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

Utility of Follow-Up Echocardiograms in Uncomplicated Surgical Secundum Atrial Septal Defect Closures: Preliminary Analysis

INTRODUCTION

Though less common in the current era, surgical closure of secundum atrial septal defects (ASD2) is still performed in certain clinical situations. Guidelines currently recommend lifelong follow-up with transthoracic echocardiograms (TTE) for patients who have undergone a surgical ASD2 closure. The goal of this study was to determine the utility of follow-up TTE in patients who underwent an uncomplicated ASD2 closure.

METHODS

Chart review was performed on patients who had a surgical ASD2 closure between April 1, 1996, and August 30, 2021. Patients were excluded if they had other congenital heart disease, had a diagnosis of a residual ASD2, atrial/ventricular arrhythmias, pulmonary hypertension, heart failure, or did not have a follow-up TTE > 6 months after the procedure. The most recent TTEs and clinic notes were evaluated.

RESULTS

A total of 30 patients met the criteria. The median age at ASD2 surgery was 4.0 years (IQ; 1.9-10.5). ASD2 was closed via patch repair in 16 patients and primarily closed in 14 patients. The most recent TTE was performed a median of 9.5 years (IQ; 4.0, 14.7) after ASD2 closure. Two patients had mild right atrial and ventricular dilation, one patient had mild right atrial dilation, and one patient had mild right ventricular dilation. All other patients had qualitatively normal right-sided chamber sizes. All patients had normal biventricular function (left ventricular fractional shortening (median 36% (IQ; 33, 42)), no evidence of residual atrial shunts, and no evidence of pulmonary hypertension. No patient was on any cardiac medications at last clinic visit. Four patients were discharged from cardiology clinic and 10 patients were lost to follow-up. There were no deaths. Twenty-four patients had 46 repeat echocardiograms > 1 year after ASD2 with no change in clinical management.

CONCLUSION

In patients who underwent an uncomplicated ASD2 closure, there were no significant abnormalities noted on follow-up TTEs. The need for repeat lifetime TTEs and their frequency, in this uncomplicated population, should be reassessed if larger studies with longer follow-up confirm these initial findings.

Incidence, risk factors and outcomes of acute kidney injury in surgical intensive care unit octogenarians at the Jordan University Hospital

BACKGROUND

Acute kidney damage (AKI) is among the most severe consequences observed in surgical intensive care units (SICUs). We aim to observe the incidence, risk factors, and outcomes of acute kidney injury in SICU octogenarians.

METHODS

A cross-sectional retrospective study was conducted at the SICU of Jordan University Hospital (JUH), a tertiary teaching hospital in a developing country, between January 2018 and December 2019. Patients who were 80 years or older at the time of data collection were included. The definition of AKI was based on Kidney Disease Improving Global Outcomes (KDIGO) criteria. Demographic, clinical, and laboratory data were reviewed.

RESULTS

A total number of 168 patients were included. The mean age was 84.0 ± 3.8 years, and 54.8% of the participants were women. Of those, 115 (68.5%) had surgery before or during ICU stay, and 28.7% of the patients' surgeries were an emergency surgery. Also, 47.8% of surgeries were considered by anesthesia to be high-risk surgeries. A total of 55 patients (32.7%) developed AKI during their SICU stay. The factors that were significantly associated with AKI in the ICU patients included use of beta blocker [AOR: 3.7; 95% CI: 1.2-11.8; p = 0.025], and inotropes [AOR:4.0; 95% CI: 1.2-13.3; p = 0.03]. The factors that were significantly associated with mortality in the ICU included using mechanical ventilation [AOR:18.7; 95% CI: 2.4-141.9; p = 0.005] and inotropes use [AOR: 12.3; 95% CI: 1.2-120.7; p = 0.031].

CONCLUSIONS

The incidence of AKI during SICU stay in this study was 32.7% and it was significantly associated with the use of beta blockers, mechanical ventilation, and inotropes. The mortality rate among octogenarians who developed AKI during SICU stay was 36.4%. Further studies are needed globally to assess the incidence of AKI in octogenarian surgical patients and identify risk factors to provide preventative measurements and strategies.

Functional Echocardiographic and Serum Biomarker Changes Following Surgical and Percutaneous Atrial Septal Defect Closure in Children

Background

Ventricular performance is temporarily reduced following surgical atrial septal defect closure. Cardiopulmonary bypass and changes in loading conditions are considered important factors, but this phenomenon is incompletely understood. We aim to characterize biventricular performance following surgical and percutaneous atrial septal defect closure and to relate biomarkers to ventricular performance following intervention.

Methods and Results

In this multicenter prospective study, children scheduled for surgical or percutaneous atrial septal defect closure were included. Subjects were assessed preoperatively, in the second week postintervention (at 2‐weeks follow‐up), and 1‐year postintervention (1‐year follow‐up). At each time point, an echocardiographic study and a panel of biomarkers were obtained. Sixty‐three patients (median age, 4.1 [interquartile range, 3.1–6.1] years) were included. Forty‐three patients underwent surgery. At 2‐weeks follow‐up, right ventricular global longitudinal strain was decreased for the surgical, but not the percutaneous, group (−17.6±4.1 versus −27.1±3.4; P<0.001). A smaller decrease was noted for left ventricular global longitudinal strain at 2‐weeks follow‐up for the surgical group (surgical versus percutaneous, −18.6±3.2 versus −20.2±2.4; P=0.040). At 1‐year follow‐up, left ventricular performance returned to baseline, whereas right ventricular performance improved, but did not reach preintervention levels. Eight biomarkers relating to cardiovascular and immunological processes differed across study time points. Of these biomarkers, only NT‐proBNP (N‐terminal pro‐B‐type natriuretic peptide) correlated with less favorable left ventricular global longitudinal strain at 2‐weeks follow‐up.

