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Guedeney P, Rodés-Cabau J, Ten Berg JM, Windecker S, Angiolillo DJ, Montalescot G, Collet JP. Antithrombotic therapy for transcatheter structural heart intervention. EUROINTERVENTION 2024; 20:972-986. [PMID: 39155752 PMCID: PMC11317833 DOI: 10.4244/eij-d-23-01084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 05/22/2024] [Indexed: 08/20/2024]
Abstract
Percutaneous transcatheter structural heart interventions have considerably expanded within the last two decades, improving clinical outcomes and quality of life versus guideline-directed medical therapy for patients frequently ineligible for surgical treatment. Transcatheter structural heart interventions comprise valve implantation or repair and also occlusions of the patent foramen ovale, atrial septal defects and left atrial appendage. These procedures expose structural devices to arterial or venous blood flow with various rheological conditions leading to potential thrombotic complications and embolisation. Furthermore, these procedures may concern comorbid patients at high risk of both ischaemic and bleeding complications. This state-of-the-art review provides a description of the device-related thrombotic risk associated with these transcatheter structural heart interventions and of the current evidence-based guidelines regarding antithrombotic treatments. Gaps in evidence for each of the studied transcatheter interventions and the main ongoing trials are also summarised.
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Affiliation(s)
- Paul Guedeney
- Sorbonne Université, ACTION Group, INSERM UMRS 1166, Institut de Cardiologie (AP-HP), Paris, France
| | - Josep Rodés-Cabau
- Quebec Heart & Lung Institute, Laval University, Quebec City, QC, Canada
| | - Jurriën M Ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital (Inselspital), University of Bern, Bern, Switzerland
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Gilles Montalescot
- Sorbonne Université, ACTION Group, INSERM UMRS 1166, Institut de Cardiologie (AP-HP), Paris, France
| | - Jean-Philippe Collet
- Sorbonne Université, ACTION Group, INSERM UMRS 1166, Institut de Cardiologie (AP-HP), Paris, France
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Rigatelli G, Zuin M. Differences and similarities in interatrial shunts management. Eur J Intern Med 2024; 120:25-28. [PMID: 38072687 DOI: 10.1016/j.ejim.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 11/11/2023] [Accepted: 12/05/2023] [Indexed: 02/06/2024]
Abstract
Atrial septal defects (ASD) and Patent foramen ovale (PFO) represent the most common congenital heart diseases (CHD) adulthood. These two clinical entities, having different embryological origin, as well as clinical manifestations, clinical course and treatment must be carefully distinguished. Right heart failure and pulmonary hypertension are considered the major determinants of morbidity and mortality in ASD. Conversely, new pathophysiology concepts have been raised in the management of PFO as left atrium cardiopathy. New diagnostic tools, including cardiac magnetic resonance and intracardiac echocardiography have joint transthoracic and transesophageal echocardiography in the diagnostic definition of both ASD and PFO as well as in guiding their percutaneous closure. Moreover, several innovations have been developed in the field of percutaneous ASD and PFO closure devices including new evidence supporting the safety and efficacy of device-based closure. Aim of the present review is to present review we provided and update overview on ASD and PFO, focusing on the novel concepts regarding their pathophysiological and therapeutic aspects.
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Affiliation(s)
- Gianluca Rigatelli
- Interventional Cardiology Unit, Ospedali Riuniti Padova Sud, Monselice, Padova, Italy.
