Should atrial septal defects in adults be closed?

Comparison of the early cardiac electromechanical remodeling following transcatheter and surgical secundum atrial septal defect closure in adults

Background

Secundum atrial septal defect (ASD) closure leads to electrical and mechanical remodeling that occurs early after shunt disappearance. The relationship between electromechanical remodeling using electrocardiogram (ECG) and cardiac magnetic resonance (CMR) after percutaneous and surgical closure has not yet been recorded in prospective studies.

Objective

We thought to study right atrium (RA) and right ventricle (RV) changes by CMR 3 months after transcatheter and surgical closure and their comparison with electrical remodeling by ECG.

Results

We prospectively evaluated 30 consecutive adult patients with isolated secundum ASD who were referred for (transcatheter and surgical) ASD closure.

There was significant reduction in all of the electrical parameters within the same group as compared to the baseline values, except P wave dispersion (Pd). (P max was 97.33 ± 16.67 (pre closure) to 76 ± 15.49 (post closure) in the device group and 97.33 ± 12.79 (preclosure) to 73.33 ± 16.32 (post closure) in the surgical group, QRS complex was 104 ± 18.82 (preclosure) to 80 ± 18.51 (post closure) in the device group and 106.67 ± 14.47 (preclosure) to 86.67 ± 17.99 (post closure) in the surgical group. QTc maximum was 478.53 ± 36.79 (preclosure) to 412.53 ± 38.03 (post closure) in the device group and 470.53 ± 65.70 (preclosure) to 405.93 ± 63.08 (post closure) in the surgical group, and QTc dispersion was 70.33 ± 24.04 (preclosure) to 60.26 ± 28.56 (post closure) in the device group and 80.73 ± 30.38 (preclosure) to 60.27 ± 28.57 (post closure) in the surgical group).There was no significant difference between two groups indicating that transcatheter and surgical closure had led to equivalent value of electrical remodeling.

In CMR study, we measured RA maximal volume and right ventricle end diastolic volume (RVEDV), RA maximal volume decreased significantly as compared to the base line values post closure in both groups (P value < 0.001). The reduction in RA max volume was more in the transcatheter closure group; however, this difference was not statistically significant when compared with the surgical arm (P value = 0.5).RVEDV decreased significantly in both groups as compared to the baseline values (P value < 0.001). Transcatheter closure resulted in more significant reduction in the RVEDV than the surgical closure (P value = 0.03).

Conclusion

Our study showed early significant electromechanical reverse remodeling in most of the study parameters from the baseline values after ASD closure. We found no significant differences in all of the electrical and RA mechanical remodeling parameters with significantly better mechanical remodeling of RV in the device group.

Atrial septal defect can be easily missed in chromosome 18q deletion syndrome

The frequency of 18q− is estimated to be approximately 1/40 000 live births and is more commonly associated with certain clinical features including short stature, intellectual disability and malformations of many major organ systems. Congenital cardiac abnormalities are present in 24–36% of cases and screening can prove difficult. A 28-year-old Caucasian female with a history of long arm chromosome 18q deletion was evaluated for persistent dyspnea and decreased activity level. Multiple hospitalizations failed to identify the etiology of her symptoms. Initial transthoracic echocardiogram failed to show any underlying cardiac etiology of her symptoms. Multiple recurrent hospitalizations with the same chief complaint. A transesophageal echo (TEE) showed large secundum atrial septal defect (ASD). Successful surgical closure of her large secundum ASD provided significant symptoms relief. The threshold of obtaining TEE should be low in patients with 18q− which permits early recognition and treatment of underlying structural heart disease.

Landmark lecture on interventional cardiology: interventional cardiac catheterisation for CHD: the past, present, and the future

CHD affects millions of patients worldwide. Interventional therapies for CHD goes back to the mid-1960s when Bill Rashkind performed balloon atrial septostomy on a cyanotic baby with transposition of the great vessels. This was followed by development of balloon catheters to perform balloon valvuloplasties and angioplasties in the early to late 1980s. Although King and Mills performed the first transcatheter closure of secundum atrial septal defect in the mid-1970s, this procedure was better realised in the mid-1990s. More intracardiac defect closures were performed in the late 1990s and early 2000. This brings us to the current era of percutaneous valve implantation as developed by Bonhoeffer. In this paper, we will discuss the past, present, and future of interventional cardiac catheterisation for CHD patients.