Conclusions

Right, and to a lesser degree left, ventricular performance was reduced early after surgical atrial septal defect closure. Right ventricular performance at 1‐year follow‐up remained below baseline levels. Several biomarkers showed a pattern over time similar to ventricular performance. These biomarkers may provide insight into the processes that affect ventricular function.

Registration

URL: https://www.trialregister.nl/; Unique identifier: NL5129

Transcatheter versus surgical closure of atrial septal defect in adult patients with tricuspid regurgitation

OBJECTIVES

Transcatheter closure using a device has been established as an effective atrial septal defect (ASD) treatment, but its value in treating patients with concomitant functional tricuspid regurgitation (TR) is relatively unknown. We sought to evaluate outcomes of patients with ASD and significant TR after transcatheter ASD closure or surgical treatment.

METHODS

A total of 252 consecutive adult patients (53.8±13.8 years, 180 females) who had a significant functional TR before ASD closure were retrospectively analysed. The primary end point was a composite of all-cause death, stroke and heart failure. The secondary end point was significant residual TR early and at 1 year after ASD closure.

RESULTS

Transcatheter ASD closure alone and surgical ASD closure along with tricuspid annuloplasty (TAP) were performed in 68 and 184 patients, respectively. Significant TR remained in 32% (81/252) early after ASD closure and in 29% (52/182) after 1 year. The severity of TR was significantly decreased after transcatheter ASD closure (p<0.001). In multivariable analysis, TAP (OR 0.07; p<0.001) and ASD diameter (OR 0.90; p=0.040) were independent predictors of the significant residual TR early after treatment, while only TAP (OR 0.08; p<0.001) was a significant predictor at 1 year after treatment. After propensity score matching in patients with moderate or severe TR, there were no significant differences between the transcatheter ASD closure group and surgical ASD closure plus TAP group in terms of the event rates at 5 years (10.3% vs 5.5%, p=0.963).

CONCLUSIONS

While TAP was effective for the treatment of significant TR, transcatheter ASD closure also significantly reduced TR as well. Transcatheter ASD closure may be considered an alternative treatment option in patients with moderate or severe TR.

Assessment of Device Neoendothelialization With Cardiac Computed Tomography Angiography After Transcatheter Closure of Atrial Septal Defect

Although the transcatheter closure of atrial septal defect was established as the treatment of choice several decades ago, the process of device neoendothelialization (NE) in humans is not well understood. We aimed to measure the extent of device NE using cardiac computed tomography angiography and analyze its risk factors.

Pre-clinical Evolution of a Novel Transcatheter Bioabsorbable ASD/PFO Occluder Device

To date, there has been limited investigation of bioabsorbable atrial septal defect (ASD) or patent foramen ovale (PFO) closure devices using clinically relevant large animal models. The purpose of this study is to explore the function and safety of a bioabsorbable ASD occluder (BAO) system for PFO and/or secundum ASD transcatheter closure. Using a sheep model, the intra-atrial septum was evaluated by intracardiac echo (ICE). If a PFO was not present, atrial communication was created via transseptal puncture. Device implantation across the intra-atrial communication was performed with fluoroscopic and ICE guidance. Our 1st generation device consisted of a main structure of thin Poly(L-lactide-co-epsilon-caprolactone) (PLCL) fibers, and an internal Poly glycolic acid (PGA) fabric. Four procedures validated procedure feasibility. Subsequently, device design was modified for improved transcatheter delivery. The 2nd generation device has a two-layered structure and was implanted in six sheep. Results showed procedural success in 9/10 (90%) animals. With deployment, the 1st generation device did not reform into its original disk shape and did not conform nicely along the atrial septum. The 2nd generation device was implanted in six animals, 3 out of 6 survived out to 1 year. At 1 year post implantation, ICE confirmed no residual shunting. By necropsy, biomaterials had partially degraded, and histology of explanted samples revealed significant device endothelialization and biomaterial replacement with a collagen layer. Our results demonstrate that our modified 2nd generation BAO can be deployed via minimally invasive percutaneous transcatheter techniques. The BAO partially degrades over 1 year and is replaced by host native tissues. Future studies are needed prior to clinical trials.

Transcatheter versus surgical closure of atrial septal defects: a systematic review and meta-analysis of clinical outcomes

BACKGROUND

Atrial septal defects are a common form of CHD and dependent on the size and nature of atrial septal defects, closure may be warranted. The paper aims to compare outcomes of transcatheter versus surgical repair of atrial septal defects.

METHODS

A comprehensive electronic literature search was conducted. Primary studies were included if they compared both closure techniques. Primary outcomes included procedural success, mortality, and reintervention rate. Secondary outcomes included residual defect and mean hospital stay.

RESULTS

A total of 33 studies were included in meta-analysis. Mean total hospital stay was significantly shorter in the transcatheter cohort across both the adult (95% confidence interval, mean difference -4.05 (-4.78, -3.32) p < 0.00001) and paediatric populations (95% confidence interval, mean difference -4.78 (-5.97, -3.60) p < 0.00001). There were significantly fewer complications in the transcatheter group across both the adult (odds ratio 0.45, 95% confidence interval, [0.28, 0.72], p < 0.00001) and paediatric cohorts (odds ratio 0.26, 95% confidence interval, [0.14, 0.49], p < 0.00001). No significant difference in overall mortality was found between transcatheter versus surgical closure across the two groups, adult (odds ratio 0.76, 95% confidence interval, [0.40, 1.45], p = 0.41), paediatrics (odds ratio 0.62, 95% confidence interval, [0.21, 1.83], p = 0.39).

CONCLUSION

Both transcatheter and surgical approaches are safe and effective techniques for atrial septal defect closure. Our study has demonstrated the benefits of transcatheter closure in terms of lower complication rates and mean hospital stay. However, surgery still has a place for more complex closure and, as we have demonstrated, shows no difference in mortality.

Angioscopic Evaluation of Atrial Septal Defect Closure Device Neo-Endothelialization

Background

Current guidelines recommend at least 6 months of antithrombotic therapy and antibiotic prophylaxis after septal‐occluding device deployment in transcatheter closure of atrial septal defect. It has been estimated that it takes ≈6 months for complete neo‐endothelialization; however, neo‐endothelialization has not previously been assessed in vivo in humans.