| | - Marco Zuin
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
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Guedeney P, Farjat-Pasos JI, Asslo G, Roule V, Beygui F, Hermida A, Gabrion P, Leborgne L, Houde C, Huang F, Lattuca B, Leclercq F, Mesnier J, Abtan J, Rouanet S, Hammoudi N, Collet JP, Zeitouni M, Silvain J, Montalescot G, Rodés-Cabau J. Impact of the antiplatelet strategy following patent foramen ovale percutaneous closure. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2023; 9:601-607. [PMID: 36963773 DOI: 10.1093/ehjcvp/pvad023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 03/01/2023] [Accepted: 03/23/2023] [Indexed: 03/26/2023]
Abstract
AIMS Temporary dual antiplatelet therapy (DAPT) is recommended following patent foramen ovale (PFO) percutaneous closure although its benefit, compared to single antiplatelet therapy (SAPT), has not been demonstrated in this setting. We aimed at assessing outcomes following PFO closure according to the antiplatelet strategy at discharge. METHODS AND RESULTS The ambispective AIR-FORCE cohort included consecutive patients from seven centres in France and Canada undergoing PFO closure and discharged without anticoagulation. Patients treated in French and Canadian centres were mostly discharged with DAPT and SAPT, respectively. The primary endpoint was the composite of death, stroke, transient ischaemic attack, peripheral embolism, myocardial infarction, or BARC type ≥2 bleeding with up to 5 years of follow-up. The impact of the antiplatelet strategy on outcomes was evaluated with a marginal Cox model (cluster analyses per country) with inverse probability weighting according to propensity score. A total of 1532 patients (42.2% female, median age: 49 [40-57] years) were included from 2001 to 2022, of whom 599 (39.1%) were discharged with SAPT and 933 (60.9%) with DAPT, for ≤3 months in 894/923 (96.9%) cases. After a median follow-up of 2.4 [1.1-4.4] years, a total of 58 events were observed. In the weighted analysis, the rate of the primary endpoint up to 5 years was 7.8% in the SAPT strategy and 7.3% in the DAPT strategy (weighted hazard ratio 1.04, 95% confidence interval 0.59-1.83). CONCLUSION The antiplatelet strategy following PFO closure did not seem to impact clinical outcomes, thus challenging the current recommendations of temporary DAPT.
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Affiliation(s)
- Paul Guedeney
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166 Institut de cardiologie (AP-HP), Paris, France
| | | | - Gabriel Asslo
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166 Institut de cardiologie (AP-HP), Paris, France
| | - Vincent Roule
- Service de Cardiologie, ACTION Study Group, Centre Hospitalier Universitaire (CHU) de Caen Normandie, Normandie Univ, INSERM UMRS 1237, GIP Cyceron, Caen, France
| | - Farzin Beygui
- Service de Cardiologie, ACTION Study Group, Centre Hospitalier Universitaire (CHU) de Caen Normandie, Normandie Univ, INSERM UMRS 1237, GIP Cyceron, Caen, France
| | - Alexis Hermida
- Cardiac Arrhythmia Service, Amiens-Picardie University Hospital, Amiens, France
| | - Paul Gabrion
- Cardiac Arrhythmia Service, Amiens-Picardie University Hospital, Amiens, France
| | - Laurent Leborgne
- Cardiac Arrhythmia Service, Amiens-Picardie University Hospital, Amiens, France
| | - Christine Houde
- Centre Hospitalier Universitaire de Québec, Quebec City, Quebec, Canada
| | - Florent Huang
- Service de Cardiologie, Hôpital Foch, Suresnes, France
| | - Benoit Lattuca
- ACTION Study Group, Cardiology Department, Nîmes University Hospital, Montpellier University, Nîmes, France
| | - Florence Leclercq
- Department of Cardiology, Arnaud de Villeneuve University Hospital, Montpellier, France
| | - Jules Mesnier
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
- FACT (French Alliance for Cardiovascular Clinical Trials), Université de Paris, INSERM U-1148, Hôpital Bichat (Assistance Publique-Hôpitaux de Paris), Paris, France
| | - Jérémie Abtan
- FACT (French Alliance for Cardiovascular Clinical Trials), Université de Paris, INSERM U-1148, Hôpital Bichat (Assistance Publique-Hôpitaux de Paris), Paris, France
