Comparison between transcatheter and surgical closure of secundum atrial septal defect in children and adults: results of a multicenter nonrandomized trial

Secundum atrial septal defects in adults: all you need to know with an emphasis on outcome

INTRODUCTION

Atrial septal defect is the most common congenital heart disease in adults. The secundum defect is the most common anatomical variant. Atrial septal defect usually causes subtle or no symptoms in pediatrics. However, as patients age, the left-to-right shunt increases and more symptoms appear. Atrial septal defect closure is indicated when there is a clinically significant left-to-right shunt, either by echocardiographic data in terms of right-sided dilation, hemodynamic parameters with Qp:Qs ratio over 1.5:1, or the appearance of clinical symptoms.

AREAS COVERED

This article reviews secundum atrial septal defects (ASD) with emphasis on device closure outcome in comparison to surgical approaches. The article covers ASD anatomy, pathophysiology, clinical presentation, natural history, imaging evaluation, indications for closure, suitability for transcatheter closure, and outcome of both device closure and surgical closure in the adult patients.

EXPERT OPINION

Atrial septal defect closure can be performed either via a transcatheter approach or a surgical approach. The transcatheter approach is preferred worldwide to close secundum ASDs, provided they meet certain anatomical criteria (size and rim sufficiency). The transcatheter approach is more cost-effective, requires a shorter hospital stay, and has similar outcomes with a lower incidence of complications.

The pathogenic role of calcitonin gene-related peptide and predictors of new-onset migraine and long-term outcomes after transcatheter atrial septal defect closure

OBJECTIVE

To evaluate factors associated with new-onset migraine (NOM) after transcatheter atrial septal defect (ASD) closure and predictors of unremitting NOM. The pathogenic role of migraine biomarkers such as calcitonin gene-related peptide (CGRP) and neuropeptide Y (NPY) were also assessed.

BACKGROUND

New-onset migraine has been observed after transcatheter ASD closure. Neuropeptides like CGRP and NPY stored both in the brain and heart are implicated in migraine pathophysiology. The potential role of those migraine biomarkers in NOM, as well as the risk factors and long-term outcomes of NOM, remain largely unknown.

METHODS

We enrolled patients without previous migraine who underwent successful transcatheter ASD closure between 2001 and 2013. The parameters of transthoracic echocardiography, and plasma CGRP and NPY levels measured by enzyme-linked immunosorbent assay, were collected prospectively before and after ASD closure, and compared between patients with NOM and those without. Predictors of NOM were assessed. Telephone interviews were performed in 2022 to assess migraine status. Clinical and procedural characteristics were compared between patients with unremitting migraine and those with transient migraine that remitted within 1 year.

RESULTS

Of the 212 patients (median age, 21 years; 75.9% female), 43 (20.3%) had NOM. Potential predictors of NOM included a young age (adjusted odds ratio [aOR] 0.98, 95% confidence interval [CI] 0.96-0.99; p = 0.040), large ASD size (aOR 1.07, 95% CI 1.01-1.14; p = 0.022), and transient residual shunting after closure (aOR 2.78, 95% CI 1.05-7.36; p = 0.039). Post-closure plasma CGRP levels, but not NPY levels, were significantly higher than pre-closure levels (47.9 vs. 38.0 pg/mL, p = 0.023) among patients with NOM. Of the 27 patients with migraine who reported their migraine status at a median 14-year follow-up, 13 (48.1%) had unremitting migraine. Patients with unremitting migraine were more likely to have a smaller device-to-ASD size ratio (1.21 vs. 1.33, p = 0.039) and a larger pulmonary flow-to-systemic flow ratio (2.9 vs. 2.3, p = 0.012) than those with transient migraine.

CONCLUSIONS

Calcitonin gene-related peptide may play a pathogenic role in NOM after transcatheter ASD closure. A young age, large ASD size, and transient residual shunting potentially predict migraine occurrence after ASD closure. NOM not reaching remission for years may result from a significant shunt before closure.

Endoscopic Delivery of a Double-Umbrella-Shaped Hydrogel Occluder with Instant Mechanical Interlock and Robust Wet Adhesion for Gastric Perforation Repair

Achieving robust adhesion of bioadhesives on wet tissues to block gastric perforation remains a challenge due to the gradually deteriorated adhesive-tissue interactions by interfacial acidity and multienzyme gastric fluids, thus accompanying failure shedding and life-threatening risks. Here, we report a biocompatible double-umbrella-shaped endoscopy-deliverable hydrogel occluder (EHO) made of caffeic acid (CA)-grafted chitosan (CS) and polyacrylamide (PAM) by molding technique, which is capable of the customizable, rapid, robust, and long-term sealing of large gastric perforations. In addition to interfacial physiochemical interactions (e.g., H-bonding, chelation) between the tissues and polymers, efficient sealing also integrates the advantages of fast mechanical interlocking in space and gradual self-expansion over time to tolerant acidic and mechanically dynamic environments. The EHO exhibits favorable biodegradability due to the reducible disulfide cross-linkers and remarkable protective barrier functions to impede the infiltration of gastric acid and digestive pepsin into the wound. To validate EHO's therapeutic efficacy, we further demonstrate the robust in vivo sealing to large gastric tissues via endoscopic delivery to the porcine stomach and monitor of healing process with improved retention of endogenous growth factors. Besides, in views of simple hydrogel fabrication using molding technique, the biodegradable EHO can be facilely tailored with various topologies according to application scenarios in surgical and minimally invasive endoscopic delivery, thus offering a promising alternative for clinical repair of gastrointestinal perforations and other organs.

Biodegradable polymeric occluder with controllable locking structure for closure of atrial septal defect via interventional treatment

Atrial septal defect (ASD) is one of the major congenital heart diseases, and transcatheter closure with a cardiac occluder is a modern method to treat ASD with the advantage of mini-invasiveness over traditional surgical closure. While current occlusion devices are mainly made of non-degradable nitinol with superelasticity, the permanent existence of a metal in vivo may trigger potential complications and especially has an adverse effect on the heart development for children. However, it is challenging to invent a superelasticity-free occluder that can be delivered through a catheter but firmly locked after being opened at the target site; it is also much desired for research and development to quickly assess the feasibility of a superelasticity-free occluder in vitro. Herein, a biodegradable poly(L-lactide) (PLLA) occluder composed of a braided PLLA frame as the skeleton and a nonwoven PLLA fabric as the flow-blocking membrane is developed, and a controllable locking structure is designed to enable firm closure for a device even without superelasticity. We also suggest and justify a series of in vitro methods to assess the efficacy of the biodegradable occluder, and the results confirm the reliability of locking, water-blocking, mechanical strength and degradability. It is found that the PLLA fabric with moderate fiber density is optimal for surface endothelialization. We also carry out biological assessments; significant endothelialization and alleviated inflammation response are observed after 6 months of subcutaneous implantation into rabbits. The porcine model illustrates that the biodegradable polymeric occluder can be successfully implanted into the atrial septum via transcatheter intervention; the follow-ups have confirmed the safety and efficacy of this biodegradable polymeric occluder with the controllable locking structure.

Covered Stent Correction for Sinus Venosus Atrial Septal Defects, an Emerging Alternative to Surgical Repair: Results of an International Registry

BACKGROUND

Covered stent correction for a sinus venosus atrial septal defect (SVASD) was first performed in 2009. This innovative approach was initially viewed as experimental and was reserved for highly selected patients with unusual anatomic variants. In 2016, increasing numbers of procedures began to be performed, and in several centers, it is now offered as a standard of care option alongside surgical repair. However, covered stent correction for SVASD is not recognized by regulatory authorities, and in the minds of many pediatric and adult congenital cardiologists and surgeons, the condition is viewed as treatable only by cardiac surgery with cardiopulmonary bypass.

METHODS

In April 2023, all centers identified from international conferences, publications, and colleague networks to be undertaking covered stent correction for SVASD were invited to participate in a retrospective audit of their procedures.

RESULTS

Data were received on 381 patients from 54 units over a 12-year period with 90% of procedures being performed over the past 5 years. Balloon-expandable stents (8 types) were used in the majority; self-expanding stents (4 types) were used in 4.5%. The commonest stent was the 10-zig covered Cheatham Platinum stent in 62% of cases. In 10 procedures, the stent embolized requiring surgical retrieval and repair of the defect, resulting in technically successful implantation in 371 of 381 (97.4%). Major complications (surgical drainage of tamponade, pacemaker implantation, surgery for pulmonary vein occlusion, and late stent removal) occurred in 5 patients (1.3%). Repeat catheterization to correct residual leaks was required in 7 patients (1.8%). Thus, 359 of 381 patients (94.2%) had successful correction without major complications or additional catheter interventions.

CONCLUSIONS

This article details the exponential uptake of covered stent correction for SVASD during the past 5 years. Cardiopulmonary bypass was avoided in the majority of patients, and major complications were infrequent. Prospective registries with standardized definitions, inclusion criteria, and follow-up and comparative studies with surgery are now required to help support the extension of covered stent correction as an alternative standard-of-care option for patients with an SVASD.

