Characterization of mid-term atrial geometrical and electrical remodeling following device closure of atrial septal defects in adults

Atrial arrhythmias in patients beyond 40 Years of age post atrial septal defect device closure

Background

Patients >40 years with an atrial septal defect (ASD) may have atrial arrhythmia which warrants treatment. It is unclear whether preventive left atrial appendage (LAA) occlusion should be performed simultaneously during ASD closure in these patients.

Objective

This study aimed to examine the incidence of de novo atrial arrhythmia in patients >40 years old post transcatheter closure of ASD.

Methods

This was a single-center, retrospective study involving all consecutive patients who have undergone device closure of ASDs at age >40 years. Standard 12-lead ECGs were performed pre-procedure and during every clinic follow-up. Ambulatory monitors were applied when indicated.

Results

Eighty-eight patients (mean age: 51.81 ± 8.01 years; male: 22.7%) were recruited and followed up over a median duration of 3.6 years (range: 1-6.5). Seven patients (8%) had documented atrial arrhythmia (AA) pre and post ASD closure. Two patients (2.5%) developed de novo atrial fibrillation and one patient (1.2%), ectopic atrial rhythm during follow-up. In univariate analyses, age >61.3 years (p < 0.001), a history of palpitation (p = 0.006), right atrial area >25.15cm2 pre-closure (p = 0.004); dilated right and left atrium immediately post ASD closure (p = 0.016 & 0.001) and pulmonary vascular resistance >1.31Woods unit (p = 0.036) were associated with increased risk of AA. However, on multivariate analyses, none were significantly associated with AA.

Conclusions

De novo atrial arrhythmia after ASD device closure is uncommon.

Crochetage sign may predict late atrial arrhythmias in patients with secundum atrial septal defect undergoing transcatheter closure

BACKGROUND

Atrial arrhythmias are well-known complications of atrial septal defect (ASD), and associated with substantial morbidity. After ASD closure, right atrial and ventricular enlargement regresses, however, the risk of atrial arrhythmia development continues. In this study, we aimed to investigate the relationship between the Crochetage sign, which is a possible reflection of heterogeneous ventricular depolarization due to long-term hemodynamic overload, and the development of late atrial arrhythmia after ASD closure.

METHODS

This retrospective study included a total of 314 patients (mean age: 39.5 (30-50) years; male: 115) who underwent percutaneous device closure for secundum ASD. The study population was divided into two groups according to the presence or absence of the Crochetage sign. The Crochetage sign was defined as an M-shaped or bifid pattern notch on the R wave in one or more inferior limb leads. Cox-regression analysis was performed to determine independent predictors of late atrial arrhythmia development.

RESULT

Fifty-seven patients (18.1%) presented with late atrial arrhythmia. Of these 57 patients, 30 developed new-onset atrial fibrillation/atrial flutter (AF/AFL), and 27 patients with pre-procedure paroxysmal AF/AFL had a recurrence of AF/AFL during follow-up. History of paroxysmal AF/AFL before the procedure (HR: 4.78; 95% CI 2,52-9.05; p < 0.001), the presence of Crochetage sign (HR: 3.90; 95% CI 2.05-7.76; p < 0.001), and older age at the time of ASD closure (HR: 1.03; 95% CI 1.01-1.06; p = 0.002) were found as independent predictors for late atrial arrhythmia.

CONCLUSION

The presence of Crochetage sign may be used to predict the risk of late atrial arrhythmia development after transcatheter ASD closure.

Efficacy of catheter ablation for patients with atrial fibrillation and atrial septal defect

INTRODUCTION

Given that few studies investigated the efficacy of catheter ablation (CA) in patients with paroxysmal atrial fibrillation (AF) and atrial septal defect (ASD), this study evaluated its effectiveness in patients with paroxysmal AF and ASD.

METHODS AND RESULTS

Of the 216 patients who underwent ASD device closure at two hospitals, 36 patients had paroxysmal AF. After April 2012, CA for AF was performed before ASD device closure (ASD-CA group; n = 20). The ASD-CA group had a significantly higher AF-free survival rate after ASD device closure compared to patients without CA for AF before ASD device closure (ASD-non-CA group; n = 16) (ASD-CA group: 2 patients vs. ASD-non-CA group: 9 patients; follow-up period: 4.2 ± 2.5 years; log-rank p = .01). In addition, the AF-free survival rates were similar between the ASD-CA group and 80 paroxysmal AF patients who underwent CA without any detectable structural heart disease (non-SHD-CA group). The two groups were matched by propensity scores for age, sex, and left atrium dimension (ASD-CA group: 2 patients vs. non-SHD-CA group: 5 patients; follow-up period: 3.3 ± 1.8 years; log-rank p = .28).

