Long-term outcome of transcatheter secundum-type atrial septal defect closure using Amplatzer septal occluders

Mid-Term Outcomes after Percutaneous Closure of the Secundum Atrial Septal Defect with the Figulla-Occlutech Device

OBJECTIVES

To evaluate the mid-term outcomes after percutaneous closure of the secundum atrial septal defects (ASD) using the Figulla-Occlutech device (FOD).

BACKGROUND

Transcatheter closure has become the method of choice for most patients with ASD. Although the FOD may have some advantageous characteristics there is a paucity of data on later outcomes after the use of this relatively new device.

METHODS

Observational, single arm study including 200 non-consecutive patients who underwent ASD closure between 04/09 and 07/15 in 2 centers. Device performance, deployment technique, and immediate and mid-term outcomes were assessed.

RESULTS

Median age and weight were 24 years (4-72) and 58 kg (15-92), respectively. Single defects were observed in 171 patients (median size of 19 mm). The remainder had multiple or multifenestrated defects. Implantation of FOD (median size of 24 mm) was successful in all (99%), but 2 patients (1 with deficient postero-inferior rim; 1 with a large ASD for the size of the child). Embolization with device retrieval occurred in 2 (1%). Median follow-up of 36 months was obtained in 172 patients. Serial echocardiographic assessment showed complete closure in all but 2 patients, in whom an additional small non-significant posterior defect was purposely left untouched. There have been no episodes of late arrhythmias, device embolization, cardiac erosion, endocarditis, thromboembolism, wire fracture, or death.

CONCLUSIONS

Transcatheter closure of ASDs in older children, adolescents, and adults using the FOD was highly successful in a wide range of anatomical scenarios with high closure rates and no complications in mid-term follow-up.

Minimally invasive endoscopic repair of atrial septal defects via right minithoracotomy

Atrial septal defect (ASD) repair has been conventionally performed via midline sternotomy with very low operative risk and excellent early and late outcomes. Recently, many of these patients with suitable anatomy are being treated with percutaneous catheter-based closure of their ASD, but issues of prosthetic device implantation, long-term antiplatelet therapy and late device complications persist. Minimally invasive repair of ASD via a 3-cm right minithoracotomy provides patients with a much less invasive surgical repair with all the durable benefits of autologous pericardial patch closure. However, widespread adoption of the minithoracotomy approach to ASD closure remains slow. This study describes the simple steps to ASD repair via a right minithoracotomy.

Long-term Follow-up of "Simple" Lesions--Atrial Septal Defect, Ventricular Septal Defect, and Coarctation of the Aorta

Surgery for congenital heart disease has advanced significantly in the past 50 years, such that repair of "simple" lesions, such as atrial septal defect, ventricular septal defect, and coarctation of the aorta carries minimal risk, with mortality risk much less than 1%. It was once thought successful repair of these lesions was definitively corrective. There is mounting evidence, however, that there are long-term complications after these repairs, prompting the need for continued follow-up. This review describes the current understanding of diagnosis, treatment, and long-term outcomes for these patients, with the goal of advocating for lifelong surveillance. As the perioperative care of these repairs has evolved significantly over time, so must the way in which we study these patients in the long-term.

Fate of Mitral Regurgitation After Transcatheter Closure of Atrial Septal Defect in Adults

Although the volume overload of pulmonary circulation improves after atrial septal defect (ASD) closure, the increasing left ventricular preload may contribute to mitral regurgitation (MR) deterioration. We aimed to evaluate the impact of MR after transcatheter ASD closure on clinical outcomes in adults. A total of 288 consecutive patients who underwent transcatheter ASD closure were enrolled. Changes in MR were assessed at 1 month after the procedure. The end point was defined as cardiovascular events. After the procedure, MR ameliorated in 3 patients and unchanged in 253, whereas MR deteriorated in 32. During a median follow-up of 24 months, patients with MR deterioration had no cardiovascular events, and the event-free survival rate was not different between patients with MR deterioration and those with MR amelioration or no-change (p = 0.355). Even in patients with MR deterioration, the New York Heart Association functional class improved after the procedure, with no cases of worsening functional class. Multivariate logistic regression analysis showed that MR deterioration was independently related to advanced age and female gender. The degree of enlargement of mitral valve annulus diameter after the procedure was greater in patients with MR deterioration than in those with MR amelioration or no-change, and it was correlated with the degree of MR deterioration. In conclusion, MR deterioration occurs in a minority of adult patients after transcatheter ASD closure; however, it is not linked with adverse outcomes. MR deterioration may be provoked by geometric changes in mitral valve annulus, especially in women with advanced age.

Intra-arterial thrombolysis of central retinal artery occlusion following percutaneous atrial septal defect closure

Use of percutaneous devices for atrial septal defect (ASD) closure is growing, given the minimally invasive nature and the long-term durability of this approach. The reported rate of thrombus formation after catheter closure is 1.2%. Thrombotic risk varies according to closure device and Dacron-covered nitinol Amplatzer devices carry a 0-0.3% rate of thrombus formation; but central retinal artery occlusion (CRAO) is rarely implicated as an adverse event. Herein, we report the first successful intra-arterial thrombolytic treatment of CRAO developing after ASD closure via Amplatzer device. © 2015 Wiley Periodicals, Inc.