Recent advances in managing septal defects: atrial septal defects

The purpose of this review is to discuss the management of atrial septal defects (ASD), paying particular attention to the most recent developments. There are four types of ASDs: ostium secundum, ostium primum, sinus venosus, and coronary sinus defects. The fifth type, patent foramen ovale-which is present in 25 to 30% of normal individuals and considered a normal variant, although it may be the seat of paradoxical embolism, particularly in adults-is not addressed in this review. The indication for closure of the ASDs, by and large, is the presence of right ventricular volume overload. In asymptomatic patients, the closure is usually performed at four to five years of age. While there was some earlier controversy regarding ASD closure in adult patients, currently it is recommended that the ASD be closed at the time of presentation. Each of the four defects is briefly described followed by presentation of management, whether by surgical or percutaneous approach, as the case may be. Of the four types of ASDs, only the ostium secundum defect is amenable to percutaneous occlusion. For ostium secundum defects, transcatheter closure has been shown to be as effective as surgical closure but with the added benefits of decreased hospital stay, avoidance of a sternotomy, lower cost, and more rapid recovery. There are several FDA-approved devices in use today for percutaneous closure, including the Amplatzer® Septal Occluder (ASO), Amplatzer® Cribriform device, and Gore HELEX® device. The ASO is most commonly used for ostium secundum ASDs, the Gore HELEX® is useful for small to medium-sized defects, and the cribriform device is utilized for fenestrated ASDs. The remaining types of ASDs usually require surgical correction. All of the available treatment modes are safe and effective and prevent the development of further cardiac complications.

Minimally invasive endoscopic surgery versus catheter-based device occlusion for atrial septal defects in adults: reconsideration of the standard of care

Objectives

Percutaneous ostium secundum atrial septal defect (ASD II) closure has become the standard of care for treatment of congenital ASD II in adults. Nevertheless, patients are frequently ineligible for this technique due to challenging morphology. In such cases, closure via minimally invasive cardiac surgery (MICS) is an appropriate treatment option. The aim of this study is to compare outcomes of MICS and use of a percutaneous Amplatzer septal occluder (ASO) device for treatment of ASD II in adults.

Methods

From July 2002 to June 2014, 95 patients underwent MICS for congenital ASD II closure. During the same period, 169 patients underwent ASO procedure. Outcomes in terms of remaining ASD II, new onset atrial fibrillation (AF), post-interventional stroke, myocardial infarction and the post procedural implementation of anticoagulation were compared.

Results

Apart from age (38.3 ± 12.7 vs 49.6 ± 15.7 years, P  < 0.0001) the groups did not differ in baseline characteristics. A significantly higher rate of residual ASD II was found in the ASO group at 3 months (0% vs 30.8%, P  < 0.0001), 6 months (0% vs 15.9%, P  < 0.0001) and 12 months follow-up (0% vs 7.1%, P  = 0.005). A significantly higher rate of new-onset AF was seen in the ASO group (0% vs 9.5%, P  = 0.0008).

Conclusions

MICS for ASD II is a safe and reproducible procedure with 0% mortality in our cohort. More complete closure of ASD, decreased rates of new onset AF and decreased need for oral anticoagulation are the advantages of the MICS procedure. Compared with the current standard of care, the MICS approach is feasible regardless of ASD morphology.

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.

[Interventional closure of atrial septal defects, patent oval foramen and ventricular septal defects]

Percutaneous transcatheter closure techniques and devices for congenital intracardiac shunts have considerably improved; therefore, catheter closure is now the treatment of choice for atrial septal defects (ASD). This is technically feasible in more than 80% of patients with a secundum ASD and the success rate is higher than 99%. General anesthesia is as a rule unnecessary and the hospital stay is very short. A patent oval foramen (POF) is a potential cause of cryptogenic stroke and peripheral embolisms. The catheter occlusion has many advantages in comparison to lifelong anticoagulation therapy and for some patients it is the only therapeutic option. Randomized trials have shown that interventional closure leads to results which are comparable to drug therapy and for some occlusion systems even evidence of significant advantages compared to drug therapy was found. Even ventricular septal defects (VSD), including perimembraneous and post-myocardial infarction VSDs can be closed by catheter techniques with a high success rate.

Surgical correction of atrial septal defect in the elderly

Introduction

Atrial septal defects (ASDs) are one of the most common congenital malformations in adults. Correction of ASDs in advanced age remains controversial, even though beneficial effects in this patient group were found in recent studies. In older patients, less invasive transcatheter closure of ASDs has been recommended.

Aim

The aim of this study was to analyze our advanced age ASD surgical cohort: early and late results.

Material and methods

Retrospective analysis of 32 patients operated on at an age of ≥ 60 years (i.e. age 66.13 ± 4.8, range from 60 to 78) in our center between 2001 and 2011 was carried out. We reviewed our experience of surgical ASD closure in elderly patients over a 10-year period to assess the effects of this type of treatment on early postoperative and long-term survival, early and late complications, preoperative and postoperative clinical status (New York Heart Association [NYHA] functional class), pulmonary hypertension (PH) and atrial arrhythmias. The patients were divided into two groups according to age.

Results

The frequency of comorbidities was lower in younger age group patients (11 [61%] vs. 13 [93%], p < 0.05). Atrial fibrillation/flutter was found in 21 (66%) of all patients. Late postoperative mortality was higher in the older patient group (3 [21%] vs. 1 [5.6%]). Despite this, we observed significant improvement of symptoms and functional ability in the older population after surgical ASD closure (group I, n = 10 [56%] vs. group II, n = 12 [86%]).

