Abnormal right ventricular size and ventricular septal motion after atrial septal defect closure: etiology and functional significance

Transcatheter closure of atrial septal defect in the elderly: a systematic review and meta-analysis

OBJECTIVE

Despite the establishment of transcatheter closure as the treatment of choice in adults with secundum atrial septal defects (ASDs), the effectiveness of this approach in the elderly is disputed. This systematic review and meta-analysis aims to explore the impact of transcatheter ASD closure in patients ≥60 years old.

METHODS

We systematically searched four major electronic databases (PubMed, CENTRAL (Cochrane Central Register of Controlled Trials), Scopus and Web of Science), ClinicalTrials.gov, article references and grey literature. Primary outcomes were the right ventricular end-diastolic diameter (RVEDD) and the New York Heart Association functional class change, whereas secondary outcomes included systolic pulmonary arterial pressure (sPAP), left ventricular end-diastolic diameter (LVEDD), brain natriuretic peptide (BNP), tricuspid valve regurgitation (TR) change, as well as the rate of atrial arrhythmias and all-cause mortality.

RESULTS

In total, 18 single-arm cohorts comprising 1184 patients were included. RVEDD was reduced after ASD closure (standardised mean difference (SMD) -0.9, 95% CI -1.2 to -0.7). Elderly patients had 9.5 times higher odds of being asymptomatic after ASD closure (95% CI 5.06 to 17.79). Furthermore, ASD closure improved sPAP (mean difference (MD) -10.8, 95% CI -14.6 to -7), LVEDD (SMD 0.8, 95% CI 0.7 to 1.0), TR severity (OR 0.39, 95% CI 0.25 to 0.60) and BNP (MD -68.3, 95% CI -114.4 to -22.1). There was a neutral effect of ASD closure on atrial arrhythmias.

CONCLUSIONS

Transcatheter ASD closure is beneficial for the elderly population since it improves functional capacity, biventricular dimensions, pulmonary pressures, TR severity and BNP. However, the incidence of atrial arrhythmias did not change significantly after the intervention.

PROSPERO REGISTRATION NUMBER

CRD42022378574.

Effectiveness and Safety of Transcatheter Atrial Septal Defect Closure in Adults with Systemic Essential Hypertension

Concomitant systemic essential hypertension (HTN) in adults with a secundum atrial septal defect (ASD) can unfavorably affect the hemodynamics and transcatheter ASD closure (ASDC) effects. This study aims to assess the effectiveness and safety of ASDC in adults with HTN in real-world clinical practice. Right ventricular (RV) reverse remodeling (RVR) and the lack of a left-to-right interatrial residual shunt (NoRS) in echocardiography 24 h and 6 months (6 M) post-ASDC, and ASDC-related complications within 6 M were evaluated in 184 adults: 79 with HTN (HTN+) and 105 without HTN (HTN−). Compared to HTN−, HTN+ patients were older and had a greater RV size and the prevalence of atrial arrhythmias, chronic heart failure, nonobstructive coronary artery disease, diabetes, hyperlipidemia, and left ventricular diastolic dysfunction. ASDC was successful and resulted in RVR, NoRS, and a lack of ASDC-related complications in the majority of HTN+ patients both at 24 h and 6 M. HTN+ and HTN− did not differ in ASD size, a successful implantation rate (98.7% vs. 99%), RVR 24 h (46.8% vs. 46.7%) and 6 M (59.4% vs. 67.9%) post-ASDC, NoRS 24 h (79% vs. 81.5%) and 6 M (76.6% vs. 86.9%) post-ASDC, and the composite of RVR and NoRS at 6 M (43.8% vs. 57.1%). Most ASDC-related complications in HTN+ occurred within 24 h and were minor; however, major complications such as device embolization within 24 h and mitral regurgitation within 6 M were observed. No differences between HTN+ and HTN− were observed in the total (12.7% vs. 9.5%) and major (5.1% vs. 4.8%) complications. Transcatheter ASDC is effective and safe in adults with secundum ASD and concomitant HTN in real-world clinical practice; however, proper preprocedural management and regular long-term follow-up post-ASDC are required.

The importance of preoperative oxygen saturation as a predictor of pulmonary arterial hypertension after surgery of atrial septal defects

OBJECTIVES

There is no concrete predictor of the change of pulmonary arterial pressure after surgical closure of an atrial septal defect (ASD) in patients with pulmonary arterial hypertension (PAH). The aim of this study was to investigate the role of preoperative room air arterial oxygen saturation (SaO2) (arterial blood gas data) as a predictor of postoperative PAH.

METHODS

The medical records of 36 patients [>20 years, mean pulmonary arterial pressure (mPAP) ≥25 mmHg] who underwent surgical closure of an ASD between March 2004 and January 2014 were retrospectively reviewed.

RESULTS

The median age was 47 years (range, 24.6-65.9 years) and mPAP was 38 ± 14 mmHg. The mean pulmonary vascular resistance (Rp) was 3.9 ± 4.2 Wood units, and fenestration was performed in 12 (33%) patients. Only 1 patient received anti-PAH medication preoperatively. The median follow-up period was 4 years (range, 0-10 years). There were two hospital deaths, one of which was related to PAH. At the last follow-up, PAH (estimated tricuspid regurgitation velocity >3 m/s) existed in 7 patients (19%), and 10 patients (28%) were receiving anti-PAH medications (considered as clinical PAH). Univariate analysis for persistent clinical PAH revealed that mPAP, Qp/Qs, Rp, room air arterial oxygen saturation and postoperative functional class were significant risk factors. Only SaO2 remained a significant risk factor in multivariate analysis (P = 0.03).

CONCLUSIONS

Preoperative room air SaO2 is a useful predictor of persistent PAH in adult patients undergoing surgical closure of an ASD.