Utility of Isovolumic Contraction Peak Velocity for Evaluation of Adult Patient Status after Transcatheter Closure of Atrial Septal Defect

BACKGROUND

Transcatheter closure is a well-established treatment for patients with atrial septal defect (ASD), but long-term outcome prognostic factors for adults have not been fully identified yet.

METHODS

Forty-nine consecutive patients (age 57 ± 17 years, 59% female), who underwent transcatheter closure of ASD, were the subjects of this study. Transthoracic echocardiography was performed before and midterm after the procedure (6 ± 1 months). Isovolumic contraction peak velocity (IVV) was measured at the lateral site of the tricuspid annulus using spectral tissue Doppler imaging, and ΔIVV was determined as the absolute change at midterm follow-up. Long-term unfavorable outcome events, tracked for 19 ± 9 months, were prespecified as primary end points comprising newly developed atrial fibrillation, cerebral infarction, and heart failure.

RESULTS

Symptomatic improvement, defined as an improvement in New York Heart Association functional class by one grade or more at midterm after the procedure, was observed in 24 patients (49%), and the remaining 25 (51%) were classified as not symptomatically improved. ΔIVV was significantly larger for patients with symptomatic improvement than for those without (from 11.5 ± 4.3 cm/s to 14.2 ± 3.7 cm/s vs. from 11.8 ± 4.1 cm/s to 12.5 ± 2.9 cm/s; P = 0.045). An important finding of the multivariate Cox proportional-hazards analysis was that only ΔIVV was independently associated with cardiovascular events (HR: 0.701; 95% CI 0.537-0.916; P = 0.01). Kaplan-Meier analysis showed that more patients with enhanced ΔIVV presented with favorable long-term outcome than those with diminished ΔIVV (log-rank P = 0.0001).

CONCLUSIONS

IVV, which is a less volume-sensitive parameter, can be useful for comprehensive evaluation of ASD patients referred for transcatheter closure.

Comparison of the Occlutech ® Figulla ® septal occluder and Amplatzer ® septal occluder for atrial septal defect device closure

The Occlutech(®) Figulla(®) septal occluder (OFSO) is a later-generation double-disk device with few reports of its success rates and complications compared with the Amplatzer(®) septal occluder (ASO), which is the worldwide standard device in percutaneous atrial septal defect (ASD) closure. We recruited and compared the results in 149 patients (76.5 % female) who underwent ASD device closure in our center between January 2003 and June 2012. The patients ranged in age from 2.3 to 77.2 years. There were no statistically significant differences between the two groups regarding patient baseline characteristics and procedure variables. The success rate using either device was excellent (ASO 94.4 % and OFSO 97.4 %; p = 0.43). Although the diameter of the ASD and the pulmonary arterial pressure in the OFSO group were slightly higher than in the ASO group, the median fluoroscopic time in the OFSO group was significantly shorter (ASO 13.7 min; OFSO 9.0 min; p < 0.001). The overall median follow-up time was 3.6 years (interquartile range 2.1-9.0 years). There were no significant differences between the major and minor complications when comparing the two devices. Both devices were safe and effective for percutaneous ASD closures. The OFSO had the benefit of a shorter fluoroscopic time.

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.

The First Ten of Everything: A Review of Past and Current Practice in Pediatric Cardiac Percutaneous Interventions

OBJECTIVES

This study was designed to compare outcomes of the most common pediatric cardiac interventions from the time of implementation with the current era.

BACKGROUND

Since the introduction of semilunar valve balloon dilation and device closure of the arterial duct and septal defects, development of interventional techniques and devices has been rapid. However, few studies have compared outcomes between those initial interventions and those in the current era.

METHODS

Five validated common catheter-based therapies were chosen for analysis, including atrial and duct device closure, balloon dilation of the aortic and pulmonary valves, and native coarctation of the aorta. A retrospective review of the first and most recent 10 consecutive patients in each group was performed.

RESULTS

There was a high mortality (30%) among neonates who underwent aortic valve (AV) dilation in the early era, but no mortality noted in other groups. In the early era, transcatheter atrial defect closure and AV dilations were associated with a low success rate (60% for both lesions) and a high complication rate (40% for atrial septal defect, 30% for AV dilations). Among the last 10 children, the atrial defect occlusion was successful in 100% without complications and AV dilations where successful in all children with a 30% complication rate (one major, two minor).

CONCLUSIONS

A learning curve with device development plays a significant role in the evolution of transcatheter techniques. These data provide baseline estimates of success and may be used as a template in the future when new techniques are adapted into practice.

Transcatheter Closure of Large Atrial Septal Defects

Background—

Data are needed on the safety and efficacy of device closure of large atrial septal defects.