Conclusions

Surgical correction of clinically significant ASD is effective even in older patients with comorbidities.

Relationship between electrocardiographic signs and shunt volume in atrial septal defect

BACKGROUND

The aim of this study was to determine whether electrocardiographic signs correlate with hemodynamics and the magnitude of the intracardiac shunt in children with ostium secundum atrial septal defects (ASD).

METHODS

A total of 100 ASD patients (median age, 6 years 4 months; 54 girls) underwent cardiac catheterization between August 1980 and April 2010. We retrospectively investigated the relationship between electrocardiographic signs and the pulmonary/systemic blood flow ratio (Qp/Qs) in these patients. We also compared 63 postoperative electrocardiograms with those recorded before surgery.

RESULTS

The mean Qp/Qs ratio of the 100 patients was 2.46 ± 0.81 (range, 1.1-5.0). The Qp/Qs ratio in patients with and without right bundle branch block (RBBB) was 2.57 ± 0.82 (n = 73) and 2.15 ± 0.72 (n = 27), respectively (P = 0.016). The Qp/Qs ratio in patients with and without isolated negative T-wave was 2.85 ± 0.87 (n = 38) and 2.22 ± 0.68 (n = 62), respectively (P = 0.0003). None of the patients with low Qp/Qs ratio (Qp/Qs ratio ≤ 1.5) had both RBBB and isolated negative T-wave. The prevalence of these two signs decreased from 73.0% (n = 46) and 36.5% (n = 23) to 15.9% (n = 10) and 15.9% (n = 10) after surgical repair, respectively.

CONCLUSIONS

RBBB and isolated negative T-wave in the precordial leads are well correlated with high Qp/Qs ratio in ASD patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Risk of pneumonia in adults with closed versus unclosed atrial septal defect (from a nationwide cohort study)

Atrial septal defect (ASD) is associated with pulmonary hyperperfusion and inflammation and has been linked with increased risk of pneumonia. We investigated the risk of pneumonia in patients with ASD and the impact of ASD closure in a nationwide cohort study. All adults in Denmark (n = 1,168) diagnosed with ASD from 1977 to 2009 were identified through Danish public registries. We compared the risk of hospitalization for pneumonia, use of antibiotics, and mortality with age- and gender-matched general population controls. The median follow-up from time of diagnosis was 9.6 years (range 1 to 33). Cox regression analysis showed that both patients with closed (n = 863) and unclosed (n = 305) ASD had a higher risk of hospitalization for pneumonia (adjusted hazard ratios [HRs] 2.8, 95% confidence interval [CI] 2.3 to 3.5 and 3.1, 95% CI 2.4 to 4.0, respectively) than controls. Patients with ASD also used more antibiotics (adjusted HR for closure 1.4, 95% CI 1.3 to 1.5 and adjusted HR for no closure 1.4, 95% CI 1.2 to 1.6) than the controls. Antibiotic use normalized (adjusted HR 1.1, 95% CI 1.0 to 1.3) and the risk of pneumonia decreased (adjusted HR 1.8, 95% CI 1.1 to 3.0) within 5 years after closure. The proportion of patients with ASD with pneumonia-related death (8.4%) was comparable with that of the general population (9.5%). In conclusion, patients with ASD had a substantially higher risk of hospitalization for pneumonia and used more antibiotics than the general population. The pneumonia risk diminished, but did not completely normalize, 5 years after closure.

Successful percutaneous closure in patients with difficult atrial septal defects: case series and review of literature

Atrial septal defect is a common form of congenital heart disease. Percutenous closure is an important treatment option for these patients. In this case series, we intend to share the percutaneous closure of the difficult types of secundum atrial septal defects.

Mid- to Long-term Results of Surgical Treatment of ASD in Patients over 60 Years Old

BACKGROUND

There is controversy about the benefit of surgical correction of an atrial septal defect (ASD) in patients over 60 years old. The purpose of this study was to determine whether surgical treatment is beneficial in those 60 years of age or older.

MATERIALS AND METHODS

We reviewed the clinical course of 57 patients (mean age: 63.54±5.59 years) diagnosed with an isolated secundum ASD after the age of 60. The 24 patients (group A) who underwent surgical repair were compared with the 33 patients (group B) who were treated non-surgically. The mean follow-up period was 6.8±4.5 years.

RESULTS

One operative death, 5 late deaths (20.8%) in group A, and 9 deaths (27.3%) in group B occurred in the study period. Symptomatic improvement was noted in 18 patients (75%) of group A after surgery. However 13 patients (39.4%) of group B showed symptomatic improvement during the follow-up period (p=0.012). The incidence of new atrial arrhythmia of the two groups was significantly different (16.7% vs 36.7%, p=0.038). The actuarial 10 year survival rate was 79% in group A and 73% in group B.

CONCLUSION

Although surgical correction of ASD did not increase survival in patients over 60 years old, the surgical outcomes of ASD showed low operative mortality and resulted in symptomatic improvement in the majority of these patients. This study has shown the benefits of surgical closure of ASD even in advanced age in comparison to medical treatment.

