Efficacy and long-term patency of fenestrated amplatzer devices in children

Short-term study of atrial shunt and improvement of functional mitral regurgitation

BACKGROUND

This study used an atrial septal shunt to compare the treatment progress and prognosis for patients with heart failure (HF) who have different ejection fractions.

METHODS

Twenty HF patients with pulmonary hypertension, who required atrial septal shunt therapy, were included in this study. The patients underwent surgery between December 2012 and December 2020. They were divided into two groups based on their ejection fraction: a group with reduced ejection fraction (HFrEF) and a group with preserved ejection fraction(HFpEF) + mid-range ejection fraction (HfmrEF). Echocardiography was utilized to evaluate parameters such as left ventricular dimension (LVD), left ventricular ejection fraction (LVEF), and left ventricular end-diastolic volume (LVEDV). Hemodynamic parameters were measured using cardiac catheterization. The patient's cardiac function was assessed using the six-minute walking test (6MWT), KCCQ score, NYHA classification, and the degree of functional mitral regurgitation (FMR). Followed-up visits were conducted at 1, 3, and 6 months, and any adverse effects were recorded.

RESULTS

The LVEF values were consistently higher in the HFpEF+HFmrEF group than HFrEF group at all periods (P < 0.05). Differences in LVD were observed between the two groups before the surgery. Statistically, significant differences were found at the preoperative stage, 1 month, and 3 months (P < 0.05, respectively). However, the LVEDV showed a significant difference between the two groups only at 3 months (P = 0.049). Notably, there were notable variations in LAPm, LAPs, and the pressure gradient between the LA-RA gradient at baeline, after implantation, and during the 6 months follow-up (all P < 0.05).

CONCLUSION

Following treatment, the HFpEF+HFmrEF group exhibited more significant improvements in echocardiographic and cardiac catheterization indices than the HFrEF group. However, there was no statistically significant difference between the two groups regarding the 6MWT and KCCQ scores. It is important to note that the findings of this study still require further investigation in a large sample size of patients.

Case report: Beneficial long-term effect of the atrial-flow-regulator device in a pediatric patient with idiopathic pulmonary arterial hypertension and recurring syncope

We report the long-term effect after successfully implanting an 8 mm Atrial-flow-regulator (AFR) device in a 7-year-old girl with idiopathic pulmonary hypertension with persistent syncope under triple therapy with significant improvement after implantation and absence of any further syncope. Early Implantation of the AFR device (Occlutech, Germany) can be efficient and safe interventional therapy option for pulmonary arterial hypertension with a history of syncope.

Is combined use of radiofrequency ablation and balloon dilation the future of interatrial communications?

INTRODUCTION

Personalized and stable interatrial communication is an important palliative therapy for patients with heart failure. However, this remains a technically challenging task.

AREAS COVERED

In the past decades, substantial advancements in atrial septostomy for the creation of controllable and durable interatrial communication have been made, and numerous novel devices and techniques are in various stages of development. In this review, we discuss the evolving indications for atrial septostomy, current approaches with or without device implantation, and indicators for optimal interatrial communication. The combined use of radiofrequency ablation and balloon dilation (CURB) is an individualized management approach based on underlying hemodynamics, which demonstrates unique advantages in creating a sufficient interatrial communication with satisfactory stability. The advantages and disadvantages of this implant-free procedure are analyzed and its clinical prospects are assessed.

EXPERT OPINION

With ready availability, high safety, and efficacy, CURB is a promising procedure for creating personalized and stable interatrial communication without device implantation. Further research is required to simplify the procedure, screen optimal reference parameters for personalized therapy, and evaluate the long-term outcome in a large population of patients.

