Atrial septal defect in adulthood: a new paradigm for congenital heart disease

Transcatheter Structural Heart Disease Interventions and Concomitant Left Atrial Appendage Occlusion: A State-of-the-Art Review

Atrial fibrillation (AF) is the most common arrhythmia in patients with valvular heart disease, and it can be associated with adverse patient outcomes. However, the need of anticoagulation to counterbalance AF-associated stroke risk may further lead to suboptimal outcomes via increasing bleeding events, especially in high-risk individuals. Currently, the option to perform a concomitant to the index procedure for limiting stroke risk is emerging, in accordance to usual practice in cardiac surgery. In specific, as the vast majority of thrombi occur in the left atrial appendage, left atrial appendage occlusion (LAAO) is an established procedure for preventing ischemic stroke in patients with AF, while limiting anticoagulation-related bleeding events. Thus, the concept of combining an index procedure for a structural heart disease (SHD) with LAAO seems promising for preventing future stroke events. A combined procedure has been described in aortic stenosis (TAVI+LAAO), mitral regurgitation (TEER+LAAO) and atrial septal defects (PFO/ASD+LAAO). Evidence shows that a combined procedure can be safely performed in a "one-stop shop" fashion, without increased rates of procedural adverse events, with the potential to limit bleeding risk and provide prophylaxis against stroke events. Thus, this review is going to analyze indications and clinical evidence regarding the safety and efficacy of combined SHD+LAAO procedure, while also providing insights in gaps in knowledge and future directions for the evolvement of this field.

From ECG to Imaging: Challenges in the Diagnosis of Adult Congenital Heart Diseases

Congenital heart diseases (CHD) are one of the most common birth defects and the main leading cause of death in children. Many patients with CHD are reaching adulthood due to the success of improved contemporary surgical procedures. Understanding the etiology of CHD remains important for patient clinical management. Both genetic and environmental factors are involved in the development and progression of CHD. Variations in many different genes and chromosomal anomalies can be associated with CHD, by expression of different mechanisms. Sporadic cases are the most frequently encountered in these patients. Atrial septal defect is a common congenital heart disease that refers to direct communication between atrial chambers, found isolated or associated with other syndromes. Imaging techniques, especially transthoracic and transesophageal echocardiography (TOE) represent the key for diagnosis and management of ASD. The disease has a major incidence in adulthood, due to late symptomatology, but assessment and treatment are important to avoid time-related complications. Ebstein's anomaly is a rare congenital disease, with a dominant genetic participation, characterized by an abnormal displacement of the tricuspid valve and right ventricular myopathy, often requiring surgical intervention. Alongside echocardiography, cardiac magnetic resonance (CMR) imaging is the gold standard tool for the assessment of ventricular volumes. Early diagnosis and adequate treatment are mandatory to avoid possible complications of CHD, and thus, ECG, as well as imaging techniques, are important diagnostic tools. However, patients with CHD need a special healthcare team for the entire monitorization in various life stages.

Perioperative Assessment and Clinical Outcomes of Percutaneous Atrial Septal Defect Closure with Three-Dimensional Transesophageal Echocardiography

BACKGROUND/OBJECTIVES

To close the atrial septal defect (ASD) with the transcatheter method, correctly defining the defect and selecting the appropriate closure device size are the most critical steps for the procedure's success. Although ASD can be successfully closed under the guidance of three-dimensional (3D) transesophageal echocardiography (TEE) and two-dimensional (2D) TEE, measurement comparisons between different types of defects are still needed.

METHODS

Our study was designed retrospectively. Sixty-one patients who underwent transcatheter ASD closure with 2D TEE and 3D TEE between 2020 and 2024 were included. The patients were divided into three groups according to the defect shape: circular, oval, and complex; and the measurement results, perioperative process, and clinical outcomes were compared in each group.

RESULTS

The average age of the patients was 35.05 ± 13.87 years, and 41 (67.2%) were women. The average follow-up period of the patients was 15.3 ± 9.18 months. No statistical significance was observed in the comparison of measurements obtained with 3D TEE and 2D TEE in the circular and oval defect groups. The differences between the minimum defect diameters of complex defects measured by 2D TEE and 3D TEE (p: 0.037), IVC rims (p < 0.001), aortic rims (p: 0.012), and the differences between implanted device dimensions and the maximum defect diameters measured by both methods were compared; statistical significance was observed (p: 0.025).

CONCLUSIONS

In circular and non-complex oval defects, it has been observed that the size of the closure device selected with 2D TEE or 3D TEE is optimal, and the procedure is practical and feasible. While the closure of complex ASDs with 3D TEE provides reliable and optimal results, using only 2D TEE in complex ASDs may lead to selecting a smaller-sized device.