Benefit of atrial septal defect closure in adults: impact of age

AIMS

To evaluate the effect of age on the clinical benefit of atrial septal defect (ASD) closure in adults.

METHODS AND RESULTS

Functional status, the presence of arrhythmias, right ventricular (RV) remodelling, and pulmonary artery pressure (PAP) were studied in 236 consecutive patients undergoing transcatheter ASD closure [164 females, mean age of 49 ± 18 years, 78 younger than 40 years (Group A), 84 between 40 and 60 years (Group B) and 74 older than 60 years (Group C)]. Defect size [median 22 mm (inter-quartile range, 19, 26 mm)] and shunt ratio [Qp:Qs 2.2 (1.7, 2.9)] did not differ among age groups. Older patients had, however, more advanced symptoms and both, PAP (r = 0.65, P < 0.0001) and RV size (r = 0.28, P < 0.0001), were significantly related to age. Post-interventionally, RV size decreased from 41 ± 7, 43 ± 7, and 45 ± 6 mm to 32 ± 5, 34 ± 5, and 37 ± 5 mm for Groups A, B, and C, respectively (P < 0.0001), and PAP decreased from 31 ± 7, 37 ± 10, and 53 ± 17 mmHg to 26 ± 5, 30 ± 6, and 43 ± 14 mmHg (P < 0.0001), respectively. Absolute changes in RV size (P = 0.80) and PAP (P = 0.24) did not significantly differ among groups. Symptoms were present in 13, 49, and 83% of the patients before and in 3, 11, and 34% after intervention in Groups A, B, and C. Functional status was related to PAP.

CONCLUSIONS

At any age, ASD closure is followed by symptomatic improvement and regression of PAP and RV size. However, the best outcome is achieved in patients with less functional impairment and less elevated PAP. Considering the continuous increase in symptoms, RV remodelling, and PAP with age, ASD closure must be recommended irrespective of symptoms early after diagnosis even in adults of advanced age.

Off-pump coronary artery bypass grafting with device closure of atrial septal defect

Patients with coronary artery disease and atrial septal defect may have unique clinical characters. We describe an off-pump combined approach for intraoperative device closure of atrial septal defect during coronary artery bypass grafting.

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.

Pulmonary arterial hypertension in patients with transcatheter closure of secundum atrial septal defects: a longitudinal study

BACKGROUND

Pulmonary arterial hypertension (PAH) may develop in patients with atrial septal defects (ASD); however, little is known about associated risk factors and its evolution after transcatheter ASD closure.

METHODS AND RESULTS

We conducted a cohort study on 215 adults with attempted transcatheter ASD closure from 1999 to 2006. Patients were classified according to baseline systolic pulmonary artery pressures as having no (I, <40 mm Hg), mild (II, 40 to 49 mm Hg), moderate (III, 50 to 59 mm Hg), or severe (IV, >or=60 mm Hg) PAH. Independent predictors of moderate or severe PAH were older age (odds ratio [OR], 1.10 per year; P<0.0001), larger ASD (OR, 1.13 per millimeter; P=0.0052), female sex (OR, 3.9; P=0.0313), and at least moderate tricuspid regurgitation (OR, 3.6; P=0.0043). At 15 (interquartile range, 8 to 43) months post-ASD closure, patients with higher baseline pressures were more likely to experience a >or=5-mm Hg decrease (33.7%, 73.9%, 79.2%, and 100.0% in groups I to IV, P<0.0001), with a larger magnitude of reduction (0, 8, 17, and 22 mm Hg; P<0.0001). However, normalization of pressures (<40 mm Hg) occurred less frequently in patients with more advanced PAH (90.2%, 71.7%, 66.7%, and 23.5%, P<0.0001). Among patients with moderate or severe PAH, independent predictors of normalization were lower baseline pressures (OR, 0.91 per mm Hg; P=0.0418) and no more than mild tricuspid regurgitation (OR, 0.14; P=0.0420).

CONCLUSIONS

In adults with ASDs, severity of PAH is modulated by age, sex, defect size, and degree of tricuspid regurgitation. Patients with moderate or severe PAH may benefit from substantial reductions in pulmonary artery pressures after transcatheter ASD closure, although the PAH values remain elevated in a sizeable proportion.

The utility of modified Butler-Leggett criteria for right ventricular hypertrophy in detection of clinically significant shunt ratio in ostium secundum-type atrial septal defect in adults

BACKGROUND

This study was performed to test the hypothesis that there exists a correlation between the Butler-Leggett (BL) criterion for right ventricular hypertrophy on the electrocardiogram and the Qp/Qs shunt ratio in adults with ostium secundum atrial septal defects (ASDs).

METHODS

Demographic, cardiac catheterization, ASD closure, and electrocardiographic data were acquired on 70 patients with secundum ASDs closed percutaneously. Simple linear regression and logistic regression models were created to test the hypothesis.