Interventionelle Behandlungsverfahren der pulmonalen Hypertension im Kindesalter

Die pulmonale Hypertension (PH) ist eine progressive Gefäßerkrankung und führt über eine Widerstands- und/oder Druckerhöhung im kleinen Kreislauf zu einem fortschreitenden Rechtsherzversagen. Auch wenn mithilfe aktueller medikamentöser Therapien eine deutliche Verbesserung der Lebensqualität und des Überlebens der Betroffenen erreicht werden konnte, bleibt die PH eine zumeist nichtheilbare Erkrankung, die im fortgeschrittenen Stadium eine Lungentransplantation notwendig macht. Interventionelle Verfahren, wie die Anlage eines interatrialen Shunts (z. B. durch atriale Septostomie oder den Atrial Flow Regulator) oder eines Reversed Potts Shunt, verbessern die RV-Funktion und die ventrikuläre Interaktion durch Schaffung einer prä- oder posttrikuspidalen „Eisenmenger-Physiologie“ und stellen eine Überbrückung oder sogar Alternative zur Lungentransplantation dar. Bei Patienten mit segmentaler PH oder chronisch thrombembolischer pulmonaler Hypertension (CTEPH) stellt die Ballonangioplastie eine bereits etablierte Intervention zur Verbesserung der pulmonalen Perfusion und damit rechtsventrikulären (RV-)Funktion dar. Dagegen ist die pulmonalarterielle Denervation ein neuartiges Verfahren, mit dem Ziel, die neurohumorale Dysregulation bei PH positiv zu beeinflussen. Der individuelle Einsatz solcher Interventionen, additiv zu den bereits etablierten medikamentösen Therapien, erweitert die Behandlungsmöglichkeiten und kann die Prognose betroffener Patienten noch weiter verbessern.

Secundum Type Atrial Septal Defect in Patients with Trisomy 21-Therapeutic Strategies, Outcome, and Survival: A Nationwide Study of the German National Registry for Congenital Heart Defects

(1) Secundum type atrial septal defect (ASD II) is usually considered a relatively benign cardiac lesion amenable to elective closure at preschool age. Patients with trisomy 21 (T21), however, are known to have a higher susceptibility for pulmonary vascular disease (PVD). Therefore, T21 children may present with clinical symptoms earlier than those without associated anomalies. In addition, early PVD may even preclude closure in selected T21 patients. (2) We performed a retrospective analysis of the German National Register for Congenital Heart Defects including T21 patients with associated isolated ASD II. We report incidence, demographics, therapeutic strategy, outcome, and survival of this cohort. (3) Of 46,628 patients included in the registry, 1549 (3.3%) had T21. Of these, 156 (49.4% female) had an isolated ASD II. Fifty-four patients (34.6%) underwent closure at 6.4 ± 9.9 years of age. Over a cumulative follow-up (FU) of 1148 patient-years, (median 7.4 years), only one patient developed Eisenmenger syndrome and five patients died. Survival of T21 patients without PVD was not statistically different to age- and gender-matched controls from the normal population (p = 0.62), whereas children with uncorrected T21/ASD II (including patients with severe PVD, in whom ASD-closure was considered contraindicated) showed a significantly higher mortality. (4) The outcome of T21-patients with ASD II and without PVD is excellent. However, PVD, either precluding ASD-closure or development of progressive PVD after ASD-closure, is associated with significant mortality in this cohort. Thus T21 patients with ASD II who fulfill general criteria for closure and without PVD should be offered defect closure analogous to patients without T21.

Advanced Surgical and Percutaneous Approaches to Pulmonary Vascular Disease

Despite progress in modern medical therapy, pulmonary hypertension remains an unremitting disease. Once severe or refractory to medical therapy, advanced percutaneous and surgical interventions can palliate right ventricular overload, bridge to transplantation, and overall extend a patient's course. These approaches include atrial septostomy, Potts shunt, and extracorporeal life support. Bilateral lung transplantation is the ultimate treatment for eligible patients, although the need for suitable lungs continues to outpace availability. Measures such as ex vivo lung perfusion are ongoing to expand donor lung availability, increase rates of transplant, and decrease waitlist mortality.

Atrial flow regulator for drug-resistant pulmonary hypertension in a young child

This case describes the successful implantation of an Occlutech Atrial Flow Regulator in a young child with idiopathic pulmonary hypertension and recurrent syncope despite targeted combination therapy, with subsequent relief of symptoms.