Transesophageal echocardiography diagnosis of abnormal left atrium to inferior vena cava communication: A case report

Abnormal traffic between the left atrium (LA) and inferior vena cava (IVC) in the database is currently rare. Herein, we present a unique case of abnormal traffic between the LA and the IVC, which was diagnosed using transesophageal echocardiography and confirmed by computed tomography angiography. This case substantiates the superiority of transesophageal echocardiography over transthoracic echocardiography in detecting specific site lesions.

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

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

The association of right ventricular-pulmonary arterial coupling and pulmonary vascular resistance in adult patients with uncorrected atrial septal defect

BACKGROUND

Atrial septal defects (ASD) are the most common type of adult congenital heart disease (ACHD) associated with a high risk developing of pulmonary arterial hypertension (PAH). ASD closure is not recommended in patients with PAH and Pulmonary Vascular Resistance (PVR) ≥ 5 Wood Unit (WU). Noninvasive methods have been proposed to measure PVR; however, their accuracy remains low. Right Ventricle (RV) - Pulmonary Artery (PA) coupling is defined as the ability of the RV to adapt to high-resistance conditions. Tricuspid Annular Plane Systolic Excursion (TAPSE)/estimated pulmonary artery systolic pressure (ePASP) calculation using echocardiography is a noninvasive technique that has been proposed as a surrogate equation to evaluate RV-PA coupling. Currently, no research has demonstrated a relationship between RV-PA coupling and PVR in patients with ASD.

METHODS

The study participants were consecutive eligible patients with ASD who underwent right heart catheterization (RHC) and echocardiography at Hasan Sadikin General Hospital, Bandung. Both the procedures were performed on the same day. RV-PA Coupling, defined as TAPSE/ePASP > 0.31, was assessed using echocardiography. The PVR was calculated during RHC using the indirect Fick method.

RESULTS

There were 58 patients with ASD underwent RHC and echocardiography. Among them, 18 had RV/PA Coupling and 40 had RV/PA Uncoupling. The PVR values were significantly different between the two groups (p = 0.000). Correlation test between TAPSE/ePASP with PVR showed moderate negative correlation (r= -0.502, p = 0.001). TAPSE/ePASP ≤ 0.34 is the cutoff point to predict PVR > 5 WU with sensitivity of 91.7% and specificity 63.6%.

CONCLUSION

This study showed a moderate negative correlation between TAPSE/ePASP and PVR. TAPSE/ePASP ≤ 0.34 could predict PVR > 5 WU with good sensitivity.

School electrocardiography screening program prompts the detection of otherwise unrecognized atrial septal defect in children in Japan

Background

Atrial septal defect (ASD) is a congenital heart disease that often presents without symptoms or murmurs. If left untreated, children with ASD can develop comorbidities in adulthood. In Japan, school electrocardiography (ECG) screening has been implemented for all 1st, 7th, and 10th graders. However, the impact of this program in detecting children with ASD is unknown.

Methods

This is a retrospective study that analyzed consecutive patients with ASD who underwent catheterization for surgical or catheter closure at ≤18 years of age during 2009-2019 at a tertiary referral center in Japan.

Results

Of the overall 116 patients with ASD (median age: 3.0 years of age at diagnosis and 8.9 years at catheterization), 43 (37%) were prompted by the ECG screening (Screening group), while the remaining 73 (63%) were by other findings (Non-screening group). Of the 49 patients diagnosed at ≥6 years of age, 43 (88%) were prompted by the ECG screening, with the 3 corresponding peaks of the number of patients at diagnosis. Compared with the non-screening group, the screening group exhibited similar levels of hemodynamic parameters but had a lower proportion of audible heart murmur, which were mainly prompted by the health care and health checkups in infancy or preschool period. Patients positive for a composite parameter (rsR' type of iRBBB, inverted T in V4, or ST depression in the aVF lead) accounted for 79% of the screening group at catheterization, each of which was correlated with hemodynamic parameters in the overall patients.

Conclusions

The present study shows that school ECG screening detects otherwise unrecognized ASD, which prompted the diagnosis of the majority of patients at school age and >one-third of overall patients in Japan. These findings suggest that ECG screening program could be an effective strategy for detecting hemodynamically significant ASD in students, who are asymptomatic and murmurless.

Headaches in Children After Transcatheter Device Closure of Atrial Septal Defects: A Single-Centre Experience

Background

Transcatheter device closure (TDC) is the most common treatment for isolated atrial septal defects in children. In the adult population, the incidence of new-onset migraine headache after TDC is well recognized and is estimated at 15%. New-onset headache after paediatric TDC has not been well described. We reviewed our centre's experience to estimate the rate of headache complaints among paediatric patients after TDC.