Methods and Results—

Between 1998 and 2013, 336 patients (161 children <15 years) with large, isolated, secundum atrial septal defects (balloon-stretched diameter ≥34 mm in adults or echocardiographic diameter >15 mm/m 2 in children) were managed using the Amplatzer device, at the Marie Lannelongue Hospital. Transthoracic echocardiographic guidance was used starting in 2005 (n=219; 65.2%). Balloon-stretched diameter was >40 mm in 36 adults; mean values were 37.6±3.3 mm in other adults and 26.3±6.3 mm/m 2 in children. Amplatzer closure was successful in 311 (92.6%; 95% confidence interval, 89%–95%) patients. Superior and posterior rim deficiencies were more common in failed than in successful procedures (superior, 24.0% versus 4.8%; P =0.002; and posterior, 32.0% versus 4.2%; P <0.001). Device migration occurred in 4 adults (2 cases each of surgical and transcatheter retrieval); in the 21 remaining failures, the device was unreleased and withdrawn. After a median follow-up of 10.0 years (2.5–17 years), all patients were alive with no history of late complications.

Conclusions—

Closure of large atrial septal defects using the Amplatzer device is safe and effective in both adults and children. Superior and posterior rim deficiencies are associated with procedural failure. Closure can be performed under transthoracic echocardiographic guidance in experienced centers. Early device migration is rare and can be safely managed by device extraction. Long-term follow-up showed no deaths or major late complications in our population of 311 patients.

Cost-effectiveness of procedures for treatment of ostium secundum atrial septal defects occlusion comparing conventional surgery and septal percutaneous implant

OBJECTIVES

The study performs a cost-effectiveness analysis of procedures for atrial septal defects occlusion, comparing conventional surgery to septal percutaneous implant.

METHODS

A model of analytical decision was structured with symmetric branches to estimate cost-effectiveness ratio between the procedures. The decision tree model was based on evidences gathered through meta-analysis of literature, and validated by a panel of specialists. The lower number of surgical procedures performed for atrial septal defects occlusion at each branch was considered as the effectiveness outcome. Direct medical costs and probabilities for each event were inserted in the model using data available from Brazilian public sector database system and information extracted from the literature review, using micro-costing technique. Sensitivity analysis included price variations of percutaneous implant.

RESULTS

The results obtained from the decision model demonstrated that the percutaneous implant was more cost effective in cost-effectiveness analysis at a cost of US$8,936.34 with a reduction in the probability of surgery occurrence in 93% of the cases. Probability of atrial septal communication occlusion and cost of the implant are the determinant factors of cost-effectiveness ratio.

CONCLUSIONS

The proposal of a decision model seeks to fill a void in the academic literature. The decision model proposed includes the outcomes that present major impact in relation to the overall costs of the procedure. The atrial septal defects occlusion using percutaneous implant reduces the physical and psychological distress to the patients in relation to the conventional surgery, which represent intangible costs in the context of economic evaluation.

New devices and technology in interventional cardiology

There have been substantial improvements made in the tools and techniques used since the advent of percutaneous coronary intervention. What was primarily developed as a treatment of coronary artery disease is now used to address a variety of structural heart disease problems. The outcomes have been remarkably successful with relatively low complication rates that rival the results of open-heart surgery. This article will review some of the new devices available for management of structural cardiac conditions including congenital defects and acquired valvular abnormalities. Transcatheter treatment offers advantages over surgical intervention in recovery time, improved patient satisfaction, lower procedural risk, and avoidance of cardio-pulmonary bypass especially in high-risk patients. We will discuss different medical conditions and introduce the devices used to treat these conditions. Each device or technique has benefits and risks, and familiarity with the devices along with patient selection will best optimize the outcome.

The benefit of atrial septal defect closure in elderly patients

Objective

Closure of an atrial septal defect in elderly patients is controversial. The aim of the study was to evaluate the outcomes of transcatheter closure of secundum atrial septal defects (ASDs) in elderly patients.

Patients and methods

From a total of 488 patients with ASDs who underwent transcatheter closure, 75 patients aged over 60 years (45 female, 30 male) with a mean age of 65.3±15.7 (60–75) years were analyzed. All patients had an isolated secundum ASD with a mean pulmonary blood flow:systemic blood flow of 2.84±1.9 (1.5–3.9). Symptom-limited treadmill exercise tests with respiratory gas-exchange analysis and transthoracic color Doppler echocardiographic study, as well as quality of life measured using the Short Form (36) Health Survey (SF-36) were repeated in all patients before the procedure and after 12 months of follow-up.

Results

The atrial septal device was successfully implanted in all patients (procedure time 37.7±4.5 [13–59] minutes, fluoroscopy time 11.2±9.9 [6–40] minutes). There were no major complications. The defect echo diameter was 17.7±15.8 (12–30) mm. The mean balloon-stretched diameter of ASDs was 22.4±7.9 (14–34) mm. The diameter of the implanted devices ranged from 16 to 34 mm. Significant improvement of exercise capacity was noted at 6 and 12 months after the procedure. Exercise time within 6 months of ASD closure was longer (P<0.001) compared to baseline values, and also oxygen consumption increased (P<0.001). Seven quality-of-life parameters (except mental health) improved at 12-month follow-up compared to baseline data. The mean SF-36 scale increased significantly in 66 (88%) patients, with a mean of 46.2±19.1 (5–69). As early as 1 month after the procedure, a significant decrease of the right ventricular dimension and the right atrium dimension was observed (P<0.001). The right ventricular dimension decreased in 67 patients (89.3%).