Study of the effect of Occlutech Atrial Flow Regulator on symptoms, hemodynamics, and echocardiographic parameters in advanced pulmonary arterial hypertension

Optimal sized balloon atrial septostomy improves hemodynamics in advanced pulmonary arterial hypertension. Occlutech Atrial Flow Regulator is designed to provide an atrial septal fenestration diameter titrated according to the age and right atrial pressures. This observational study analyzed symptoms, exercise distance, oxygen saturations, hemodynamics and echocardiographic parameters after Atrial Flow Regulator implantation in patients with syncope or right-heart failure. Patients with high-risk predictors of mortality during septostomy were scrutinized. Thirty-nine patients (9 children) with syncope (34/39) or right-heart failure (27/39) underwent Atrial Flow Regulator implantation without procedural complications. Six-minute walk distance increased from 310 ± 158.2 to 376.4 ± 182.6 m, none developed syncope. Oxygen saturations reduced from 96.4 ± 6.4% to 92 ± 4.9% at rest and further to 80.3 ± 5.9% on exercise. Right atrial pressures reduced from 9.4 ± 5 (2-27) mmHg to 6.9 ± 2.6 (1-12) mmHg, while cardiac index increased from 2.4 ± 0.8 (0.98-4.3) to 3 ± 1 (1.1-5.3) L/min/m² and systemic oxygen transport increased from 546.1 ± 157.9 (256.2-910.5) to 637.2 ± 191.1 (301.3-1020.2) ml/min. Echocardiographic improvement included significant reduction of pericardial effusion and inferior caval congestion at a median follow-up of 37 months. Overall survival improved except two early and one late deaths in high-risk patients. Five of seven patients with advanced disease and key hemodynamic predictors of mortality survived. Acute hemodynamic benefits in pulmonary arterial hypertension after Atrial Flow Regulator were improved cardiac output, systemic oxygen transport, and reduced right atrial pressures. Improvement of symptoms especially syncope, exercise duration, and right ventricular systolic function as well as device patency were sustained on mid-term follow-up. Implantation was safe in all including young children without procedural complications. Mortality was noted only in patients who had high-risk predictors and patients at advanced stage of the disease.

Outcomes of Atrioseptostomy with Stenting in Patients with Pulmonary Arterial Hypertension from a Large Single-Institution Cohort

The aim of this study was to analyze results of stenting atrioseptostomy in patients with pulmonary arterial hypertension and a different level of risk for one-year mortality that is not well described. Patients that underwent atrioseptostomy with stenting were retrospectively divided in two groups: "intermediate" (n = 55) or "high" risk (n = 13), according to the 2015 ESC/ESR guideline. Results of atrioseptostomy were assessed during hospital period and at follow-up. Patients from "intermediate" risk group demonstrated lower mortality rate (10/55, vs. 6/13) during the course of the study period, as well as higher freedom from lung transplantation or Potts shunt. At discharge, patients of both groups presented improvement in functional class and mobility. Patients from "intermediate" risk group showed longer 6-min walking distance, and lower levels of brain natriuretic peptide. At the latest follow-up, stable position and full patency of stents with right-to-left or bidirectional shunt at atrial level and absence of syncope was confirmed in patients of both groups. Patients from the "intermediate" risk group demonstrated higher functional class, better performance of walking test, and lower levels of brain natriuretic peptide. Stenting atrioseptostomy reliably secured interatrial communication and improved clinical condition in patients with idiopathic pulmonary arterial hypertension. Mid-term results were better in "intermediate" risk group.

Creation of a defined and stable Fontan fenestration with the new Occlutech Atrial Flow Regulator (AFR®)

This report describes the first clinical experience with the new Occlutech Atrial Flow Regulator (AFR®) device for implementation of a late Fontan fenestration. The AFR® device secured a defined diameter of the fenestration without spontaneous re-occlusion of this extra-anatomic perforation. This ensured a permanent clinical improvement of our failing Fontan patient.