RESULTS

The mean Qp/Qs ratio and BL criterion value were 1.61 +/- 0.46 and 0.11 +/- 0.41, respectively. The BL criterion values correlated with shunt ratios (r(2) = 0.11 and P = .004). A BL criterion value greater than 0 mV predicted a significant shunt ratio (Qp/Qs > or = 1.5) (odds ratio, 4.8; 95% confidence interval, 1.3, 18.1; P = or <.0001) with a sensitivity of 0.68 and specificity of 0.65.

CONCLUSION

Our results indicate that there is limited utility of the BL criterion at detecting right ventricular volume overload, although a BL criterion value greater than 0 mV being used to identify patients with significant intracardiac shunts yielded a sensitivity of 0.68 and specificity of 0.65.

Closure of atrial septal defect with the Amplatzer septal occluder in adults

Transcatheter closure of atrial septal defects (ASDs) was performed mainly in children and adolescents. Information about outcome and complications in adults was limited. From November 1997 to November 2005, percutaneous closure of ASDs using the Amplatzer septal occluder was attempted in 650 consecutive adult patients. Median patient age was 45.8 +/- 16.2 years (range 18 to 90), mean systolic artery pressure was 33.3 +/- 10.6 mm Hg (range 11 to 85), and mean pulmonary and systemic blood flow (Qp/Qs) ratio was 1.9 +/- 0.7 (range 0.8 to 6.6). Mean stretched diameter of the ASD was 21.2 +/- 5.1 mm (range 3.1 to 43). Seventy-eight patients (12%) had multiple defects. Of 572 patients with a single ASD, device implantation was successful in 563 patients (98%). During follow-up, complete closure could be achieved in 96% of patients with a single ASD and 71% of patients with multiple defects. Mean systolic artery pressure decreased to 28.3 +/- 10.1 mm Hg and mean Qp/Qs ratio decreased to 1 +/- 0.3. The 3 complications that occurred during the procedure were device embolization (2 patients; 0.3%) and transient ST depression (1 patient; 0.2%). The most common complication immediately after the procedure and during follow-up was new-onset atrial fibrillation (28 patients; 4.3%). Electrical cardioversion was successfully in most. Complications requiring emergency or elective surgery occurred in 6 patients (0.9%; hemopericardium, 2 patients, 0.3%; device embolization, 3 patients, 0.5%, and pericardial tamponade, 1 patient, 0.2%). In conclusion, closure of ASDs using the Amplatzer septal occluder in adults was efficient and safe, with excellent long-term success rates. Serious complications were rare.

Surgical atrial septal defect closure after interventional occluder placement: Incidence and outcome

OBJECTIVE

Closure of ostium secundum atrial septal defects is generally performed by using an interventional approach. We evaluated the outcome of patients requiring secondary surgical therapy.

METHODS

From September 1996 until December, 2005, 418 patients received interventional and 297 patients underwent surgical closure of an ostium secundum atrial septal defect at our center. Another 15 patients (local, 5; regional, 5; and national, 5 referrals) had complications after occluder placement, and they form the study population.

RESULTS

Indications for surgical repair in these 15 patients were dislocation of the occluder in 5, neurologic events after occluder placement in 5, residual defects in 4, and sepsis with questionable occluder infection in 1 patient. A total of 7 patients had neurologic events, 5 of embolic origin. The interval between interventional occluder placement and definitive surgical repair was 319 +/- 416 days (median 123 days; range 0-1395 days). Patient age at operation was 34.9 +/- 18.6 years. Nine patients were operated on via an anterolateral minithoracotomy, and 6 received a conventional sternotomy. One patient with sepsis underwent abdominal surgery on postoperative day 1 and subsequently died of multiorgan failure; there was no proof of occluder endocarditis. At 2.2 +/- 1.9 years of follow-up, all other patients had returned to full-time work without residual neurologic impairment.

CONCLUSIONS

Complications may arise after interventional ostium secundum atrial septal defect closure. This must be evaluated against the extremely low risk of a standard surgical closure. The functional outcome after secondary surgical ostium secundum atrial septal defect closure with removal of an occluder system is excellent.

Results of the U.S. Multicenter Pivotal Study of the HELEX Septal Occluder for Percutaneous Closure of Secundum Atrial Septal Defects

OBJECTIVES

This study sought to compare the safety and efficacy of the HELEX septal occluder (HSO) with surgical repair of atrial septal defect (ASD).

BACKGROUND

The HSO is a low-profile, double-disk occluder device for percutaneous closure of secundum ASD.

METHODS

Patients were enrolled (HSO arm prospectively, surgery arm prospectively/retrospectively) from 14 U.S. sites and followed up for 12 months postprocedure. Investigator-reported outcomes were evaluated, including closure success (no or clinically insignificant residual shunt) and the incidence of adverse events. The first 3 HSO patients at each site were considered training cases and were excluded from analysis.

