Atrial Septal Defect

Patent Foramen Ovale and Atrial Septal Defect

Patent foramen ovale (PFO) and atrial septal defects (ASDs) are two types of interatrial communications with unique clinical presentations and management strategies. The PFO is a normal part of fetal development that typically closes shortly after birth but may persist in as many as 25% to 30% of adults. The communication between atria may result in paradoxic embolism and embolic stroke. On the other hand, ASDs (anatomically defined as secundum, primum, sinus venosus, and coronary sinus in order of prevalence) typically result in right heart volume overload and are often associated with other congenital defects. The diagnostic methods, treatment options including surgical and percutaneous approaches, and potential complications are described. Both conditions underline the significance of precise diagnosis and appropriate management to mitigate risks and ensure optimal patient outcomes.

Congenital heart disease: types, pathophysiology, diagnosis, and treatment options

Congenital heart disease (CHD) is a structural abnormality of the heart and/or great vessels and patients with CHD are at an increased risks of various morbidities throughout their lives and reduced long-term survival. Eventually, CHD may result in various complications including heart failure, arrhythmias, stroke, pneumonia, and sudden death. Unfortunately, the exact etiology and pathophysiology of some CHD remain unclear. Although the quality of life and prognosis of patients with CHD have significantly improved following technological advancement, the influence of CHD is lifelong, especially in patients with complicated CHD. Thus, the management of CHD remains a challenge due to its high prevalence. Finally, there are some disagreements on CHD among international guidelines. In this review, we provide an update of the pathophysiology, diagnosis, and treatment in most common type of CHD, including patent foramen ovale, atrial septal defect, ventricular septal defect, atrioventricular septal defect, patent ductus arteriosus, coarctation of the aorta, transposition of the great arteries, congenitally corrected transposition of the great arteries, coronary anomalies, left and right ventricular outflow tract obstruction, tetralogy of Fallot and Ebstein anomaly. In particular, we focus on what is known and what is unknown in these areas, aiming to improve the current understanding of various types of CHD.

Atrial Septal Defect Detection in Children Based on Ultrasound Video Using Multiple Instances Learning

Thoracic echocardiography (TTE) can provide sufficient cardiac structure information, evaluate hemodynamics and cardiac function, and is an effective method for atrial septal defect (ASD) examination. This paper aims to study a deep learning method based on cardiac ultrasound video to assist in ASD diagnosis. We chose four standard views in pediatric cardiac ultrasound to identify atrial septal defects; the four standard views were as follows: subcostal sagittal view of the atrium septum (subSAS), apical four-chamber view (A4C), the low parasternal four-chamber view (LPS4C), and parasternal short-axis view of large artery (PSAX). We enlist data from 300 children patients as part of a double-blind experiment for five-fold cross-validation to verify the performance of our model. In addition, data from 30 children patients (15 positives and 15 negatives) are collected for clinician testing and compared to our model test results (these 30 samples do not participate in model training). In our model, we present a block random selection, maximal agreement decision, and frame sampling strategy for training and testing respectively, resNet18 and r3D networks are used to extract the frame features and aggregate them to build a rich video-level representation. We validate our model using our private dataset by five cross-validation. For ASD detection, we achieve 89.33 ± 3.13 AUC, 84.95 ± 3.88 accuracy, 85.70 ± 4.91 sensitivity, 81.51 ± 8.15 specificity, and 81.99 ± 5.30 F1 score. The proposed model is a multiple instances learning-based deep learning model for video atrial septal defect detection which effectively improves ASD detection accuracy when compared to the performances of previous networks and clinical doctors.

Association study of FLT4 and HYDIN single nucleotide polymorphisms with atrial septal defect susceptibility in the Han Chinese population of Southwest China

BACKGROUND

Atrial septal defect (ASD) is a common form of congenital heart disease. Although several genes related to ASD have been found, the genetic factors of ASD remain unclear. This study aimed to evaluate the correlation between 10 candidate single nucleotide polymorphisms (SNPs) and sporadic atrial septal defects.

METHODS

Based on the results of 34 individual whole exome sequences, 10 candidate SNPs were selected. In total, 489 ASD samples and 420 normal samples were collected. The 10 SNPs in the case group and the control group were identified through Snapshot genotyping technology. The χ2-test and unconditional regression model were used to evaluate the relationship between ASD and each candidate SNP. Haploview software was used to perform linkage disequilibrium and haplotype analysis.