Interventional Therapies in Pulmonary Hypertension

Despite advances in drug therapy, pulmonary hypertension-particularly arterial hypertension (PAH)-remains a fatal disease. Untreatable right heart failure (RHF) from PAH eventually ensues and remains a significant cause of death in these patients. Lowering pulmonary input impedance with different PAH-specific drugs is the obvious therapeutic target in RHF due to chronically increased afterload. However, potential clinical gain can also be expected from attempts to unload the right heart and increase systemic output. Atrial septostomy, Potts anastomosis, and pulmonary artery denervation are interventional procedures serving this purpose. Percutaneous balloon pulmonary angioplasty, another interventional therapy, has re-emerged in the last few years as a clear alternative for the management of patients with distal, inoperable, chronic thromboembolic pulmonary hypertension. The current review discusses the physiological background, experimental evidence, and potential clinical and hemodynamic benefits of all these interventional therapies regarding their use in the setting of RHF due to severe pulmonary hypertension.

Fenestrated Transcatheter ASD Closure in Adults with Diastolic Dysfunction and/or Pulmonary Hypertension: Case Series and Review of the Literature

OBJECTIVES

This study aims to evaluate the safety and efficacy of transcatheter fenestrated ASD closure and to summarize the literature regarding the published techniques and outcomes of transcatheter partial ASD closure.

BACKGROUND

Patients with left ventricular diastolic dysfunction (LVDD) or right ventricular (RV) dysfunction and/or pulmonary hypertension (PHT) may suffer untoward consequences of complete closure of an ostium secundum atrial septal defect (ASD). Therefore, for patients that fall under these categories we suggest partial occlusion of the defect, which may be better tolerated than complete defect closure.

METHODS AND PATIENTS

After obtaining IRB approval, a search for patients that have undergone percutaneous ASD closure was performed in the Ahmanson/UCLA Adult Congenital Heart Disease Center database to identify which patients received a fenestrated ASD closure device.

RESULTS

Eight consecutive patients ranging between 22 and 83 years of age (mean 48 years) with PHT and/or LVDD or RV dysfunction who underwent fenestrated transcatheter ASD closure at UCLA were identified. None of the subjects experienced complications related to the procedure. Postprocedure clinical evaluation showed improvement in symptoms and exercise capacity. Available follow-up transthoracic echocardiography data (mean 4 months, range 0-20 months) demonstrated patent fenestrations in four of eight patients. None of the patients had thromboembolic or infectious complications and there were no device migrations, erosions or embolizations.

CONCLUSIONS

Partial ASD occlusion in patients with diastolic dysfunction or RV dysfunction and/or PHT is safe and may be better tolerated than complete ASD closure in selected patients.

Can pulmonary vasodilator therapy expand the operative indications for congenital heart disease?

The operability of congenital heart disease with left to right shunt depends on the severity of the pulmonary vascular disease induced by the increased pulmonary blood flow. Although some recommendations exist regarding operative indications according to pathological, hemodynamic, and epidemiological factors, the evidence underlying these recommendations is not conclusive. Recently, oral pulmonary vasodilator therapy has been reported to improve outcomes in patients with idiopathic pulmonary arterial hypertension, and this therapy also appears to be effective in patients with congenital heart disease and pulmonary arterial hypertension, including those with postoperative pulmonary hypertension and Eisenmenger syndrome. It is expected that the availability of novel pulmonary vasodilator therapy will expand the operative indications in patients with congenital heart disease with left to right shunt, but there is currently insufficient evidence to definitively determine this. A multicenter double-blind study should be conducted to further examine this issue.

Interventional and surgical therapeutic strategies for pulmonary arterial hypertension: Beyond palliative treatments

Despite significant advances in pharmacological treatments, pulmonary arterial hypertension remains an incurable disease with an unreasonably high morbidity and mortality. Although specific pharmacotherapies have shifted the survival curves of patients and improved exercise endurance as well as quality of life, it is also true that these pharmacological interventions are not always accessible (particularly in developing countries) and, perhaps most importantly, not all patients respond similarly to these drugs. Furthermore, many patients will continue to deteriorate and will eventually require an additional, non-pharmacological, intervention. In this review we analyze the role of atrial septostomy and Potts anastomosis in the management of patients with pulmonary arterial hypertension, we summarize the current worldwide clinical experience (case reports and case series), and discuss why these interventional/surgical strategies might have a therapeutic role beyond that of a "bridge" to transplantation.