Conclusion

Closure of ASDs in elderly patients caused significant clinical and hemodynamic improvement after percutaneous treatment, which was maintained during long-term follow-up, justifying this procedure in old age.

Is it worth closing the atrial septal defect in patients with insignificant shunt?

Introduction

Closure of the atrial septal defect in patients with insignificant shunt is controversial.

Aim

To evaluate the outcomes of transcatheter closure of atrial septal defect (ASD) in symptomatic patients with borderline shunt.

Material and methods

One hundred and sixty patients (120 female, 40 male) with a mean age of 30.1 ±16.2 (20–52) years with a small ASD who underwent transcatheter closure were analyzed. All patients had a small ASD with Qp: Qs ratio ≤ 1.5, mean 1.2 ±0.9 (1.1–1.5) in echo examination. Cardiopulmonary exercise tests, clinical study, transthoracic echocardiographic study as well as quality of life (QoL) (measured using the SF36 questionnaire (SF36q)) were repeated in all patients before and after the procedure.

Results

The devices were successfully implanted in all patients. After 12 months of ASD closure, all the patients showed a significant improvement of exercise capacity (oxygen consumption – 21.9 ±3.1 vs. 30.4 ±7.7, p > 0.001). The QoL improved in 7 parameters at 12-month follow-up. The mean SF36q scale increased significantly in 141 (88.1%) patients of mean 43.2 ±20.1 (7–69). A significant decrease of the right ventricular area (20.3 ±1.3 cm² vs. 18.3 ±1.2 cm², p < 0.001) and the right atrial area (15.2 ±1.9 cm² vs. 12.0 ±1.6 cm², p < 0.001) was observed at 12-month follow-up.

Conclusions

Closure of ASD in the patients with insignificant shunt resulted in significant durable clinical and hemodynamic improvement after percutaneous treatment.

Transcatheter treatment of heart failure with preserved or mildly reduced ejection fraction using a novel interatrial implant to lower left atrial pressure

BACKGROUND

Heart failure with preserved or mildly reduced ejection fraction (HFpEF) is common and, to date, therapeutic options are limited. Increased left atrial pressure is a key contributor to the symptoms associated with HFpEF, particularly during physical activity. We report the 30-day outcome of patients treated with a novel device intended to lower left atrial pressure by creating an 8 mm permanent shunt in the atrial septum.

METHODS AND RESULTS

Eleven patients were enrolled in the pilot trial. Key inclusion criteria were: EF >45%; baseline PCWP ≥15 mmHg (rest), or ≥ 25 mmHg (exercise); and ≥1 hospitalization for heart failure within the past 12 months, or persistent NYHA class III/IV for at least 3 months. Mean age, LVEF, and NYHA class were 70 ± 12 years, 57 ± 9%, and 3.2 ± 0.4, respectively. Most patients had significant co-morbidities. The interatrial septal device (IASD) device was implanted using percutaneous trans-septal access via the femoral vein. The device was successfully implanted in all patients. At 30 days, LV filling pressures were significantly reduced by 5.5 mmHg (19.7 ± 3.4 vs. 14.2 ± 2.7; P = 0.005), and NYHA class was improved by two classes in two patients, one class in five patients, and worsened by one class in one patient. No patient developed pulmonary hypertension. Two serious adverse events occurred; heart failure re-hospitalization, and implant malposition successfully treated with a new device.

CONCLUSION

Contemporary management of HFpEF patients is confounded by the lack of effective therapies. The use of a device-based approach to reduce left atrial pressure provides a novel means to improve haemodynamic and symptomatic status in HFpEF patients and warrants further investigation.

Pulmonary hypertension in adult congenital heart disease

OPINION STATEMENT

There is a growing patient population with adult congenital heart disease that needs specialized medical attention and careful long-term evaluation. Pulmonary arterial hypertension (PAH) associated with congenital heart disease (PAH-CHD) is a common late complication, and is associated with increased morbidity and mortality. There are no clear current guidelines for the treatment of PAH-CHD. There are few trials to date investigating PAH treatment specifically in this group of patients. However, the available data seems to demonstrate that with the advent of PAH-targeted therapies, the quality of life, exercise capacity, and outcomes in these patients is improving. In addition, PAH-targeted therapies may be useful in select patients for a combined medical-surgical approach to treatment. Here we discuss the epidemiology and pathophysiology of PAH-CHD, current therapies, and the data supporting their use, and how to evaluate feasibility of late surgical repair.

Percutaneous closure of atrial septal defect with situs solitus and dextrocardia

Percutaneous closure of secundum atrial septal defect associated with situs solitus and dextrocardia has not been reported previously. We describe the technical difficulties encountered during transcatheter closure of a secundum atrial septal defect in a 19-month-old girl with situs solitus and dextrocardia.