RESULTS

The χ2 results showed that the FLT4 rs383985 (P = 0.003, OR = 1.115-1.773), HYDIN rs7198975 (P = 0.04621, OR = 1.003-1.461), and HYDIN rs1774266 (P = 0.04621, OR = 1.003-1.461) alleles were significantly different between the control group and the case group (P < 0.05). Only the association with the FLT4 polymorphism was statistically significant after adjustment for multiple comparisons.

CONCLUSION

These findings suggest that a possible molecular pathogenesis associated with sporadic ASD is worth exploring in future studies.

RNA binding proteins in cardiovascular development and disease

Congenital heart disease (CHD) is the most common birth defect affecting>1.35 million newborn babies worldwide. CHD can lead to prenatal, neonatal, postnatal lethality or life-long cardiac complications. RNA binding protein (RBP) mutations or variants are emerging as contributors to CHDs. RBPs are wizards of gene regulation and are major contributors to mRNA and protein landscape. However, not much is known about RBPs in the developing heart and their contributions to CHD. In this chapter, we will discuss our current knowledge about specific RBPs implicated in CHDs. We are in an exciting era to study RBPs using the currently available and highly successful RNA-based therapies and methodologies. Understanding how RBPs shape the developing heart will unveil their contributions to CHD. Identifying their target RNAs in the embryonic heart will ultimately lead to RNA-based treatments for congenital heart disease.

Pediatric Chest Pain: A Review of Diagnostic Tools in the Pediatric Emergency Department

Pediatric chest pain is a common chief complaint in the emergency department. Not surprisingly, children with chest pain are usually brought to the emergency department by their parents out of fear of heart disease. However, chest pain in the pediatric population is generally a benign disease. In this review, we have identified musculoskeletal pain as the most prevalent etiology of chest pain in the pediatric population, accounting for 38.7-86.3% of cases, followed by pulmonary (1.8-12.8%), gastrointestinal (0.3-9.3%), psychogenic (5.1-83.6%), and cardiac chest pain (0.3-8.0%). Various diagnostic procedures are commonly used in the emergency department for cardiac chest pain, including electrocardiogram (ECG), chest radiography, cardiac troponin examination, and echocardiography. However, these examinations demonstrate limited sensitivity in identifying cardiac etiologies, with sensitivities ranging from 0 to 17.8% for ECG and 11.0 to 17.2% for chest radiography. To avoid the overuse of these diagnostic tools, a well-designed standardized algorithm for pediatric chest pain could decrease unnecessary examination without missing severe diseases.

Cardiac Devices and Kidney Disease

A growing variety of cardiac devices are available to monitor or support cardiovascular function. The entwined nature of cardiovascular disease and kidney disease makes the relationship of these devices with kidney disease a multifaceted question relating to the use of these devices in individuals with kidney disease and to the effects of the devices and device placement on kidney health. Cardiac devices can be categorized broadly into cardiac implantable electronic devices, structural devices, and circulatory assist devices. Cardiac implantable electronic devices include devices for monitoring and managing cardiac electrical activity and devices for monitoring hemodynamics. Structural devices modify cardiac structure and include valve prostheses, valve repair clips, devices for treating atrial septal abnormalities, left atrial appendage closure devices, and interatrial shunt devices. Circulatory assist devices support the failing heart or support cardiac function during high-risk cardiac procedures. Evidence for the use of these devices in individuals with kidney disease, effects of the devices on kidney health and function, specific considerations with devices in kidney disease, and important knowledge gaps are surveyed in this article. With the growing prevalence of combined cardiorenal disease and the increasing variety of cardiac devices, kidney disease considerations are an important aspect of device therapy.

Large Secundum Atrial Septal Defect Managed Conservatively in an Adult Dog

•ASDs can be medically managed in dogs if interventional options are not selected. •3D modeling can be used for canine congenital heart disease. •3D imaging helps with preprocedural planning for ASD.

Residual networks models detection of atrial septal defect from chest radiographs

OBJECT

The purpose of this study was to explore a machine learning-based residual networks (ResNets) model to detect atrial septal defect (ASD) on chest radiographs.

METHODS

This retrospective study included chest radiographs consecutively collected at our hospital from June 2017 to May 2022. Qualified chest radiographs were obtained from patients who had finished echocardiography. These chest radiographs were labeled as positive or negative for ASD based on the echocardiographic reports and were divided into training, validation, and test dataset. Six ResNets models were employed to examine and compare by using the training dataset and was tuned using the validation dataset. The area under the curve, recall, precision and F1-score were taken as the evaluation metrics for classification result in the test dataset. Visualizing regions of interest for the ResNets models using heat maps.