Incomplete RV Remodeling After Transcatheter ASD Closure in Pediatric Age

Published data showing the intermediate effect of transcatheter device closure of atrial septal defect (ASD) in the pediatric age-group are scarce. The objective of the study was to assess the effects of transcatheter ASD closure on right and left ventricular functions by tissue Doppler imaging (TDI). The study included 37 consecutive patients diagnosed as ASD secundum by transthoracic echocardiography and TEE and referred for transcatheter closure at Cairo University Specialized Pediatric Hospital, Egypt, from October 2010 to July 2013. Thirty-seven age- and sex-matched controls were selected. TDI was obtained using the pulsed Doppler mode, interrogating the right cardiac border (the tricuspid annulus) and lateral mitral annulus, and myocardial performance index (MPI) was calculated at 1-, 3-, 6- and 12-month post-device closure. Transcatheter closure of ASD and echocardiographic examinations were successfully performed in all patients. There were no significant differences between two groups as regards the age, gender, weight or BSA. TDI showed that patients with ASD had significantly prolonged isovolumetric contraction, relaxation time and MPI compared with control group. Decreased tissue Doppler velocities of RV and LV began at one-month post-closure compared with the controls. Improvement in RVMPI and LVMPI began at 1-month post-closure, but they are still prolonged till 1 year. Reverse remodeling of right and left ventricles began 1 month after transcatheter ASD closure, but did not completely normalize even after 1 year of follow-up by tissue Doppler imaging.

Early and six-month assessment of bi-ventricular functions following surgical closure of atrial septal defect

BACKGROUND

The effect of surgical closure of atrial septal defect (ASD) on biventricular functions is not well studied. We studied effect of surgical closure of ASD on bi-ventricular functions.

METHODS

Patients undergoing surgical closure of ASD from December 2007 to June 2009 had 3 sequential echocardiograms examination: pre-procedure, post surgery at 1-month and at 6-month of follow up. Pulse Doppler velocities across mitral and tricuspid valves were measured as peak early diastolic (E wave) and peak late diastolic (A wave). Tissue Doppler velocities across lateral wall of both right ventricle (RV) and left ventricle (LV) were measured as peak early diastolic (E'), peak late diastolic (A'), and peak systolic (S') wave. Radionuclide angiography was performed to assess RV and LV ejection fraction at baseline and at 1-month follow up.

RESULTS

The mean age of 20 enrolled patients was 21.85 ± 10.9 years; 8 females & 12 males. Trans-tricuspid flow velocities significantly decreased following surgery at one and 6-month (p < 0.005). There was no significant change in trans-mitral flow velocities at one and 6-months. Tricuspid and mitral E/A ratio and E/E' ratio also had an insignificant change following surgery. There was no significant change in LV ejection fraction as assessed by echocardiography (p = 0.132) and radionuclide scan (p = 0.143). Right ventricular ejection fraction had a significant improvement at 1-month of follow up (p = 0.005).

CONCLUSIONS

There was a significant improvement in RV systolic function and an insignificant change in RV and LV diastolic functions following surgical closure of ASD.

Prevalence and determinants of incomplete right atrial reverse remodeling after device closure of atrial septal defects

Whether the relief of chronic right atrial (RA) volume load by device closure of an atrial septal defect (ASD) normalizes RA size is unknown. The present study evaluated the prevalence and determinants of incomplete RA reverse remodeling (RAR) after ASD closure in adults. Transthoracic echocardiography was performed in 44 consecutive patients with secundum ASD (age 43 ± 17 years, 10 men) without a history of atrial arrhythmia shortly before and at 3 months after device closure of ASD. The pulmonary/systemic flow ratio was derived using invasive oximetry. The RA size had significantly decreased at 3 months of follow-up (RA volume index [RAVI] 52 ± 29 to 27 ± 17 ml/m(2), p <0.001). Incomplete RAR (defined as a RAVI of ≥21 ml/m(2)) was detected in 25 patients (57%) after closure. They were older, had a larger pulmonary/systemic flow ratio, a higher pulmonary arterial systolic pressure, more tricuspid regurgitation, and larger RA, left atrial, and right ventricular sizes before closure than those with a normalized right atrium. Before closure, RAVI was the only independent determinant for incomplete RAR (odds ratio 1.115, 95% confidence interval 1.019 to 1.220; p = 0.018). A cutoff value of RAVI of ≥40 ml/m(2) has a sensitivity of 84% and specificity of 72% in the receiver operating characteristic curve. The preclosure RAVI correlated moderately with the shunt-duration index, calculated by multiplying the age to pulmonary/systemic flow ratio (r = 0.64, p <0.01). In conclusion, incomplete RAR occurred in >1/2 of the adult patients at 3 months after ASD device closure and was related to excessive preclosure RA dilation.

Intermediate-term effects of transcatheter secundum atrial septal defect closure on cardiac remodeling in children and adults