The Role of Catheter-Based and Surgical Treatments in Patients With Congenital Heart Disease and Pulmonary Hypertension

This manuscript is intended to provide a brief overview of the indications for and outcomes of surgical and transcatheter interventions for congenital heart disease and pulmonary hypertension (PH). Pulmonary hypertension is frequently encountered in children and adults with congenital heart disease and is most commonly related to large “central” shunts, ie, those occurring at the ventricular or great arterial level (Figure 1). If uncorrected early in infancy or childhood, large central shunts result in increased pulmonary blood flow, left heart volume overload, PH, and heart failure. If the child survives this initial period of volume overload and heart failure, they will very likely develop effacement of the normal pulmonary arterial architecture and severe elevations in pulmonary arterial resistance, eventually resulting in cyanosis and Eisenmenger syndrome.1

Application of the defect area in transcatheter closure of atrial septal defect

OBJECTIVES

It was our aim to evaluate whether the defect area plays a crucial role in successful device closure of atrial septal defects (ASDs).

METHODS

The long and short diameters of the defect were measured on en-face images. The defect area was then measured by planimetry. The device size compared to the defect length and defect area was analyzed in each group.

RESULTS

There were 22 patients in the circular group and 45 patients in the noncircular group. The defect area did not differ between the groups (201.6 ± 107.1 vs. 245.6 ± 127.6 mm(2)). Although the length between the device size and the long diameter differed between the groups (3.4 ± 2.0 vs. 0.8 ± 3.7 mm; p = 0.003), there was no difference in the ratio of the device area compared to the defect area, which was constant even in the noncircular defect (1.73 ± 0.41 vs. 1.72 ± 0.53 mm(2); p = 0.947). The device size was positively correlated with the defect area (p < 0.01).

CONCLUSION

The defect area measured by planimetry on en-face images might be useful in selecting the device size for transcatheter closure of ASDs.

Balloon occlusive diameter of non-circular atrial septal defects in transcatheter closure with amplatzer septal occluder

Background and Objectives

The aim of this study was to investigate the balloon occlusive diameter (BOD) of non-circular defects in the transcatheter closure of atrial septal defect (ASD).

Subjects and Methods

A total of 67 patients who had undergone transcatheter closure of an ASD were reviewed retrospectively. A non-circular defect was defined as the ratio of the short diameter to the long diameter of the defect on the en-face image less than 0.75. The BOD was compared with the long diameter of the defect and then compared between the two groups.

Results

There were 22 patients with circular defects and 45 patients with non-circular defects. The difference in BOD measuring from the long diameter of the defect was quite different between the two groups and significantly smaller in non-circular morphology (0.1±4.0 vs. 2.3±2.1, p=0.006). The difference in BOD measurement from the long diameter of ASD showed a positive correlation with the ratio of the short diameter to the long diameter of ASD (b/a) (r²=0.102, p=0.008). In the non-circular morphology of ASD, the difference in BOD measured from the long diameter had a significant negative correlation with the long diameter of ASD (r²=0.230, p=0.001), whereas in circular ASD, no significant correlation was found between the difference in BOD and the long diameter of ASD (p=0.201).

Conclusion

The BOD compared with the long diameter measured from three-dimensional transesophageal echocardiography was smaller in non-circular ASD than in circular ASD. This difference was much smaller in non-circular ASD with a large long diameter.

Clinical validation of the planar radionuclide ventriculography in patients with right ventricular dysfunction

OBJECTIVES

Gated radionuclide ventriculography (RNV) may be used for the evaluation of the right ventricular function. However, the accuracy of the method should be clinically validated in patients suffering from diseases with specific pathology of the right ventricle (RV) and with possible left ventricular (LV) interaction.

METHODS

Three groups of 15 patients each, diagnosed with arrhythmogenic right ventricular dysplasia (ARVD), pulmonary artery hypertension (PAH) or atrial septal defect (ASD) were compared to a group of normal subjects. The parameters for both ventricles were evaluated separately (ejection fractions: LVEF and RVEF, and intraventricular synchronism quantified as phase standard deviation: LVPSD and RVPSD) as well as the relation or interdependence of the right to left ventricle (RV/LV volume ratio, LV/RV ejection fraction and stroke volume ratios, and interventricular synchronism). All the variables as a whole were analyzed to identify groups of patients according to their functional behaviour.

RESULTS

Significant differences were found between the patients and control group for the RV function while the LV function remained mostly within normal limits. When the RV function was considered, the control group and ASD patient group showed differences regarding the ARVD and PAH patients. On evaluating the RV/LV ratios, differences were found between the control group and the ASD group. In the PAH patients, LV function showed differences in relation to the rest of the groups.

CONCLUSION

RNV is a reliable clinical tool to evaluate RV function in patients with RV abnormality.

Outcome of transcatheter closure of oval shaped atrial septal defect with amplatzer septal occluder

PURPOSE

For the successful completion of transcatheter closure of atrial septal defects with the Amplatzer septal occluder, shape of the defects should be considered prior to selecting the device. The purpose of this study is to evaluate the results of a transcatheter closure of oval shaped atrial septal defect.