Methods and Results

The neointimal coverage of septal occluder devices was evaluated 6 months after implantation in 15 patients by angioscopy from the right atrium. Each occluder surface was divided into 9 areas; the levels of endothelialization in each area were semiquantitatively assessed by 4‐point grades. Device neo‐endothelialization was sufficient in two thirds of patients, but insufficient in one third. In the comparison between patients with sufficiently endothelialized devices of average grade score ≥2 (good endothelialization group, n=10) and those with poorly endothelialized devices of average grade score <2 (poor endothelialization group, n=5), those in the poor endothelialization group had larger devices deployed (27.0 mm [25.0–31.5 mm] versus 17.0 mm [15.6–22.5 mm], respectively) and progressive right heart dilatation. The endothelialization was poorer around the central areas. Moreover, the prevalence of thrombus formation on the devices was higher in the poorly endothelialized areas than in the sufficiently endothelialized areas (Grade 0, 94.1%; Grade 1, 63.2%; Grade 2, 0%; Grade 3, 1.6%).

Conclusions

Neo‐endothelialization on the closure devices varied 6 months after implantation. Notably, poor endothelialization and thrombus attachment were observed around the central areas and on the larger devices.

Transcatheter Device Closure of Secundum Atrial Septal Defect in Adult Patient

Background:

Atrial septal abnormalities are common congenital lesions remaining asymptomatic until adulthood in a great number of patients. The most frequent atrial septal defects in adults are ostium secundum atrial septal defect (ASD). Complications from untreated, hemodynamically significant ASD are atrial arrhythmia, paradoxical embolization, Eisenmenger’s syndrome, pulmonary hypertension, and right ventricular failure.

Objective:

We present a case report of secundum ASD in adult female patient who underwent transcatheter device closure with Amplatzer occluder.

Methods and Results:

The case of female Bosnian patient 50 years old who lives in Belgium for 20 years ago and during her visit to Bosnia she came to our polyclinic for cardiological exam. Echocardiographic exam showed enlargement of left atrium (LAD 51mm), right atrium and ventricle (RAD 46mm, RVd 33mm), atrial septal defect 9mm with left right shunt Qp:Qs 2,3:1. Several months later transcatheter device closure with Amplatzer occluder was performed and subsequent symptomatic improvement reported after closure.

Conclusion:

Echocardiography has superior role for precise evaluation of ASD type secundum who are suitable for transcatheter device closure as primary treatment option. Transcatheter techniques has now become preferable to surgical repair and provide valid option of treatment for this type of CHD.

Secundum atrial septal defects transcatheter closure versus surgery in adulthood: a 2000-2020 systematic review and meta-analysis of intrahospital outcomes

INTRODUCTION

Technologically, advances in both transcatheter and surgical techniques have been continuing in the past 20 years, but an updated comprehensive comparison in device-based versus surgery in adults in terms of incidence of in-hospital mortality, perioperative stroke, and atrial fibrillation onset is still lacking. We investigate the performance of transcatheter device-based closure compared to surgical techniques by a systematic review and meta-analysis of the last 20 years literature data.

MATERIAL AND METHODS

The analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Literature search was performed based on Cochrane Library, Embase, PubMed, and Google Scholar to locate articles published between January 2000 and October 2020, regarding the comparison between short-term outcome and post-procedural complications of atrial septal defect patients receiving transcatheter or surgical closure. The primary outcome was the comparison of in-hospital mortality from all causes between patients treated with transcatheter closure or cardiac. Secondary outcomes were the onset of post-procedural atrial fibrillation or perioperative stroke.

RESULTS

A total of 2360 patients were included of which 1393 [mean age 47.6 years, 952 females (68.3%)] and 967 [mean age 40.3 years, 693 females (71.6%)] received a transcatheter device-based and surgery closure, respectively. In-hospital mortality [OR 0.16 (95% CI (0.66-0.44)), p = 0.0003, I2 = 0%], perioperative stroke [OR 0.51 (95% CI (0.31-0.84)), p = 0.003, I2 = 79%], and post-procedural atrial fibrillation [OR 0.14 (95% CI (0.03-0.61)), p = 0.009, I2 = 0%] significantly favoured transcatheter device-based closure.

CONCLUSION

Transcatheter atrial septal defect closure resulted safer in terms of in-hospital mortality, perioperative stroke, and post-procedural atrial fibrillation compared to traditional surgery.

Time Course of Ventricular Remodeling after Atrial Septal Defect Closure in Adult Patients

Background

Atrial septal defect (ASD) is the most common congenital heart disease. However, the details of cardiac chamber remodeling after surgery are not well known, although this is an important issue that should be analyzed to understand long-term outcomes.

Methods

Between November 2017 and January 2019, cardiac magnetic resonance imaging was performed preoperatively, at a 1-month postoperative follow-up, and at a 1-year postoperative follow-up. Cardiac chamber volume, valve regurgitation volume, and ejection fraction were measured as functions of time.

Results

Thirteen patients (10 men and 3 women) were included. The median age at surgery was 51.4 years. The preoperative median ratio of flow in the pulmonary and systemic circulation was 2.3. The preoperative mean right ventricular (RV) end-diastolic volume index (EDVi) and RV end-systolic volume index (ESVi) had significantly decreased at the 1-month postoperative follow-up (p<0.001, p=0.001, respectively). The decrease in the RVEDVi (p=0.085) and RVESVi (p=0.023) continued until the postoperative 1-year follow-up, although the rate of decrease was slower. Tricuspid valve regurgitation had also decreased at the 1-month postoperative follow-up (p=0.022), and continued to decrease at a reduced rate (p=0.129). Although the RVEDVi and RVESVi improved after ASD closure, the RV volume parameters were still larger than the left ventricular (LV) volume parameters at the 1-year follow-up (RVEDVi vs. LVEDVi p=0.016; RVESVi vs. LVESVi p=0.001).