Methods

We performed a single-centre, retrospective review of all children who underwent TDC between January 1, 2018, and December 31, 2021. For the included patients, we comprehensively reviewed the electronic medical record to identify patients reported to experience post-TDC headache.

Results

A total of 165 consecutive patients underwent TDC during the study period. Of these, 134 met inclusion criteria, and 20 patients (15%) had headache documented in the electronic medical record. Of 20 patients, 4 (20%) had headaches that led to further investigation or changed postprocedural medical management. Two patients had brain magnetic resonance imaging to investigate headaches; both studies were interpreted as nonpathologic. One patient required emergency department management for status migrainosus. A second, with a prior history of migraine, required admission for migraine exacerbation. In addition to those needing symptomatic management, 3 patients had a change in their antiplatelet regimen from aspirin to clopidogrel.

Conclusions

Our study suggests a minimal estimate of 15% as the incidence of headache in children who undergo TDC. This estimate can inform counselling before TDC. Determination of the true incidence will require focused prospective data collection.

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.

Sinus Venosus Atrial Septal Defect as an Overlooked Source of Shortness of Breath Among Patients With Pulmonary Arterial Hypertension

Sinus venosus atrial septal defects (SVASD) associated with partial anomalous pulmonary venous return (PAPVR) can be overlooked as a source of dyspnea in adult patients with pulmonary hypertension. We present the case of a 61-year-old male with exertional dyspnea initially attributed to pulmonary hypertension, who was subsequently diagnosed with SVASD and right superior PAPVR. This case underscores the critical importance of maintaining high clinical awareness and utilizing multimodal imaging techniques in cardiology to accurately diagnose and manage pulmonary hypertension secondary to congenital heart disease. Timely surgical correction can significantly improve morbidity and mortality outcomes.

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.

The valuable role of cardio-pulmonary exercise testing in the diagnosis of atrial septal defect in a competitive triathlete: a case report

Background

Atrial septal defect (ASD) is characterized by a diverse clinical presentation influenced by the type, size, and haemodynamics. Endurance athletes with ASD may exhibit higher than normal performance levels, however they face an elevated risk of exercise-induced cardiac volume and pressure strain, potentially expediting a maladaptation of the right heart.

Case summary

An asymptomatic 28-year-old female elite triathlete sought a pre-participation sports medical examination. Her past medical history revealed right heart enlargement. Transthoracic echocardiography and magnetic resonance imaging did not ascertain a definitive diagnosis such as shunting. The examination revealed a remarkably high maximum oxygen uptake during cardio-pulmonary exercise testing (CPET), yet an abnormal oxygen uptake/workload slope and a low, plateauing oxygen pulse. The athlete agreed to transoesophageal echocardiography that demonstrated a superior sinus venosus-type ASD. Surgical intervention, conducted with minimally invasive endoscopic robotic technology and a pericardial patch, was performed at a tertiary centre under full cardio-pulmonary bypass. At seven-month follow-up, the patient reported engaging in swim sessions without limitations and participating in high intensity cycling sessions with performances similar to pre-surgery. Cardio-pulmonary exercise testing revealed increased maximum oxygen consumption and normalization of oxygen uptake/workload slope and maximum oxygen pulse.

Discussion

Endurance athletes with ASD may have abnormal haemodynamic response during CPET despite an exceptional high maximum oxygen uptake. This underscores the value of CPET in the diagnostic work-up of right heart enlargement.

Cardiopulmonary functional capacity in Taiwanese children with atrial septal defects

BACKGROUND

Most existing studies measure atrial septal defect (ASD) outcomes based on morbidity rates such as atrial arrhythmias and heart failure rather than the functional assessment of physical capacity postprocedure. Few studies have evaluated cardiopulmonary function in ASD children. This study represents the largest sample population in the current research, encompassing a total of 122 Taiwanese children with ASD who had undergone treatment, to evaluate cardiopulmonary functional capacity through the implementation of cardiopulmonary exercise testing (CPET), and to investigate whether variations in treatment may impact their cardiopulmonary function.

METHODS

This is a retrospective cohort study with the data collected from January 2010 to December 2021. All patients and controls (age-, sex-, and body mass index-matched) underwent CPET and pulmonary function testing.

RESULTS

In total, 122 ASD patients (surgically closed ASDs 27, transcatheter-closed ASDs 48, and follow-up unrepaired ASD 47) and 244 healthy controls were recruited. The ASD group exhibited lower peak metabolic equivalent (MET), peak oxygen consumption (VO 2 , p < 0.001), and peak minute ventilation ( p = 0.028) along with MET and VO 2 at the anaerobic threshold (AT) ( p = 0.012) compared to the control group. No statistically significant differences were observed in the pulmonary function test. Among surgically closed, transcatheter closed and unrepaired ASD subgroups, no significant variances were seen in CPET and pulmonary function tests.