| | - Stéphanie Rouanet
- Statistician Unit, StatEthic, ACTION Study Group, Levallois-Perret, France
| | - Nadjib Hammoudi
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166 Institut de cardiologie (AP-HP), Paris, France
| | - Jean-Philippe Collet
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166 Institut de cardiologie (AP-HP), Paris, France
| | - Michel Zeitouni
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166 Institut de cardiologie (AP-HP), Paris, France
| | - Johanne Silvain
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166 Institut de cardiologie (AP-HP), Paris, France
| | - Gilles Montalescot
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166 Institut de cardiologie (AP-HP), Paris, France
| | - Josep Rodés-Cabau
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
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Antithrombotic Therapy Duration after Patent Foramen Ovale Closure for Stroke Prevention: Impact on Long-Term Outcome. J Interv Cardiol 2022; 2022:6559447. [PMID: 36348991 PMCID: PMC9633204 DOI: 10.1155/2022/6559447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/26/2022] [Accepted: 09/10/2022] [Indexed: 11/18/2022] Open
Abstract
Background The optimal duration of antithrombotic therapy (ATT) after patent foramen ovale (PFO) closure remains under debate. This study sought to compare the clinical outcome of patients receiving antithrombotic agents for a short (6 months) versus extended (>6 months) period after the procedure. Methods This was a retrospective cohort study using a propensity score matching analysis on 259 consecutive patients (131 males, 43 ± 10 years) undergoing PFO closure due to cryptogenic stroke, with complete follow-up (median duration of 10 [4–13] years). The outcome was compared between patients receiving short-term (Group short, N = 88) versus extended ATT (Group long, N = 171). Results The PFO closure device was successfully implanted in all cases, with 3% of minor complications. After propensity score matching, there were no differences between Groups short and long in the rate of stroke (0.3 vs. 0.4% patient-year, p=1.00), bleeding (2 vs. 2% patient-year, p=0.17), and device thrombosis (0.3 vs. 0.1% patient-year; p=0.60). Univariate analysis showed that short-term ATT was not associated with an increased risk of recurrent stroke (HR: 1.271 [95% CI: 0.247–6.551], p=0.775) or prosthesis thrombus (HR: 0.50 [95% CI: 0.070–3.548], p=0.72). Kaplan–Meier analysis revealed similar overall survival in Group short and long (100 vs. 99 ± 1%, respectively; p=0.25). Conclusions Short-term (6 months) ATT after PFO closure did not impair the clinical outcome, with a preserved low rate of recurrent stroke (0.3% patient-year) and device thrombosis (0.2% patient-year) at 10-year follow-up.
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Xiong W, Tang L, Long W, Liu J, Song H. Case report: Bi-atrial thrombus after occlusion of atrial septal defect with acute cerebral infarction and pulmonary embolism. Front Cardiovasc Med 2022; 9:987538. [PMID: 36158837 PMCID: PMC9489941 DOI: 10.3389/fcvm.2022.987538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 08/15/2022] [Indexed: 11/25/2022] Open
Abstract
A 49-year-old man presented to the hospital with symptoms of acute cerebral infarction and pulmonary embolism who underwent transcatheter closure of atrial septal defect a year before. Transthoracic echocardiography showed a 13 × 9 mm hypoechoic mass attached to the left-atrial side of the device, which was suspected to be a neoplasm or thrombus. The patient was indicated for surgery after multidisciplinary discussion due to ineffective medical therapy and typical stroke and pulmonary embolism symptoms. Three-dimensional transesophageal echocardiography (3D-TEE) revealed left-atrial vegetation (21 × 16 mm) and right-atrial vegetation (8 × 6 mm) attached to the device, which was confirmed as thrombus by surgical separation and laboratory examination. This case highlights the importance of 3D-TEE and a multidisciplinary team in the diagnosis and therapy of device-related thrombus.