Impact of differential right-to-left shunting on systemic perfusion in pulmonary arterial hypertension

OBJECTIVES

This study aimed at identifying the ideal right-to-left shunt-fraction to improve cardiac output (CO) and systemic perfusion in pulmonary arterial hypertension (PHT).

BACKGROUND

Atrial septostomy (AS) has been a high-risk therapeutic option for symptomatic drug-refractory patients with PHT. Results have been unpredictable due to limited knowledge of the optimal shunt-quantity.

METHODS

In nine dogs, an 8-mm shunt-prosthesis was inserted between the superior vena cava (SVC) and the left atrium. With pulmonary artery (PA) banding, mean (± SEM) systolic right ventricular pressure increased from 37 ± 1 mm Hg at baseline to 44 ± 1 mm Hg (moderate PHT, P = 0.005) and 50 ± 2 mm Hg (severe PHT, P < 0.001). Shunt-flow was adjusted by total (forcing all flow through the shunt) or partial occlusion of the SVC and partial or total clamping of the shunt. Caval-, shunt-, and aortic-flow were measured by ultrasonic flow-probes. Blood gases were drawn from the aortic root and PA.

RESULTS

At severe PHT, a shunt-flow of 11 ± 1% of CO (253 ± 90 mL/min) increased CO significantly by 25% (1.8 ± 0.1 to 2.4 ± 0.2 L/min, P = 0.005) causing an increase of systemic oxygen delivery index (DO2 I) by 23% (309 ± 23 to 399 ± 32 mL/min/m(2), P = 0.035). Arterial O2 -saturation did not change significantly until a shunt-flow of 18 ± 2% was exceeded, causing a drop from 96 ± 1% to 84 ± 4% (P = 0.013). At moderate PHT, CO or DO2 I did not improve significantly at any shunt-flow.

CONCLUSIONS

In severe PHT, a shunt-flow of 11% of CO represented the ideal shunt-fraction. Augmentation of CO compensated for declined O2 -saturation due to right-to-left shunting and improved DO2 I. In moderate PHT, AS is less promising.

Atrial septostomy in patients with pulmonary hypertension: should it be recommended?

Treatment options for patients with advanced pulmonary hypertension (PH) are limited. Iatrogenic creation of an interatrial communication (i.e., atrial septostomy [AS]) has been suggested as a possible treatment option or as a bridge to transplantation in selected patients and has been incorporated into current PH guidelines. Uptake of the procedure has been slow and the worldwide experience with AS is limited to approximately 280 published cases, over a period of more than 25 years. The rationale for creating an AS has been provided by the observation that patients with congenital heart disease, shunt lesions and PH have a better survival compared with patients with idiopathic PH. We review pathophysiologic data and the published clinical experience and discuss the rationale, indication and potential pitfalls of AS in patients with severe PH.

Fenestrated ASD closure in a child with idiopathic pulmonary hypertension and exercise desaturation

Pulmonary arterial hypertension is a progressive disorder that may result in right heart failure and death. Atrial level shunts in the presence of pulmonary hypertension may allow right-to-left mixing with maintenance of cardiac output and improved survival. However, excessive mixing at the atrial level can cause undue systemic desaturation, increased fatigue and decreased exercise tolerance even in the presence of adequate cardiac output. A 5½-year-old was diagnosed with pulmonary hypertension, a large atrial septal defect and right-to-left shunting. Medical therapy over an 18-month period was successful in decreasing pulmonary artery pressure and pulmonary vascular resistance. However, because of the size and position of the intracardiac defect, symptoms of fatigue, and severe systemic desaturation with only minor activities persisted. Fenestrated surgical closure of the defect was thus undertaken to decrease the degree of atrial mixing, but still allow atrial decompression if necessary. Subsequent hemodynamic evaluation has demonstrated continued improvement, and all previous symptoms have resolved. Repeated echocardiography has confirmed patency of the atrial fenestration with left-to-right atrial flow.