The study aimed to investigate the intermediate-term effects of transcatheter atrial septal defect (ASD) closure on cardiac remodeling in children and adult patients. Between December 2003 and February 2009, 117 patients (48 males, 50 adults) underwent transcatheter ASD closure with the Amplatzer septal occluder (ASO). The mean age of the patients was 15 years, and the mean follow-up period was 25.9 +/- 12.4 months. New York Heart Association (NYHA) class, electrocardiographic parameters, and transthoracic echocardiographic (TTE) examination were evaluated before the ASD closure, then 1 day, 1 month, 6 months, 12 months, and yearly afterward. Transcatheter ASD closure was successfully performed for 112 (96%) of the 117 patients. The mean ASD diameter measured by transesophageal echocardiography (TEE) was 14.0 +/- 4.2 mm, and the mean diameter stretched with a sizing balloon was 16.6 +/- 4.8 mm. The mean size of the implanted device was 18.6 +/- 4.9 mm. The Qp/Qs ratio was 2.2 +/- 0.8. The mean systolic pulmonary artery pressure was 40 +/- 10 mmHg. At the end of the mean follow-up period of 2 years, the indexed right ventricular (RV) end-diastolic diameter had decreased from 36 +/- 5 to 30 +/- 5 mm/m(2) (p = 0.005), and the indexed left ventricular (LV) end-diastolic diameter had increased from 33 +/- 5 to 37 +/- 6 mm/m(2) (p = 0.001), resulting in an RV/LV ratio decreased from 1.1 +/- 0.2 to 0.8 +/- 0.2 (p = 0.001). The New York Heart Association (NYHA) functional capacity of the patients was improved significantly 24 months after ASD closure (1.9 +/- 0.5 to 1.3 +/- 0.5; p = 0.001). At the 2-year follow up electrocardiographic examination, the P maximum had decreased from 128 +/- 15 to 102 +/- 12 ms (p = 0.001), the P dispersion had decreased from 48 +/- 11 to 36 +/- 9 ms (p = 0.001), and the QT dispersion had decreased from 66 +/- 11 to 54 +/- 8 ms (p = 0.001). Five of six patients experienced resolution of their preclosure arrhythmias, whereas the remaining patient continued to have paroxysmal atrial fibrillation. A new arrhythmia (supraventricular tachycardia) developed in one patient and was well controlled medically. Transcatheter ASD closure leads to a significant improvement in clinical status and heart cavity dimensions in adults and children, as shown by intermediate-term follow-up evaluation. Transcatheter ASD closure can reverse electrical and mechanical changes in atrial myocardium, resulting in a subsequent reduction in P maximum and P dispersion times.

Fenestrated occluders for treatment of ASD in elderly patients with pulmonary hypertension and/or right heart failure

Atrial septal defect (ASD) occlusion in adult patients with advanced age and left or right heart diastolic or systolic heart failure and in patients with pulmonary arterial hypertension bears a considerable risk of deterioration of heart failure. Therefore, we conducted this feasibility trial in 15 ASD patients with pulmonary hypertension and/or right heart failure using a fenestrated Amplatzer septal occluder (AGA Medical Corporation, Golden Valley, MN), allowing an overflow of blood in both directions in case of univentricular diastolic or systolic heart failure. In all patients, the device could be implanted without complications. All symptomatic patients showed an improvement in the New York Heart Association (NYHA) class, and no right or left heart decompensation occurred. On echocardiography, right ventricular end diastolic dimension (RVEDD) and pulmonary artery pressure (PAP) decreased significantly, whereas left ventricular end diastolic dimension (LVEDD) increased. Our series of 15 patients with fenestrated ASD occlusion shows that high-risk ASD occlusion can safely be accomplished with excellent clinical results and without complications by a fenestrated occluder.

Hemodynamic improvement is faster after percutaneous ASD closure than after surgery

OBJECTIVES

Hemodynamic effects of surgical and percutaneous closure of atrial septal defect (ASD) were evaluated.

BACKGROUND

ASD causes volume overload of right ventricle (RV) and is associated with distortion and dysfunction of left ventricle (LV). The amount and timing of hemodynamic changes after ASD closure are not well known.

METHODS

The study group consisted of 7 children treated surgically and 17 treated in the catheterization laboratory. In the control group, there were 51 healthy children. RV size and LV end-diastolic and systolic dimensions, volumes, and function were examined by two- and three- dimensional echocardiography and serum concentrations of natriuretic peptides measured prior to ASD closure, and 1, 6, and 12 months thereafter.

RESULTS

In all children with ASD, during the 1-year follow-up, the z score of RV end-diastolic diameter decreased from a median 5.00 SD to 2.25 SD (P < 0.001). Dilatation of RV did not resolve entirely during 1-year follow-up in either treatment group. End-diastolic LV diameter increased from -1.50 to -0.50 SD (P < 0.001). LV size increased slower in the surgical subgroup but reached control levels in both groups. Concentrations of natriuretic peptides increased during the first month after ASD closure and normalized thereafter in patients treated percutaneously but remained higher than in controls in patients treated surgically.

CONCLUSIONS

During 1-year follow-up after ASD closure, RV size decreases but does not normalize in all patients. The size of the LV normalizes after ASD closure but the increase in LV size is slower in patients treated surgically. Serum levels of ANPN and proBNP are elevated prior to ASD closure but decrease thereafter to control levels in patients treated with the percutaneous technique but not in those treated surgically.

Pathophysiological basis of right ventricular remodeling

The pathophysiology of right ventricular (RV) remodeling is a complex process and may include unique elements not observed in left ventricular (LV) remodeling. The RV also has a relatively irregular geometry not accounted for in LV analyses. RV remodeling includes basic changes in geometry, wall thickness, and ventricular pressure-volume relationships. Also, myocyte dimensions and number increase, and myocardial extracellular matrix and biochemical milieu are modified. Remodeling has been associated with such diseases as pulmonary hypertension, lung transplant, LV pathology, Chagas' disease, and arrhythmogenic right ventricular cardiomyopathy. Disease progression may lead to further RV changes, including hypertrophy, dilatation, and subsequently to variable alterations in RV hemodynamic status. The multiple methods to assess RV hypertrophy include cine magnetic resonance imaging and 3-D echocardiography. Each technique offers different precision in evaluating RV dimensions and functional performance characteristics. Strategies to prevent RV remodeling include pharmacological agents, such as vasodilators and angiotensin-converting enzyme inhibitors, as well as more invasive interventions, such as ventricular assist devices.

Similar cardiac remodelling after transcatheter atrial septal defect closure in children and young adults

OBJECTIVE

To study the cardiac geometric changes after transcatheter closure of large atrial septal defects (ASDs) according to patient age at the time of the procedure.

DESIGN

Prospective echocardiographic follow-up study.

SETTING

Tertiary referral centre.

PATIENTS AND INTERVENTION

25 asymptomatic patients younger than 16 years (median 8 years; group 1) and 21 asymptomatic adults (median 38 years; group 2) underwent percutaneous closure of large ASD with the Amplatzer septal occluder device (mean 25 (SD 7) mm).

MAIN OUTCOME MEASURES

Cardiac remodelling was assessed by M mode and two dimensional echocardiography one and six months after ASD closure.

