Early Complications After Percutaneous Closure of Atrial Septal Defect in Infants with Procedural Weight Less than 15 kg

Impact of Gore Cardioform Atrial Septal Defect Occluder on Atrial and Ventricular Electromechanics in a Pediatric Population

Transcatheter closure is the first-line treatment for ostium secundum atrial septal defect (ASD). The GORE Cardioform ASD Occluder (GCA) is potentially innovative compared with other self-centering devices. This study aimed to compare the mechanic changes in atrial and ventricular properties before and after GCA implantation. All consecutive patients aged <18 years who underwent isolated ASD closure with a single GCA device were enrolled from 2 centers. Echocardiography and electrocardiogram were performed the day before, 24 hours, and 6 months after ASD closure. Between January 2020 and February 2021, 70 pediatric patients with ASD were enrolled. The mean age was 7.9 ± 3.9 years, and the mean defect diameter was 17.1 ± 4.5 mm. Global longitudinal strain analysis showed no change in left ventricular longitudinal function (T0 -23.2 ± 2.8%, 24 hours -23.0 ± 2.8%, and 6 months -23.5 ± 2.7%). An early and transient reduction in longitudinal strain was detected in the basal septal segments (T0 -19.8 ± 3.3%, 24 hours -18.7 ± 3.6%, and 6 months -19.2 ± 3.4%), left atrium (T0 41.4 ± 15.3%, 29.2 ± 1.4%, and 39.0 ± 12.9%), and right ventricle (-27.6 ± 5.4%, -23.6 ± 5.0%, and -27.3 ± 4.6) 24 hours after closure, secondary to hemodynamic changes because of flow redirection after ASD closure. Six months after the procedure, only the left atrium showed a mild global longitudinal strain reduction because of the presence of the device within the septum. GCA device had no impact on global and regional ventricular function. Atrial mechanics were preserved, except for the segments covered by the device. This is the first device demonstrating no impact on the left and right ventricular mechanics, irrespective of the device size.

Can Artificial Intelligence Revolutionize the Diagnosis and Management of the Atrial Septal Defect in Children?

Atrial septal defects (ASDs) present a significant healthcare challenge, demanding accurate and timely diagnosis and precise management to ensure optimal patient outcomes. Artificial intelligence (AI) applications in healthcare are rapidly evolving, offering promise for enhanced medical decision-making and patient care. In the context of cardiology, the integration of AI promises to provide more efficient and accurate diagnosis and personalized treatment strategies for ASD patients. In interventional cardiology, sometimes the lack of precise measurement of the cardiac rims evaluated by transthoracic echocardiography combined with the floppy aspect of the rims can mislead and result in complications. AI software can be created to generate responses for difficult tasks, like which device is the most suitable for different shapes and dimensions to prevent embolization or erosion. This paper reviews the current state of AI in healthcare and its applications in cardiology, emphasizing the specific opportunities and challenges in applying AI to ASD diagnosis and management. By exploring the capabilities and limitations of AI in ASD diagnosis and management. This paper highlights the evolution of medical practice towards a more AI-augmented future, demonstrating the capacity of AI to unlock new possibilities for healthcare professionals and patients alike.

Outcomes Following Closure of Secundum Atrial Septal Defect in Children ≤ 15 kg in a French Tertiary Centre

Secundum atrial septal defects (sASDs) are common congenital cardiac defects mostly treated using a transcatheter approach. However, small children (<15 kg) are still undergoing surgical sASD closure in many centres. Although both options have been proved to have excellent results in children, comparative data of the two techniques are missing for patients ≤ 15 kg. The medical records of children ≤ 15 kg who underwent sASD surgical (group A) and transcatheter (group B) closure between 2010 and 2023 were reviewed retrospectively. Twenty-five children in group A and twenty-two in group B were included (mean weight 8.9 kg in group A and 10.3 kg in group B). The main indications for closure were right heart enlargement and failure to thrive. Major complications occurred in two patients in group A and none in group B. Minor complications occurred in eight patients in group A and one in group B. At last follow-up, symptoms resolved completely or improved significantly for all infants, with the exception of failure to thrive in the sub-population of children with extra-cardiac comorbidities. sASD closure can be performed safely in symptomatic infants ≤ 15 kg, even in the presence of comorbidity, and should not be postponed. However, in patients with extra-cardiac comorbidities, the only indication of growth retardation must be carefully evaluated.

Case report: Early thrombosis in left atrial during transcatheter closure of ASD in a child with favorable outcome after use of GPIIb/IIIa receptor antagonist and heparin

Background

Acute thrombus in atrial septal defect occluders is a rare complication that requires aggressive, effective, and safe management. Tirofiban, a platelet glycoprotein IIb/IIIa receptor antagonist, is widely used for the management of thromboembolic diseases, such as coronary heart disease and stroke. To date, there is no report using the GPIIb/IIIa receptor antagonist tirofiban for the management of ASD closure-related thrombosis in children.