CONCLUSION

Taiwanese ASD children exhibited diminished exercise capacity and cardiopulmonary performance compared to their healthy counterparts. Differences among specific ASD treatments in cardiopulmonary tests were non-significant.

A 24-Year-Old Male Patient With an Ostium Secundum Complex Atrial Defect Secondary to a Perforated Aneurysm With Inferior Vena Cava Agenesis

The article describes a successful clinical outcome in the case of a 24-year-old male with a diagnosis of an ostium secundum atrial defect secondary to a perforated aneurysm associated with vena cava agenesis. During hospitalization, an echocardiogram revealed the presence of ostium secundum inter-atrial communication with a left to right shunt, a left ventricular ejection fraction (LVEF) of 60%, and mild pulmonary hypertension, measured at 40 mmHg. CT imaging showed anomalous dilation of the azygos vein (16.8 mm), associated with interruption of the vena cava in the intrahepatic and adrenal portion, continuing through the azygos system and draining into the superior vena cava. Open-heart surgery was performed with pericardium patch placement on the defect. Postoperative transthoracic echocardiography revealed a tracking of the interatrial septum, with adequate placement of the surgical patch and no evidence of residual short circuits. The postoperative recovery was favorable, and the patient was discharged five days after surgery. Outpatient monitoring at the first and third months showed no complications during physical examination and echocardiogram imaging.

How Will Artificial Intelligence Shape the Future of Decision-Making in Congenital Heart Disease?

Improvements in medical technology have significantly changed the management of congenital heart disease (CHD), offering novel tools to predict outcomes and personalize follow-up care. By using sophisticated imaging modalities, computational models and machine learning algorithms, clinicians can experiment with unprecedented insights into the complex anatomy and physiology of CHD. These tools enable early identification of high-risk patients, thus allowing timely, tailored interventions and improved outcomes. Additionally, the integration of genetic testing offers valuable prognostic information, helping in risk stratification and treatment optimisation. The birth of telemedicine platforms and remote monitoring devices facilitates customised follow-up care, enhancing patient engagement and reducing healthcare disparities. Taking into consideration challenges and ethical issues, clinicians can make the most of the full potential of artificial intelligence (AI) to further refine prognostic models, personalize care and improve long-term outcomes for patients with CHD. This narrative review aims to provide a comprehensive illustration of how AI has been implemented as a new technological method for enhancing the management of CHD.

Identification of miR-20b-5p as an inhibitory regulator in cardiac differentiation via TET2 and DNA hydroxymethylation

BACKGROUND

Congenital heart disease (CHD) is a prevalent congenital cardiac malformation, which lacks effective early biological diagnosis and intervention. MicroRNAs, as epigenetic regulators of cardiac development, provide potential biomarkers for the diagnosis and treatment of CHD. However, the mechanisms underlying miRNAs-mediated regulation of cardiac development and CHD malformation remain to be further elucidated. This study aimed to explore the function of microRNA-20b-5p (miR-20b-5p) in cardiac development and CHD pathogenesis.

METHODS AND RESULTS

miRNA expression profiling identified that miR-20b-5p was significantly downregulated during a 12-day cardiac differentiation of human embryonic stem cells (hESCs), whereas it was markedly upregulated in plasma samples of atrial septal defect (ASD) patients. Our results further revealed that miR-20b-5p suppressed hESCs-derived cardiac differentiation by targeting tet methylcytosine dioxygenase 2 (TET2) and 5-hydroxymethylcytosine, leading to a reduction in key cardiac transcription factors including GATA4, NKX2.5, TBX5, MYH6 and cTnT. Additionally, knockdown of TET2 significantly inhibited cardiac differentiation, which could be partially restored by miR-20b-5p inhibition.

CONCLUSIONS

Collectively, this study provides compelling evidence that miR-20b-5p functions as an inhibitory regulator in hESCs-derived cardiac differentiation by targeting TET2, highlighting its potential as a biomarker for ASD.