RESULTS

This study included a total of 2105 chest radiographs of children with ASD (mean age 4.14 ± 2.73 years, 54% male), patients were randomly assigned to training, validation, and test dataset with an 8:1:1 ratio. Healthy children's images were supplemented to three datasets in a 1:1 ratio with ASD patients. Following the training, ResNet-10t and ResNet-18D have a better estimation performance, with precision, recall, accuracy, F1-score, and the area under the curve being (0.92, 0.93), (0.91, 0.91), (0.90, 0.90), (0.91, 0.91) and (0.97, 0.96), respectively. Compared to ResNet-18D, ResNet-10t was more focused on the distribution of the heat map of the interest region for most chest radiographs from ASD patients.

CONCLUSION

The ResNets model is feasible for identifying ASD through children's chest radiographs. ResNet-10t stands out as the preferable estimation model, providing exceptional performance and clear interpretability.

First experience with real-time magnetic resonance imaging-based investigation of respiratory influence on cardiac function in pediatric congenital heart disease patients with chronic right ventricular volume overload

BACKGROUND

Congenital heart disease (CHD) is often associated with chronic right ventricular (RV) volume overload. Real-time magnetic resonance imaging (MRI) enables the analysis of cardiac function during free breathing.

OBJECTIVE

To evaluate the influence of respiration in pediatric patients with CHD and chronic RV volume overload.

METHODS AND MATERIALS

RV volume overload patients (n=6) and controls (n=6) were recruited for cardiac real-time MRI at 1.5 tesla during free breathing. Breathing curves from regions of interest reflecting the position of the diaphragm served for binning images in four different tidal volume classes, each in inspiration and expiration. Tidal volumes were estimated from these curves by data previously obtained by magnetic resonance-compatible spirometry. Ventricular volumes indexed to body surface area and Frank-Starling relationships referenced to the typical tidal volume indexed to body height (TTVi) were compared.

RESULTS

Indexed RV end-diastolic volume (RV-EDVi) and indexed RV stroke volume (RV-SVi) increased during inspiration (RV-EDVi/TTVi: RV load: + 16 ± 4%; controls: + 22 ± 13%; RV-SVi/TTVi: RV load: + 21 ± 6%; controls: + 35 ± 17%; non-significant for comparison). The increase in RV ejection fraction during inspiration was significantly lower in RV load patients (RV load: + 1.1 ± 2.2%; controls: + 6.1 ± 1.5%; P=0.01). The Frank-Starling relationship of the RV provided a significantly reduced slope estimate in RV load patients (inspiration: RV load: 0.75 ± 0.11; controls: 0.92 ± 0.02; P=0.02).

CONCLUSION

In pediatric patients with CHD and chronic RV volume overload, cardiac real-time MRI during free breathing in combination with respiratory-based binning indicates an impaired Frank-Starling relationship of the RV.

The development and validation of an artificial intelligence-based screening method for atrial septal defect in children's chest x-rays

Purpose

For precise diagnosis and effective management of atrial septal defects, it is of utmost significance to conduct elementary screenings on children. The primary aim of this study is to develop and authenticate an objective methodology for detecting atrial septal defects by employing deep learning (DL) on chest x-ray (CXR) examinations.

Methods

This retrospective study encompassed echocardiographs and corresponding Chest x-rays that were consistently gathered at Qingdao Women's and Children's Hospital from 2018 to 2022. Based on a collaborative diagnosis report by two cardiologists with over 10 years of experience in echocardiography, these radiographs were classified as positive or negative for atrial septal defect, and then divided into training and validation datasets. An artificial intelligence model was formulated by utilizing the training dataset and fine-tuned using the validation dataset. To evaluate the efficacy of the model, an assessment of the area under the curve, sensitivity, specificity, accuracy, positive predictive value, and negative predictive value was conducted employing the validation dataset.

Results

This research encompassed a total of 420 images from individuals. The screening accuracy and recall rate of the model surpass 90%.

Conclusions

One of profound neural network models predicated on chest x-ray radiographs (a traditional, extensively employed, and economically viable examination) proves highly advantageous in the assessment for atrial septal defect.

Case report: A unique quadruple coexisting anomaly-scimitar syndrome, atrial septal defect, vascular ring, and pulmonary sequestration

The article describes a successful clinical outcome in the case of a 5-month old female with a diagnosis of incomplete vascular ring of aberrant right subclavian artery and ostium secundum atrial septal defect associated with partial anomalous pulmonary venous return of scimitar syndrome type, coexisting with right pulmonary sequestration. During hospitalization, surgical correction of the heart defect and resection of the lung sequestration were performed. To the best of our knowledge, described constellation of defects is a unique phenomenon, posing a challenge for complex treatment and disease management.