RESULTS

By six months, right atrial volume decreased from 31 (15) to 19 (5) ml/m(2) (p < 0.001) and right ventricular (RV) transverse diameter decreased from 29.8 (8.6) to 23.2 (5.6) mm/m(2) (p < 0.001). Conversely, left atrial volume did not change significantly (from 18 (6) to 20 (6) ml/m(2), NS) and left ventricular (LV) transverse diameter increased from 27.8 (6.4) to 31.8 (7.3) mm/m(2) (p < 0.05). Ventricular remodelling resulted in an RV:LV diameter ratio decrease from 1.1 (0.2) to 0.7 (0.1) (p < 0.001). The magnitude and time course of cardiac remodelling did not differ significantly between the age groups. Indeed, right atrial volume decreased by 33 (26)% versus 37 (23)%, RV diameter decreased by 26 (10)% versus 20 (13)%, LV diameter increased by 17 (15)% versus 15 (10)%, and RV:LV diameter ratio decreased by 36 (8)% versus 27 (15)% in groups 1 and 2, respectively.

CONCLUSIONS

Cardiac remodelling after percutaneous ASD closure seems to be independent of the patient's age at the time of the procedure up to early adulthood. Thus, postponing ASD closure for a few years may be a reasonable option for potentially suitable asymptomatic children.

Time-course of cardiac remodeling following transcatheter closure of atrial septal defect

BACKGROUND

Right chamber dilatation and right-to-left volumetric unbalance are well-known cardiac consequences of atrial septal defect (ASD) shunt, accounting for most of its long-term complications. Thus, cardiac volumetric unloading is a major aim of ASD closure. Different from surgery, transcatheter option might be considered as an "unbiased" tool to evaluate the cardiac geometric remodeling following ASD closure.

METHODS

Extent and time-course of cardiac geometric changes were assessed by echocardiography 24 h, 1 and 6 months after percutaneous closure of large ASD (mean diameter 17+/-6 mm, QP/QS 2.2+/-0.9) in 42 asymptomatic patients (age 22+/-18 years).

RESULTS

Transcatheter closure was accomplished using the Amplatzer Septal Occluder device (mean 23+/-7 mm, median 24 mm), achieving a complete occlusion in all patients at the 6-month follow-up control. After ASD closure, right atrial (RA) volume reduced from 45+/-24 to 28+/-12 ml (-37.8%, p<0.001), while left atrial (LA) volume did not significantly change. Inlet and infundibulum right ventricular (RV) end-diastolic diameters reduced by 23+/-2% and 23+/-3%, respectively (p<0.001 for both measurements), although with a different time-course of changes. Finally, transverse left ventricular (LV) end-diastolic diameter increased from 39+/-7 to 44+/-5 mm (+11.4%, p<0.01). These geometric changes resulted in an RV/LV diameter ratio decrease by 34+/-3% (p<0.001). Nearly 90% of cardiac remodeling ensued within 1 month from shunt disappearance (50% within 24 h).

CONCLUSIONS

Percutaneous ASD closure results in early and striking cardiac geometric changes that almost completely revert the right-to-left volumetric unbalance. Most of this geometric remodeling ensues within a few weeks from ASD closure.

Transcatheter atrial septal defect closure with the Amplatzer septal occluder: five-year follow-up

We report 5-year follow-up data of patients following atrial septal defect (ASD) closure with the Amplatzer septal occluder (ASO). Patients completed a questionnaire related to symptoms pre- and post-ASO implantation. Complete transthoracic echocardiography was used to assess residual atrial septal defect, right ventricular volume overload, and degree of mitral regurgitation. Mean follow-up duration was 4.8 +/- 0.6 years (range, 5.7-3.0 years). Complete closure was observed in all patients. Right ventricular volume overload, present in all patients prior to ASD closure, had resolved in 82% of patients. No mitral valve sequelae were found; 75% of patients were asymptomatic or felt much improved compared to their preclosure symptoms. New onset of migraine-type headaches was encountered in two patients, one for 12 months and one patient persisted with intermittent migrainous episode. In conclusion, we report 100% closure rate of ASD with ASO device, with return of right ventricular size to normal in the majority of patients. New onset of migraine headaches after ASO implantation can persist more than a few months.

Early electrical and geometric changes after percutaneous closure of large atrial septal defect

Cardiac arrhythmias and right chamber enlargement are well known long-term sequelae of atrial septal defect (ASD). Surgical ASD closure relieves patient symptoms but often fails to revert cardiac volume overload findings. Transcatheter ASD closure might be an attractive alternative to surgery, also because of the possibility to study the amount and time-course of the electro-geometric modifications following shunt disappearance. Between March 2000 and December 2002, 24 patients (age 22.7 +16.8 years) underwent percutaneous closure of large ASD (stretched diameter >20 mm and/or QP/QS ratio >1.5:1). ASD closure was performed with the Amplatzer Septal Occluder device (mean 25 +/- 7 mm), achieving a complete occlusion in all patients at 1 month. In 6 patients, right ventricular (RV) monophasic action potential was recorded during the procedure. All patients underwent standard 12-lead electrocardiography and transthoracic echocardiography before and at 24 hours and 1 month after ASD closure. After the procedure, monophasic action potential length increased from 359 +/- 27 to 372 +/- 27 ms (p <0.0001). At 1 month, QT dispersion decreased from 54 +/- 25 to 41 +/- 17 ms (p <0.05), RV diastolic diameter decreased from 42 +/- 6 to 34 +/- 5 mm (p <0.00001), and left ventricular (LV) diastolic diameter increased from 39 +/- 5 to 44 +/- 5 mm (p <0.0001), resulting in a decrease in the RV/LV ratio from 1.11 +/- 0.22 to 0.79 +/- 0.11 (-28.8%, p <0.00001). Electrocardiographic changes, as well as the amount and time-course of RV overload relief, did not significantly differ between pediatric (<16 years of age; n = 11) and adult patients (n = 13). In conclusion, regardless of age at procedure, percutaneous ASD closure results in early striking electrical and geometric cardiac changes that may be beneficial during long-term follow-up.