A Comparison of Long-Term Right Ventricular Functions in Children with Transcatheter and Surgically Closed Secundum Atrial Septal Defects (ASDs): A Strain Echocardiography Study

Background/Objectives: Secundum-type atrial septal defect (ASD) is one of the most common congenital heart defects, with an incidence of 5.64 per 10,000 live births worldwide. In our study, long-term follow-up results of children who underwent percutaneous ASD closure and patients who underwent surgical treatment were evaluated using right ventricular strain echocardiography and electrocardiography. Methods: 30 patients who underwent transcatheter ASD closure and 30 patients provided with surgical ASD closure were prospectively compared with 50 healthy children with similar demographic characteristics. ECG and transthoracic echocardiography were performed for all patients. The evaluated echocardiography variables are Tricuspid annular plane systolic excursion (TAPSE), 2D right ventricle (RV) and right atrium (RA) dimensions, right ventricular segmental longitudinal strain, and global longitudinal strain. ECG evaluation was performed especially in terms of QRS duration and its correlation with strain echo measurements. Results: The surgical treatment group has statistically significant ASD size compared to patients who underwent transcatheter closure (20 ± 3.6 and 14.87 ± 3.7 mm, p < 0.001). Patients who had surgical treatment have increased RA and RV diameters, and a statistically significant decrease was observed in right ventricular free-wall longitudinal strain and right ventricular four-chamber longitudinal strain compared to patients in transcatheter and the control group (p < 0.001). QRS durations were similarly normal in electrocardiography in the transcatheter and the control groups, and the QRS duration was observed as statistically significantly increased in the patients in the surgical treatment group (p < 0.001). Conclusions: Strain values of the patients who underwent surgical closure were lower, and the QRS values on the ECG were longer, compared to the transcatheter group, which is an indicator that a large ASD diameter has a negative effect on long-term right ventricular function. With this in mind, we argue that early surgical closure is an appropriate treatment option for children whose ASD is large for their age and who are not suitable candidates for transcatheter treatment.

Air embolism during unsuccessful transcatheter closure of secundum atrial septal defect in a patient with an undetected left-sided inferior vena cava

A 46-year-old man with a history of secundum atrial septal defect and interstitial lung disease was admitted to the hospital for a planned transcatheter closure of the atrial septal defect. Following multiple failed attempts to place a right femoral vein catheter, the procedure was aborted. Another attempt was made to the left femoral vein, but that attempt was complicated by an unfamiliar resistance. Even though resistance was met during insertion, the catheter was further inserted until a position in the inferior vena cava above the liver was obtained at fluoroscopy. Simultaneously, the patient became unresponsive. The procedure was immediately aborted and the atrial septal defect closure was not completed. Air embolism to the heart and brain was detected using echocardiography and computed tomography. The patient died 15 days after the procedure. Death was attributed to severe cerebral edema due to air embolism. The autopsy revealed a left-sided inferior vena cava. This case report demonstrates that unexpected congenital vascular anomalies complicating a routine transcatheter closure of the atrial septal defect can result in a fatal outcome.

Percutaneous atrial septal defect closure in limited-resource setting: a decade-long experience from Ethiopia

Introduction

Secundum Atrial septal defect (ASD) is the most common type of ASD. When it is large and hemodynamically significant, it can cause symptoms such as dyspnea, exercise intolerance, and palpitations. Following diagnosis confirmation, an ASD with hemodynamic significance should be closed electively. Percutaneous closure (PC) is an effective treatment option for ostium secundum ASD with adequate rims, despite the potential for several complications. This is the first study in Ethiopia and sub-Saharan Africa to report on percutaneous closure of secundum atrial septal defects (ASD) in children, adolescents, and adults. The study assessed the clinical characteristics, immediate and in-hospital outcomes, and complication rates following PC of secundum ASD.

Methodology

his follow-up study, conducted between October 2023 and January 2024, involved 99 patients who underwent percutaneous closure (PC) of ASD at the Cardiac Center of Ethiopia between January 2013 and January 2023. The patients were divided into two groups based on age: Group 1 included children and adolescents (≤18 years of age; n = 42), while Group 2 consisted of adults (>18 years of age; n = 57), at the time of device percutaneous closure. The median and interquartile range was used to describe continuous variables. The absolute frequency and percentages were used to describe the categorical variables. The data were shown using tables and graphs. Baseline characteristics of patients of ≤18 years vs. >18 years were compared using the Mann-Whitney U-test for continuous variables and the Chi-square or Fisher exact test for categorical data.

Results

There was a female predominance with female to male ratio of 1.3. Compared to Group 1 (children and adolescents of age ≤ 18 years), more patients in Group 2(adults of age > 18 years) experienced symptoms (p-value < 0.001). The most common symptoms in adults were easy fatigability and dyspnea (63.2% of adult patients), while the most common symptom in children was recurrent respiratory tract infections (23.8%). Patients in Group 2 had greater pulmonary artery systolic pressure than those in Group 1 (p-value < 0.001). Overall, 88.9% of patients attained immediate success; there was no statistically significant difference between the two groups in immediate success rate (p = 0.52; Group 1 85.7% vs. Group 2 91.2%). Overall, patients' median length of hospital stay was 2 days (IQR, 2-2.5 days). There was no statistically significant difference between the two groups' median hospital stays [Group 1: 2 (IQR, 2-2.5) and Group 2: 2.5 (IQR 2-2.5); P-value = 0.111]. 23.2% of patients experienced complications, with no significant difference between the two groups (Group 1 28.6% and Group 2 19.3%, p = 0.28). The most common complications for patients in Groups 1 and 2 were atrioventricular (AV) valve encroachment (4.8) and paroxysmal supraventricular tachycardia (SVT) (5.3%), respectively. The major complication rates in the two groups did not show a statistically significant difference. Group 1 had a rate of 4.8%, whereas Group 2 had a rate of 0% (p-value = 0.18). The length of stays significantly increased in both groups in the presence of complications (p-value < 0.001).

Conclusion

This study emphasized that Percutaneous Closure of ASD can be successfully performed in resource-limited settings with a high immediate success rate and minimal complications such as AV valve encroachment and paroxysmal SVT. Given that complications impact length of hospital stays, preventing them is crucial.

Evaluating Procedural Performance: A Composite Outcome for Atrial Septal Defect and Patent Ductus Arteriosus Closures

Background

Technical success (TS) and procedural safety (PS) have been reported individually for transcatheter atrial septal defect (ASD) and patent ductus arteriosus (PDA) closures. A composite procedural performance (PP) metric as a patient-centered strategy has not been developed or studied.

Methods

A multicenter expert working group created PP metrics for ASD and PDA device closures as a composite of TS and PS. TS criteria were defined and categorized into 3 classes (optimal, satisfactory, and unsatisfactory). PS was defined using established adverse event (AE) definitions from the Congenital Cardiac Catheterization Project on Outcomes (C3PO) registry. PP was divided into 3 outcome classes (I to III). Retrospective C3PO data were collected for all cases of isolated ASD and PDA closure from 2014 through 2017. Exclusion criteria included complex congenital heart disease, significant comorbidities, ASD patients with multiple defects or ≥2 deficient rims, and PDA patients weighing <6 kg or with pulmonary hypertension. Factors correlating with class III (suboptimal) PP were analyzed.

Results

A total of 542 ASD and 688 PDA closure cases were included. Most ASD cases (99%) had optimal or satisfactory TS while 1% had a high severity AE. Class III PP occurred in 2% of ASD cases, mostly due to new mitral valve insufficiency. There were no identified patient or procedural factors associated with class III PP for ASD closures. Optimal or satisfactory TS occurred in 98% of PDA cases, with high severity AEs in <1%. Class III PP occurred in 2% of PDA cases, predominantly due to new arch obstruction, and was associated with younger age (P < .001) and lower weight (P = .001).

Conclusions

This study introduces PP as a composite variable to comprehensively measure outcomes of standard-risk ASD and PDA device closure. The incorporation of both TS and PS aims to better reflect patient outcomes compared to individual measurements alone. PP may serve as a valuable tool for identifying areas for further investigation and quality improvement.

Interventions for adult congenital heart disease

Advances in imaging diagnostics, surgical techniques and transcatheter interventions for paediatric patients with severe congenital heart disease (CHD) have substantially reduced mortality, thereby extending the lifespan of these individuals and increasing the number of adults with complex CHD. Transcatheter interventions have emerged as an alternative to traditional open-heart surgery to mitigate congenital defects. The evolution of techniques, the introduction of new devices and the growing experience of operators have enabled the treatment of patients with progressively more complex conditions. The general cardiology community might be less aware of contemporary interventions for adult CHD, their clinical indications and associated outcomes than interventional cardiologists and congenital heart specialists. In this Review, we provide a comprehensive evaluation of the available transcatheter interventions for adult patients with CHD.

Secundum atrial septal defect closure in adults in the UK

AIMS

To examine determinants of access to treatment, outcomes, and hospital utilization in patients undergoing secundum atrial septal defect (ASD) closure in adulthood in England and Wales.

METHODS AND RESULTS

Large retrospective cohort study of all adult patients undergoing secundum ASD closures in England and Wales between 2000/01 and 2016/17. Data were from population-based official data sets covering congenital heart disease procedures, hospital episodes, and death registries. Out of 6541 index closures, 79.4% were transcatheter [median age 47 years, interquartile range (IQR) 34-61] and 20.6% were surgical (40 years, 28-52). The study cohort was predominantly female (66%), with socioethnic profile similar to the general population. Mortality in hospital was 0.2% and at 1 year 1.0% [95% confidence interval (CI) 0.8-1.2%]. Risk of death was lower for transcatheter repairs, adjusting for age, sex, year of procedure, comorbidities, and cardiac risk factors [in-hospital adjusted odds ratio 0.09, 95% CI 0.02-0.46; 1-year adjusted hazard ratio 0.5, 95% CI 0.3-0.9]. There was excess mortality 1 year after ASD closure compared with matched population data. Median (IQR) peri-procedural length of stay was 1.8 (1.4-2.5) and 7.3 (6.2-9.2) days for transcatheter and surgical closures, respectively. Hospital resource use for cardiac reasons started the year before repair (median two inpatient and two outpatient-only days) and decreased post-repair (zero inpatient and one outpatient days during the first 2 years).