Case presentation

Herein, we reported a case of a 5-year-old girl with ASD who presented with acute thrombus on the left disc of the occluder device immediately after transcatheter closure of ASD. The thrombus was successfully dissolved 24 h after a combined infusion of heparin and tirofiban, followed by 1 months of aspirin and clopidogrel and 5 months of aspirin alone. No thromboembolism or hemorrhage events occurred during follow-up for more than 2 years.

Conclusion

The continuous infusion of GPIIb/IIIa receptor antagonist tirofiban combined with heparin may have beneficial effects for the management of thrombosis during ASD closure procedure.

Transcatheter Occluder Devices for the Closure of Atrial Septal Defect in Children: How Safe and Effective Are They? A Systematic Review

Atrial septal defect (ASD) is a hole in the interatrial septum (IAS) of the heart that is one of the most common congenital heart diseases (CHD). Percutaneous transcatheter device occlusion is one of the techniques that have been developed for the closure of atrial septal defects. The primary objective of this study is to assess the safety and efficacy of septal occluder devices in the management of atrial septal defect in children. We searched PubMed, Science Direct, and Google Scholar databases to collect relevant articles according to a predetermined eligibility criteria and included 21 papers of different study designs in this systematic review. We found that transcatheter closure is safe and effective in most children with ASD. The major complications reported could be avoided by comprehensive clinical assessment and echocardiographic evaluation to determine appropriate device size and implantation strategy per individual child. Further research involving more clinical trials with larger sample size and longer duration of followup is required to improve the safety of existing devices for their use in all children with ASD despite their weight and defect size, and also the efficacy of newer devices such as biodegradable septal occluders.

Association between the Use of Diuretics and Size Reduction in Pediatric Atrial Septal Defect

The effect of diuretics on ASD size reduction remains unclear. In pediatric patients with a large secundum ASD (≥10 mm), diuretic administration seemed to be associated with changes in ASD size. There seemed to be a little possibility of ASD size reduction in case of rim deficiency other than the aortic rim. The patients receiving diuretics may have a lower possibility to undergo surgical closure. The diuretics administration may be associated with the use of smaller ASD devices.

Background and Objectives

While diuretics are sometimes used in atrial septal defect (ASD) treatment, their effect on ASD size reduction remains unclear. We aimed to evaluate the efficacy of diuretics in ASD size reduction in pediatric patients.

Methods

We retrospectively reviewed the medical records of patients with secundum ASD (size ≥10 mm), between 2005 and 2019. Patients were divided into two groups based on the diuretic administration.

Results

Of the 73 enrolled patients, 40 received diuretics. The initial age at ASD diagnosis (2.8±1.7 vs. 2.5±2.0 years, p=0.526) and follow-up duration (22.3±11.4 vs. 18.7±13.2 months, p=0.224) were not significantly different between the groups. The ASD diameter at the initial diagnosis (13.7±2.0 vs. 13.5±3.4 mm, p=0.761) and the indexed ASD diameter (25.5±5.9 vs. 26.9±10.3 mm/m², p=0.493) were also not significantly different between two groups. The ASD diameter significantly increased in the non-diuretic group during follow-up (0.0±2.9 vs. +2.6±2.0 mm, p<0.001). The indexed ASD diameter significantly decreased in the diuretic group during follow-up (−5.7±6.5 vs. +0.2±3.9 mm/m², p<0.001). In the linear mixed model analysis, diuretic use was associated with ASD diameter decrease (p<0.001) and indexed ASD diameter reduction (p<0.001) over time. Device closure was more frequently performed in the diuretic (75.0%) than in the non-diuretic group (39.4%).

Conclusions

Patients receiving diuretics are less likely to undergo surgery. The diuretics administration may be associated with the use of smaller ASD devices for transcatheter treatment through ASD size reduction.