Atrial Fibrillation Ablation in a Patient With SV ASD and PAPVR Preceding Transcatheter Septal Closure

Atrial fibrillation (AF) is common in adults with unrepaired atrial septal defects (ASDs). Sinus venosus (SV) ASDs associated with partial anomalous pulmonary venous return (PAPVR) are traditionally managed surgically. We report the first AF catheter ablation in a patient with SV ASD and PAPVR preceding transcatheter ASD repair with a covered stent. (Level of Difficulty: Advanced.).

Atrial Septal Defect Associated With Right Bundle Branch Block Masking Brugada Syndrome

A type 1 Brugada electrocardiogram pattern may be masked by typical right bundle branch block aspect. We present 2 cases (male patients, aged 18 and 22 years) of associated ostium secundum atrial septal defect with a right bundle branch block aspect and symptomatic confirmed Brugada syndrome. Both patients underwent cardiac defibrillator implantation. (Level of Difficulty: Advanced.).

A soldier's return to duty after minimally invasive correction of complex congenital cardiovascular disease

We report a case of incidental detection of severe aortic coarctation, severe secundum atrial septal defect, and bicuspid aortic valve in an active-duty military service member. A single complex minimally invasive procedure successfully corrected his coarctation and atrial septal defect allowing this patient to continue military service.

Automatic Detection of Secundum Atrial Septal Defect in Children Based on Color Doppler Echocardiographic Images Using Convolutional Neural Networks

Secundum atrial septal defect (ASD) is one of the most common congenital heart diseases (CHDs). This study aims to evaluate the feasibility and accuracy of automatic detection of ASD in children based on color Doppler echocardiographic images using convolutional neural networks. In this study, we propose a fully automatic detection system for ASD, which includes three stages. The first stage is used to identify four target echocardiographic views (that is, the subcostal view focusing on the atrium septum, the apical four-chamber view, the low parasternal four-chamber view, and the parasternal short-axis view). These four echocardiographic views are most useful for the diagnosis of ASD clinically. The second stage aims to segment the target cardiac structure and detect candidates for ASD. The third stage is to infer the final detection by utilizing the segmentation and detection results of the second stage. The proposed ASD detection system was developed and validated using a training set of 4,031 cases containing 370,057 echocardiographic images and an independent test set of 229 cases containing 203,619 images, of which 105 cases with ASD and 124 cases with intact atrial septum. Experimental results showed that the proposed ASD detection system achieved accuracy, recall, precision, specificity, and F1 score of 0.8833, 0.8545, 0.8577, 0.9136, and 0.8546, respectively on the image-level averages of the four most clinically useful echocardiographic views. The proposed system can automatically and accurately identify ASD, laying a good foundation for the subsequent artificial intelligence diagnosis of CHDs.

Evaluation of the association between maternal folic acid supplementation and the risk of congenital heart disease: a systematic review and meta-analysis

Background

Folic acid (FA), as a synthetic form of folate, has been widely used for dietary supplementation in pregnant women. The preventive effect of FA supplementation on the occurrence and recurrence of fetal neural tube defects (NTD) has been confirmed. Incidence of congenital heart diseases (CHD), however, has been parallelly increasing worldwide. The present study aimed to evaluate whether FA supplementation is associated with a decreased risk of CHD.

Methods

We searched the literature using PubMed, Web of Science and Google Scholar, for the peer-reviewed studies which reported CHD and FA and followed with a meta-analysis. The study-specific relative risks were used as summary statistics for the association between maternal FA supplementation and CHD risk. Cochran's Q and I² statistics were used to test for the heterogeneity.

Results

Maternal FA supplementation was found to be associated with a decreased risk of CHD (OR = 0.82, 95% CI: 0.72–0.94). However, the heterogeneity of the association was high (P < 0.001, I² = 92.7%). FA supplementation within 1 month before and after pregnancy correlated positively with CHD (OR 1.10, 95%CI 0.99–1.23), and high-dose FA intake is positively associated with atrial septal defect (OR 1.23, 95%CI 0.64–2.34). Pregnant women with irrational FA use may be at increased risk for CHD.

Conclusions

Data from the present study indicate that the heterogeneity of the association between maternal FA supplementation and CHD is high and suggest that the real relationship between maternal FA supplementation and CHD may need to be further investigated with well-designed clinical studies and biological experiments.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12937-022-00772-2.