CONCLUSION

This national study confirms that ASD closure in adults, by surgical or transcatheter methods, is provided independently of ethnic or socioeconomic differences, it is low (but not no) risk, and appears to reduce future cardiac hospitalization even in older ages.

An Amplatzer Septal Occluder Trapped in the Left Ventricular Outflow Tract: A Case Report

We present the case of a 32-year-old female patient who presented at the cardiology consultation with shortness of breath and palpitations. A large inter-atrial defect was identified through echocardiography, prompting the cardiology team to perform a percutaneous closure procedure using the Amplatzer Atrial Septal Occluder (Abbott Laboratories, Abbott Park, IL, USA). Seven weeks later, a migration of the prosthetic device into the left ventricular outflow tract was diagnosed. A surgical procedure was immediately performed to explant the device and repair the defect. This case highlights the importance of vigilant monitoring in patients undergoing percutaneous closure procedures to detect severe complications such as device migration at an earlier stage.

Iatrogenic atrial septal defects in structural heart interventions: Opening the Pandora's box

In the modern era of structural heart interventions, the total number of transseptal procedures is growing exponentially, thus increasing the rate and need for management of iatrogenic atrial septal defects (iASDs). To date, there are no official guidelines on the assessment and management of iASDs, due to inconclusive evidence on whether patients benefit more from the percutaneous closure of iASD than from conservative management and vigorous follow-up. Despite the abundance of observational studies on iASDs, there is still a lack of randomized studies. Evidence so far show that percutaneous closure is no superior over conservative treatment in patients with iASDs, however, it has been demonstrated that patients with spontaneous closure of iASDs experience less heart failure (HF) hospitalizations. On the other hand, researchers have investigated the beneficial nature of interatrial shunt therapy in patients with HFpEF and, more recently, with HFrEF, due to the presumed hemodynamic benefits. Herein, we provide an updated review of relevant literature, focusing on iASD persistence rates, predicting factors for their persistence, and clinical outcomes of iASD persistence, to summarize available evidence and discuss future directions in the field.

Safety and feasibility of transcatheter closure of atrial septal defects in small children weighing less than 10 kg

BACKGROUND

When young patients with an oval fossa defect present early with symptoms of heart failure and pulmonary hypertension, surgical treatment is recommended in small bodyweight rather than transcatheter closure.

METHODS

Outcomes of device closure in consecutive symptomatic children weighing under 10 kg were compared with young children aged below 4 years but weighing above 10 kg. Transthoracic echocardiography under conscious sedation guided the procedure in all without need for balloon sizing, transesophageal echocardiogram, and intubation anaesthesia. Symptoms, anthropometry, shunt ratio, pulmonary pressures, defect and device size, percentage oversizing, device/body weight ratio, complications, and post-procedural growth spurt were compared.

RESULTS

Ninety-six patients weighing under 10 kg were compared with 160 patients weighing above 10 kg. In total, 83.3% of patients in the study group and 25% of controls were severely malnourished. The median indexed defect size was 35.2 mm/sq.m and 27.4 mm/sq.m, and the device was oversized by 8.7% and 14.2% in the study group and controls, respectively. The device/body weight ratio was 1.93 in study group and 1.4 in controls. Procedure was successful in all except one patient weighing under 10 kg who had a device embolisation. Both groups showed significant growth spurts and proportion, with severe malnutrition reduced to 42% and 11% in the two groups.

CONCLUSIONS

Device closure was feasible and safe in patients under 10 kg. Transthoracic echocardiographic imaging on conscious sedation provided adequate guidance. Symptoms and growth significantly improved after intervention. Despite a larger defect size, smaller patients had comparable outcomes. In symptomatic children under 10 kg needing early closure, transcatheter intervention should not be deferred.

Long-Term Results of the Atrial Septal Defect Occluder ASSURED Trial for Combined Pivotal/Continued Access Cohorts

BACKGROUND

The GORE CARDIOFORM ASD Occluder (GCA, W. L. Gore & Associates) was approved in 2019 for ostium secundum atrial septal defect (ASD) closure.

OBJECTIVES

This study sought to report the combined pivotal and continued access cohorts of the ASSURED (Safety and Efficacy Study of Transcatheter Closure of Ostium Secundum ASDs) trial results through 36 months.

METHODS

This prospective, multicenter, single-arm trial evaluated procedural and clinical outcomes of ASD closure with the GCA. The primary endpoints were 6-month closure success following device implantation and composite clinical success (deployment/retention of device, safety, and closure). Technical and procedure success, safety, clinically significant new arrhythmia (CSNA) secondary endpoints, and wire frame fracture (WFF, with fluoroscopy) at 6 and 36 months were evaluated.

RESULTS

Of 569 patients (median age of 10.4 years and median weight of 35.0 kg) who underwent attempted secundum ASD closure, 526 were technical successes. The mean stop-flow ASD diameter was 17.6 ± 5.3 mm. All 478 patients with 6-month imaging achieved closure success. Composite clinical success at 6 and 36 months was achieved in 87.6% (468/534) and 84.0% (351/418) of patients, respectively. Technical failure occurred in 8.1% (43/548), 30-day device- or procedure-related serious adverse event in 3.9% (21/534), and 6-month device events in 2.8% (15/534) of patients. At 30 days, 21 of 569 patients (3.7%) had CSNA. At 6 months, 138 of 436 (31.7%) patients had WFFs and 105 of 185 (56.8%) at 36 months (without sequelae).

CONCLUSIONS

In this large congenital ASD device trial, the GCA had acceptable results. WFFs, although common, did not result in any clinical sequelae. The unique features, size range, and safety profile expand the options for secundum ASD closure. (Safety and Efficacy Study of Transcatheter Closure of Ostium Secundum ASDs [ASSURED]; NCT02985684).

Right thoracotomy with central cannulation for valve surgery: 10 years of experience

BACKGROUND

The aim of this study is to report the early outcomes of valvular heart surgeries performed via the right thoracotomy approach. While thoracotomy with femoro-femoral bypass is an established method for minimally invasive open-heart surgeries, thoracotomy with conventional cannulation is still being explored. In our center, we conducted 958 valvular heart surgery cases using the right anterolateral thoracotomy approach with central cannulation and data were analyzed.

METHODS

This is a retrospective observational study based on prospectively collected data from patients who underwent valvular heart surgery at our center spanning from April 2013 to April 2023. The data encompass demographics, procedures, operative techniques, post-operative morbidity, mortality, and a 1-month follow-up.

RESULTS

Our study revealed no procedure-related mortality. No patient required conversion to median sternotomy. Smooth cannulation and satisfactory exposure were achieved in all patients. The study encompassed a wide age range, from 14 to 68 years, with 618 female patients (64.5%) and 340 male patients (35.5%). The average cross-clamp time ranged from 38 to 90 min, the duration of cardio-pulmonary bypass ranged from 45 to 105 min, post-operative extubation ranged from 3 to 8 h, the average drain volume ranged from 100 to 350 ml, and the incision size ranged from 5 to 7 cm.

CONCLUSIONS

Our data demonstrate that conventional cannulation via the right antero-lateral thoracotomy approach for valvular heart disease is a viable alternative to reduce the side effects associated with sternotomy and femoral cannulation. This procedure is safe, reproducible, and provides the same level of treatment quality.

Efficacy and Safety of Transthoracic Versus Transesophageal Echocardiography for Monitoring Closure of Atrial or Ventricular Septal Defects: A Systematic Review and Meta-Analysis

PURPOSE

For the repair of atrial/ventricular septal defects (ASD/VSD), transthoracic echocardiography (TTE) is easy to perform, cost-effective, and does not require general anesthesia and intubation. Still, TTE is not universally accepted. To compare efficacy and safety of TTE versus transesophageal echocardiography (TEE) to guide percutaneous ASD/VSD closure.

METHODS

PubMed, Embase, and the Cochrane library were searched for articles published from their inception to December 2023. The primary outcome was the procedural success rate. The secondary outcomes were residual shunt, late complications, procedure time, and fluoroscopy time. All meta-analyses were performed using a random-effects model.

RESULTS

Eight studies and 1295 patients were included. There were no significant differences between TTE and TEE regarding the procedural success rate (OR = 1.93, 95% CI: 0.90-4.13, p = 0.092; I2 = 52.2%, Pheterogeneity = 0.063) and residual shunt rate (OR = 0.81, 95% CI: 0.38-1.76, p = 0.600; I2 = 0%, Pheterogeneity = 0.518). Compared with TEE, TTE reduced the frequency of late complications (OR = 0.25, 95% CI: 0.14-0.43, p < 0.001; I2 = 13.8%, Pheterogeneity = 0.326), reduced the procedure time (WMD = -8.92, 95% CI: -12.08, -5.75, p < 0.001; I2 = 87.4%, Pheterogeneity < 0.001), and reduced the fluoroscopy time (WMD = -5.08, 95% CI: -9.59, -0.56, p = 0.028; I2 = 95.6%, Pheterogeneity < 0.001). The sensitivity analyses showed that the results of the meta-analyses were robust.

CONCLUSION

Compared with TEE, TTE showed no differences regarding the rates of success and residual shunt, but there were lower rates of late complications and shorter procedure and fluoroscopy times.

Polyphenol-Reinforced Glycocalyx-Like Hydrogel Coating Induced Myocardial Regeneration and Immunomodulation

Although minimally invasive interventional occluders can effectively seal heart defect tissue, they still have some limitations, including poor endothelial healing, intense inflammatory response, and thrombosis formation. Herein, a polyphenol-reinforced medicine/peptide glycocalyx-like coating was prepared on cardiac occluders. A coating consisting of carboxylated chitosan, epigallocatechin-3-gallate (EGCG), tanshinone IIA sulfonic sodium (TSS), and hyaluronic acid grafted with 3-aminophenylboronic acid was prepared. Subsequently, the mercaptopropionic acid-GGGGG-Arg-Glu-Asp-Val peptide was grafted by the thiol-ene "click" reaction. The coating showed good hydrophilicity and free radical-scavenging ability and could release EGCG-TSS. The results of biological experiments suggested that the coating could reduce thrombosis by promoting endothelialization, and promote myocardial repair by regulating the inflammatory response. The functions of regulating cardiomyocyte apoptosis and metabolism were confirmed, and the inflammatory regulatory functions of the coating were mainly dependent on the NF-kappa B and TNF signaling pathway.