MATERIALS AND METHODS

From November 2009 until November 2011, cardiac computed tomography was performed on 69 patients who needed a transcatheter closure of atrial septal defect. We defined an oval shaped atrial septal defect as the ratio of the shortest diameter to the longest diameter ≤ 0.75 measured using computed tomography. A trans-thoracic echocardiogram was performed one day after and six months after.

RESULTS

The transcatheter closure of atrial septal defect was performed successfully in 24 patients in the ovoid group and 45 patients in the circular group. There were no serious complications in both groups and the complete closure rate at 6 months later was 92.3% in the ovoid group and 93.1% in the circular group (p>0.05). The differences between the device size to the longest diameter of the defect and the ratios of the device size to the longest diameter were significantly smaller in the ovoid group (1.8 ± 2.8 vs. 3.7 ± 2.6 and 1.1 ± 0.1 vs. 1.2 ± 0.2).

CONCLUSION

Transcatheter closure of an oval shaped atrial septal defect was found to be safe with the smaller Amplatzer septal occluder device when compared with circular atrial septal defects.

Device size for transcatheter closure of ovoid interatrial septal defect

BACKGROUND

For successful transcatheter closure of an atrial septal defect with the Amplatzer septal occluder, the shape of the defect should be considered before selecting the device size. The purpose of this study was to evaluate the results of transcatheter closure of an ovoid atrial septal defect.

METHODS

Between January 2010 and February 2012, cardiac computer tomography examinations were performed in 78 patients who subsequently underwent transcatheter closure of an atrial septal defect. In this retrospective study, we reviewed these patients' medical records. We defined an ovoid atrial septal defect as a value of 0.75 for the ratio of the shortest diameter of the defect to the longest diameter, as measured in a computed tomography image. Transthoracic echocardiography examinations were made at 1 day and 6 months after the procedure.

RESULTS

Transcatheter closure of an atrial septal defect was successful in 26 patients in the ovoid-defect group and in 52 patients in the round-defect group. There were no serious complications in either group, and the rate of complete closure at 6 months was 92.3% in the ovoid-defect group and 93.1% in the round-defect group (P > .05). The mean (SD) difference between the device size and the defect's longest diameter, and the mean ratio of the device size to the longest diameter were significantly smaller in the ovoid-defect group (1.7 ± 2.9 versus 3.8 ± 2.5 and 1.1 ± 0.1 versus 1.3 ± 0.2, respectively).

CONCLUSIONS

Transcatheter closure of an atrial septal defect is indicated even for an ovoid atrial septal defect. Ovoid atrial septal defects can be closed successfully with smaller sizes of the Amplatzer septal occluder than for round atrial septal defects.

Late bacterial endocarditis of an Amplatzer atrial septal device

A 59-year-old male with an secundum atrial septal defect status post repair with an Amplatzer occluder in 2001 was admitted with sepsis and MRSA bacteremia. Transesophageal Echocardiography (TEE) showed presence of an overlying mobile echogenic structure on the left atrial surface of the device suggestive of a vegetation/infected thrombus. This is only the 3rd case description of late endocarditis involving the Amplatzer ASD closure device in an adult.

Clinical advantage of real-time three-dimensional transesophageal echocardiography for transcatheter closure of multiple atrial septal defects

This study sought to evaluate the usefulness of real-time three-dimensional (3D) transesophageal echocardiography (TEE) to guide the repair of multiple atrial septal defects (ASDs). Of 212 consecutive patients with secundum ASD who were scheduled for transcatheter closure of their ASDs, 27 had multiple ASDs. These patients underwent two-dimensional (2D) transthoracic echocardiography, 2D TEE, and 3D TEE. Overall, 18 patients had two defects, and 9 patients had three or more defects. The latter group included three patients with multi-fenestrated defects. Optimal 3D images were obtained in 93 % of the patients. In patients with two defects, information on the positional relation of the defects was obtained using 2D TEE and 3D TEE in 71 and 94 % of patients, respectively (P = 0.22). The positional relations of the defects could not be evaluated with 2D TEE in patients with three or more defects, whereas it could be evaluated with 3D TEE in all of these patients (0 vs. 100 %, P = 0.008). In all patients, 3D TEE proved superior to 2D TEE for providing sufficient information (96 vs. 48 %, P = 0.002). Procedural success was obtained in 26 patients (96.3 %), without complications. Transcatheter closure of multiple ASDs under 3D TEE guidance is effective and safe. Real-time 3D TEE can provide useful information regarding complex ASD morphology. It can thus contribute to developing a successful treatment strategy, especially in patients with three or more defects.

Transcatheter closure of secundum atrial septal defect in patients over 60 years old

BACKGROUND AND OBJECTIVES

Atrial septal defect (ASD) is the one of most common congenital heart diseases detected in adults. Along with remarkable development of device technology, the first treatment strategy of secundum ASD has been transcatheter closure in feasible cases. However, there are only a few publications regarding the results of transcatheter closure of ASD in elderly patients, especially those over 60 years of age. We report our results of transcatheter closure of ASD in patients over 60 years old.