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Rigatelli G, Gianese F, Zuin M. Secundum atrial septal defects transcatheter closure: An updated reappraisal. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 44:92-97. [PMID: 35680528 DOI: 10.1016/j.carrev.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/03/2022] [Accepted: 06/03/2022] [Indexed: 11/30/2022]
Abstract
Transcatheter device-based closure is considered the first line therapy for congenital secundum atrial septal defect (ASD). The last 20 years literature data have been reviewed to offer an updated reappraisal of current evidences. Anatomical and functional details, appreciated at both pre-procedural and intraprocedural steps, remain of paramount importance for planning ASD transcatheter -based closure procedure. Routes for interventions should include femoral, and eventually the jugular and hepatic vein approaches. Intraprocedural transoesophageal echocardiography (TTE) or intracardiac echocardiography (ICE) is used at least in most complex cases to have the exact definition of the anatomy of the defects. The clinical outcomes are excellent also compared to surgical series with few complications even compare to surgical series. Transcatheter ASD closure represents the first line therapy in secundum ASD. Future developments of device's material and imaging tools are expected to improve safety and long-term efficacy, even in most complex cases.
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Affiliation(s)
| | - Filippo Gianese
- Division of Cardiology, Rovigo General Hospital, Rovigo, Italy
| | - Marco Zuin
- Section of Internal and Cardiopulmonary Medicine, Department of Medical Science, University of Ferrara, Ferrara, Italy
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Secundum atrial septal defects transcatheter closure versus surgery in adulthood: a 2000-2020 systematic review and meta-analysis of intrahospital outcomes. Cardiol Young 2021; 31:541-546. [PMID: 33827735 DOI: 10.1017/s1047951121001232] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
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.
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Martín Mañero C, Medina Durán P, Morales Delgado N, Martín Rioboó E. [Patent foramen ovale. An update for primary care]. Semergen 2021; 47:189-196. [PMID: 33509725 DOI: 10.1016/j.semerg.2020.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 12/08/2020] [Accepted: 12/10/2020] [Indexed: 10/22/2022]
Abstract
Patent foramen ovale (FOP) is the most prevalent cause of cryptogenic strokes in people under 60 years old. Although it is usually asymptomatic, it has a high risk of producing paradoxical embolism and, therefore, stroke with indeterminate outcomes. The study should be started based on clinical suspicion, and includes a multidisciplinary assessment and a determination of the type of treatment to be performed. The therapeutic possibilities range from conservative treatment (indefinite antithrombotic treatment), to its percutaneous closure (currently the most widely used). The first objective is to decrease the number of stroke recurrences. Conservative treatment should be reserved for those cases of low embolic risk. The risk assessment must be individualised, fundamentally based on the anatomical characteristics of the FOP and the patient clinic picture. The use of the RoPE risk scale (The Risk of Paradoxical Embolism) should be a tool to consider.
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Affiliation(s)
- C Martín Mañero
- Medicina Familiar y Comunitaria, Centro de Salud Ribera del Muelle, Distrito Sanitario Bahía de Cádiz-La Janda, Puerto Real, Cádiz, España
| | - P Medina Durán
- Servicio de Urgencias, Hospital Alta Resolución Montilla, Montilla, Córdoba, España
| | - N Morales Delgado
- Medicina Familiar y Comunitaria, Unidad de Gestión Clínica Poniente, Distrito Sanitario Córdoba Guadalquivir, Córdoba, España
| | - E Martín Rioboó
- Unidad de Gestión Clínica Poniente, Distrito Sanitario Córdoba Guadalquivir, Grupo de Investigación clínico-epidemiológica (GICEAP), IMIBIC, Hospital Reina Sofía Córdoba, Córdoba, España.