Quantitative evaluation of right ventricular myocardial function changes in patients with atrial septal defect before and after occlusion by noninvasive right ventricular pressure-strain loop

OBJECTIVE

The noninvasive right ventricular pressure-strain loop (PSL) represents a novel method for the quantitative assessment of right ventricular myocardial function. Given that atrial septal defect (ASD) is a prevalent congenital heart anomaly associated with right ventricular volume overload, this study aimed to quantitatively assess the myocardial function of the right ventricle in ASD patients pre- and post-occlusion by noninvasive right ventricular PSL.

METHODS

This study included 36 patients diagnosed with secundum ASD group and 30 healthy adults (control group). We compared conventional right ventricular echocardiographic parameters, right ventricular strain, and myocardial work in the ASD group before occlusion, two days post-occlusion, and three months post-occlusion, with those in the control group.

RESULTS

Prior to and two days following occlusion, the ASD group exhibited higher right ventricular global work index (RVGWI), right ventricular global wasted work (RVGWW), and right ventricular global constructive work (RVGCW) compared to the control group (P < .05). Within the ASD group, post-occlusion, RVGWI, RVGCW, and RVGWW values were significantly reduced compared to pre-occlusion values (P < .001). Furthermore, RVGWI and RVGCW showed a significant decrease three months after occlusion compared to two days post-occlusion (P < .05). Multivariate regression analysis identified ASD diameter and pulmonary artery systolic pressure (PASP) as independent predictors of RVGWI (β = .405, P < .001; β = 2.307, P = .037) and RVGCW(β = .350, P<.001; β = 1.967, P = .023).

CONCLUSIONS

The noninvasive right ventricular PSL effectively demonstrates the alterations in right ventricular myocardial function in ASD patients, pre- and post-occlusion. The metrics of right ventricular myocardial work (RVMW) offer a novel indicator for evaluating right ventricular myocardial function in these patients. Moreover, ASD diameter and PASP emerge as independent determinants of RVGWI and RVGCW.

Initial Experience With an Amplatzer Cribriform Occluder in Patients With Atrial Septal Defects in Pakistan

Background Due to their delayed onset of symptoms, atrial septal defects (ASDs) are common congenital cardiac defects that are frequently identified in adulthood. In cases of complicated ASD morphology, transcatheter closure employing devices such as the Amplatzer septal occluder (ASO) presents with difficulties. While the Amplatzer cribriform occluder (ACO) has gained popularity as a specialized option, little is known about its initial use or results, especially in older patients. Objective The goal of this study was to describe the early experience with ACO in patients aged 18 to 38 years who had ASDs at a tertiary care hospital in Pakistan, with a focus on the device's efficacy, safety, and viability. Methods A total of six cases with ASD who underwent ASD closure with the ACO were retrospectively reviewed at Lady Reading Hospital-Medical Teaching Institution (LRH-MTI), Peshawar, Pakistan. All the required data were obtained from the hospital management information system (HMIS), including patient demographics, defect features, procedure specifics, complications, and outcomes. Results Of all patients, 83.3% (n=5) were females and 16.7% (n=1) were males, and the mean age of the group was 27.7 ± 7.9 years. The results of echocardiography showed variation, with a mean fenestrated septum size of 22.4 mm (SD ± 5.4) and a range of device sizes between 18 and 35 mm. The ideal access method for device deployment in every situation was the right femoral vein. There were very few complications; in one instance, a residual shunt necessitated replacing the device. During the six-month follow-up, no complications were found, and all patients were discharged without any problems. Conclusion In conclusion, our study indicates that the ACO is a good choice for young adult patients' ASD closure, showing good safety and efficacy. To verify these results and evaluate the long-term functioning of the device, more prospective trials with larger cohorts are required.

Complications and Efficacies of Surgical Versus Transcatheter Closure for Pediatric Ostium Secundum Atrial Septal Defect: A Meta-Analysis

INTRODUCTION

The optimal approach for pediatric ostium secundum atrial septal defect (ASD) closure remains uncertain. This study aims to assess complications and efficacies of surgical and transcatheter closures.

METHODS

Systematic search in Medline, Cochrane, and EMBASE databases identified cohort studies until July 2023. Complications, length of hospital stay, and efficacy outcomes were evaluated. Subgroup analyses considered ethnicity, ASD size, age, and rim deficiency involvement.

RESULTS

Fourteen cohort studies involving 9695 patients were comprehensively analyzed. Regarding complications, the pediatric patients in the surgery group exhibited higher occurrences of cardiac arrhythmia (odds ratio [OR]: 1.87, 95% confidence interval [CI]: 1.22-2.87, p=0.004), pericardial effusion (OR: 14.80, 95% CI: 6.97-31.43, p<0.00001), and pulmonary complications (OR: 2.58, 95% CI: 1.73-3.85, p<0.00001) compared with those in the transcatheter group. However, no significant difference in fever incidence was observed (OR: 2.57, 95% CI: 0.90-7.34, p=0.08). Furthermore, length of hospital stay was notably shorter in the pediatric transcatheter group (mean difference [MD]: 4.00, 95% CI: 1.71-6.29, p=0.0006). Regarding efficacies, both groups demonstrated similar rates of successful closure (OR: 1.97, 95% CI: 0.56-6.92, p=0.29) and residual shunting (OR: 0.55, 95% CI: 0.17-1.77, p=0.31) in the pediatric cohort. Subgroup analyses revealed that surgical residual shunting was notably lower in the European pediatric population (OR: 0.18, 95% CI: 0.07-0.45, p=0.0002), in cases with ASD size exceeding 15 mm (OR: 0.19, 95% CI: 0.08-0.49, p=0.0006), and in pediatric patients younger than 8 years (OR: 0.33, 95% CI: 0.12-0.92, p=0.03). Interestingly, residual shunting involving complex ASD with rim deficiency was more pronounced in the surgery group (OR: 2.66, 95% CI: 1.33-5.32, p=0.006).

CONCLUSIONS

Both surgical and transcatheter closures are equally effective, with transcatheter closure showing significantly fewer complications.

CLINICAL IMPACT

This meta-analysis offers pivotal insights for clinicians grappling with the optimal approach to pediatric ostium secundum ASD closure. The observed higher incidence of cardiac arrhythmias, pericardial effusions, and pulmonary complications in surgical closures underscores the challenges associated with this modality. In contrast, transcatheter closure, with its comparable efficacy and shorter hospital stays, emerges as an appealing and less invasive alternative. These findings equip clinicians with evidence to make informed decisions, optimizing patient outcomes. Subgroup analyses further refine recommendations, emphasizing tailored considerations for European pediatric patients, larger ASDs, and those under 8 years old, ultimately fostering personalized and improved care strategies.

Transcatheter Closure of Secundum Atrial Septal Defects in Pediatric Patients: A 15-Year Single-Center Experience

PURPOSE

Transcatheter closure is the first-line treatment option for hemodynamically significant secundum atrial septal defects (ASDs). This study examines our center's experience with this procedure over the last 15 years.

MATERIALS AND METHODS

Pediatric patients aged 0-18 years with secundum ASDs who were planned for transcatheter closure in our clinic between January 2007 and January 2023 were retrospectively evaluated.

RESULTS

Transcatheter secundum ASD closure was planned for a total of 334 patients during the study period: 191 girls (57.2%) and 143 boys (42.8%). Their mean age was 8.08±3.9 years, and their mean weight was 30±15.6 kg. Defect diameter measured transesophageally ranged from 5 to 35 mm, with a mean of 12.56±4.02 mm. Transesophageal echocardiographic examination revealed a single secundum ASD in 319 patients (95.5%) and multiple secundum ASDs in 15 patients (4.5%). In 11 patients (3.3%), the procedure was terminated before initiating transcatheter ASD closure because of insufficient vena cava rims or a very large or multi-fenestrated defect. The 323 patients (96.7%) who underwent transcatheter ASD closure had a mean pulmonary artery pressure of 15.1±4.0 mmHg and a mean Qp/Qs ratio of 1.97±0.56. The procedure failed in four patients (1.3%) because of device embolization (n=2) or the inability to properly position the device (n=2). Major complications other than device embolization observed during or after transcatheter closure included anesthetic-induced respiratory depression (n=1) and total atelectasis of the lung (n=1). No new major complications were detected during the patients' long-term follow-up.

CONCLUSION

With appropriate patient and device selection, transcatheter closure is a safe and effective treatment for secundum ASD and should be the first treatment of choice.

Mitral regurgitation outcomes after transcatheter atrial septal defect closure

BACKGROUND

Worsening mitral regurgitation (MR) is a complication of intervention for atrial septal defect (ASD). Little is known about mitral valve (MV) characteristics associated with worsening MR. We aimed to elucidate MR outcomes and predictors of worsening MR after transcatheter ASD closure.

METHODS

We analyzed changes in MR from prior to transcatheter ASD closure to 6 months after the procedure and predictors of worsening MR via baseline transthoracic echocardiography in 238 patients (64.7% females; mean age, 53 ± 22 years).