Effect of Patient Age at Surgical Intervention on Long-Term Right Ventricular Performance in Atrial Septal Defect: A Pulsed Wave Tissue Doppler Echocardiography Study

Controversy exists about the influence of patient age on the benefit of surgery in atrial septal defect (ASD). Tissue Doppler echocardiography (TDE) when applied to atrioventricular annuli provides variables reliably reflecting the performance of the corresponding ventricle. We sought to investigate the effect of timing of surgery on biventricular functions by comparing the conventional echocardiography variables and TDE profiles of right and left atrioventricular annuli in patients treated at various ages. Conventional echocardiography and TDE analysis of mitral and tricuspid annuli were performed in 20 controls and 61 patients who underwent surgical ASD closure 2.8 +/- 2.5 years before the study. Standard parameters included were right and left-sided dimensions, estimated pulmonary artery pressure, ejection fraction, and tricuspid annular motion amplitude. TDE variables were systolic, early and late diastolic peak velocities at tricuspid lateral-and mitral-annulus at lateral and septal corners. Two subsets of patients who underwent surgery before (group 1, n = 20) and after 25 years (group 2, n = 41) formed our subgroups. Peak systolic TDE velocity and tricuspid annular motion amplitude had the lowest value in group 2 (P < 0.01 and <0.02, respectively). Late diastolic TDE velocity was significantly lower in group 2 compared to group 1 (P < 0.05). Increased right ventricular and atrial dimensions (P < 0.001 for both) and the estimated pulmonary artery pressure (P < 0.03) were the conventional measurements discriminating group 2 from group 1. The TDE profile of the mitral annulus was similar between the groups. These results suggest that delayed ASD closure is a relatively less effective procedure to restore secondary right ventricular dysfunction, as demonstrated by significantly different TDE measurements reflecting right ventricular longitudinal contraction and relaxation.

[Surgical closure of atrial septal defect before or after the age of 25 years. Comparison with the natural history of unoperated patients]

INTRODUCTION

Surgical closure of an atrial septal defect (ASD) before the age of 25 years has been demonstrated to reduce complications during adulthood. However, the outcome for patients operated after the age of 25 is still debated.

METHODS

In a retrospective study we examined the outcome of early and late surgical repair of ASD in adults, as compared with the natural evolution of unoperated patients. The study population was 280 patients (mean age 40 18 years) with non-restrictive ASD: 102 patients (group 1) underwent surgery before the age of 25 years, 90 patients (group 2) underwent surgery after the age of 25 years, and 88 unoperated patients were older than 25 years at the time of study (group 3). The variables analyzed were left ventricular systolic function, left atrial dimensions, systolic pulmonary pressure, right ventricular dimensions, the degree of mitral and tricuspid regurgitation, and the prevalence of late atrial fibrillation.

RESULTS

Left ventricular systolic function and the degree of mitral regurgitation were not statistically different between groups. Compared with the patients in group 2, the patients in group 1 had a significantly lower systolic pulmonary arterial pressure (p < 0.001) and less dilated right ventricle (p < 0.001) and left atrium (p < 0.001). The degree of tricuspid regurgitation (p < 0.001) and prevalence of atrial fibrillation (p < 0.001) were significantly higher in the patients of group 2. Compared with group 3, the patients in group 2 had a significantly lower systolic pulmonary arterial pressure (p < 0.001) and less dilated right ventricle (p < 0.001). However, the left atrial dimensions, degree of tricuspid regurgitation, and prevalence of atrial fibrillation did not differ in a statistically significant way between the two groups.

CONCLUSIONS

Surgical repair of an atrial septal defect in patients over 25 years of age does not fully prevent hemodynamic deterioration and the development of atrial arrhythmias. Therefore it seems that the surgical closure of ASD before adulthood should be strongly recommended.

Right ventricular form and function after percutaneous atrial septal defect device closure

OBJECTIVES

We sought to assess the right heart's response to percutaneous device closure of moderate sized atrial septal defects (ASDs) in adults over a one-year follow-up period.

BACKGROUND

Percutaneous ASD device closure is a safe and effective means of reducing or eliminating interatrial shunting. The response of the adult's right heart to device closure is incompletely understood.

METHODS

Forty consecutive patients had 40 device implantations (32 with the CardioSeal implant and 8 with the Amplatzer device). The patients were assessed with echocardiography, chest radiography and electrocardiography before the procedure and at 1, 6 and 12 months.

RESULTS

The mean ASD size was 13+/-4 mm, and the device size ranged from 33 to 40 mm for CardioSeal and 12 to 36 mm for Amplatzer. At one month, heart size (49% vs. 46%), four-chamber right ventricular (RV) size (45 vs. 41 mm), paradoxical septal motion (60% vs. 5%), QRS duration (125 vs. 119 ms), PR interval (181 vs. 155 ms) and echocardiographically determined pulmonary artery systolic pressure decreased significantly and was maintained at 12-month follow-up. At six months, right atrial length decreased from 50 to 47 mm. At one year, 29% of patients had persistent RV enlargement.

CONCLUSIONS

Right heart morphology undergoes rapid improvement within one month of defect closure, with associated mechanoelectrical benefit. A small number of patients had persistent RV enlargement or pulmonary hypertension, or both, at one year. Our data support the application of transcatheter methods in achieving excellent hemodynamic and anatomic outcomes.

Effect of surgical repair of secundum-type atrial septal defect on right atrial, right ventricular, and left ventricular volumes in adults

Surgical repair of atrial septal defect in adults reduces right ventricular and right atrial diameters and volumes, and improves left ventricular filling.