Pathology and Advanced Imaging—Characterization of a Congenital Cardiac Defect and Complex Hemodynamics in a Pig: A Case Report

Domestic pigs are widely used in cardiovascular research as the porcine circulatory system bears a remarkable resemblance to that of humans. In order to reduce variability, only clinically healthy animals enter the study as their health status is assessed in entry examination. Like humans, pigs can also suffer from congenital heart disease, such as an atrial septal defect (ASD), which often remains undetected. Due to the malformation of the endocardial cushion during organ development, mitral valve defects (e.g., mitral clefts) are sometimes associated with ASDs, further contributing to hemodynamic instability. In this work, we report an incidental finding of a hemodynamically highly relevant ASD in the presence of incompetent mitral and tricuspid valves, in an asymptomatic, otherwise healthy juvenile pig. In-depth characterization of the cardiac blood flow by four-dimensional (4D) flow magnetic resonance imaging (MRI) revealed a prominent diastolic left-to-right and discrete systolic right-to-left shunt, resulting in a pulmonary-to-systemic flow ratio of 1.8. Severe mitral (15 mL/stroke) and tricuspid (22 mL/stroke) regurgitation further reduced cardiac output. Pathological examination confirmed the presence of an ostium primum ASD and found a serous cyst of lymphatic origin that was filled with clear fluid partially occluding the ASD. A large mitral cleft was identified as the most likely cause of severe regurgitation, and histology showed mild to moderate endocardiosis in the coaptation area of both atrio-ventricular valves. In summary, although not common, congenital heart defects could play a role as a cause of experimental variability or even intra-experimental mortality when working with apparently heathy, juvenile pigs.

Complications caused by iatrogenic right-to-left shunt after surgical closure of atrial septal defect: a case report

Background

Atrial septal defect (ASD) is a common congenital heart disease. For this condition, surgical treatment can be required depending on the size and type of ASD. This study included a case of a patient who complained of persistent dyspnoea after the surgical treatment for ASD.

Case summary

A 16-year-old girl who underwent a surgical patch closure for ASD at the age of 2 years presented to the emergency department and was diagnosed with acute stroke. Since childhood, she had suffered from exertional dyspnoea due to an unknown cause. Transthoracic echocardiography revealed normal chambers size and function and no signs of right heart strain. Transoesophageal echocardiography (TOE) revealed a misplaced interatrial patch from the previous surgery, which allowed the whole blood to flow from the inferior vena cava (IVC) to the left atrium (LA), creating a large right-to-left shunt that resulted in stroke and heart failure. The patient underwent surgical treatment, and her symptoms improved significantly. Six months later, she was doing well without neurological complications and dyspnoea.

Discussion

This patient experienced stroke at the age of 16 years and had been suffering from heart failure since childhood. A large right-to-left shunt flow from the IVC to the LA by misplaced interatrial patch was found using TOE, right-sided heart catheterization, and inferior caval venography. This diagnosis should be considered in patients complaining of persistent dyspnoea with hypoxia after the surgical repair of ASD.

Prediction of arrhythmia after intervention in children with atrial septal defect based on random forest

BACKGROUND

Using random forest to predict arrhythmia after intervention in children with atrial septal defect.

METHODS

We constructed a prediction model of complications after interventional closure for children with atrial septal defect. The model was based on random forest, and it solved the need for postoperative arrhythmia risk prediction and assisted clinicians and patients' families to make preoperative decisions.

RESULTS

Available risk prediction models provided patients with specific risk factor assessments, we used Synthetic Minority Oversampling Technique algorithm and random forest machine learning to propose a prediction model, and got a prediction accuracy of 94.65 % and an Area Under Curve value of 0.8956.

CONCLUSIONS

Our study was based on the model constructed by random forest, which can effectively predict the complications of arrhythmia after interventional closure in children with atrial septal defect.

Case report of an atrial septal defect with negative transthoracic echocardiography, a diagnostic challenge in a middle-aged female with marked dyspnoea

A 39-year-old G3P3 female presented with abrupt onset dyspnoea of one month duration. She was markedly symptomatic when lying supine and resorted to prone sleeping. Chest X-ray reported as cardiomegaly. Transthoracic echocardiography was unremarkable twice. Computed tomography chest showed a dilated pulmonary artery. Transesophageal echocardiography identified a 12-mm ostium secundum atrial septal defect with mild pulmonary hypertension. The defect was closed with a cocoon device and rendered her symptom free. This case highlights the importance of timely organization of transesophageal echocardiography when transthoracic echocardiography is negative. It also illustrates marked dyspnoea could be a presentation of undiagnosed atrial septal defect with mild pulmonary hypertension.