RESULTS

Worsening MR was defined as worsening to moderate in patients with less than or equal to mild MR at baseline or vena contracta width increasing of ≥2 mm by 6-month follow-up in patients with moderate MR. Worsening MR was observed in 29 patients (12.2%). The associated echocardiographic findings were pseudoprolapse, hamstringing, stiffness, and anteroposterior and intercommissural mitral annulus diameter in the univariable logistic regression analysis (all P < 0.05). Multivariable analysis after adjusting for age; long-standing persistent atrial fibrillation; and ASD size showed that models combining MV leaflet findings such as pseudoprolapse or hamstringing, or anterior leaflet stiffness with the ratio of the sum of anterior and posterior leaflet lengths to intercommissural mitral annulus diameter were statistically significant for predicting worsening MR (R2 = 0.393, P < 0.001 and R2 = 0.385, P < 0.001, respectively).

CONCLUSIONS

Worsening MR after transcatheter ASD closure might depend on MV leaflet findings and annulus size in patients with long-standing persistent atrial fibrillation.

Impact of Gore Cardioform Atrial Septal Defect Occluder on Atrial and Ventricular Electromechanics in a Pediatric Population

Transcatheter closure is the first-line treatment for ostium secundum atrial septal defect (ASD). The GORE Cardioform ASD Occluder (GCA) is potentially innovative compared with other self-centering devices. This study aimed to compare the mechanic changes in atrial and ventricular properties before and after GCA implantation. All consecutive patients aged <18 years who underwent isolated ASD closure with a single GCA device were enrolled from 2 centers. Echocardiography and electrocardiogram were performed the day before, 24 hours, and 6 months after ASD closure. Between January 2020 and February 2021, 70 pediatric patients with ASD were enrolled. The mean age was 7.9 ± 3.9 years, and the mean defect diameter was 17.1 ± 4.5 mm. Global longitudinal strain analysis showed no change in left ventricular longitudinal function (T0 -23.2 ± 2.8%, 24 hours -23.0 ± 2.8%, and 6 months -23.5 ± 2.7%). An early and transient reduction in longitudinal strain was detected in the basal septal segments (T0 -19.8 ± 3.3%, 24 hours -18.7 ± 3.6%, and 6 months -19.2 ± 3.4%), left atrium (T0 41.4 ± 15.3%, 29.2 ± 1.4%, and 39.0 ± 12.9%), and right ventricle (-27.6 ± 5.4%, -23.6 ± 5.0%, and -27.3 ± 4.6) 24 hours after closure, secondary to hemodynamic changes because of flow redirection after ASD closure. Six months after the procedure, only the left atrium showed a mild global longitudinal strain reduction because of the presence of the device within the septum. GCA device had no impact on global and regional ventricular function. Atrial mechanics were preserved, except for the segments covered by the device. This is the first device demonstrating no impact on the left and right ventricular mechanics, irrespective of the device size.

Left Atrial Stiffness Increases after Trans-Catheter Atrial Septal Closure

BACKGROUND

Transcatheter atrial septal closures for secundum atrial septal defects (ASD) have demonstrated favorable clinical outcomes. However, the impact of device implantation on the stiffness of the left atrium remains unclear.

METHOD

Patients with secundum ASD undergoing transcatheter closure and follow-up right heart catheterization at six months were included. We investigated the relationship between post-procedural (E/e' ratio)/(LAs strain) ratio, an index of left atrial stiffness, and baseline characteristics, including echocardiographic and hemodynamic parameters.

RESULTS

Forty patients were included (median 69 (56, 75) years, 12 men, and pulmonary systemic flow ratio 2.27 (1.96, 2.86)). Trans-catheter ASD closure was successfully performed without any major complications, accompanying a significant reduction in right ventricular to left ventricular size ratio from 1.04 (0.87, 1.13) to 0.74 (0.66, 0.86) (p < 0.01). The (E/e' ratio)/(LAs strain) ratio was markedly elevated the day after the procedure and was further increased 6 months later (before: 0.25 (0.17, 0.34), 1 day later: 0.34 (0.27, 0.50), 6 months later: 0.43 (0.27, 0.76), p < 0.01). The groups with higher (E/e' ratio)/(LAs strain) ratios at 6 months had significantly more severe heart failure conditions including lower cardiac output and higher plasma B-type natriuretic peptides.

CONCLUSIONS

Patients undergoing transcatheter ASD closure experienced improvement in hemodynamics and clinical symptoms but an elevation in left atrial stiffness post-procedure. The clinical ramifications of this finding, particularly during the longer-term observation period subsequent to ASD closure, warrant further investigation.

Evaluating variation in pre-operative evaluation and planning for children undergoing atrial or ventricular septal defect repair

BACKGROUND

CHD care is resource-intensive. Unwarranted variation in care may increase cost and result in poorer health outcomes. We hypothesise that process variation exists within the pre-operative evaluation and planning process for children undergoing repair of atrial septal defect or ventricular septal defect and that substantial variation occurs in a small number of care points.

METHODS

From interviews with staff of an integrated congenital heart centre, an initial process map was constructed. A retrospective chart review of patients with isolated surgical atrial septal defect and ventricular septal defect repair from 7/1/2018 through 11/1/2020 informed revisions of the process map. The map was assessed for points of consistency and variability.

RESULTS

Thirty-two surgical atrial septal defect/ventricular septal defect repair patients were identified. Ten (31%) were reviewed by interventional cardiology before surgical review. Of these, 6(60%) had a failed catheter-based closure and 4 (40%) were deemed inappropriate for catheter-based closure. Thirty (94%) were reviewed in case conference, all attended surgical clinic, and none were admitted prior to surgery. The process map from interviews alone identified surgery rescheduling as a point of major variability; however, chart review revealed this was not as prominent a source of variability as pre-operative interventional cardiology review.

CONCLUSIONS

Significant variation in the pre-operative evaluation and planning process for surgical atrial septal defect/ventricular septal defect patients was identified. If such process variation is widespread through CHD care, it may contribute to variations in outcome and cost previously documented within CHD surgery. Future research will focus on determining whether the variation is warranted or unwarranted, associated health outcomes and cost variation attributed to these variations in care processes.

Outcomes Following Closure of Secundum Atrial Septal Defect in Children ≤ 15 kg in a French Tertiary Centre

Secundum atrial septal defects (sASDs) are common congenital cardiac defects mostly treated using a transcatheter approach. However, small children (<15 kg) are still undergoing surgical sASD closure in many centres. Although both options have been proved to have excellent results in children, comparative data of the two techniques are missing for patients ≤ 15 kg. The medical records of children ≤ 15 kg who underwent sASD surgical (group A) and transcatheter (group B) closure between 2010 and 2023 were reviewed retrospectively. Twenty-five children in group A and twenty-two in group B were included (mean weight 8.9 kg in group A and 10.3 kg in group B). The main indications for closure were right heart enlargement and failure to thrive. Major complications occurred in two patients in group A and none in group B. Minor complications occurred in eight patients in group A and one in group B. At last follow-up, symptoms resolved completely or improved significantly for all infants, with the exception of failure to thrive in the sub-population of children with extra-cardiac comorbidities. sASD closure can be performed safely in symptomatic infants ≤ 15 kg, even in the presence of comorbidity, and should not be postponed. However, in patients with extra-cardiac comorbidities, the only indication of growth retardation must be carefully evaluated.

Safety and efficacy of the Amplatzer™ Trevisio™ intravascular delivery system: Post-approval study results

BACKGROUND

The Amplatzer™ Trevisio™ Intravascular Delivery System (Trevisio DS; Abbott Laboratories, Chicago, IL, USA) facilitates the delivery of Amplatzer™ Occluders and features an ultraflexible tip, which improves assessment of occluder position before release.

AIMS

To assess the safety and efficacy of the Trevisio DS for transcatheter closure of patent foramen ovale and atrial septal defect.

METHODS

The Amplatzer™ Trevisio™ Intravascular Delivery System Post-Approval Study was a prospective, postmarket, single-arm, multicentre, observational study of the Trevisio DS. Enrolled patients were indicated for transcatheter closure of patent foramen ovale or atrial septal defect. In all procedures, the Trevisio DS was used to deliver Amplatzer™ Occluders. Technical success was defined as successful deployment and release of at least one occluder. Device- or procedure-related serious adverse events were tracked until discharge or day 7, whichever occurred earlier.

RESULTS

The study enrolled 144 patients with patent foramen ovale and 107 patients with atrial septal defect at 22 European sites; 53 patients with atrial septal defect (49.6%) were aged<18years. The rate of technical success was 98.4% (97.2% for atrial septal defect, 99.3% for patent foramen ovale). There was one serious adverse event (0.4%), an acute periprocedural device embolization that occurred after occluder release in a patient with atrial septal defect; the device was retrieved percutaneously. This was determined by the implanter to be unrelated to the performance of the Trevisio DS.

CONCLUSIONS

The Trevisio DS exhibited a high rate of technical success and an excellent safety profile during transcatheter closure of patent foramen ovale and atrial septal defect.

Outcome of transcatheter atrial septal defect closure in a nationwide cohort

BACKGROUND

Transcatheter (TC) atrial septal defect (ASD) closure has been the mainstay of therapy for secundum-type ASDs for over 20 years.

AIMS

This nationwide cohort evaluated the long-term outcome of transcatheter-closed ASDs.

METHODS

The study enrolled every transcatheter ASD closure performed in Finland from 1999 to 2019. Five age, sex, and municipality-matched controls per ASD patient were gathered from the general population. The median follow-up period was 5.9 years (range 0-20.8). We used the hospital discharge register to gather all hospital visits and diagnoses. Closure complications and echocardiographic changes were collected from the electronic health records.