Conclusion

Cardiac remodeling after ASD closure is common and mainly occurs in the early postoperative period. However, complete normalization does not occur.

Long-Term Outcome After Transcatheter Atrial Septal Defect Closure in Adults: A Systematic Review and Meta-Analysis

AIMS

We performed a systematic review and meta-analysis of published studies to characterize the current literature and help determine the long-term outcomes after transcatheter ASD closure in adults.

METHODS AND RESULTS

Two investigators searched the manuscript databases for all eligible studies in accordance with the considered keywords. The pooled prevalence of each event according to the meta-analysis and considering the weight calculated for each study included 10.1% (for arrhythmia), 1.8% (for emboli), 2.3% (for stroke), 12.5% (for residual shunt), 1.8% (for erosion), and 2.5% (for death).

CONCLUSION

The present meta-analysis show high long-term successfulness of transcatheter ASD closure in adults.

Diagnosis and treatment of adults with congenital heart disease

Approximately 50 million adults worldwide have known congenital heart disease (CHD). Among the most common types of CHD defects in adults are atrial septal defects and ventricular septal defects followed by complex congenital heart lesions such as tetralogy of Fallot. Adults with CHDs are more likely to have hypertension, cerebral vascular disease, diabetes and chronic kidney disease than age-matched controls without CHD. Moreover, by the age of 50, adults with CHD are at a greater than 10% risk of experiencing cardiac dysrhythmias and approximately 4% experience sudden death. Consequently, adults with CHD require healthcare that is two- to four-times greater than adults without CHD. This paper discusses the diagnosis and treatment of adults with atrial septal defects, ventricular septal defects and tetralogy of Fallot.

Atrial tachyarrhythmias following percutaneous device closure of secundum atrial septal defects

Background

Atrial tachyarrhythmias (ATs) are a major source of morbidity in the atrial septal defect (ASD) patient cohort. The optimal timing and approach of anti-arrhythmic intervention is currently unclear. Here, we sought to determine the overall rate of ATs following percutaneous ASD closure and risk factors that may predict this.

Methods

A systematic search of the literature was performed using the search terms '(Secundum Atrial Septal Defects AND Atrial arrhythmias) AND (transcatheter closure or percutaneous closure or device closure)'. All studies in English reporting the rate of ATs following percutaneous closure of secundum ASDs in adult patients were included. The primary outcome was documented AT detection during follow-up ECG monitoring. A meta-regression was then performed to test for an interaction between demographic/procedural characteristics and the primary outcome.

Results

13 observational studies including 2366 patients were analysed. The overall post-procedure AT event detection rate was 8.6%. Multivariate meta-regression analysis revealed that only male gender was associated with a higher rate of post-procedure AT detection while utilisation of the Amplatzer Septal Occluder device was associated with a lower AT detection rate and comprised 96.2% of all devices used. A high level of heterogeneity was observed (I²-statistic 92.3%, Q value 156.8).

Conclusions

Our study illustrates that despite percutaneous ASD closure, a high proportion of adult patients have ATs with male gender correlating with higher AT rates. While the Amplatzer Septal Occluder device correlated with lower AT rates, this was the overwhelmingly the predominant device used hence comparison to other devices remains challenging.

Transcatheter closure vs totally endoscopic robotic surgery for atrial septal defect closure: A single-center experience

BACKGROUND

Transcatheter closure is the preferred method for atrial septal defect (ASD) closure. Robotic surgery has become the least invasive technique for ASD closure. Therefore, we sought to evaluate the outcomes in patients who underwent ASD closure with transcatheter or robotic surgery techniques.

METHODS

A total of 462 patients underwent totally endoscopic robotic (n = 217) or transcatheter ASD closure (n = 245). Demographic data, perioperative data, and outcomes were compared.

RESULTS

The mean age was lower in the robotic surgery group than the transcatheter group (31.4 ± 11.8 vs 39.4 ± 13.2 years; P = .001). Ventilation time, intensive care unit (ICU) stay, and hospital stay was significantly lower in the transcatheter group. The postoperative new-onset neurological event was seen in one (0.5%) patient in robotic surgery, and four (1.6%) patients in the transcatheter closure group. New-onset atrial fibrillation was found to be higher in transcatheter closure (two vs seven patients; P = .133) group. Surgical conversion to a larger incision occurred in two patients (1%) in robotic surgery, while two patients (0.5%) underwent emergency median sternotomy due to device embolization to the main pulmonary artery. There was no mortality in both groups. During follow-up, one patient (0.5%) who underwent robotic surgery was reoperated, and two patients (0.8%) who underwent transcatheter procedure required surgical intervention due to device migration and severe residual shunting (P = .635).

CONCLUSION

Both transcatheter and robotic surgery approaches had excellent outcomes but transcatheter closure had shorter hospital and ICU stays. Robotic surgery provides a similar complication risk that can be comparable to the transcatheter approach as well as patient comfort and cosmetic advantage over the other surgical techniques.

Biodegradable atrial septal defect occluders: A current review

Atrial septal defect (ASD) is a common structural congenital heart disease. With the development of interventional closure devices and transcatheter techniques, interventional closure therapy has become the most well-accepted therapeutic alternative worldwide, as it offers a number of advantages over conventional therapies such as improved safety, easier operation, lower complication rates and invasiveness, and shorter anesthetic time and hospitalizations. During the past decades, various types of occluders based on nondegradable shape memory alloys have been used in clinical applications. Considering that the permanent existence of foreign nondegradable materials in vivo can cause many potential complications in the long term, the research and development of biodegradable occluders has emerged as a crucial issue for interventional treatment of ASD. This review aims to summarize partially or fully biodegradable occlusion devices currently reported in the literature from the aspects of design, construction, and evaluation of animal experiments. Furthermore, a comparison is made on the advantages and disadvantages of the materials used in biodegradable ASD occlusion devices, followed by an analysis of the problems and limitations of the occlusion devices. Finally, several strategies are proposed for future development of biodegradable cardiac septal defect occlusion devices. STATEMENT OF SIGNIFICANCE: Although occlusion devices based on nondegradable alloys have been widely used in clinical applications and saved numerouspatients, biodegradable occlusion devices may offer some advantages such as fewer complications, acceptable biocompatibility, and particularly temporary existence, thereby leaving "native" tissue behind, which will certainly become the development trend in the long term. This review summarizes almost all partially or fully biodegradable occlusion devices currently reported in the literature from the aspects of design, construction, and evaluation of animal experiments. Furthermore, a comparison is made on the advantages and disadvantages of the materials used in biodegradable ASD occlusion devices, followed by an analysis of the problems and limitations of the occlusion devices. Finally, several strategies are proposed for future development of biodegradable cardiac septal defect occlusion devices.