CONCLUSION

CA for AF before ASD device closure might be an effective treatment option for patients with paroxysmal AF and ASD.

Elaborate evaluation of serial changes in electrocardiograms of atrial septal defects after transcatheter closure for a better understanding of the recovery process

Serial changes of electrocardiograms (ECG) could be used to assess their clinical features in atrial septal defects (ASD) after transcatheter closure together with other clinical parameters. We retrospectively studied 100 ASD patients who underwent transcatheter closure. Complications of persistent atrial fibrillation occurred in five ASD patients, and they were excluded. We divided the other 95 patients according to PQ intervals before closure (normal: < 200 ms, n = 51; prolonged: ≥ 200 ms, n = 44) to evaluate their clinical characteristics and parameters such as echocardiography, chest X-rays, and brain natriuretic protein (BNP) levels. Individuals in the prolonged PQ group were significantly older, had higher incidences of paroxysmal atrial fibrillation (PAF) and heart failure (HF) treated with more β-blockers and diuretics, and with a higher tendency of NYHA functional classification and BNP levels than the normal PQ group. The prolonged PQ group also had a significantly higher incidence of complete right bundle branch block, wider QRS intervals, and larger cardiothoracic ratios in chest X-rays accompanied by larger right atrial-areas and larger left atrial dimensions in echocardiograms. Furthermore, the prolonged PQ intervals with less PQ interval shortening after transcatheter closure revealed that the patients were the oldest at the time of closures and showed less structural normalization of the right heart and left atrium after ASD closure. PAF and HF also occurred more frequently in this subgroup. These results suggested that the ASD patients with prolonged PQ intervals with less PQ shortening were accompanied by more advanced clinical conditions. Together with other clinical parameters, detailed analyses of ECG and their changes after closure could elucidate the clinical characteristics and status of ASD patients with transcatheter closure and were useful for predicting structural normalization after transcatheter closure.

Impact of Transcatheter Device Closure of Atrial Septal Defect on Atrial Arrhythmias Propensity in Young Adults

Atrial septal defect (ASD) is a condition that requires early intervention because of the consequences over the right-side heart. Chronic atrial stretching promotes atrial conduction delay and the imbalance of the conduction homogeneity, which lead to the propensity to atrial arrhythmias (AA). We aim to evaluate the impact of transcatheter closure of ASD on atrial vulnerability markers leading to late AA in young adults. We conducted a prospective, longitudinal study in one hundred patients (mean age 25.2 ± 5.4 years) who underwent transcatheter closure of ASD at Cardiocentro Pediátrico William Soler. P-wave maximum (P_max) and P-wave dispersion (P_d) were analyzed from 12-lead electrocardiogram. Left-side and right-side intraatrial and interatrial electromechanical delay (EMD) were measured with tissue Doppler imaging. Both electrocardiographic and echocardiographic analyses were performed during the study period. Compared to baseline, there was a significant reduction in P max (p ≤ 0.001) and P_d (p ≤ 0.001) after 3 months of procedure. All atrial electromechanical coupling parameters significantly reduced at 6 months of ASD closure and tend to remain at lower values till the last evaluation. Over 9.2 ± 1.6 years of follow-up, 15 subjects (15%) developed AA, of which intraatrial reentrant tachycardia (66.6%) became the main rhythm disturbance. Intra-right atrial EMD ≥ 16 ms (HR 4.08, 95% CI 1.15-14.56; p = 0.03) and P_d 45 ms (HR 1.66, 95% CI 1.06-2.59; p = 0.02) were identified as predictors of late AA. Transcatheter device closure of ASD in young adults promotes a significant reduction of electrocardiographic and echocardiographic markers of AA vulnerability, which persist during the long-term follow-up. Nevertheless, P_d and interatrial EMD were identified as independent risk factors of AA.