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

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

Large Secundum Atrial Septal Defect Managed Conservatively in an Adult Dog

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

Cor Triatriatum Dexter With a Sinus Venosus Atrial Septal Defect in a 50-Year-Old Woman: A Case Report

The diagnosis of atrial septal defect (ASD) may be delayed until adulthood or even later in life as it is a well-tolerated congenital heart disease. If patients are not examined and investigated well in childhood, the diagnosis may be delayed until later in adulthood when patients present with palpitations and sometimes dyspnea due to the right chambers dilatation from right ventricular volume overload. In this report, we present a case of a 50-year-old female patient with symptoms of heart failure and atrial fibrillation who was found to have dilated right cardiac chambers, dilated pulmonary artery, severe tricuspid regurgitation, pulmonary hypertension, and a pulmonary-to-systemic flow ratio (Qp/Qs) of more than 1.5 by transthoracic echocardiography and Doppler, indicating left to right shunt at the atrial level. However, transthoracic echocardiography could not visualize the defect, and two-dimensional (2D) transesophageal echocardiography was done in this patient and documented the presence of a sinus venosus ASD with an incomplete cor triatriatum dexter membrane; all four pulmonary veins were identified going to the left atrium. Since the presence of an incomplete cor triatriatum dexter membrane (despite causing no symptoms) makes the percutaneous closure of the sinus venosus ASD and the percutaneous repair of tricuspid regurgitation very difficult, we decided to advise surgical ASD closure and tricuspid valve repair for the patient.

Residual networks models detection of atrial septal defect from chest radiographs

OBJECT

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

METHODS

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

RESULTS

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

CONCLUSION

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

Arrhythmic Risk and Treatment after Transcatheter Atrial Septal Defect Closure

Atrial septal defect (ASD) represents the most common congenital heart defect identified in adulthood. Atrial and ventricular geometric remodeling due to intracardiac shunt increase the risk of arrhythmias, especially atrial fibrillation (AF). Clinical, echocardiography, electrocardiogram, and device-related predictors may be used to assess the risk of atrial arrhythmias after ASD closure. The underlying mechanisms in these patients are complex and at least in part independent of the structural remodeling secondary to hemodynamic overload. Device closure of the ASD itself and its timing impact future arrhythmia risk, as well as posing a challenge for when transseptal puncture is required. Sudden cardiac death (SCD) risk is higher than in the general population and an implantable cardioverter-defibrillator (ICD) may be indicated in selected cases.

Massive Right Ventricle Enlargement in Unrepaired Sinus Venosus Atrial Septal Defect: Repair or Not?

Sinus venosus atrial septal defect (SVASD) with partial anomalous pulmonary venous return is a rare congenital heart defect that may present in adulthood when right heart enlargement has already occurred. We describe a case of unrepaired sinus venosus atrial septal defect and partial anomalous pulmonary venous return with massive right heart enlargement and recurrent atrial arrhythmias.

Unveiling an Unusual Cause of Cardiac Tamponade

This case presents a 48-year-old woman initially diagnosed with an ostium secundum atrial septal defect (ASD) at the age of 36. Twelve years post-intervention, she presented to the emergency department with cardiac tamponade. This case highlights the importance of maintaining prolonged follow-up for individuals undergoing percutaneous ASD closure, given the possibility of potentially fatal late complications of ASD occlusion devices.

Artificial intelligence-enabled 8-lead ECG detection of atrial septal defect among adults: a novel diagnostic tool

Background

Patients with atrial septal defect (ASD) exhibit distinctive electrocardiogram (ECG) patterns. However, ASD cannot be diagnosed solely based on these differences. Artificial intelligence (AI) has been widely used for specifically diagnosing cardiovascular diseases other than arrhythmia. Our study aimed to develop an artificial intelligence-enabled 8-lead ECG to detect ASD among adults.

Method

In this study, our AI model was trained and validated using 526 ECGs from patients with ASD and 2,124 ECGs from a control group with a normal cardiac structure in our hospital. External testing was conducted at Wuhan Central Hospital, involving 50 ECGs from the ASD group and 46 ECGs from the normal group. The model was based on a convolutional neural network (CNN) with a residual network to classify 8-lead ECG data into either the ASD or normal group. We employed a 10-fold cross-validation approach.

Results

Statistically significant differences (p < 0.05) were observed in the cited ECG features between the ASD and normal groups. Our AI model performed well in identifying ECGs in both the ASD group [accuracy of 0.97, precision of 0.90, recall of 0.97, specificity of 0.97, F1 score of 0.93, and area under the curve (AUC) of 0.99] and the normal group within the training and validation datasets from our hospital. Furthermore, these corresponding indices performed impressively in the external test data set with the accuracy of 0.82, precision of 0.90, recall of 0.74, specificity of 0.91, F1 score of 0.81 and the AUC of 0.87. And the series of experiments of subgroups to discuss specific clinic situations associated to this issue was remarkable as well.

Conclusion

An ECG-based detection of ASD using an artificial intelligence algorithm can be achieved with high diagnostic performance, and it shows great clinical promise. Our research on AI-enabled 8-lead ECG detection of ASD in adults is expected to provide robust references for early detection of ASD, healthy pregnancies, and related decision-making. A lower number of leads is also more favorable for the application of portable devices, which it is expected that this technology will bring significant economic and societal benefits.