Transcatheter closure of atrial septal defect in adults: time-course of atrial and ventricular remodeling and effects on exercise capacity

Investigate ventricular and atrial remodeling following atrial septal defect (ASD) closure and examine if pulmonary-to-systemic flow ratio (QP/QS) and right ventricular (RV) volume predict improvement, determined as percentage of predicted oxygen uptake (VO₂%). Long-term cardiovascular magnetic resonance (CMR) data on atrial and ventricular remodeling after ASD-closure is limited and treatment effect on exercise capacity is debated. Sixteen patients undergoing transcatheter ASD closure and 16 age and sexmatched controls were studied. CMR was performed before treatment, the day after and 3 and 12 months later. Exercise test with gas analysis was performed before and 12 months after treatment. QP/QS decreased from 2.1 ± 0.5 to 1.4 ± 0.3 at day 1 and 1.1 ± 0.1 at 3 and 12 months. Left ventricular (LV) volumes increased and normalized on day 1 whereas left atrial volumes were unchanged. RV and right atrial volumes decreased the first 3 months. LV and RV volumes had not equalized at 12 months (RV/LV ratio 1.2 ± 0.1, P < 0.01) and RV ejection fraction remained decreased compared to controls. Improvement of VO₂% after ASD closure (P < 0.01) was inversely related to QP/QS at rest (r = - 0.56, P < 0.05) but unrelated to RV end-diastolic volume (P = 0.16). Following transcatheter ASD closure, LV adaptation is rapid and RV adaptation is prolonged, with decreased systolic RV function. Patients with smaller shunts had larger improvement in VO₂% suggesting patients with defects of borderline hemodynamic significance might benefit from closure. This may be due to impaired LV diastolic function influencing shunt size and exercise capacity following ASD closure.

Strategy of treating secundum atrial septal defect not referred to percutaneous closure

OBJECTIVE

To evaluate safety and effectiveness of intraoperative device closure for secundum atrial septal defect (ASD) not referred to percutaneous closure.

DESIGN AND PATIENTS

From April 2010 to December 2018, 231 secundum ASD children (≤14 years) directly recommended to surgical repair were enrolled in this study. These patients were divided into two groups according to the parents' choice based on surgeons' recommendation. Follow-up evaluations were adopted at 2 weeks, 3 months, 6 months, and 12 months after the procedure and yearly thereafter. In Group A, 127 patients underwent an initial attempt at device closure. In Group B, 104 patients underwent a repair procedure under cardiopulmonary bypass.

RESULTS

All patients survived. Group A had lower values of operation time, mechanical ventilation time, cardiac intensive care unit duration and amount of blood transfusion. Nevertheless, postoperative hospitalization time between two groups showed no statistical difference. In group A, 109 (85.83%) patients were successfully occluded, whereas 18 (14.17%) patients were converted to open-heart surgery. No severe complications occurred in the follow-up period.

CONCLUSION

Intraoperative device closure is safe, effective procedure for selected cases with secundum ASDs which were not referred to percutaneous closure because of more suitable occluder selection, no "unbutton effect" and stitching enhancement.

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

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

Long term evaluation of electromechanical delay in patients with atrial septal defect after transcatheter closure

Some studies have been showed that electromechanical delay, which may pose an increased tendency to atrial fibrillation, may prolong in patients with various clinical conditions. In addition, the electromechanical delay in patients with secundum type atrial septal defect (ASD) compared to healthy people have been reported previously. Therefore, in the present study, we prospectively evaluated the mid-term and long-term effects of the transcatheter closure of secundum type ASD on the lateral atrial conduction time (PA), septal PA, tricuspid PA, left and right intra-atrial electromechanical delay (ILeft-EMD and IRight-EMD, respectively) and inter-atrial electromechanical delay (IA-EMD) measured by means of Doppler echocardiography. Our prospective study included a total of 45 secundum type ASD patients who undergone percutaneous transcatheter closure from December 2012 to April 2015. All patients underwent transthoracic echocardiography (TTE) before the closure, at sixth and twelfth months after the closure. In comparison of the EMD sixth months after the device closure, there were statistically significant decrease in lateral PA, septal PA, tricuspid PA, ILeft-EMD, IRight-EMD and IA-EMD compared to pre-device closure values. Twelfth months after the device closure, we also observed statistically significant decrease in lateral PA, septal PA, tricuspid PA, ILeft-EMD, IRight-EMD and IA-EMD compared to 6-month post-device closure values. In the present study, we observed that the atrial EMD improves after device closure and continues to improve after twelfth month following post-device closure.

Closure of Secundum Atrial Septal Defects With the AMPLATZER Septal Occluder: A Prospective, Multicenter, Post-Approval Study

Background—

Prospective data on the medium-term safety and effectiveness of the AMPLATZER Septal Occluder in clinical practice are not available. The objective of this study was to prospectively evaluate the risk of hemodynamic compromise and obtain medium-term survival data on patients implanted with the AMPLATZER Septal Occluder for percutaneous closure of secundum atrial septal defects.