Efficacy of catheter ablation for paroxysmal atrial fibrillation in patients with atrial septal defect: a comparison with transcatheter closure alone

Aims

There is no valid treatment strategy for addressing paroxysmal atrial fibrillation (AF) in patients with unclosed atrial septal defect (ASD). We aimed to assess the efficacy of catheter ablation (CA) compared with transcatheter ASD closure alone for treating pre-existing paroxysmal AF in patients with ASD.

Methods and results

Among 908 patients who underwent transcatheter ASD closure, we evaluated 50 consecutive patients (63 ± 12 years) with paroxysmal AF. We compared the AF outcomes of these patients after transcatheter ASD closure between those with and without CA prior to ASD closure. Thirty (60%) patients underwent CA. During the follow-up period after ASD closure (mean: 49 ± 23 months), recurrence of AF was observed in 6/30 (20%) patients with upfront CA and 12/20 (60%) patients with ASD closure alone. Kaplan–Meier analysis showed that the AF-free survival rate was significantly higher for patients with CA than for those with ASD closure alone (79% vs. 37% at 5 years, P = 0.002). Upfront CA and previous heart failure hospitalization were associated with recurrence of AF after ASD closure [hazard ratio (HR) 0.18, 95% confidence interval (CI) 0.06–0.53; P = 0.002 and HR 4.64, 95% CI 1.60–13.49; P = 0.005, respectively].

Conclusion

In ASD patient with paroxysmal AF, transcatheter ASD closure alone demonstrated high AF recurrence rate after ASD closure. On the other hand, upfront CA prior to ASD closure substantially suppressed AF recurrence over the long term. A combination of CA and transcatheter ASD closure may be a feasible treatment strategy for paroxysmal AF in patients with ASD.

Electrical remodeling after percutaneous atrial septal defect closure in pediatric and adult patients

BACKGROUND

Several studies have reported changes in electrocardiographic variables after atrial septal defect (ASD) closure. However no temporal electro-and vectorcardiographic changes have been described from acute to long-term follow-up at different ages. We aimed to study electrical remodeling after percutaneous ASD closure in pediatric and adult patients.

METHODS

ECGs of 69 children and 75 adults (median age 6 [IQR 4-11] years and 45 [IQR 33-54] years, respectively) were retrospectively selected before percutaneous ASD closure and at acute (1-7 days), intermediate (4-14 weeks) and late (6-18 months) follow-up. Apart from electrocardiographic variables, spatial QRS-T angle and ventricular gradient (VG) were derived from mathematically-synthesized vectorcardiograms.

RESULTS

In both pediatric and adult patients, the heart rate decreased immediately post-closure, which persisted to late follow-up. The P-wave amplitude also decreased acutely post-closure, but remained unchanged at later follow-up. The PQ duration shortened immediately in children and at intermediate follow-up in adults. The QRS duration and QTc interval decreased at intermediate-term follow-up in both children and adults. In both groups the spatial QRS-T angle decreased at late follow-up. The VG magnitude increased at intermediate follow-up in children and at late follow-up in adults, after an initial decrease in children.

CONCLUSION

In both pediatric and adult ASD patients, electrocardiographic changes mainly occurred directly after ASD closure except for shortening of QRS duration and QTc interval, which occurred at later follow-up. Adults also showed late changes in PQ duration. At 6-to-18 month post-closure, the spatial QRS-T angle decreased, reflecting increased electrocardiographic concordance. The initial acute decrease in VG in children, which was followed by a significant increase, may be the effect of action potential duration dynamics directly after percutaneous ASD closure.

Immediate and short term effects of percutaneous atrial septal defect device closure on cardiac electrical remodeling in children

Background

The beneficial effects of atrial septal defect (ASD) device closure on electrical cardiac remodeling are well established. The timing at which these effects starts to take place has yet to be determined.

Objectives

To determine the immediate and short term effects of ASD device closure on cardiac electric remodeling in children.

Methods

30 pediatric patients were subjected to 12 lead Electrocardiogram immediately before ASD device closure, 24 h post procedure, 1 and 6 months after. The maximum and minimum P wave and QT durations in any of the 12 leads were recorded and P wave and QT dispersions were calculated and compared using paired T test.