Predictors of the Need for an Atrial Septal Defect Closure at Very Young Age

An asymptomatic Atrial Septal Defect (ASD) is often closed at the age of 3–5 years using a transcatheter or surgical technique. Symptomatic ASD or ASD associated with pulmonary hypertension (PHT) may require earlier closure, particularly in combination with other non-cardiac risk factors for PHT, but the indications for early closure and the potential risk for complications are largely unknown. The aim of this study was to assess risk factors for needing ASD closure during the first and second years of life. This case-control study included all children treated with surgical or percutaneous ASD closure between 2000 and 2014 at two out of three pediatric heart centers in Sweden. “Cases” were children with ASD closure at ≤1 or ≤2 years of age. Clinical data were retrieved from medical journals and national registries. Overall, 413 children were included. Of these, 131 (32%) were ≤2 years, and 50 (12%) were ≤1 year. Risk factors associated with a ≤2 years ASD closure were preterm birth, OR = 2.4 (95% CI: 1.5–3.9); additional chromosomal abnormalities, OR = 3.4 (95% CI: 1.8–6.5); pulmonary hypertension, OR = 5.8 (95% CI: 2.6–12.6); and additional congenital heart defects, OR = 2.6 (95% CI: 1.7–4.1). These risk associations remained after adjustments for confounding factors, such as need for neonatal respiratory support, neonatal pulmonary diseases, neonatal sepsis, additional congenital heart defects (CHD) and chromosomal abnormalities. ASD size:body weight ratio of 2.0, as well as a ratio of 0.8 (upper and lower limit of the ASD size:body weight ratios), was associated with increased risk of an early ASD closure. Risk factors such as very premature birth, very low birth weight, congenital, and chromosomal abnormalities, neonatal pulmonary disease and need for ventilation support, as well as pulmonary hypertension, were associated with very early (<1 year of age) ASD closure. Several independent neonatal risk factors were associated with an increased risk of early ASD closure at 2 and at 1 year of age. An ASD size:body weight ratio is a poor predictor for indications for ASD closure.

The efficacy and safety of using amplatzer for transcatheter closure of atrial septal defect in small children with less than 10 kg

BACKGROUND

Atrial septal defect (ASD) accounts for about 10% of congenital heart diseases (CHDs). Self-closure of these defects in patients with defects less than 8 mm has been reported in several studies. In children, transcatheter closure of the ASD is suggested for asymptomatic patients older than two years and with weight > 15 kg. The purpose of this study was to show that transcatheter closure of ASD in small children with body weight less than 10 kg is an effective and safe method.

METHODS

Between July 2016 and September 2018, 35 children with body weight less than 10 kg underwent percutaneous closure of ASD using amplatzer. All patients had minimum defect size of 6 mm, pulmonary blood flow (Qp) to systemic blood flow (Qs) ratio above 1.5, right atrial and ventricular dilation, symptoms of delayed growth, and recurrent respiratory infections in their evaluation and had acceptable rims for intervention. Follow-up evaluations were done 1 day, 1 week, 1 month, 6 months, and yearly after discharge with transthoracic echocardiography (TTE) and electrocardiography (ECG).

RESULTS

The mean age of patients at procedure was 12.06 ± 4.47 months (range: 6 to 14 months), mean weight was 8.32 ± 0.72 kg (range: 7.5 to 9.8 kg). The mean defect size was 10.00 ± 2.32 mm (range: 6-13 mm). The mean device size used was 10.57 ± 2.57 mm (range: 7.5 to 15 mm). Mean duration of follow-up was 16.66 ± 6.93 months (range: 1-29 months). Respiratory rate, heart rate, pulmonary stenosis (PS), and Qp to Qs ratio had significant difference before and after procedure during the follow up (P < 0.001).

CONCLUSION

Transcatheter closure of ASD with amplatzer in symptomatic small children and infants is a safe and effective treatment associated with excellent success, but long-term follow-up in a large number of patients would be warranted.

Percutaneous ASD closure of children weighing less than 10 kg

Background: Traditionally the procedure of percutaneous ASD closure is carried out in children weighing more than 15 kg. The aim of this study was to discuss the success, efficacy and safety of the percutaneous closure of symptomatic ASD in children weighing less than 10 kg. Material and methods: This study was performed in two centres. A total of 44 patients were included. Demographic and angiographic data of these patients were gathered retrospectively from patients' records. Main indications for ASD closure were: failure to thrive, recurrent respiratory infections, bronchopulmonary dysplasia and genetic syndromes. Results: Median weight of patients was 9.0(8.12-9.50) kg. Bodyweight of 22 patients was less than 3 percentiles. In the follow-up, this number was lowered to 9 patients at 12 months. Median age of patients was 18.0(12.0-285) months. Minimum age and weight of patients was 3 months and 4.5 kg, respectively. Median mean pulmonary pressure was 24.0(20.0-29.5). The values of median defect size were measured in Cath lab as 13.0(10.75-15.3) mm. Median device size was 13(9-15) mm. Defect size was evaluated according to body weight and body surface area. The ratio of weight per defect size was 0.65(0.54-0.84) also the ratio of body surface area per defect size was 0.032(0.028-0.04). The ratio of total septum per device diameter was 2.5(2.1-3.1). Types of devices used were Amplatzer Septal Occluder, Cera Flex Septal Occluder, Figulla Flex II Atrial Septal Occluder, Memopart Septal Occluder. All cases were closed successfully, but the device had to be retrieved in one patient after successful positioning because it was detected that device compressed the aorta. No major complications were seen. Conclusion: In the experienced centres, percutaneous ASD closure can be done effectively and safely in symptomatic children weighing less than 10 kg.