The adult patient with congenital heart disease

In adults with congenital heart disease who are confronted with noncardiac surgery, perioperative risks can be reduced, often appreciably, when problems inherent to this patient population are anticipated. The first necessity is to clarify the diagnosis and to be certain that appropriate information is obtained from a cardiologist with adequate knowledge of congenital heart disease in adults. Physiology and anatomy can vary significantly among patients who superficially carry identical diagnoses. Elective noncardiac surgery should be preceded by clinical assessment including review of clinical and laboratory data and securing the results of necessary diagnostic studies. Preoperative assessment should be performed far enough in advance of the anticipated date of surgery to allow critical assessment of the data and potential discussions with colleagues. Appropriate cardiovascular laboratory studies to be obtained or reviewed include electrocardiograms, chest radiographs, echocardiograms, and cardiac catheterization data, which may include specialized intracardiac electrophysiologic testing. Congenital heart disease in adults is a new and evolving area of special interest and expertise in cardiovascular medicine. Multidisciplinary centers for the care of these patients are being developed. The 22nd Bethesda Conference recommended that these centers include among their consultants anesthesiologists with special expertise in managing patients with congenital heart disease. These anesthesiologists can have the option of serving either as the attending anesthesiologists when patients require noncardiac surgery or as consultants and resource individuals to other anesthesiologists.

Long-term follow-up (9 to 20 years) after surgical closure of atrial septal defect at a young age

To assess the long-term cardiac status after surgical closure of an atrial septal defect (ASD) at a young age, 104 of 135 children who consecutively underwent surgery (aged 0 to 14 years) at 1 institution between 1968 and 1980 participated in a follow-up study and underwent a complete cardiologic examination. Mean follow-up was 14.5 +/- 2.8 years. Most patients (87%) believed their health to be good or very good. At physical examination, all patients were in good health. Ninety-three patients (89%) were in sinus rhythm. Echocardiography showed that right ventricular dilatation was present in 27 patients (26%), 2 of whom had a residual ASD. Bicycle ergometry revealed that 88 patients (88%) had a normal exercise capacity. Both supraventricular and ventricular arrhythmias were observed in 67% of patients by 24-hour ambulatory electrocardiography, but only 3 (3%) had received antiarrhythmic medication, and 4 (4%) had needed a pacemaker. In the group of patients with right ventricular dilatation, the exercise capacity and prevalence of arrhythmias did not differ significantly from those in the group with a normal sized right ventricule. The outcome in patients with a secundum-type ASD was not different from that of those with a sinus venosus-type ASD. The finding of anatomic, functional or electrophysiologic abnormalities was not associated with a longer duration of follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)

Three-dimensional left ventricular midwall dynamics in the transplanted human heart

To quantify the three-dimensional regional dynamics of the left ventricular (LV) midwall and the centroid and cross-sectional shape of the LV chamber in the transplanted human heart, 12 miniature radiopaque tantalum markers were implanted in the LV midwall of the donor heart at the time of cardiac transplantation in 15 patients. Stereo cineradiography in the late postoperative period (mean, 52 days after surgery) allowed computer-aided measurements of the three-dimensional coordinates of multiple sites in anterior, inferior, lateral, and septal LV regions at 16.7-msec intervals throughout the cardiac cycle. In awake, supine patients, from maximum to minimum LV volume, group mean translations of free wall markers ranged from 0.80 to 1.24 cm, directed toward the LV interior, whereas translations of septal wall markers were significantly less, 0.46 and 0.34 cm (p less than 0.01), directed away from the LV interior. A component of this translation along the septal-lateral axis was also significantly less (p less than 0.01) in the septum (0.19 and 0.20 cm) than in the free wall, where it ranged from 0.32 to 0.97 cm. The LV cross section was not circular, and anterior-inferior dimensions (7.18 +/- 0.66 and 6.13 +/- 0.79 cm, at maximum and minimum volumes, respectively) were significantly greater (p less than 0.01) than septal-lateral dimensions (5.78 +/- 0.65 and 5.12 +/- 0.48 cm), yielding an unchanging transverse elliptical LV eccentricity (0.58 +/- 0.13). The position of the LV center of volume did not change significantly from maximum to minimum volume in the direction of either the LV long axis or the anterior-inferior axis, but it did change significantly (0.55 +/- 0.23 cm, p less than 0.01) along the septal-lateral axis. We conclude 1) as viewed in a fixed external reference system, midwall sites in the interventricular septum of the transplanted human heart move paradoxically yet are relatively immobile compared with the three-dimensional dynamics of midwall sites in the LV free wall; 2) the transverse cross-sectional shape of the LV in the transplanted human heart is decidedly oval, with significantly greater anterior-posterior than septal-lateral dimensions at the time of maximum and minimum LV volumes; and 3) the center of volume in the transplanted human LV is remarkably stable in the directions of the LV long axis and anterior-posterior axis, suggesting a balance of forces along these axes, yet it moves significantly toward the interventricular septum, presumably counterbalancing the opposite translation during systole of the right ventricular (RV) center of volume.(ABSTRACT TRUNCATED AT 400 WORDS)

Exercise after surgical repair of congenital cardiac lesions

Congenital heart defects arise in approximately 1% of all live births, independent of ethnic and geographical considerations. With the development of new surgical procedures and current technologies a large number of these heart lesions can be surgically corrected in infancy. In the majority of cases patients evaluated some 10 to 20 years after surgery are asymptomatic and can lead a normal life. Despite their satisfactory clinical outcome patients may, nevertheless, show an abnormal pattern of physiological responses when submitted to dynamic exercise. This paper reviews the scientific literature concerning the exercise capabilities and the cardiorespiratory adjustments to exercise in patients surgically corrected for 4 of the most common congenital heart lesions: isolated atrial septal defect, isolated ventricular septal defects, pulmonary stenosis and tetralogy of Fallot. The maximal exercise tolerance of postoperative congenital heart defect patients may usually be related to: (a) the age of the patients at the time of surgery; (b) the severity of the lesions remaining after surgery; and (c) the age of the patients at the time of investigation. Although normal maximal exercise capabilities may be found in a good number of patients operated for either of the 4 lesions considered, this does not imply normal exercise haemodynamics. A general observation made in these 4 groups of patients is that of a subnormal exercise cardiac output which may or may not be fully compensated by an increase in peripheral oxygen extraction. The limitation in exercising cardiac output may, in turn, be attributed to either a subnormal stroke volume or a limitation in the chronotropic response to exercise or a combination of both factors. Residual pulmonary stenosis, increased pulmonary vascular resistance, increased myocardial stiffness are all factors that may contribute to the cardiac output limitation. A thorough explanation of underlying causes for the abnormal haemodynamic response to exercise, however, still remains to be provided.

