graft (CABG) surgery between 1991 and 2001 with 3+ ischemic MR, including 31 patients who had concomitant mitral annuloplasty. Univariate and multivariable testing was employed.

RESULTS

Actuarial 1-, 5-, and 10-year survival was 84.0%, 67.5%, and 37.1% in the overall group of 251 patients. Independent predictors of long-term mortality were age 70 years or more (hazard ratio 2.50 [95% confidence interval 1.82 to 3.44]), prior myocardial infarction (3.99 [2.15 to 7.39]), unstable angina (2.27 [1.69 to 3.04]), chronic renal failure (4.87 [3.13 to 7.58]), atrial fibrillation (2.21 [1.65 to 2.96]), left internal mammary artery to left anterior descending artery graft (0.28 [0.18 to 0.43]), preoperative beta-blocker (0.43 [0.28 to 0.67]), ejection fraction (0.71/10% [0.64 to 0.80]), left atrium size (0.88/mm [0.84 to 0.92]), diffuse wall motion abnormalities (2.83 [1.77 to 4.55]), and mitral leaflet restriction (3.85 [2.46 to 5.99]). The model controlled for the performance of annuloplasty, which did not emerge as an independent predictor. Patients undergoing annuloplasty did have less mean late MR than those having CABG alone (p = 0.005). Overall, 57.8% of patients (63 of 109) with follow-up echocardiograms had improvement in grade of MR compared with baseline. In 54 of 95 patients (56.8%), intraoperative transesophageal echocardiography downgraded the degree of MR compared with the preoperative study.

CONCLUSIONS

Patients with moderate ischemic MR undergoing CABG had relatively poor long-term survival, with significant differences when stratified according to preoperative characteristics. Performance of mitral annuloplasty reduced the degree of regurgitation but was not a predictor of long-term survival. Intraoperative transesophageal echocardiography frequently downgraded the degree of MR.

Effect of Atrial Septal Mobility on Transcatheter Closure of Interatrial Communications

BACKGROUND

Transcatheter techniques have evolved as alternatives to surgical closure of interatrial communications due to its less invasive nature and low morbidity. The technique may be limited by the inability to deploy the device and, thus, may be complicated by significant residual shunting. Mobile or redundant septal tissue has been implicated as a possible cause of unsuccessful closure.

METHODS

To determine if atrial septal hypermobility precludes successful transcatheter device closure of interatrial communications, 69 patients (mean age 46.4 +/- 17.5 years [male:female ratio 34:35]) with periprocedural transesophageal echocardiograms were reviewed. Septal excursion was defined as the maximal transit of the interatrial septum between either side of the plane connecting the superior and inferior attachment points. Unsuccessful closure was defined as subsequent cardiac surgery to close the defect, inability to deploy the device, recurrent attempts at closure, device malalignment, residual shunting greater than mild in degree on follow-up transthoracic study, and procedural complications.

RESULTS

Reasons for closure were the following: embolic events (n = 48); platypnea/orthodeoxia (n = 15); atrial septal defect with right ventricular dilatation and paroxysmal atrial tachycardia (n = 2); atrial septal defect (n = 3); and prophylactic patent foramen ovale closure in a scuba diver (n = 1). Successful closure occurred in 76% of patients (n = 53). Compared with those patients with successful transcatheter closure, the mean septal excursion in patients with failed closure was 0.66 +/- 0.56 cm versus 0.76 +/- 0.47 cm (P = not significant [NS]).

CONCLUSION

Our results do not support the concern that exaggerated septal mobility compromises successful device closure of interatrial communications.