Transcatheter Closure of Superior Sinus Venosus Defects

Superior sinus venosus defect is a communication between the right and left atrium located above the upper margin of the oval fossa, immediately inferior to the junction of the superior vena cava and the right atrium. It is systematically associated with partial anomalous pulmonary venous drainage, especially of the right upper pulmonary vein. Surgical repair has been the gold standard approach to close that defect. Introduced in 2014, percutaneous closure has gradually become a safe and effective alternative to surgery in carefully selected patients, although worldwide experience remains limited. This article provides an appraisal of the patients' selection process and a step-by-step description of the procedure as well as a comprehensive review of its outcomes.

Volume overload impedes the maturation of sarcomeres and T-tubules in the right atria: a potential cause of atrial arrhythmia following delayed atrial septal defect closure

Introduction: Adult patients with atrial septal defects (ASD), the most common form of adult congenital heart disease, often die of arrhythmias, and the immaturity of cardiomyocytes contributes significantly to arrhythmias. ASD typically induces a left-to-right shunt, which then leads to the right atrium (RA) volume overload (VO). Whether or not VO contributes to RA cardiomyocyte immaturity and thereby causes arrhythmias in adult patients with ASD remains unclear. Methods: Here, we developed the first neonatal RA VO mouse model by creating a fistula between the inferior vena cava and abdominal aorta on postnatal day 7. RA VO was confirmed by increases in the mean flow velocity, mean pressure gradient, and velocity time integral across the tricuspid valve, and an increase in the RA diameter and RA area middle section. Results: We found that VO decreased the regularity and length of sarcomeres, and decreased the T-element density, regularity, and index of integrity of T-tubules in RA cardiomyocytes, suggesting that the two most important maturation hallmarks (sarcomere and T-tubules) of RA cardiomyocytes were impaired by VO. Accordingly, the calcium handling capacity of cardiomyocytes from postnatal day 21 (P21) RA was decreased by VO. VO caused a significant elongation of the PR interval. The expression of connexin 43 (Cx43) was decreased in RA VO. Moreover, gene ontology (GO) analysis of the downregulated genes in RA demonstrated that there was an abundance of enriched terms associated with sarcomeres and T-tubules exposed to VO. The results were further verified by qRT-PCR. Conclusions: In conclusion, the first neonatal RA VO mouse model was developed; furthermore, using this neonatal RA VO mouse model, we revealed that VO impeded RA sarcomere and T-tubule maturation, which may be the underlying causes of atrial arrhythmias in adult patients with ASD.

Echocardiography in Simple Congenital Heart Diseases: Guiding Adult Patient Management

This article provides comprehensive insights into the evaluation of simple congenital heart diseases (CHDs) in adults, emphasizing the pivotal role of echocardiography. By focusing on conditions such as congenital aortic stenosis, aortic coarctation, patent ductus arteriosus, atrial septal defects (ASDs), and ventricular septal defects (VSDs), the review underscores echocardiography's intricate contributions to precise clinical decision-making. Echocardiography serves as the primary imaging modality, offering high-resolution visualization of anatomical anomalies and quantification of hemodynamic parameters. It enables tailored therapeutic strategies through its capacity to discern the dimensions, spatial orientation, and dynamic shunt dynamics of defects such as ASDs and VSDs. Moreover, echocardiography's advanced techniques, such as tissue Doppler imaging and speckle tracking, provide detailed insights into atrial mechanics, diastolic function, and ventricular filling kinetics. Integration of echocardiographic findings into clinical practice empowers clinicians to create personalized interventions based on quantified ventricular function, which spans systolic and diastolic aspects. This approach facilitates risk stratification and therapeutic planning, particularly pertinent in heart failure management within the CHD patient population. In summary, echocardiography transcends its role as an imaging tool, emerging as a precision-guided instrument adept at navigating the complexities of simple CHD in adults. Its ability to expedite diagnosis, quantify hemodynamic impacts, and unravel multifaceted functional dynamics culminates in a comprehensive depiction of these conditions. The fusion of these insights with clinical expertise empowers clinicians to navigate the intricate pathways of CHD, crafting tailored therapeutic strategies characterized by precision and efficacy.

Postoperative Complications, Readmissions, Lengths of Stay, and Cost Analyses of Patients Who Have Atrial Septal Defects After Total Joint Arthroplasty

BACKGROUND

Atrial septal defects (ASDs) are a common congenital heart defect. This study aimed to determine whether patients diagnosed with ASDs undergoing total joint arthroplasty have differences in 1) medical complications, 2) readmissions, 3) lengths of stay (LOS), and 4) costs.