RESULTS

Transcatheter ASD closure was performed in 1000 patients (68.5% females) during the study period. The median (range) age at the time of the procedure was 37.9 (1.8-87.5) years. ASD patients had an increased risk for new-onset atrial fibrillation (RR 2.45, 95% CI: 1.84-3.25), migraine (RR 3.61, 95% CI: 2.54-5.14), ischemic heart disease (RR 1.73, 95% CI: 1.23-2.45), ventricular fibrillation/tachycardia (RR 3.54 (95% CI: 1.48-8.43) and AV conduction disorder (RR 3.60, 95% CI: 1.94-6.70) compared to the control cohort. Stroke risk was not increased (RR 1.36, 95% CI: 0.91-2.03). Adverse events occurred in 6.3% (n = 63) of the patients, including four erosions and ten device embolizations.

CONCLUSION

After TC closure of ASD, patients had a higher risk of new-onset atrial fibrillation and migraine than controls without ASD. As novel findings, we found an increased risk for ischemic heart disease, AV conduction disorders, and ventricular fibrillation/tachycardia.Key messagesEven though patients have an excellent overall prognosis after percutaneous ASD closure, the increased incidence of major comorbidities like atrial fibrillation and heart failure prompts more thorough lifelong follow-up.This study's novel findings revealed the increased risk for ischemic heart disease, AV conduction disorders, or ventricular tachycardia/fibrillation during the follow-up.Major complications after the closure are rare; erosion is seen in 0.4% of the patients and embolization in 1.0% of the patients.

Minimally Invasive Surgery for Simple Congenital Heart Defects: Preserving Aesthetics without Jeopardizing Patient Safety

Minimally invasive surgeries for pediatric patients have been proposed for decades, with different approaches in mind. Minimal right axillary thoracotomy (MRAT), proposed two decades ago, allows the preservation of patients' safety alongside faster aesthetic and functional recovery. The MRAT did not become widely adopted due to the prejudice that to follow a minimally invasive approach, safety and efficacy must be compromised. With this study, we aim to compare MRAT to the standard median sternotomy approach with a focus on safety and clinical outcomes. Between January 2017 and April 2021, 216 patients diagnosed with ASD, pAVSD, or PAPVD underwent surgical repair with different approaches in the same period. MRAT was used for 78 patients, and median sternotomy was used for 138 patients. In this last group, standard median sternotomy (SMS) was used for 116 patients, while a minimal skin incision (SMS mini) was used for 22 patients. There were no major complications overall nor in each specific approach. MRAT enabled the successful repair of simple heart defects, providing similar post-operative and cardiological recovery. MRAT does not compromise patients' safety and does not prolong the duration of surgery once the learning curve is overcome, which is generally after 15-20 consecutive operations.

Case report: Amplatzer septal occluder device migration into the descending thoracic aortic isthmus: percutaneous retrieval and redeployment

Percutaneous closure has emerged as the standard treatment for secundum-type atrial septal defects (ASDs). However, there is a rare but serious complication of occluder device migration and embolization to the heart chambers or distal vasculature during or shortly after implantation. Although this occurrence is extremely rare, it can have disastrous consequences. Fortunately, advancements in equipment and technology have facilitated the transition from surgical procedures to percutaneous techniques for removing embolized occluder devices. In this report, we present a case in which an Amplatzer septal occluder (ASO) device embolized to the descending thoracic aortic isthmus two days after implantation. The device was successfully retrieved using a percutaneous technique, and another ASO device was subsequently redeployed to the ASD. Regrettably, the patient experienced an intraoperative cardiac arrest. Despite prompt rescue efforts and recovery of vital signs, the patient still suffered postoperative sequelae. The main reason for occluder device migration in this case may have been the undersizing of the ASO device due to the operator's lack of caution.

Robotic-Assisted Solutions for Invasive Cardiology, Cardiac Surgery and Routine On-Ward Tasks: A Narrative Review

Robots are defined as programmable machines that can perform specified tasks. Medical robots are emerging solutions in the field of cardiology leveraging recent technological innovations of control systems, sensors, actuators, and imaging modalities. Robotic platforms are successfully applied for percutaneous coronary intervention, invasive cardiac electrophysiology procedures as well as surgical operations including minimally invasive aortic and mitral valve repair, coronary artery bypass procedures, and structural heart diseases. Furthermore, machines are used as staff-assisting tools to support nurses with repetitive clinical duties i.e., food delivery. High precision and resolution allow for excellent maneuverability, enabling the performance of medical procedures in challenging anatomies that are difficult or impossible using conventional approaches. Moreover, robot-assisted techniques protect operators from occupational hazards, reducing exposure to ionizing radiation, and limiting risk of orthopedic injuries. Novel automatic systems provide advantages for patients, ensuring device stability with optimized utilization of fluoroscopy. The acceptance of robotic technology among healthcare providers as well as patients paves the way for widespread clinical application in the field of cardiovascular medicine. However, incorporation of robotic systems is associated with some disadvantages including high costs of installation and expensive disposable instrumentations, the need for large operating room space, and the necessity of dedicated training for operators due to the challenging learning curve of robotic-assisted interventional systems.

Transcatheter Closure of Atrial Septal Defect: A Review of Currently Used Devices

Over the past seven decades, significant advancements and innovations have occurred in the field of percutaneous atrial septal defect (ASD) closure using transcatheter-based devices. This article focuses on the current literature surrounding the three Food and Drug Administration (FDA)-approved devices for ASD and patent foramen ovale (PFO) closure in the United States, namely, the Amplatzer Septal Occluder (ASO), Amplatzer Cribriform Occluder, and Gore Cardioform ASD Occluder. The ASO has been widely used since its FDA approval in 2001. Studies have shown its high success rate in closing ASDs, especially small-sized defects. The RESPECT trial demonstrated that PFO closure using the ASO reduced the risk of recurrent ischemic stroke compared to medical therapy alone. The Closure of Atrial Septal Defects With the Amplatzer Septal Occluder Post-Approval Study (ASD PMS II) evaluated the safety and effectiveness of ASO in a large cohort of patients, reporting a high closure success rate and rare hemodynamic compromise. The Amplatzer Cribriform Occluder is designed for the closure of multifenestrated ASDs and has shown promising results in small-scale studies. It successfully closed the majority of fenestrated ASDs, leading to improved right ventricular diastolic pressure without major complications. The REDUCE trial compared PFO closure using the Gore Helex Septal Occluder and Gore Cardioform Septal Occluder with antiplatelet therapy alone. The study demonstrated that PFO closure significantly reduced the risk of recurrent stroke and brain infarction compared to antiplatelet therapy alone. However, the closure group had a higher incidence of atrial fibrillation or atrial flutter. There is a risk of atrial fibrillation with the use of ASO as well. The FDA-approved Gore Cardioform ASD Occluder showed excellent performance in the ASSURED clinical study. The device achieved high technical success and closure rates, with low rates of serious adverse events and device-related complications. A meta-analysis comparing transcatheter ASD closure with surgical closure revealed that the transcatheter approach had a high success rate, lower rates of adverse events, and shorter hospital stays compared to surgery, without any mortality. Complications associated with transcatheter ASD closure have been reported, including femoral arteriovenous fistulas, device embolization, cardiac erosion, aortic incompetence, and new-onset migraine. However, these complications are relatively rare. In conclusion, transcatheter ASD closure using FDA-approved devices has proven to be safe and effective in the majority of cases. These devices offer excellent closure rates, reduced risk of recurrent stroke, and shorter hospital stays compared to surgery. However, careful patient selection and follow-up are necessary to minimize complications and ensure optimal outcomes.

The Prevalence of and Predisposing Factors for Late Atrial Arrhythmias after Transcatheter Closure of Secundum Atrial Septal Defects in Children

BACKGROUND

A 24 h Holter study in children after transcatheter secundum ASD (ASD II) closure was conducted to detect the prevalence of defects and/or device-related late atrial arrhythmias (LAAs). ASD II closure with an Amplatzer septal occluder (ASO) is an established procedure. Little is known about LAAs after device implantation.

METHODS

The eligible participants were children who had undergone ASO implantation, with a follow-up of ≥5 years, as well as one pre- and at least one post-procedural Holter ECG.

RESULTS

In total, 161 patients (mean age: 6.2 ± 4.3 years), with a mean follow-up of 12.9 ± 3.1 years (range 5-19), were included. A median of four Holter ECGs per patient were available. LAAs occurred before intervention in four patients (2.5%), and it was peri-interventional in four patients (2.5%), sustained in three patients (1.9%), and developed in three patients (1.9%). In patients with pre- and peri-interventional LAAs, the Qp/Qs ratio was higher (6.4 ± 3.9 vs. non-AA: 2.0 ± 1.1 (p = 0.002)) and the IAS/ASO ratio was lower (1.18 ± 0.27 vs. non-AA: 1.7 ± 0.4 (p < 0.001)). The patients with LAAs differed from those without LAAs in their Qp/Qs (6.8 ± 3.5 vs. 2.0 ± 1.3; p < 0.0001) and IAS/ASO ratios (1.14 ± 0.19 vs. 1.73 ± 0.45; p < 0.001). The patients with LAAs had a Qp/Qs ratio ≥2.94:1, and those who developed LAAs had an IAS/ASO ratio <1.15.

CONCLUSIONS

LAAs occurred in 1.9% of patients and were sustained in another 1.9% of patients but persisted in those with large shunt defects and large occluders in relation to the atrial septal length. The predisposing factors for LAAs after ASD closure were a high Qp/Qs ratio, pre-existing atrial arrhythmias, and a low IAS/ASO ratio.

Novel technique to reduce prolapsed device in atrial septal defect closure

Objective

Transcatheter closure of atrial septal defect (ASD) has become an alternative treatment to surgical repair. One of the challenges is the prolapse of the left atrial disc during the procedure. Many techniques have been developed to prevent the prolapse but not reduce it. In this study, we present a novel technique, termed push back technique, that help reduce the prolapsed device.