Adverse events within 1 year after surgical and percutaneous closure of atrial septal defects in preterm children

INTRODUCTION

Atrial septal defect is the third most common CHD. A hemodynamically significant atrial septal defect causes volume overload of the right side of the heart. Preterm children may suffer from both pulmonary and cardiac comorbidities, including altered myocardial function. The aim of this study was to compare the rate of adverse events following atrial septal defect closure in preterm- and term-born children.

METHOD

We performed a retrospective cohort study including children born in Sweden, who had a surgical or percutaneous atrial septal defect closure at the children's hospitals in Lund and Stockholm, between 2000 and 2014, assessing time to the first event within 1 month or 1 year. We analysed differences in the number of and the time to events between the preterm and term cohort using the Kaplan-Meier survival curve, a generalised model applying zero-inflated Poisson distribution and Gary-Anderson's method.

RESULTS

Overall, 413 children were included in the study. Of these, 93 (22.5%) were born prematurely. The total number of adverse events was 178 (110 minor and 68 major). There was no difference between the cohorts in the number of events, whether within 1 month or within a year, between major (p = 0.69) and minor (p = 0.84) events or frequencies of multiple events (p = 0.92).

CONCLUSION

Despite earlier procedural age, larger atrial septal defects, and higher comorbidity than term children, preterm children appear to have comparable risk for complications during the first year after surgical or percutaneous closure.

State-of-the-Art Atrial Septal Defect Closure Devices for Congenital Heart

This article describes current devices and indications for transcatheter device closure of atrial septal defect (TC-ASD) and patent foramen ovale in children and young adults. TC-ASD has a proven record of efficacy and safety, but device erosion raises questions about the relative safety of TC-ASD versus operative open heart surgical ASD closure. New devices for ASD closure with properties to reduce risk of erosion are being developed. Recent studies demonstrating superiority of patent foramen ovale device closure over medical therapy for cryptogenic stroke may lead to changes in practice for structural/interventional cardiologists. Care should be taken in extrapolating data to children and younger adults.

Impact of hospital volume on outcomes of percutaneous ASD/PFO closure in pediatric patients

BACKGROUND

We investigated the effect of hospital volume on percutaneous closure of atrial septal defect/patent foramen ovale (ASD) among pediatric patients.

METHODS

We identified patients undergoing percutaneous closure of ASD with device using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) procedure code 35.52 from the National Inpatient Sample, years 2002-2011. Patients with age ≤ 18 years and primary diagnosis code 745.5 for ASD were included. Hospital volume was calculated using unique identification numbers and divided into tertiles for analysis. Multivariate regression analysis was performed to determine independent predictors of procedure-related complications which were coded using specific codes released by Healthcare Cost and Utilization Project.

RESULTS

6162 percutaneous ASD closure procedures were analyzed. There was no mortality associated with percutaneous ASD closure. Cardiac complications (9.5%) were most common. On multivariate analysis, age increment of 3 years decreased the odds of developing complications (OR 0.83, 95% CI 0.79-0.87, P < 0.001). Odds of developing complications in the 2nd (OR 0.74, 95% CI 0.62-0.89, P = 0.007) and 3rd tertiles (OR 0.34, 95% CI 0.27-0.42, P < 0.001) were lower as compared to the 1st tertile of hospital volume.

CONCLUSION

Increasing annual hospital volume is an independent predictor of lower complication rates in percutaneous ASD closure cases with no associated mortality in pediatric patients.

Transcatheter device closure of atrial septal defects: more to think about than just closing the hole

PURPOSE OF REVIEW

To review current controversies in the transcatheter device closure of ostium secundum atrial septal defects (ASD).

RECENT FINDINGS

Transcatheter device closure of ASD (TC-ASD) has well established efficacy and safety. For most individual patients with suitable anatomy, TC-ASD is the preferred method for treating ASD. The availability of large multicenter data sets has made it possible to study practice patterns at a range of hospitals across the United States. These studies have revealed differences in practice that were not previously appreciated. Interpretation of the indications for TC-ASD, specifically the definition of right ventricular volume overload varies between hospitals. In response to concern about device erosion, an increasing proportion of patients are being referred for operative ASD closure. Over the last decade, the average age at which ASD closure occurs has decreased. These trends demonstrate previously underappreciated differences in opinion between cardiologists across the country and suggest that further research is necessary to address knowledge gaps limiting consistency of practice.

SUMMARY

As TC-ASD and congenital interventional cardiology mature as a field, studies of real-world practice provide increasingly valuable information about aspects of care in which there are disagreements about best practices and in which further research is necessary.