RESULTS

Between March 2001 and April 2003, 119 nontraining cases received an HSO and 128 had surgical repair. The groups were similar with statistical but clinically unimportant differences in median age, weight, and preprocedural echocardiographic defect size. Anesthesia time and hospital stay were significantly shorter in the HSO group. Closure success, defined as complete closure or a clinically insignificant residual shunt, was similar in both groups. Major and minor adverse events rates were not statistically different. The most common major adverse events for the HSO group was device embolization requiring catheter retreival (1.7%), and in the surgery group was postpericardiotomy syndrome (6.3%), including one death because of tamponade. The primary end point, clinical success, a composite of closure success and no major adverse events at 12 months, satisfied the noninferiority hypothesis comparing device closure with surgery.

CONCLUSIONS

Closure of ASD with the HELEX septal occluder is safe and effective when compared with surgical repair, with reduced anesthesia time and hospital stay. (U.S. Multicenter Pivotal Study of the HELEX Septal Occluder for Percutaneous Closure of Secundum Atrial Septal Defects; this study was approved by the Food and Drug Administration before the National Institutes of Health website was active, so there is not a URL or registration number.).

Risk factors for prolonged intensive care treatment following atrial septal defect closure in adults

BACKGROUND

Today, percutaneous or surgical closure of atrial septal defects (ASD) in adults are considered effective and safe treatments. However, some cases of severe left ventricular dysfunction after ASD closure were observed. This study aims at identifying predictors for prolonged intensive care unit stay, and postoperative inotropic support after ASD closure.

METHODS

Records of 281 adult patients who had undergone surgical closure of a secundum ASD between 1974 and 2000 at an age over 30 years (mean 43.8, maximum 76 years) were reviewed retrospectively. The endpoints were defined as prolonged intensive care unit stay (>2 days), and postoperative inotropic support (Dopamine, Dobutamine or Adrenalin).

RESULTS

Thirty-day mortality rate was 0.7% (2 patients). Prolonged intensive care unit stay was observed in 70 patients (25%). Postoperative inotropic support was necessary in 84 patients (30%). Independent risk factors for prolonged intensive care unit stay in multivariate analysis were preoperative atrial fibrillation (p=0.011), and larger ASD (p=0.026). Older age at operation (p<0.001) and longer time on extracorporeal circulation (p<0.001) emerged as independent risk factor for postoperative use of inotropic support in multivariate analysis.

CONCLUSIONS

Surgical ASD closure in adults is usually safe. However, a distinct subgroup of patients is at risk for prolonged intensive care treatment. Timely closure of the ASD must be advised since older age emerged as a predictor for postoperative use of inotropic support. Since atrial fibrillation is a strong independent risk factor for prolonged intensive care unit stay the preservation of sinus rhythm must be aimed at.

Transcatheter closure of atrial septal defects in adults > or =40 years of age: immediate and follow-up results

BACKGROUND

Controversy still exists regarding closure of atrial septal defects (ASDs) in patients >40 years of age who are largely asymptomatic or do not have large shunts (LS). If left unrepaired, the majority of patients will experience symptoms and will have a shorter life span compared to patients who undergo repair. This study presents the outcomes of closure of ASDs in adults >40 years using the Amplatzer septal occluder.

METHODS

A total of 113 patients (79F/34M) with a mean age of 57.9 years (SD 11.9) who had indications for closure (right ventricular [RV] enlargement by echocardiograpy, clinically symptomatic) underwent an attempt of transcatheter closure. The mean size of ASD as measured by transesophageal echocardiography (TEE) (30 patients) or intracardiac echocardiography (83 patients) was 17.2 mm (SD 7.3) with mean Qp:Qs of 2.2:1 (SD 1.1). Follow-up at 24 hours, 6 month, and yearly thereafter included physical examination, TEE, and/or transthoracic echocardiography; furthermore, chart review (n = 112) as well as telephone interviews (n = 56) were conducted to determine clinical symptomatic status.

RESULTS

The procedure was successful in 112 patients and 1 patient failed due to the presence of a large defect (44 mm). One hundred four patients had a single device implanted, 7 had two, and 1 had three. Following the procedure, 96 patients had immediate complete closure (CC), 3 had trivial shunt (TS), 11 had small shunt (SS), and 2 had moderate shunt (MS). At 24 hours postprocedure, 100 patients had CC, 7 had TS, 3 had SS, 1 had MS, and 1 had LS. Four patients had complications: one had device migration within 24 hours, two had atrial arrhythmias (supraventricular tachycardia, atrial tachycardia), and one had large hematoma. At 6 months postprocedure, 100 patients had CC, 6 had TS, 5 had SS, and 1 had MS. At 6-month follow-up, the right ventricle end-diastolic dimension decreased from 35.3 mm (SD 7.6) preprocedure to 23.8 mm (SD 6.6) (P < 0.001) and the majority of patients reported improvement in their symptoms.

CONCLUSIONS

ASD closure is safe and effective in patients over 40 years of age with minimal complications. The procedure resulted in a decrease in the RV size that was accompanied by improvement in clinical symptoms. Our findings suggest that device closure of ASDs in adult patients >40 years of age should be the first option of management.