Methods and Results—

Subjects were enrolled prospectively at 50 US sites and followed for 2 years. Between 2008 and 2012, atrial septal defect closure with the AMPLATZER Septal Occluder was attempted in 1000 patients (aged 0.3–83.6 years, mean 21±22 years). Procedural closure occurred in 97.9%, with 1-month and 2-year closure 98.5% and 97.9%, respectively. Hemodynamic compromise occurred in 6 subjects (0.65%), because of dysrhythmia in 2, device embolization in 1, and cardiac erosion in 3. The rate of cardiac erosion was 0.3% (average 83, range 12–171 days from implant).

Conclusions—

Closure of atrial septal defect with the AMPLATZER Septal Occluder is safe and effective. The rate of hemodynamic compromise and cardiac erosion is rare. The risk factors for cardiac erosion after device closure are not yet clear.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00650936.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Lower Hospital Charges and Societal Costs for Catheter Device Closure of Atrial Septal Defects

Atrial septal defects (ASD) are among the most common congenital heart defects. As more ASDs are corrected by interventional catheterization instead of surgery, it is critical to understand the associated clinical and societal costs. The goal of this study was to use a national U.S. database to describe hospital charges and societal costs for surgical and catheter-based (ASD) closure. Retrospective review of hospital discharge data from the Kids' Inpatient Database from January 2010 to December 2012. The database was queried for admissions for <21 years old with ICD-9 procedure codes for surgical (35.51 or 35.61) or catheter (35.52) ASD closure; those with other cardiac conditions and/or additional cardiac procedures were excluded. Age, length of stay (LOS), and hospital charges and lost parental wages (societal costs) were compared between groups using t test or Mann-Whitney U test, as appropriate. Four hundred and eighty-six surgical and 305 catheter ASD closures were identified. LOS, hospital charges, and total societal costs were higher in surgical ASD compared to catheter ASD admissions (3.6 vs. 1.3 days, p < 0.001, $87,465 vs. $64,109, p < 0.001, and $90,000 vs. $64,966, p < 0.001, respectively). In this review of a large national inpatient database, we found that hospital and societal costs for surgical ASD closure are significantly higher than catheter ASD closure in the United States in the current era. Factors that likely contribute to this include longer LOS and longer post-operative recovery. Using "real-world" data, this study demonstrates a substantial cost advantage for catheter ASD closure compared to surgical.

Increasing propensity to pursue operative closure of atrial septal defects following changes in the instructions for use of the Amplatzer Septal Occluder device: An observational study using data from the Pediatric Health Information Systems database

Concern for device erosion following transcatheter treatment of atrial septal defects (TC-ASD) led in 2012 to a United States Food and Drug Administration panel review and changes in the instructions for use of the Amplatzer Septal Occluder (ASO) device. No studies have assessed the effect of these changes on real-world practice. To this end a multicenter observational study was performed to evaluate trends in the treatment of ASD.

METHODS

A retrospective observational study was performed using data from the Pediatric Health Information Systems database of all patients with isolated ASD undergoing either TC-ASD or operative ASD closure (O-ASD) from January 1, 2007, to September 30, 2015, hypothesizing that the propensity to pursue O-ASD increased beginning in 2013.

RESULTS

A total of 6,392 cases from 39 centers underwent ASD closure (82% TC-ASD). Adjusting for patient factors, between 2007 and 2012, the probability of pursuing O-ASD decreased (odds ratio [OR] 0.95 per year, P = .03). This trend reversed beginning in 2013, with the probability of O-ASD increasing annually (OR 1.21, P = .006). There was significant between-hospital variation in the choice between TC-ASD and O-ASD (median OR 2.79, P < .0001). The age of patients undergoing ASD closure (regardless of method) decreased over the study period (P = .04). Cost of O-ASD increased over the study period, whereas cost of TC-ASD and length of stay for both O-ASD and TC-ASD was unchanged.

CONCLUSIONS

Although TC-ASD remains the predominant method of ASD closure, the propensity to pursue O-ASD has increased significantly following changes in instructions for use for ASO. Further research is necessary to determine what effect this has on outcomes and resource utilization.

Supraventricular Arrhythmias in Patients with Adult Congenital Heart Disease

An increasing number of patients with congenital heart disease survive to adulthood; such prolonged survival is related to a rapid evolution of successful surgical repairs and modern diagnostic techniques. Despite these improvements, corrective atrial incisions performed at surgery still lead to subsequent myocardial scarring harbouring a potential substrate for macro-reentrant atrial tachycardia. Macroreentrant atrial tachycardias are the most common (75 %) type of supraventricular tachycardia (SVT) in patients with adult congenital heart disease (ACHD). Patients with ACHD, atrial tachycardias and impaired ventricular function - important risk factors for sudden cardiac death (SCD) - have a 2-9 % SCD risk per decade. Moreover, ACHD imposes certain considerations when choosing antiarrhythmic drugs from a safety aspect and also when considering catheter ablation procedures related to the inherent cardiac anatomical barriers and required expertise. Expert recommendations for physicians managing these patients are therefore mandatory. This review summarises current evidence-based developments in the field, focusing on advances in and general recommendations for the management of ACHD, including the recently published recommendations on management of SVT by the European Heart Rhythm Association.

Infective endocarditis after device closure of atrial septal defects: Case report and review of the literature

We report a case of late infective endocarditis in an 8-year-old boy 3 years after transcatheter closure of an atrial septal defect with the Amplatzer Atrial Septal Occluder Device. Echocardiography showed a very thick pannus lining the left atrial disc of the prosthesis, with some mobile elements. MRI showed several cerebral microemboli. The patient had dental caries and blood cultures found Staphylococcus aureus. Patient was treated with gentamicin and oxacillin before surgical removal of the prosthesis. Twenty-one cases of infective endocarditis after atrial defect device closure have been reported in the literature (13 ostium secundum ASD and 8 patent foramen ovale). Seven pediatric cases were reported. S. aureus was the most frequent bacterium. Antibiotics were administered in all cases and most patients (n = 18) underwent surgical removal of the device. Incomplete endothelialization of the prosthesis was a suggested mechanism. Two patients died after surgery. © 2016 Wiley Periodicals, Inc.