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Takeuchi M, Okada T, Iwato K, Kawamoto K, Ikegami Y, Nakamoto Y, Idei N, Ohashi N. Pulmonary Embolism and Splenic Infarction after Minocycline Infusion in a Patient with Polycythemia Vera. Intern Med 2021; 60:275-279. [PMID: 32921692 PMCID: PMC7872807 DOI: 10.2169/internalmedicine.5635-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 55-year-old man treated with polycythemia vera visited our hospital, complaining of left abdominal pain and dyspnea. He had received minocycline infusions three weeks earlier for mycoplasma pneumonia. Contrast-enhanced computed tomography revealed pulmonary embolism and splenic infarction. Ultrasonography of the vein in the forearm revealed a thrombus filling the distal brachial veins to the radial veins on both sides. His condition improved after anticoagulant therapy, and right and left shunts were detected on transesophageal echocardiography. This suggested that thrombus in the forearm may have been the source of the embolism.
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Affiliation(s)
- Makoto Takeuchi
- Department of Cardiology, Hiroshima Red Cross Hospital and Atomic-bomb Survivors Hospital, Japan
| | - Takenori Okada
- Department of Cardiology, Hiroshima Red Cross Hospital and Atomic-bomb Survivors Hospital, Japan
| | - Kouji Iwato
- Department of Hematology, Hiroshima Red Cross Hospital and Atomic-bomb Survivors Hospital, Japan
| | - Kazuma Kawamoto
- Department of Respiratory, Hiroshima Red Cross Hospital and Atomic-bomb Survivors Hospital, Japan
| | - Yuki Ikegami
- Department of Cardiology, Hiroshima Red Cross Hospital and Atomic-bomb Survivors Hospital, Japan
| | - Yumiko Nakamoto
- Department of Cardiology, Hiroshima Red Cross Hospital and Atomic-bomb Survivors Hospital, Japan
| | - Naomi Idei
- Department of Cardiology, Hiroshima Red Cross Hospital and Atomic-bomb Survivors Hospital, Japan
| | - Norihiko Ohashi
- Department of Cardiology, Hiroshima Red Cross Hospital and Atomic-bomb Survivors Hospital, Japan
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Alkashkari W, Albugami S, Hijazi ZM. Current practice in atrial septal defect occlusion in children and adults. Expert Rev Cardiovasc Ther 2020; 18:315-329. [PMID: 32441165 DOI: 10.1080/14779072.2020.1767595] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Atrial septal defect (ASD) is one of the most common congenital heart diseases (CHD) in children and adults. This group of malformations includes several types of atrial communications allowing shunting of blood between the systemic and the pulmonary circulations. Early diagnosis and treatment carries favorable outcomes. Patients diagnosed during adulthood often present with complications related to longstanding volume overload such as pulmonary artery hypertension (PAH), atrial dysrhythmias, and right (RV) and left (LV) ventricular dysfunction. AREA COVERED This article intended to review all aspects of ASD; anatomy, pathophysiology, clinical presentation, natural history, and indication for treatment. Also, we covered the transcatheter therapy in detail, including the procedural aspect, available devices, and outcomes. EXPERT OPINION There has been a remarkable improvement in the treatment strategy of ASD over the last few decades. Transcatheter closure of ASD is currently accepted as the treatment of choice in most patients with appropriately selected secundum ASDs. This review will focus on the most recent advances in diagnosis and treatment strategy of secundum ASD.
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Affiliation(s)
- Wail Alkashkari
- Department of Cardiology, King Faisal Cardiac Center, Ministry of National Guard Health Affairs , Jeddah, Saudi Arabia.,Department of Postgraduate, King Saud Bin Abdulaziz University for Health Science , Jeddah, Saudi Arabia.,Department of Medical Research, King Abdullah International Medical Research Center , Jeddah, Saudi Arabia
| | - Saad Albugami
- Department of Postgraduate, King Saud Bin Abdulaziz University for Health Science , Jeddah, Saudi Arabia
| | - Ziyad M Hijazi
- Sidra Heart Center, Sidra Medicine , Doha, Qatar.,Weill Cornell Medicine , New York, NY, USA
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