The surgical anatomy and treatment of interatrial communications

Holes permitting shunting between the atrial chambers can take various anatomical forms, varying from the patent oval foramen, which shunts only from right-to-left, to the so-called sinus venosus defect, which is associated with anomalous connection of the pulmonary veins. Our review deals with all forms of interatrial communications, except for the so-called 'primum' defect, since although the lesion produces interatrial shunting of blood, the atrioventricular septal defect with common atrioventricular junction but separate valvar orifices for the right and left ventricles, is strictly an atrioventricular septal defect. In addition, the review illustrates in detail the morphological features of interatrial communications, and describes surgical challenges and approaches.

The right ventricle in congenital heart disease

In patients with congenital heart disease the right ventricle (RV) may support the pulmonary (subpulmonary RV) or the systemic circulation (systemic RV). During the last 50 years evidence is accumulating that RV dysfunction develops in many of these patients and leads to considerable morbidity and mortality. Therefore RV function in certain groups of congenital heart disease patients needs close surveillance and timely and appropriate intervention to optimise outcomes. Despite major progress being made, assessing the RV either in the subpulmonary or the systemic circulation remains challenging, often requiring a multi-imaging approach and expertise (echocardiography, magnetic resonance imaging, nuclear and occasionally invasive assessment with angiography). This review discusses the implications of volume and pressure loading of the RV in the context of congenital heart disease and describes the most relevant imaging modalities for monitoring RV function.

The impact of interventional cardiology for the management of adults with congenital heart defects

The objective of this study is to assess the impact of interventional cardiology procedures for the management of ACHD. The interventional approach to the management of CHD in the adult population is becoming increasingly recognized as the preferred treatment option for a wide number of congenital cardiac conditions. The files of all consecutive patients over 18 years of age who were hospitalized in our department from January 2000 to December 2004 were reviewed. Over the study period, 1,115 ACHD (583 women; mean age 41 +/- 13.8, years, range 18-72 years) were hospitalized in our department; 752 patients underwent cardiac catheterization and 82.4% of them had an interventional procedure carried out. ASD (329/620) and PFO (159/620) closure account for 78% of all the procedures carried out, with a 2.7% of major complications incidence (all of them closing ASDs). Other procedures such as stenting aortic coarctation (40/620), ventricular septal defect closure (33/620), patent ductus arteriosus embolization (30/620), pulmonary valvuloplasty (12/620), stenting pulmonary artery branches (8/620), etc (5/620) were carried out. The most important complication was one death, which occurred in the case of a 22-year-old woman after stent implantation for a recurrent aortic coarctation. A trivial residual shunt was detected in only 5% of the patients who had a 6-month follow-up after VSD closure; no residual shunt was found after PDA embolization during the 12-month follow-up. In conclusion, we believe that the interventional approach is a safe and successful treatment option for a wide number of congenital cardiac conditions. The increasing use of catheter interventions for these patients will be responsible for an increase of complex cases in surgery.

Evaluation of Exercise Capacity with Cardiopulmonary Exercise Testing and Type B Natriuretic Peptide Concentrations in Adult Patients with Patent Atrial Septal Defect

Adults with patent atrial septal defect (ASD) usually find their exercise capacity satisfactory, and therefore hesitate to accept proposed surgical treatment of the heart disease. The aim of our study was to evaluate both the exercise capacity, using the cardio-pulmonary stress test, and brain natriuretic peptide (BNP) levels in asymptomatic adults with ASD. Thirty-six patients with patent secundum type ASD (aged mean 44.7 +/- 8.2 years) were studied. The control group consisted of 25 healthy subjects at the mean age of 45.6 +/- 6.1 years. Echocardiography and CPST were performed and BNP levels measured in all subjects. Oxygen uptake (VO2 max) was lower in ASD patients than in controls (22.1 +/- 5.6 vs. 30.0 +/- 6.8 ml/kg/min, p = 0.00001); the VE/VO2 slope was elevated in ASD patients compared with healthy subjects (31.3 +/- 6.6 vs. 26.9 +/- 3.3, p = 0.001), and exceeded 34 in 5 patients. VO2 max showed a negative correlation with the pulmonary to systemic flow ratio Qp:Qs (r = -0.46, p = 0.004), and a positive correlation was found between the VE/VO2 slope and Qp:Qs (r = 0.32, p = 0.05). BNP levels were higher in the ASD group than in the controls (60.6 +/- 49.9 vs. 32.6 +/- 24.5 pg/ml, p = 0.02). BNP correlated positively with RV diameter and Qp:Qs (r = 0.38 and 0.39 respectively, p = 0.03) and negatively with maximum VO2 (r = -0.5, p = 0.004) and VO2% (r = -0.32, p = 0.07).

CONCLUSIONS

Although most adult patients with ASD perceive their exercise capacity as satisfactory, objective assessment reveals that in fact it is significantly decreased. BNP levels are increased comparing to healthy individuals. Decreased exercise capacity and increased BNP levels seem to result from right ventricular volume overload.