Contributors to and impact of residual shunting after device closure of atrial septal defects

BACKGROUND

The prevalence of residual shunt in patients after device closure of atrial septal defect and its impact on long-term outcome has not been previously defined.

METHODS

From a prospective, single-institution registry of 408 patients, we selected individuals with agitated saline studies performed 1 year after closure. Baseline echocardiographic, invasive hemodynamic, and comorbidity data were compared to identify contributors to residual shunt. Survival was determined by review of the medical records and the Social Security Death Index. Survival analysis according to shunt included construction of Kaplan-Meier curves and Cox proportional hazards modeling.

RESULTS

Among 213 analyzed patients, 27% were men and age at repair was 47 ± 17 years. Thirty patients (14%) had residual shunt at 1 year. Residual shunt was more common with Helex (22%) and CardioSEAL/STARFlex (40%) occluder devices than Amplatzer devices (9%; P = .005). Residual shunts were more common in whites (79% vs 46%, P = .004). At 7.3 ± 3.3 years of follow-up, 13 (6%) of patients had died, including 8 (5%) with Amplatzer, 5 (25%) with CardioSEAL/STARFlex, and 0 with Helex devices. Patients with residual shunting had a higher hazard of death (20% vs 4%, P = .001; hazard ratio 4.95 [1.59-14.90]). In an exploratory multivariable analysis, residual shunting, age, hypertension, coronary artery disease, and diastolic dysfunction were associated with death.

CONCLUSIONS

Residual shunt after atrial septal defect device closure is common and adversely impacts long-term survival.

The Changing Epidemiology of Pediatric Endocarditis

The epidemiology of infective endocarditis (IE) appears to be related to changes in the management of children with congenital heart disease (CHD) and the virtual disappearance of rheumatic heart disease. To better understand these changes, we divide the history into: I. The pre-surgical era, II. The early years of CHD surgical intervention, correlated with introduction of antibiotics, III. The modern era of cardiac interventions. Microbiologic changes include an early predominance of viridans streptococci and an overtaking by staphylococci. Additionally, there have been advances in imaging that allow earlier detection of IE and a reduction in IE-related mortality.

The influence of deficient retro-aortic rim on technical success and early adverse events following device closure of secundum atrial septal defects: An Analysis of the IMPACT Registry®

BACKGROUND

Concern regarding aortic erosion has focused attention on the retro-aortic rim in patients undergoing device closure of atrial septal defects (ASD), but its effect on early outcomes is not well studied.

METHODS

A multicenter retrospective cohort study of patients undergoing device occlusion of ASD between 1/2011-10/2014 was performed, using data from the IMproving Pediatric and Adult Congenital Treatment Registry. Subjects were divided between those with retro-aortic rim <5 and ≥5 mm. Primary outcomes were technical failure and major early adverse events. Case times were measured as surrogates of technical complexity. The effect of deficient retro-aortic rim on primary outcomes was assessed using hierarchical logistic regression, adjusting for other suspected covariates and assessing whether they represent independent risk factors RESULTS: 1,564 subjects (from 77 centers) were included, with deficient retro-aortic rim present in 40%. Technical failure occurred in 91 subjects (5.8%) and a major early adverse event in 64 subjects (4.1%). Adjusting for known covariates, the presence of a deficient retro-aortic rim was not significantly associated with technical failure (OR: 1.3, 95% CI: 0.9-2.1) or major early adverse event (OR: 0.7, 95% CI: 0.4-1. 2). Total case (P = 0.01) and fluoroscopy time (P = 0.02) were greater in subjects with deficient rim, but sheath time was not significantly different (P = 0.07). Additional covariates independently associated with these outcomes were identified.

CONCLUSION

Deficient retro-aortic rim was highly prevalent but not associated with increased risk of technical failure or early adverse events. Studies with longer follow-up are necessary to assess other outcomes, including device erosion. © 2016 Wiley Periodicals, Inc.

Transcatheter Closure of Atrial Septal Defects using the GORE(®) Septal Occluder in Children Less Than 10 kg of Body Weight

The GORE(®) Septal Occluder (GSO) is a well-evaluated device for interventional ASD closure with closure rates comparable to the Amplatzer(®) Septal Occluder (ASO), but there are no published reports of its use in small children weighing less than 10 kg. This may be due to the necessity of a large-sized introducing sheath of at least 10 Fr and therefore the assumed risk of complications in vascular access. The GSO is an alternative option for interventional ASD closure in children weighing less than 10 kg. Fourteen infants and children with a median body weight 8900 g (range 6350-9650 g) underwent successful ASD closure using the GSO. The closure was performed under fluoroscopic and transthoracic echocardiographic guidance. Postprocedure, the vessels passed by the occluder and delivery catheter were examined by duplex sonography. The median ASD diameter was 11 mm (5-17 mm), and the median GSO size was 22.5 mm (15-30 mm), whereas the median ASO left disc size that would have been recommended was 25 mm (17-31 mm). All ASDs were successfully closed. During a median follow-up of 1.57 years (range 0.5-4.2), no complications like erosion, embolization, arrhythmias, or vascular injuries occurred. Although using a 10-Fr introducer sheath, no vascular complications were detected. Our data suggest that the small usable size as well as the soft and flexible design of the device allows successful use of the GSO in young children.