METHODS

Using an administrative claims data set, a retrospective query from 2010 to 2020 was performed. The ASD patients were 1:5 ratio matched with controls, yielding a total of 45,695 total knee arthroplasty (TKA) (ASD = 7,635, control = 38,060) and 18,407 total hip arthroplasty (THA) (ASD = 3,084, control = 15,323) patients. Outcomes included medical complications, readmissions, LOS, and costs. Logistical regressions were used to calculate odds ratios (ORs) and P values. P values < 0.001 were significant.

RESULTS

The ASD patients had higher odds of medical complications after TKA (38.8 versus 21.0%; OR 2.09; P < .001) and THA (45.2 versus 23.5%; OR 2.1; P < .001), noticeably deep vein thromboses, strokes, and other thromboembolic complications. The ASD patients were not significantly more likely to be readmitted after TKA (5.3 versus 4.7%; OR 1.13; P = .033) or THA (6.0 versus 5.7%; OR 1.05; P = .531). Patient LOS was not significantly greater in ASD patients undergoing TKA (3.2 versus 3.2 days; P = .805) but was greater after THA (5.3 versus 3.76 days; P < .001). Same-day surgery costs were not significantly increased in ASD patients after TKA ($23,892.53 versus $23,453.40; P = .066) but were after THA ($23,981.93 versus $23,579.18; P < .001). Costs within 90 days were similar between cohorts.

CONCLUSION

The ASD patients have greater 90-day complications following primary total joint arthroplasty. Providers may consider preoperative cardiac clearance or adjusting anticoagulation in this population to mitigate these risks.

LEVEL OF EVIDENCE

III.

Adults with small, unrepaired atrial septal defects have reduced cardiac index during exercise

OBJECTIVES

Small, unrepaired atrial septal defects are considered a benign lesion with good prognosis. Recently, clinical and register-based studies discovered increased long-term mortality and morbidity. The nature of these findings is not fully understood. Therefore, MRI was performed to evaluate cardiac function at rest and during exercise.

METHODS

Adults with open or spontaneously closed atrial septal defects and healthy, matched controls underwent MRI for evaluation of cardiac chamber volume. Quantitative flow scans measured blood flow in the ascending aorta and the proximal pulmonary artery at rest and during increasing supine exercise.

RESULTS

In total, 15 open defects (39 ± 11 years) and 15 matched controls (38 ± 12 years) were included, along with 20 spontaneously closed (36 ± 13 years) and 20 controls (36 ± 11 years). Cardiac chamber volumes and flow measurements at rest were comparable between groups, as were heart rates and workloads during exercise. At maximal exercise, open defects reached 31% lower cardiac index and had 38% higher retrograde flow in the pulmonary artery than their controls, p < 0.01. Shunt ratio remained unchanged during exercise, 1.2 ± 0.2. Closed defects reached 18% lower cardiac index, p = 0.02, with comparable pulmonary retrograde flow. Maximal cardiac index was inversely correlated with increasing age for patients only.

CONCLUSION

Adults with a small, open or spontaneously closed atrial septal defects exhibit markedly lower exercise capacity compared with healthy peers. Moreover, open defects exhibit higher retrograde flows with increasing exercise. Finally, increasing age is related to poorer results in patients but not healthy controls. Longitudinal studies are necessary in order to determine potential accelerated worsening of physical capacity along with age-related changes in patients.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Case report: Intraoperative reversal of flow through an atrial septal defect presenting as hypoxemia during off-pump coronary artery bypass grafting

The co-existence of atrial septal defect and coronary artery disease in a patient is rare in clinical practice. In the combined surgery of off-pump coronary artery bypass grafting and atrial septal defect closure, the unusual cardiac positions may affect the direction of blood shunting between the atriums, leading to more complex hemodynamic changes. Here, we report a case of a 67-year-old female who underwent refractory hypoxemia related to heart position in such a combined operation.

Heart-brain axis: Association of congenital heart abnormality and brain diseases

Brain diseases are a major burden on human health worldwide, and little is known about how most brain diseases develop. It is believed that cardiovascular diseases can affect the function of the brain, and many brain diseases are associated with heart dysfunction, which is called the heart-brain axis. Congenital heart abnormalities with anomalous hemodynamics are common treatable cardiovascular diseases. With the development of cardiovascular surgeries and interventions, the long-term survival of patients with congenital heart abnormalities continues to improve. However, physicians have reported that patients with congenital heart abnormalities have an increased risk of brain diseases in adulthood. To understand the complex association between congenital heart abnormalities and brain diseases, the paper reviews relevant clinical literature. Studies have shown that congenital heart abnormalities are associated with most brain diseases, including stroke, migraine, dementia, infection of the central nervous system, epilepsy, white matter lesions, and affective disorders. However, whether surgeries or other interventions could benefit patients with congenital heart abnormalities and brain diseases remains unclear because of limited evidence.