Persistent electrical and morphological atrial abnormalities after early closure of atrial septal defect

Atrial arrhythmias are associated with enlarged atrial chambers and an increased duration of the P wave. Repair of atrial defects within the oval fossa is expected to normalize atrial size. Few studies, however, have evaluated electrical and morphological atrial features after repair. Our study was performed to determine if atrial abnormalities exist after surgical closure of such atrial septal defects, and whether early closure improves outcome. We recruited patients who had undergone surgical closure of a defect within the oval fossa, so-called "secundum" atrial septal defects. Electrocardiograms, signal averaged electrocardiograms, and echocardiograms were performed. Two-tailed test and Pearson correlation was utilized for statistical analysis. The population consisted of 20 patients and 27 controls, with the mean age of the patient being 11.25 +/- 5.10 years, their age at surgery 6.55 +/- 5.10 years, and the time since surgery 4.70 +/- 2.61 years. The size of the right (23.88 +/- 6.35 ml/m2 versus 18.84 +/- 4.43 ml/m2) and left (21.91 +/- 12.47 ml/m2 versus 17.72 +/- 4.83 ml/m2) atrium were significantly larger in the patients. The duration of the P wave (108 +/- 16 ms versus 96 +/- 8 ms) and the duration of the PR interval (155 +/- 18 ms versus 138 +/- 23 ms) were longer. No correlation existed between age or interval since surgery with atrial sizes or measurements of the signal averaged electrocardiogram. We conclude that, despite surgical repair, abnormalities exist in patients with an atrial septal defect. Early surgery does not appear to prevent the atrial abnormalities.

[Percutaneous closure of the inter-auricular communications, well defined indications]

POSSIBLITIES FOR PROGNOSTIC IMPROVEMENT: The inter-auricular communication (IAC) is the most frequent of congential malformations in adults and is responsible for enhanced morbidity and rduction in life expectancy. The closure of an IAC with volumic overload eradicates such morbidity and mortality. The technical progress in the conception of prosthesises that obstrue the interauricular communications via the percutaneous route make this technique a reliable alternative to surgery that, itself, leads to a certain degree of discomfort and considerable morbidity. DEPENDING ON THE ECHOCARDIOGRAPHICAL DATA: The selection of patients is crucial and relies on trans-thoracic echocardiography. It is indicated in isolated ostium secundum-type inter-auricular communications with a border of at least 4 mm separating it from the adjacent structures of the heart; the size on the echocardiography must not exceed 30 mm. FROM A TECHNICAL POINT OF VIEW: The closure is made under fluoroscopic and echocardiographic control via the trans-oesophageal route. It is rapid, simple, and induces a low rate of morbidity. With Amplatz's prosthesis, the percentage of complete closure is equivalent to that obtained with surgery but with less morbidity with regard to arrhythmia. Today the reliable percutaneous closure of an IAC will probably permit the extension of the indications for the closure of this congenital abnormality in adults.

Atrial septal defect in adults > or =40 years old: negative impact of low arterial oxygen saturation

BACKGROUND

Although good prognosis and clinical long-term outcome have been commonly reported in minimally symptomatic adult patients with ASD, this information has been based on studies with a relatively small number of adult patients. We studied unoperated patients aged over 40 years to define the patterns of presentation, anatomical characteristics, outcome and predictive factors for free-event survival of major cardiovascular and pulmonary events.

METHODS AND RESULTS

Two-hundred survivors of atrial septal defect aged over 40-yr attended from 1985 to 1998 were reviewed and followed-up from 1.6 to 22 years. Patients were classified in three groups according to age at entry: Group 1, between 40 and 49; Group 2; 50 and 59; and Group 3, > or =60 years old. The mean age at presentation was 48.8+/-9.2 years, and the most common clinical presentations were arrhythmia and dyspnea (51.4%). There were 37 (18.5%) events: 7 heart failure-related, 5 sudden death, 13 severe pulmonary infections, 5 embolisms, and 4 strokes. According to Cox's regression analysis, predictors of primary end point included age group at presentation (hazard ratio 1.71, 95% confidence limits 1.16 to 2.54), and either pulmonary hypertension (mean pulmonary pressure >35 mmHg; hazard ratio=0.65 (4.6, confidence limits 2.2 to 9.5) or, arterial oxygen saturation <80% (hazard ratio 1.71, 95% confidence limits 1.16 to 2.54).

CONCLUSIONS

This study supports that long term outcome of patients aged >40 years with unoperated ASD is importantly determined by the mPAP (>35 mmHg), SaO2% (_80) and the age at diagnosis. Nevertheless we identified an inverse association between the mPAP level and SaO2% (interaction). The event-free survival expectancy may be estimated using the age at diagnosis and either SaO2% or mPAP. This prognostic stratification based on pathophysiological principles, may help in making decisions for therapeutic interventions. SaO2% should always be measured as a part of the initial clinical approach of those patients with atrial septal defect aged over 40 years.