Cross-sectional echocardiographic measurement of right atrial and right ventricular size in children with atrial septal defect before and after surgery

A total of 25 children operated on for atrial septal defect were studied by cross-sectional echocardiography before and after operation. Right atrial and right ventricular dimensions and areas were measured preoperatively and 1-4 years (median, 32 months) postoperatively. The length, width, and area of the right atrium (RA) and the right ventricle (RV) were measured in the apical and the subcostal four-chamber views. The dimension of the RV outflow tract (RVOT) was measured in the parasternal short-axis view. Preoperatively, all group mean values except the subcostal four-chamber length of the RV were significantly larger than normal. After surgery, there was a significant decrease in all of the parameters studied, except for RV length. The mean postoperative values of RA measurements in the apical four-chamber view and of RVOT were still significantly larger than normal. The RV four-chamber measurements except the apical four-chamber length were not significantly enlarged. The greatest decrease in RA and RV size occurred in the first postoperative year. Longer follow-up periods did not change the measurements significantly.

The repair of atrioventricular septal defects in infancy

Two (3%) of 72 patients undergoing repair of atrioventricular septal defects, 1984-September 1985, died in hospital, and among the 58 patients with isolated atrioventricular septal defect, one (2%) died in hospital. One (3%) of the 30 patients with isolated atrioventricular septal defects undergoing repair in the first year of life died. The absence of an incremental risk of young age is a continuation of the trend demonstrated in a parametric analysis of the earlier 1967-1982 experience (n = 310). The hospital mortalities were similar in 1984-September 1985 after repair of partial and complete atrioventricular septal defects, again a continuation of the earlier trend as is the lessened hospital mortality (7%) in the current era among patients with major associated cardiac anomalies. The continuity of results in the two eras, and the predictability of the results in the current era from equations developed from the earlier one, give a high degree of confidence in the inference that primary repair in the first year of life is advisable for most patients with atrioventricular septal defects. Ten-year survival of such patients operated upon currently is predicted to be 99 and 95% for partial and complete atrioventricular septal defects, respectively.

Usefulness of echocardiographic assessment of right ventricular and pulmonary trunk size for estimating magnitude of left-to-right shunt in children with atrial septal defect

M-mode and 2-dimensional echocardiographic studies were performed in 42 patients, aged 1 to 16 years (mean 6), with a secundum or sinus venosus type atrial septal defect (ASD) and normal pulmonary artery pressure. Twenty normal children served as a control group. In patients with ASD the echocardiographic variables were correlated with the magnitude of the left-to-right shunt (Qp/Qs) calculated by the Fick principle. Although M-mode echocardiograms showed increased right ventricular (RV) dimension in 69% of the patients, the correlation between RV dimension index (RV dimension/body surface area) and Qp/Qs was weak (r = 0.49). When RV dimension was related to left ventricular (LV) dimension and expressed by the RV/LV ratio, 90% of the patients were found to have an abnormally large right ventricle. The correlation between the RV/LV ratio and Qp/Qs was fairly good (r = 0.64). In 33 patients (78%), the pulmonary trunk (PT) was adequately visualized and measured on 2-dimensional echocardiograms. The dimension of the PT was related to the aortic root dimension and expressed by the PT dimension/aortic dimension ratio. This ratio was 0.99 +/- 0.06 in normal children and 1.35 +/- 0.23 in patients with ASD (p less than 0.001). The PT/aortic ratio exceeded the upper limit of normal (the normal mean value + 2 standard deviations) in each of the 27 patients with a Qp/Qs of 1.5 or greater. In 5 of the 6 patients with a Qp/Qs of less than 1.5 the PT/aortic ratio was close to 1 and within the normal range. An excellent correlation (r = 0.89) was found between the PT/aortic ratio and Qp/Qs.(ABSTRACT TRUNCATED AT 250 WORDS)

Ventricular performance in adults after operation for congenital heart disease

Symptomatic ventricular dysfunction in adults who have had reparative operations for the more common congenital heart defects is uncommon. However, both invasive and noninvasive laboratory assessments of ventricular function have revealed abnormalities in some subsets of patients after repair of atrial septal defect, ventricular septal defect, aortic or pulmonary stenosis, tetralogy of Fallot, transposition of the great arteries and tricuspid atresia. Possible causative factors of late ventricular dysfunction after repair include the duration and severity of volume or pressure overload; the duration and severity of cyanosis; intermittent episodes of imbalance between myocardial oxygen supply and demand; residuae, sequelae and complications of treatment; and acquired disease. Further long-term follow-up studies are needed to assess the effect of current methods of therapy as well as timing of operative intervention on ventricular function in adults.

Postoperative abnormalities of interventricular septal motion: two-dimensional and M-mode echocardiographic correlations

Our hypothesis was that the postoperative abnormalities in septal motion observed by M-mode echocardiography (MME) are due to changes of either ventricular shape or of total cardiac motion within the thorax. We obtained preoperative and early and late postoperative MME and two-dimensional echocardiograms on 25 patients undergoing cardiac surgery. No patient had coronary artery disease. All patients had normal preoperative septal motion; 11 patients retained normal (group N) septal motion on postoperative MME; 14 patients developed abnormal (group A) septal motion. Comparison of these two groups revealed that the group A patients had a greater degree of posterior epicardial motion toward the chest wall during systole. This indicates a greater anterior motion of the entire heart within the thorax, which produces the observed septal motion abnormality by carrying the septum forward passively as the whole heart moves anteriorly. This excessive forward cardiac motion may be due to fixation of the heart anteriorly by postoperative sternal-cardiac adhesions. No changes in left ventricular shape, size, or function were found to be associated with abnormal septal motion, nor was septal contraction impaired. Changes in intrathoracic cardiac motion are the probable cause of septal motion abnormalities after cardiac surgery.