In-Hospital and 4-Year Clinical Outcomes Following Transcatheter Versus Surgical Closure for Secundum Atrial Septal Defect in Adults: A National Cohort Propensity Score Analysis

Atrial septal defect (ASD) closure is major therapy for patients with secundum ASD. Although surgical closure (SC) and transcatheter closure (TC) are usually performed in such patients, data on the long-term outcomes comparing TC and SC in adults are limited. Data on the participants of this cohort study were retrieved from Taiwan's National Health Insurance Research Database from 2004 to 2011. Secundum ASD patients > 18 years of age who underwent TC or SC were initially enrolled, and those with associated comorbidities were excluded. After propensity score matching, the clinical outcomes between the TC and SC groups were analyzed. There were 595 patients recruited in the TC group and 308 patients in the SC group. The SC group had a higher incidence of systemic thromboembolism (P < 0.001), ischemic stroke (P = 0.002), and all-cause mortality (P = 0.013) when compared with those of the TC group at the index hospitalization, and similar phenomena could also be seen in a around 4-year follow-up period after the procedures (systemic thromboembolism (P < 0.001, HR = 11.48, 95% CI: 3.29-40.05), ischemic stroke (P = 0.005, HR = 9.28, 95% CI: 1.94-44.39), and all-cause mortality (P = 0.035, HR = 2.28, 95% CI: 1.06-4.89). In addition, atrial fibrillation (P = 0.005) and atrial flutter (P = 0.049) more frequently developed in the SC group than in the TC group at the index hospitalization. The adult secundum ASD patients had lower incidence rates of systemic thromboembolism, ischemic stroke, and all-cause mortality after TC than those after SC in the 4-year follow-up after procedures. Transcatheter ASD closure should therefore be given priority.

Cost comparison of transcatheter and operative closures of ostium secundum atrial septal defects

BACKGROUND

Clinical outcomes for transcatheter and operative closures of atrial septal defects (ASDs) are similar. Economic cost for each method has not been well described.

METHODS

A single-center retrospective cohort study of children and adults<30 years of age undergoing closure for single secundum ASD from January 1, 2007, to April 1, 2012, was performed to measure differences in inflation-adjusted cost of operative and transcatheter closures of ASD. A propensity score weight-adjusted multivariate regression model was used in an intention-to-treat analysis. Costs for reintervention and crossover admissions were included in primary analysis.

RESULTS

A total of 244 subjects were included in the study (64% transcatheter and 36% operative), of which 2% (n = 5) were ≥18 years. Crossover rate from transcatheter to operative group was 3%. Risk of reintervention (P = .66) and 30-day mortality (P = .37) were not significantly different. In a multivariate model, adjusted cost of operative closure was 2012 US $60,992 versus 2012 US $55,841 for transcatheter closure (P < .001). Components of total cost favoring transcatheter closure were length of stay, medications, and follow-up radiologic and laboratory testing, overcoming higher costs of procedure and echocardiography. Professional costs did not differ. The rate of 30-day readmission was greater in the operative cohort, further increasing the cost advantage of transcatheter closure. Sensitivity analyses demonstrated that costs of follow-up visits influenced relative cost but that device closure remained favorable over a broad range of crossover and reintervention rates.

CONCLUSION

For single secundum ASD, cost comparison analysis favors transcatheter closure over the short term. The cost of follow-up regimens influences the cost advantage of transcatheter closure.

Post-pericardiotomy syndrome in pediatric patients following surgical closure of secundum atrial septal defects: incidence and risk factors

Surgical repair for atrial septal defects (ASD) generally occurs during childhood. Post-pericardiotomy syndrome (PPS) after cardiac surgery has a reported incidence of 1-40 %. We focused exclusively on secundum ASD repair to evaluate the incidence of PPS. The purpose of this study is to determine the incidence of PPS after surgical repair of secundum ASD and investigate what risk factors may be predictive of its development. A retrospective study was performed, and 97 patients who underwent surgical closure of a secundum ASD were identified. 27 (28 %) were diagnosed with PPS within the first postoperative year. Diagnosis was made if they had evidence of new or worsening pericardial effusion and the presence of ≥2 of the following criteria: fever >72 h postoperatively, irritability, pleuritic chest pain, or pericardial friction rub. Closure of secundum ASDs was performed at a median age of 3.8 years (Interquartile Range (IQR): 2.2-6.0 years) and a median weight of 14.3 kilograms (IQR: 10.9-19.3 kilograms). The median time for development of PPS was 8 days post-op (IQR: 5-14). Significantly, 19 (27 %) of 70 patients in the non-PPS group had a small pericardial effusion on their discharge echocardiogram, while of the 27 patients who developed PPS, 17 (63 %) had a small pericardial effusion on their discharge echocardiogram (p = 0.001). PPS is relatively common following surgical closure of secundum ASDs. A small pericardial effusion on discharge echocardiogram is predictive of development of PPS postoperatively. In patients who develop PPS, there is a good response to therapy with a benign course.

Evaluation of Valsalva sinus wall deformation due to compression by the Amplatzer septal occluder and the potential for erosion development

OBJECTIVES

We studied whether the pressure exerted by the Amplatzer septal occluder (ASO) disk on the Valsalva sinus wall (VW) is a risk factor for erosion and attempted to determine the pressure that may trigger erosion.

BACKGROUND

The causes and mechanisms of erosion after ASO placement remain unclear.

METHODS

We reviewed 665 consecutive patients with atrial septal defects who underwent ASO closure at our hospital from 2005 to 2012. We used transesophageal echocardiography and other tests to evaluate disk-related VW deformation as a risk factor for erosion.

RESULTS

Immediately after ASO placement, intermittent VW deformation from either disk was determined in 54 of the 665 patients (8%). Of these 54 patients, only 1 exhibited late erosion (0.15%) during a follow-up of more than 4 years (0.035% a year). The maximum VW deformation depth relative to the standard curve, or dent, was 2.6 mm in this patient, whereas that in the remaining patients ranged from 0.5 to 2.0 mm. The dent values were significantly deeper in patients with contact between the left atrial disk and posterior atrial wall than in those without contact (P = 0.03). There was a significant negative correlation between dent and the aortic side-maximum device thickness (DT)/middle part-DT ratio (P = 0.04).

CONCLUSION

Although VW deformation, particularly deep VW deformation caused by pressure from either disk after ASO placement must be a recognized risk for erosion, which deformation level carries a stronger risk for erosion could not be concluded.