SUBJECTS AND METHODS

Between May 2006 and December 2011, 31 patients over 60 years old (25 female and 6 male; mean 66.7±5.25 years old, range 61-78 years old) were referred to our center.

RESULTS

A total of 23 patients underwent therapeutic catheterization to close secundum ASD, and the closure was successful in 22 patients (95.7%). All patients who underwent the procedure survived except for one patient who expired because of left ventricular dysfunction. A small residual shunt was observed in two (9%) of 21 patients before discharge but disappeared at follow-up. All patients eventually had complete closure. There were five patients who had coronary problems. One patient underwent percutaneous coronary intervention using a stent at the same time as transcatheter closure of ASD. Atrial arrhythmias were detected in 6 of 23 patients (26.1%) before the procedure. One patient was successfully treated by radiofrequency ablation before the procedure. No patients displayed new onset arrhythmia during the follow-up period. Follow-up echocardiographic evaluation showed a significantly improved right ventricular geometry.

CONCLUSION

We conclude that transcatheter closure of ASD is a safe and an effective treatment method for patients over 60 years old if the procedure is performed under a thorough evaluation of comorbidities and risk factors.

Outcomes After Transcatheter ASD Closure

Ostium secundum-type atrial septal defect closure has evolved from a surgical procedure requiring cardiopulmonary bypass to a percutaneous, catheter-based procedure usually requiring only an overnight hospital stay. The overall safety and effectiveness has compared favorably with surgical repair. Although rare, complications have been described, including erosion, device embolization, or malfunction and arrhythmias. The overall long-term clinical outcomes have been excellent: good quality of life, functional class improvement, and ventricular remodeling have been the rule after the procedure. It is mandatory to recommend indefinite follow-up of patients undergoing this procedure for potential long-term complications.

Midterm results of percutaneous closure of very large atrial septal defects in children: role of multislice computed tomography

AIMS

The aim of this study was to assess the midterm results of percutaneous closure of very large atrial septal defects (ASD) in children with transthoracic echocardiography (TTE) and multislice computed tomography (MSCT).

METHODS AND RESULTS

Among 142 children who underwent percutaneous ASD closure with the AMPLATZER® Septal Occluder (ASO) (AGA Medical Corporation, Plymouth, MN, USA) during an eight year period, 51 patients with very large defects, were evaluated by TTE and MSCT after a period of at least two years following ASD closure. Median age at ASD closure was six years (range 4-10), with mean ASD size 20.9±2.9 mm. Median device size was 20 mm (range 15-26) and median device: septal length ratio 0.95 (range 0.8-1). Early complications included one transient complete atrioventricular block and one device embolisation. At a median follow-up of 55 months (range 25-92) all patients were clinically asymptomatic and had a normal ECG. TTE did not demonstrate device protrusion across the lumen of either the systemic or pulmonary veins. The mean device: septal length ratio had decreased from 0.96±0.05 to 0.8±0.02 (p<0.001). There was good correlation between the measure of atrial septum length by TTE and MSCT (r: 0.79, p<0.001). MSCT identified moderate dynamic device protrusion into the lumen of systemic or pulmonary veins in five patients and partial device malpositioning in two patients.

CONCLUSIONS

Occlusion of very large ASD in children can be performed with low complications rate. MSCT provides detailed information regarding the location of the device with respect to surrounding anatomic structures and reveals anomalies not evident by TTE.

Early-mid term follow-up results of percutaneous closure of the interatrial septal defects with occlutech figulla devices: a single center experience

BACKGROUND

Percutaneous closure of secundum type atrial septal defect (ASD) and patent foramen ovale (PFO) has gained widespread use in recent years. Herein, we evaluated the safety and efficacy of the Occlutech® Figulla devices for PFO and ASD closure in a reference tertiary center.

METHODS

All 143 patients (46.9% male, mean age 39.3 ± 12.2 years) who underwent transcatheter PFO (n = 85) and ASD (n = 58) closure with Occlutech® Figulla devices between February 2009 and October 2011 were included in this study. An echocardiographic follow-up examination was performed at the 1st, 6th, and 12th month visits.

RESULTS

The devices were successfully implanted in all 143 patients (100%). In-hospital periprocedural complications were device embolization (0.7%; 1 ASD patient), atrial fibrillation (1.4%; 1 ASD and 1 PFO patients), supraventricular tachycardia (0.7%; 1 PFO patient), and vascular access hematoma (0.7%; 1 ASD patient). Among ASD patients, 2 patients had trivial (jet width <1 mm in diameter) and 1 patient had small (1-2 mm) residual shunts before hospital discharge, which disappeared after the 6-month visit. During the mean 15.4 ± 9.6 months follow-up, all patients were asymptomatic and no ischemic stroke, cardiac perforation, device erosion, embolization, thrombus formation, or malposition of the device was observed.

CONCLUSIONS

Percutaneous PFO and secundum type ASD closure with the novel Occlutech® Figulla Occluder devices without left atrial central pin and with significantly reduced meshwork was safe, feasible, and effective.