Shunt reduction with a fenestrated Amplatzer device

BACKGROUND

In specific high-risk patients with congenital heart disease (CHD), a complete closure of an intracardiac defect/shunt is not possible for a variety of reasons. We report our experiences with an interventional approach for shunt-reduction using various modifications of a self-fabricated Amplatzer device in our institution.

METHODS

Retrospective analysis of patients with CHD having received an interventional partial shunt occlusion since 09/2005.

RESULTS

Five patients, mean age 18.6(3.4-66) years, mean weight 36.4(14-102) kg, have been treated. In three patients (3.4, 3.9, 66 years) with an atrial septal defect (ASD) and a restrictive left ventricle (LV) (n = 1) or pulmonary arterial hypertension (PAH) (n = 2), respectively, an Amplatzer Septal Occluder (ASO) with a predilated (n = 2) or a presutured (n = 1) central hole was implanted. After successful immediate volume release in all, the balloon-dilated holes closed spontaneously during mid-term follow-up, pulmonary artery (PA) pressure and LV function remained normal. Two patients (2.7 and 17 years) with a Fontan circulation and severe cyanosis (saturation ≤80%) due to a large fenestration and elevated PA pressures received a partial occlusion of their shunt by implanting a centrally stented ASO or Amplatzer Vascular plug. After a follow-up of 31 and 39 months both stents remained patent under oral anticoagulation, oxygen saturation remained >85% with PA pressures unchanged, and both patients were in good clinical conditions.

CONCLUSIONS

In patients with an ASD and significant PAH and/or restrictive LV physiology as well as in Fontan patients with a large surgically created fenestration but failing Fontan circulation, a partial closure with a self-fenestrated Amplatzer device can be a feasible and successful therapeutic option. Balloon-dilated fenestrations in the Amplatzer device tend to close spontaneously during follow-up. Nonresorbable sutures or stenting can ensure patency of the created holes.

Antiplatelet therapy in pediatric cardiovascular patients

Platelets play a critical role in normal physiologic processes such as hemostasis, wound healing, inflammation, and innate immunity. However, they also play a role in the pathologic process of thrombosis. Although antiplatelet therapy is most commonly used to prevent thrombotic events for adults with atherosclerotic vascular disease, children with certain types of congenital heart disease, stroke, and Kawasaki disease also are at risk for thrombosis and may benefit from antiplatelet therapy. Unfortunately, very little data on the efficacy and safety of antiplatelet therapy for pediatric patients are available. As a consequence, consistent clinical practice among pediatric practitioners is lacking. Furthermore, much of what is practiced results from extrapolation from adult studies, which may be problematic because many aspects of platelet biology differ between children and adults. This review discusses aspects of antiplatelet therapy for pediatric patients.

A modified technique of stent fenestration of the interatrial septum improves patients with pulmonary hypertension

AIMS

A significant number of patients with pulmonary hypertension are resistant to medical therapy. We wanted to evaluate whether the modified technique of stent fenestration of the interatrial septum would be feasible and safe, and offer clinical benefit.

METHODS AND RESULTS

The medical records of all patients with pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension who underwent a stent fenestration of the interatrial septum between 2001 and 2008 were reviewed. In all fifteen patients (12 female, mean age 48.2 +/- 20.5 years) a successful fenestration procedure could be performed. Median follow-up time between diagnosis and fenestration was 2.3 years (range from 0.5 to 18.6 years). Mean event free survival since diagnosis and after septostomy was 9.8 +/- 2.9 and 3.2 +/- 0.8 years, respectively. When one extreme outlier was excluded, the 6 min walk distance improved significantly from 309 +/- 69 m immediately before fenestration to 374 +/- 84 m, 3-4 months after fenestration (n = 8, paired t-test, P = 0.03). No stent occlusion occurred.

CONCLUSION

The modified stent fenestration technique is feasible and safe in patients with severe pulmonary hypertension. In a selected group of patients, functional capacity might improve although disease progression continues.