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.

The Right Ventricle: From Embryologic Development to RV Failure

PURPOSE OF REVIEW

The right ventricle (RV) and left ventricle (LV) have different developmental origins, which likely plays a role in their chamber-specific response to physiological and pathological stress. RV dysfunction is encountered frequently in patients with congenital heart disease (CHD) and right heart abnormalities emerge from different causes than increased afterload alone as is observed in RV dysfunction due to pulmonary hypertension (PH). In this review, we describe the developmental, structural, and functional differences between ventricles while highlighting emerging therapies for RV dysfunction.

RECENT FINDINGS

There are new insights into the role of fibrosis, inflammation, myocyte contraction, and mitochondrial dynamics in the pathogenesis of RV dysfunction. We discuss the current state of therapies that may potentially improve RV function in both experimental and clinical trials. A clearer understanding of the differences in molecular alterations in the RV compared to the LV may allow for the development of better therapies that treat RV dysfunction.

Genetic Variants of CITED2 Gene Promoter in Human Atrial Septal Defects: Case-Control Study and Cellular Functional Verification

Atrial septal defect (ASD) is one of the most common forms of congenital heart disease (CHD). Genetic variants in the coding region of the CITED2 gene are known to be significantly correlated with CHD, but the role of variants in the promoter region of CITED2 is unknown. We investigated variants in the promoter of the CITED2 gene in 625 subjects (332 ASD and 293 healthy controls) through Sanger sequencing. Four variants in the CITED2 gene promoter were found only in eight ASD patients with zero occurrence in the control subjects (one case of g.4078A>C(rs1165649373), one case of g.4240C>A(rs1235857801), four cases of g.4935C>T(rs111470468), two cases of g.5027C>T(rs112831934)). Cellular functional analysis showed that these four variants significantly changed the transcriptional activity of the CITED2 gene promoter in HEK-293 and HL-1 cells. Electrophoretic mobility change assay results and JASPAR database analysis demonstrated that these variants created or destroyed a series of possible transcription factor binding sites, resulting in changes in the expression of CITED2 protein. We conclude that the variants of CITED2 promoter in ASD patients affect the transcriptional activity and are likely involved in the occurrence and development of ASD. These findings provide new perspectives on the pathogenesis and potential therapeutic insights of ASD.

The Treatment Strategy for the Atrial Septal Defect in the Presence of Severe Pulmonary Hypertension

Atrial septal defect is one of the most common congenital heart diseases in adults. The defect often leads to volume overload in the right heart coupled with the potential risk of right heart failure and pulmonary arterial hypertension. These conditions lead to worsening in quality of life, decrease in physical capacity, and even to fatal outcomes. The main strategy for treatment of atrial septal defect is a transcatheter or surgical closure of the defect, but in patients with severe pulmonary arterial hypertension, it is recommended to manage pulmonary arterial hypertension and after that treat the defect invasively. This strategy is called “treat and repair” strategy. We present an illustrative case report of management and treatment of atrial septal defect, complicated with severe pulmonary arterial hypertension. In this case, surgical closure of the defect was contraindicated because of the high pulmonary vascular resistance. Therefore, the “treat and repair” strategy was approached. After specific medical treatment of pulmonary arterial hypertension, surgical closure of the defect was chosen and proven successful.

Base Editing of Human Pluripotent Stem Cells for Modeling Long QT Syndrome

Human pluripotent stem cells (hPSCs) have great potential for disease modeling, drug discovery, and regenerative medicine as they can differentiate into many different functional cell types via directed differentiation. However, the application of disease modeling is limited due to a time-consuming and labor-intensive process of introducing known pathogenic mutations into hPSCs. Base editing is a newly developed technology that enables the facile introduction of point mutations into specific loci within the genome of living cells without unwanted genome injured. We describe an optimized stepwise protocol to introduce disease-specific mutations of long QT syndrome (LQTs) into hPSCs. We highlight technical issues, especially those associated with introducing a point mutation to obtain isogenic hPSCs without inserting any resistance cassette and reproducible cardiomyocyte differentiation. Based on the protocol, we succeeded in getting hPSCs carrying LQTs pathogenic mutation with excellent efficiency (31.7% of heterozygous clones, 9.1% of homozygous clones) in less than 20 days. In addition, we also provide protocols to analyze electrophysiological of hPSC-derived cardiomyocytes using multi-electrode arrays. This protocol is also applicable to introduce other disease-specific mutations into hPSCs.