Results

The immediate 24 h follow up electrocardiogram showed significant decrease in P maximum (140.2 ± 6 versus 130.67 ± 5.4 ms), P dispersion (49.73 ± 9.01 versus 41.43 ± 7.65 ms), PR interval (188.7 ± 6.06 ms versus 182.73 ± 5.8 ms), QRS duration (134.4 ± 4.97 ms versus 127.87 ± 4.44), QT maximum (619.07 ± 15.73 ms versus 613.43 ± 11.87), and QT dispersion (67.6 ± 5.31 versus 62.6 ± 4.68 ms) (P = 0.001). After 1 month all the parameters measured showed further significant decrease with P dispersion reaching 32.13 ± 6 (P = 0.001) and QT dispersion reaching 55.0 ± 4.76 (P = 0.001). These effects were maintained 6 months post device closure.

Conclusion

Percutaneous ASD device closure can reverse electrical changes in atrial and ventricular myocardium as early as the first 24 h post device closure.

Comparison of primary repair and patch plasty procedure on the P wave in adult atrial septal defect closure

Introduction:

In this study we compared the effects of two different surgical procedures for closure of adult atrial septal defect (ASD) on postoperative P-wave changes.

Methods:

Patients who underwent cardiac surgery for secundum type ASD closure were evaluated retrospectively. Seventy-two patients with primary repair of ASD and 29 patients with pericardial patch plasty repair were compared according to P_max, P_min and P-wave dispersions (P_d).

Results:

In each group, the increases in postoperative maximum P-wave duration (P_max) and minimum P-wave duration (P_min) were statistically significant. There was no statistically significant difference between post- and pre-operative P_d values. In the comparison between group 1 and group 2 in terms of postoperative P-wave changes (P_max, P_min, P_d) there was no statistically significant difference.

Conclusion:

Comparing patch plasty and primary repair for the surgical closure of ASD in the early to mid-postoperative period, no difference was found and both surgical procedures can be performed in adult ASDs.

Longitudinal evaluation of P-wave dispersion and P-wave maximum in children after transcatheter device closure of secundum atrial septal defect

Transcatheter device closure of the secundum atrial septal defect (ASD) in children prevents atrial arrhythmias in older age. However, the benefits of favourable atrial electrocardiographic markers in these children remain elusive. We aimed to review the electrocardiographic markers of atrial activity in a longitudinal fashion. We retrospectively reviewed longitudinal data of all children who underwent transcatheter device closure at the National University Hospital between 2004 and 2013. The inclusion criteria included the presence of a secundum-type ASD with left to right shunt and evidence of increased right ventricular volume load (Q p/Q s ratio >1.5 and/or right ventricular dilatation). A total of 25 patients with a mean follow-up of 44.7 ± 33.47 (7.3-117.4) months were included. P maximum and P dispersion decreased at 2 months, P amplitude at 1 week and remained so until last follow-up. A positive trend was seen with a correlation coefficient of +0.12 for P maximum, +0.08 for P dispersion and 0.34 for P amplitude. There was a higher baseline P amplitude and P dispersion in patients who were older than 10 years and a non-significant trend to support an increase in both P maximum (71.0 ± 8.8 vs. 73.2 ± 12.7), P dispersion (17.0 ± 6.5 vs. 22.0 ± 11.3) and P amplitude (0.88 ± 0.25 vs. 1.02 ± 0.23) in patients with an ASD more than 15 mm compared with an ASD <15 mm. There is reduction in both P maximum and P dispersion as early as 2 months, which persisted on follow-up. Earlier closure may result in more favourable electrocardiographic results.

Pathophysiology and Management of Arrhythmias Associated with Atrial Septal Defect and Patent Foramen Ovale

Atrial septal defects (ASDs) are among the most common of congenital heart defects and are frequently associated with atrial arrhythmias. Atrial and ventricular geometrical remodelling secondary to the intracardiac shunt promotes evolution of the electrical substrate, predisposing the patient to atrial fibrillation and other arrhythmias. Closure of an ASD reduces the immediate and long-term prevalence of atrial arrhythmias, but the evidence suggests that patients remain at an increased long-term risk in comparison with the normal population. The closure technique itself and its timing impacts future arrhythmia risk profile while subsequent transseptal access following surgical or device closure is complicated. Newer techniques combined with increased experience will help to alleviate some of the difficulties associated with optimal management of arrhythmias in these patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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