Methods

We enrolled 24 patients (8 males, 16 females) between May 2008 and January 2023 who underwent the push back technique during transcatheter closure of ASD in Taichung Veterans General Hospital. We recorded the hemodynamic data, success rate and complications including device embolization/migration, valvular regurgitation, pericardial effusion, and residual shunt.

Results

The median age was 6.3 years (1.2-70.5 years) and the median weight was 19.1 kg (7.8-90 kg). Fifteen (62.5%) patients had mild pulmonary hypertension. The median Qp/Qs was 2.54 (1.5-8.8). The median ASD stretched size was 21.2 mm (7.7-35.3 mm). The median device size was 22 mm (8-40 mm). The median fluoroscopy time was 14 min (5-23 min) and median procedure time was 47 min (25-78 min). The push back technique successfully reduced the prolapsed device in 21 (87.5%) patients. There was no complication in all patients.

Conclusion

We present a novel push back technique that can successfully reduce the prolapsed device in 87.5% (21/24) patients without complications. It is feasible, safe and effective.

Minimal-Access Atrial Septal Defect (ASD) Closure

Progress towards the development and adoption of minimally invasive techniques in cardiac surgery has been slower than that seen in other surgical specialties. Congenital heart disease (CHD) patients represent an important population within cardiac disease, of which atrial septal defect (ASD) is one of the most common diagnoses. Management of ASD encompasses a range of minimal-access and minimally invasive approaches, including transcatheter device closure, mini-sternotomy, thoracotomy, video-assisted, endoscopic, and robotic approaches. In this article, we will discuss the pathophysiology of ASD, along with diagnosis, management, and indications for intervention. We will review the current evidence supporting minimally invasive and minimal-access surgical ASD closure in the adult and paediatric patient, highlighting peri-operative considerations and areas for further research.

Atrial septal defect occluder device embolization: Experience of a tertiary care cardiac center

Background

Percutaneous device closure of atrial septal defect (ASD) has become an increasingly popular procedure as it offers several advantages. However, it is associated with infrequent, but life-threatening complications such as device embolization.

Objective

To analyze the risk factors, common sites of embolization, associated complications, timing of embolization, and the treatment executed.

Settings and Design

A retrospective study was performed at a tertiary referral center for cardiac services.

Material and Methods

Pre-procedure, intra-procedure, and post-procedure data of patients whose ASD device embolized was collected retrospectively and analyzed for risk factors, common sites of embolization, associated complications, timing of embolization, and the treatment executed. Results: Thirty devices were embolized, out of which 13 were retrieved percutaneously in the Catheter laboratory, whereas 17 patients underwent surgery. Fourteen patients had an unfavorable septal morphology for device closure. Ten devices were embolized in the catheter laboratory, five in the intensive care unit, and two in the ward. The devices were embolized to almost all chambers of the heart and great vessels. One patient had an inferior vena cava rim tear while attempting percutaneous retrieval. One patient required a short period of total circulatory arrest (TCA) for retrieval of the device from ascending aorta, while another required a lateral position for retrieval from descending aorta. One patient required re-exploration for bleeding, while another had an air embolism and succumbed.

Conclusions

Once embolization occurs, the risks associated increase manifold. Most of the surgical extractions are uneventful; however, there could be certain complications that may need repair of valvular apparatus, the institution of TCA, or the need for the lateral position. Air embolization though very rare can occur which could be fatal.

Sterilization effects on poly(glycerol dodecanedioate): A biodegradable shape memory elastomer for biomedical applications

Biodegradable shape memory polymers provide unique regenerative medicine approaches in minimally invasive surgeries. Once heated, thermally responsive shape memory polymer devices can be compressed, programmed to fit within a small profile, delivered in the cold programmed state, and expanded when heated to body temperature. We have previously developed a biodegradable shape memory elastomer (SME), poly(glycerol dodecanedioate) (PGD), with transition temperatures near 37°C exhibiting nonlinear elastic properties like numerous soft tissues. Using SMEs in the clinic requires disinfection and sterilization methods that conserve physiochemical, thermomechanical, and shape recovery properties. We evaluated disinfection protocols using 70% ethanol and UV254 nm for research applications and ethylene oxide (EtO) gas sterilization for clinical applications. Samples disinfected with ethanol for 0.5 and 1 min showed no changes in physiochemical material properties, but after 15 min showed slower recovery rates than controls (p < .05). EtO sterilization at 54.4°C decreased transition temperatures and shape recovery rate compared to EtO sterilization at 37.8°C (p < .01) and controls (p < .05). Aging samples for 9 months in a vacuum desiccator significantly reduced shape recovery, and the recovery rate in EtO sterilized samples compared to controls (p < .001). Cytotoxicity testing (ISO-10993.5C:2012) revealed media extractions from EtO sterilized samples, sterilized at 37.8°C, and high-density polyethylene negative control samples exhibit lower cytotoxicity (IC50) than Ethanol 1 min, UV 2 h, and EtO 54.4°C. Cell viability of NIH3T3 fibroblasts on sterilized surfaces was equivalent on EtO 37.7°C, EtO 54.4°C and Ethanol sterilized substrates. Finally, chromogenic bacterial endotoxin testing showed endotoxin levels were below the FDA prescribed levels for devices contacting blood and lymphatic tissues for ethanol 1 min, UV 120 min, EtO 37.7°C, EtO 54.4°C. These findings outline various disinfection and sterilization processes for research and pre-clinical application and provide a pathway for developing custom sterilization cycles for the translation of biomedical devices utilizing PGD shape memory polymers.

Catheter-based Interventions to Reduce or Modify Surgical Risk in High-Risk Adult Congenital Heart Disease Patients

The field of adult congenital heart disease has changed greatly over the past sixty years. As patients are now surviving longer into adulthood due to various improvements in surgical technique and medical technology, the demographic of patients with congenital heart disease (CHD) has changed, such that there are now more adults with CHD than there are children with CHD. This older and more medically complex population needs more interventions to treat residual defects or sequelae of their initial surgeries, and many of these patients are now deemed high risk for surgery. When the surgical risk becomes too great, either due to patient complexity, surgical complexity, or both, then transcatheter procedures may have a role in either mitigating or avoiding the risk altogether.

Percutaneous delivery and degradation of a shape memory elastomer poly(glycerol dodecanedioate) in porcine pulmonary arteries

Shape memory biodegradable elastomers are an emergent class of biomaterials well-suited for percutaneous cardiovascular repair requiring nonlinear elastic materials with facile handling. We have previously developed a chemically crosslinked shape memory elastomer, poly (glycerol dodecanedioate) (PGD), exhibiting tunable transition temperatures around body temperature (34-38 °C), exhibiting nonlinear elastic properties approximating cardiac tissues, and favorable degradation rates in vitro. Degree of tissue coverage, degradation and consequent changes in polymer thermomechanical properties, and inflammatory response in preclinical animal models are unknown material attributes required for translating this material into cardiovascular devices. This study investigates changes in the polymer structure, tissue coverage, endothelialization, and inflammation of percutaneously implanted PGD patches (20 mm × 9 mm x 0.5 mm) into the branch pulmonary arteries of Yorkshire pigs for three months. After three months in vivo, 5/8 samples exhibited (100%) tissue coverage, 2/8 samples exhibited 85-95% tissue coverage, and 1/8 samples exhibited limited (<20%) tissue coverage with mild-moderate inflammation. PGD explants showed a (60-70%) volume loss and (25-30%) mass loss, and a reduction in polymer crosslinks. Lumenal and mural surfaces and the cross-section of the explant demonstrated evidence of degradation. This study validates PGD as an appropriate cardiovascular engineering material due to its propensity for rapid tissue coverage and uneventful inflammatory response in a preclinical animal model, establishing a precedent for consideration in cardiovascular repair applications.

Cause-Specific Mortality of Patients With Atrial Septal Defect and Up to 50 Years of Follow-Up

Background This study aimed to evaluate the long-term mortality and cause-specific mortality of patients with atrial septal defect (ASD) in a nationwide cohort. Methods and Results All patients diagnosed with simple ASD in the hospital discharge registry from 1969 to 2019 were included in the study. Complex congenital defects were excluded. Each subject was matched with 5 controls according to sex, age, and municipality at the index time. Adjusted mortality risk ratios (MRRs) were calculated using Poisson regression models. The median follow-up time was 11.1 years. Patients with ASD had higher overall mortality during follow-up, with an adjusted MRR of 1.72 (95% CI, 1.61-1.83). Patients with closed ASDs also had higher total mortality (MRR, 1.29 [95% CI, 1.10-1.51]). However, no difference in mortality was detected if the defect was closed before the age of 30 (MRR, 1.58 [95% CI, 0.90-2.77]), and transcatheter closed defects had lower mortality than the control cohort (MRR, 0.65 [95% CI, 0.42-0.99]). Patients with ASD had significantly more deaths due to congenital malformations (MRR, 54.61 [95% CI, 34.03-87.64]), other diseases of the circulatory system (MRR, 2.90 [95% CI, 2.42-3.49]), stroke (MRR, 1.89 [95% CI, 1.52-2.33]), diseases of the endocrine (MRR, 1.88 [95% CI, 1.10-3.22]) and respiratory system (MRR, 1.71 [95% CI, 1.19-2.45]), ischemic heart disease (MRR, 1.62 [95% CI, 1.41-1.86]), and accidents (MRR, 1.41 [95% CI, 1.05-1.89]). Conclusions Patients with ASD had higher overall mortality compared with a matched general population cohort. Increased cause-specific mortality was seen in congenital malformations, stroke, and heart diseases.