Atrial septum defect closure device in a beating heart, from the perspective of a researcher in artificial organs

Transcatheter closure of atrial septum defect (ASD) with a closure device is increasing, but the history of clinical use of this procedure is still short, and the efficacy and long-term safety remain unproved. The total number of closure devices implanted throughout the world has not been counted accurately. Therefore, the probability of complications occurring after implantation is uncertain. Device-related complications that occur suddenly late after implantation are life-threatening, and quite often necessitate emergency surgical intervention. In Japanese medical journals, authors reporting closure devices have mentioned no complications and problems in their facilities. Detailed studies of device-related complications and device removal have not been reported in Japan. In fact, this literature search found an unexpectedly large number of reports of various adverse events from many overseas countries. When follow-up duration is short and the number of patients is small, the incidence of complications cannot be determined. Rare complications may emerge in a large series with a long observation period. Consequently, the actual number of incidents related to ASD closure devices is possibly several times higher than the number reported. Guidelines for long-term patient management for patients with an implanted closure device are necessary and post-marketing surveillance is appropriate. Development of a national database, a worldwide registration system, and continuous information disclosure will improve the quality of treatment. The devices currently available are not ideal in view of reports of late complications requiring urgent surgery and the need for life-long follow-up. An ideal device should be free from complications during life, and reliability is indispensable.

Long-term outcomes of device closure of very large secundum atrial septal defects: a comparison of transcatheter vs intraoperative approaches

BACKGROUND

Transcatheter device closure (TCDC) and intraoperative device closure (IODC) have emerged as minimally invasive methods in the treatment of secundum atrial septal defects (ASDs), but the long-term safety and efficacy remains uncertain for the large ASDs.

HYPOTHESIS

TCDC may be as safe and efficacious as IODC for closure of large ASDs in terms of long-term clinical outcomes.

METHODS

Ninety-two patients who had ASDs with a defect diameter of ≥30 mm were included in this study. The patients received either TCDC (n = 42) or IODC (n = 50). An Amplatzer septal occluder was used in both groups. The dumbbell-like device deploying technique was introduced in the TCDC group. Physical exams, electrocardiography, and echocardiography were performed preprocedurally and postprocedurally at the index follow-up visits.

RESULTS

The procedural immediate success rate was 97.6% for TCDC and 98.0% for IODC (P = 0.328). The rate of periprocedural complications was 9.5% for TCDC and 28.0% for IODC (P = 0.026). The mean hospital stay was 7.5 ± 2.7 days for TCDC and 11.9 ± 3.8 days for IODC (P < 0.001). For the mean follow-up of 5.4 ± 0.5 years, there were no cardiac deaths and late complications in either group. No significant residual shunts were documented, and symptoms were significantly improved in both groups. Right and left ventricular diameter, pulmonary artery diameter, and pulmonary systolic pressure were all significantly decreased in both groups (P < 0.05).

CONCLUSIONS

The present study confirmed the long-term safety and efficacy for closing a large ASD either by TCDC or IODC. Either of them could become an effective alternative to the surgery for large ASD closure. The authors have no funding, financial relationships, or conflicts of interest to disclose.

The Management of Atrial Fibrillation in a Patient with Unrepaired Atrial Septal Defect

Atrial fibrillation (AF) is a frequent comorbidity in adults with atrial septal defect (ASD), one of the most common congenital heart defects. However, there are currently limited recommendations for the management of AF associated with ASD. This article describes a case using a planned approach of catheter ablation followed by transcatheter device closure and discusses management options.

Long-term (5- to 20-year) outcomes after transcatheter or surgical treatment of hemodynamically significant isolated secundum atrial septal defect

Truly long-term follow-up data after transcatheter closure (TC) of atrial septal defects (ASDs) are scarce. We report the 5- to 20-year outcomes of TC and surgical closure (SC) for typical secundum ASD. We reviewed the records of patients with isolated secundum ASD and right ventricular volume overload who underwent TC or SC (January 1, 1986 to September 30, 2005). Follow-up was obtained through a combination of chart review, physician records, and telephone survey. We identified 375 patients (207 SC and 168 TC) and obtained follow-up data >5 years (median follow-up 10 years) for 300 (152 SC, 148 TC). Nine patients have died (3%). The New York Heart Association functional class was unchanged in 227 patients, improved in 25, and was worse in 15. Clinically significant arrhythmia was found in 28 patients (9.3%); 21% aged >40 years developed arrhythmia. On multivariate analysis, the odds of significant arrhythmia tended to be greater in the SC group, but this was statistically insignificant (95% confidence interval 0.68 to 3.9, p = 0.27). Age and preprocedure arrhythmia, but not TC or SC, were independent risk factors for late arrhythmia (p <0.001). No difference was found in the incidence of late, probably embolic, stroke in the TC (3%) versus SC (2%) groups. In conclusion, long-term outcomes after secundum ASD closure using modern methods are excellent. No significant differences were found between TC versus SC with regard to survival, functional capacity, atrial arrhythmias, or embolic neurologic events. Arrhythmia and neurologic events remain long-term risks after ASD closure, especially if the patient had pre-existing arrhythmia.