Long-term follow-up study after closure of secundum atrial septal defect in children: an echocardiographic study

Serial echocardiography was performed in 51 children with isolated secundum atrial septal defect before and after surgery to measure the effects of chronic right ventricular overload on ventricular function. Right ventricular dilation increased dramatically with growth and with size of the left to right shunt only in the youngest children (body surface area less than 0.5 m2). A lesser effect of growth and no significant effect of shunt size were noted in older children. Although an initial decrease in right ventricular size occurred in the first 3 months after operation, persistent right ventricular dilation remained up to 5 years after closure of the interatrial defect in more than 80 percent of patients. Preoperatively, the ratio of the right ventricular preejection period to ejection time was significantly less than that of normal children. This ratio increased dramatically after operation, exceeding normal values early in the postoperative period in 18 of 48 children and persisting in 6 of 22 after 3 months. Left ventricular dimensions were normal early and late after operation. Left ventricular function was apparently normal, although an exceptionally high shortening fraction was noted in 22 (44 percent) of 51 children after operation. Aortic systolic time interval ratios decreased after operation from high normal to low normal values. It is hypothesized that the persistent enlargement of the right ventricle after operation may be due to the chronic preoperative dilation secondary to chronic interatrial shunting. The abnormally high shortening fraction after operation may result from an abnormal left ventricular geometric configuration or abnormality of filling. It is suggested that surgical closure of the atrial defect in the first 3 years of life may prevent these abnormalities.

Radionuclide ventriculography: a noninvasive method for the detection and quantification of left-to-right shunts in atrial septal defect

The present investigation was undertaken to assess a new scintigraphic method for the diagnosis of left-to-right shunts due to atrial septal defect based on the differing stroke volumes of left and right ventricles and to compare it with oxymetric data. Radionuclide ventriculography was carried out after injection of 20 mCi 99mtechnetium-labeled red blood cells. Time-activity curves were obtained from the left and right ventricular regions, and the ratio (A) of end-diastolic-end-systolic count rate differences for the left and right ventricles was calculated. The left-to-right shunt (in percent of the pulmonary flow rate) is then given as 100 X (1 - A/1.43; 1.43 being the previously determined mean value of A in 66 normal patients. In 16 patients with an atrial septal defect and/or partial anomalous pulmonary venous connection a correlation of r = 0.81 was found between those shunts determined by the scintigraphic method and those calculated by oxymetric data. The specificity of the method and the sensitivity in detecting left-to-right shunts exceeding 30% are high. The method is practical and already widely used for determination of ejection fraction end-diastolic volume and other factors. The combination of this technique with other methods for shunt diagnosis such as gamma-fit analysis may prove of special value.

Non-invasive diagnosis in clinically suspected atrial septal defect of secundum or sinus venosus type. Value of combining chest x-ray, phonocardiography, and M-mode echocardiography

Twenty-three consecutive patients with clinical (auscultatory and electrocardiographic) signs of uncomplicated atrial septal defect of secundum or sinus venosus type were examined by chest x-ray, phonocardiography, and echocardiography, before right heart catheterisation. Seventeen (74%) had atrial septal defect, two patients (9%) had insignificant pulmonary stenosis, and four subjects (17%) were normal. No false positive diagnosis of atrial septal defect was made by chest x-ray examination, whereas increased vascular markings were incorrectly interpreted as pulmonary congestion in one case. Four patients had x-ray films showing questionable signs of left-to-right shunt. Six of 15 patients with a large left-to-right shunt were correctly selected for surgery based on radiological findings. One false negative but no false positive diagnosis of atrial septal defect was made by phonocardiography. Four cases with and four cases without atrial septal defect were classified as having questionable phonocardiographic signs of atrial septal defect. Echocardiographic distinction between those with atrial septal defect and those without atrial septal defect was correct in all cases; quantitative measurement of left-to-right shunt, however, was unsatisfactory. Combined normal findings by x-ray film and echocardiography appeared adequate in all cases for the exclusion of atrial septal defect (six patients). When the six patients who were correctly identified for surgery from the radiological findings are included, there was a total of 12 patients out of 23 (52%:95% confidence limits 31 to 73%) who were evaluated definitively by the non-invasive tests.

Effect of atrial septal defect repair on left ventricular geometry and degree of mitral valve prolapse

To ascertain the effects of surgical closure of atrial septal defect on left ventricular geometry and degree of mitral prolapse, 14 patients with atrial septal defect were studied by cross-sectional and M-mode echocardiography preoperatively and 7 days postoperatively. Seven of the 14 patients (50%) had mitral valve prolapse preoperatively by cross-sectional echocardiography. To quantitate the degree of prolapse, we measured the net algebraic area subtended by the apposed mitral valve leaflets in systole (MVAS) with respect to the mitral ring. The mitral valve prolapse group had an MVAS of 0.3 +/- 3.1 units (mean +/- SEM) preoperatively, while the group without mitral valve prolapse had an MVAS of 12.5 +/- 3.1 units (p less than 0.02). Postoperatively, prolapse either decreased in degree or was abolished in six of seven patients (86%), associated with an increase in MVAS to 14.7 +/- 4.4 units (p less than 0.02). In all patients, septal curvature in diastole on short-axis view normalized either partially or completely postoperatively, resulting in decreased left ventricular eccentricity (1.34 +/- 0.06 preop vs. 1.06 +/- 0.07 postop, p less than 0.001). Atrial septal defect closure, therefore, leads to normalization of left ventricular geometry and in patients with evidence of mitral valve prolapse, is associated with a decrease in the degree of prolapse.