Late bacterial endocarditis after percutaneous atrial septal defect closure

Percutaneous atrial septal defect closure is widely used as an alternative to surgical repair in many hospitals. Infective endocarditis related to occluding devices is commonly known, but following that atrial septal defect closure with a device in a child is rare. This report describes an 11-year-old girl who developed late-stage bacterial endocarditis following incomplete endothelialisation after a percutaneous procedure.

A fully biodegradable polydioxanone occluder for ventricle septal defect closure

Ventricular septal defect (VSD) is one of the commonest congenital heart diseases (CHDs). Current occluders for VSD treatment are mainly made of nitinol, which has the risk of nickel allergy, persistent myocardial abrasion and fatal arrythmia. Herein, a fully biodegradable polydioxanone (PDO) occluder equipped with a shape line and poly-l-lactic acid PLLA membranes is developed for VSD closure without the addition of metal marker. PDO occluder showed great mechanical strength, fatigue resistance, geometry fitness, biocompatibility and degradability. In a rat subcutaneous implantation model, PDO filaments significantly alleviated inflammation response, mitigated fibrosis and promoted endothelialization compared with nitinol. The safety and efficacy of PDO occluder were confirmed in a canine VSD model with 3-year follow-up, demonstrating the biodegradable PDO occluder could not only effectively repair VSD, induce cardiac remodeling but also address the complications associated with metal occluders. Furthermore, a pilot clinical trial with five VSD patients indicated that all the occluders were successfully implanted under the guidance of echocardiography and no adverse events occurred during the 3-month follow-up. Collectively, the fully bioresorbable PDO occluder is safe and effective for clinical VSD closure and holds great promise for the treatment of structural CHDs.

Comparative effectiveness of devices for transcatheter closure of atrial septal defects: Systematic review and network meta-analysis

Atrial septal defect is a common congenital heart disease, producing a left-to-right shunt in the atrial septum; the current preferred treatment is transcatheter device closure. The aim is to conduct a systematic review to synthesize information on the comparative effectiveness and safety of atrial septal defect closure devices. The methods used: a comprehensive search of Ovid MEDLINE®, Embase, and Cochrane Central databases was conducted. Studies comparing procedural and follow-up outcomes of atrial septal defect devices were included. Network meta-analyses were conducted to generate direct and indirect evidence for comparative effectiveness and safety outcomes between devices. The results are as follows: Twelve studies met our inclusion criteria and were compared in network meta-analyses. The meta-analyses evaluated contemporary devices: the AMPLATZER Septal Occluder; the GORE CARDIOFORM Septal Occluder; the Figulla Flexible II Occluder; the CeraFlex Septal Occluder; and the HELEX Septal Occluder. These studies represented 3998 patients. The primary safety and efficacy outcomes were device embolization and follow-up residual shunt, respectively. Secondary clinical outcomes included procedural success and major and minor complications. No differences were found between devices in terms of device embolization and secondary clinical outcomes. Follow-up residual shunt was higher with the HELEX Septal Occluder compared with the AMPLATZER Septal Occluder (odds ratio 2.92, 95% confidence interval 1.12-7.61). To conclude: although most outcomes were similar between devices, evidence was largely based on observational low-quality studies. There were inconsistencies in outcome reporting and definitions; this merits future studies, with head-to-head device comparisons and standardization of outcomes.

Transcatheter Interventions in Patients With Adult Congenital Heart Disease

Patients with congenital heart disease now live well into adulthood because of advances in surgical techniques, improvements in medical management, and the development of novel therapeutic agents. As patients grow older into adults with congenital heart disease, many require catheter-based interventions for the treatment of residual defects, sequelae of their initial repair or palliation, or acquired heart disease. The past 3 decades have witnessed an exponential growth in both the type and number of transcatheter interventions in patients with congenital heart disease. With improvements in medical technology and device design, including the use of devices designed for the treatment of acquired valve stenosis or regurgitation, patients who previously would have required open-heart surgery for various conditions can now undergo percutaneous cardiac catheter-based procedures. Many of these procedures are complex and occur in complex patients who are best served by a multidisciplinary team. This review aims to highlight some of the currently available transcatheter interventional procedures for adults with congenital heart disease, the clinical outcomes of each intervention, and any special considerations so that the reader may better understand both the procedure and patients with adult congenital heart disease.

Assessment of Transcatheter or Surgical Closure of Atrial Septal Defect using Interpretable Deep Keypoint Stadiometry

Automated echocardiogram interpretation with artificial intelligence (AI) has the potential to facilitate the serial diagnosis of heart defects by primary clinician. However, the fully automated and interpretable analysis pipeline for suggesting a treatment plan is largely underexplored. The present study targets to build an automatic and interpretable assistant for the transthoracic echocardiogram- (TTE-) based assessment of atrial septal defect (ASD) with deep learning (DL). We developed a novel deep keypoint stadiometry (DKS) model, which learns to precisely localize the keypoints, i.e., the endpoints of defects and followed by the absolute distance measurement with the scale. The closure plan and the size of the ASD occluder for transcatheter closure are derived based on the explicit clinical decision rules. A total of 3,474 2D and Doppler TTE from 579 patients were retrospectively collected from two clinical groups. The accuracy of closure classification using DKS (0.9425 ± 0.0052) outperforms the "black-box" model (0.7646 ± 0.0068; p < 0.0001) for within-center evaluation. The results in cross-center cases or using the quadratic weighted kappa as an evaluation metric are consistent. The fine-grained keypoint label provides more explicit supervision for network training. While DKS can be fully automated, clinicians can intervene and edit at different steps of the process as well. Our deep learning keypoint localization can provide an automatic and transparent way for assessing size-sensitive congenital heart defects, which has huge potential value for application in primary medical institutions in China. Also, more size-sensitive treatment planning tasks may be explored in the future.

Balloon Interrogation of Intervening Tissue: A Novel Method to Decide Strategy for Closing Multiple Atrial Septal Defects

BACKGROUND

Two separate ostium secundum atrial septal defects are a challenging substrate for device closure due to lack of a well-described strategy or an adequately evaluated protocol.

METHODS

This is a prospective study comprising 20 patients with 2 atrial septal defects who underwent device closure. All of them underwent balloon interrogation (BI) of the intervening tissue to decide 1- versus 2-device strategy. During BI, if the flow through both the defects could be stopped completely implying adequate mobility of the separating tissue, a single device strategy was used. The size of the device in this subset was determined by BI diameter. In case the flow persisted, 2 devices were used to close the defects separately.

RESULTS

The mean age was 24±17 years. The main defect size was (mean 14.5 mm±SD 2.69 mm), whereas the second defect measured (mean 8.5±SD 3.02 mm). The tissue separating the 2 defects was measured (mean 6.1±SD 2.6 mm). In 15 of them, based on the BI results, a single device was used successfully to close both the defects without a residual shunt. In the remaining 5 patients, 2 devices were used. There were no complications during the procedure or at follow-up period of 41.9±16.9 months.

CONCLUSIONS

BI in patients with 2 atrial septal defects is helpful in defining 1- versus 2-device strategies and in choosing the size of the device to be used. Nearly 3/4 of the patients may get away with a single device for closing both the defects successfully thereby decreasing the cost and complexity of the procedure.

Transcatheter closure of secundum atrial septal defect using Cocoon septal occluder: immediate and long-term results

Background

Atrial septal defect (ASD) is one of the common congenital heart defects. Its management has transformed dramatically in the last 4 decades with the transition from surgical to percutaneous transcatheter closure for most secundum-type ASDs. Various devices are available for transcatheter closure of ASD with Amplatzer atrial septal occluder being most commonly used worldwide. Cocoon septal occlude has a nanocoating of platinum using nano-fusion technology over nitinol framework that imparts better radiopacity and excellent biocompatibility and prevents leaching of nickel into circulation, and by smoothening nitinol wire makes this device very soft and smooth. The aim of this study was to evaluate feasibility, effectiveness, safety, and long-term outcome of transcatheter closure of ASD using Cocoon septal occluder (Vascular Innovation, Thailand).

Results

All patients undergoing transcatheter closure of hemodynamically significant ASD between September 2012 and July 2019 in our institute were included into this single-center, prospective study. Exclusion criteria were defect > 40 mm, unsuitable anatomy, Eisenmenger syndrome, and anomalous pulmonary venous return. Three hundred and twenty patients underwent device closure, of which 238 (74%) were female. The mean age was 14.6 years (range 6–29), and the median weight was 30.2 kg (range 10–53 kg). Procedure was performed under fluoroscopy using transthoracic and transesophageal echocardiography in 298 (93.1%) and 22(6.9%) patients, respectively. Balloon-assisted technique was used, when septal defect was ≥ 34 mm, in 9 (2.8%) patients. The mean diameter of defect and device was 21.4 mm (range 12–36 mm) and 26.9 mm (range 14–40 mm), respectively. Aortic rim was absent in 11 (3.4%) patients. Primary success was achieved in 312 (97.5%) patients. Early embolization to right ventricle was noted in 2 (0.6%) patients. In both cases, 40-mm device was attempted for defect of 36 mm with inadequate aortic rim using balloon-assisted technique. One (0.3%) patient developed perforation of right atrium. All were surgically repaired. Three (0.9%) patients developed complete heart block following device deployment requiring device retrieval. Two patients had had moderate residual shunt at 6 months of follow-up. After mean follow-up of 50.92 months (range 12.5–89 months), no erosion, allergic reactions to nickel, or other major complications were reported.

Conclusions

Percutaneous transcatheter closure of ASD by Cocoon septal occluder (up to 36 mm) is safe and feasible with high success rate and without any significant device-related major complications over long-term follow-up. With unique device design and excellent long-term safety, it could be preferred dual-disk occluder for transcatheter closure of atrial septal defect. In most of the patients, ASD device can be safely deployed under transthoracic echocardiographic guidance.