The prospective follow-up of the natural course of interatrial communications diagnosed in 847 newborns

Natural History of Secundum ASD in Preterm and Term Neonates: A Comparative Study

Atrial septal defects (ASDs) are common in neonates. Although past studies suggest ASDs  ≥ 3 mm in term neonates (TNs) are less likely to close, there is paucity of data regarding the natural history in preterm neonates (PNs), information that would inform surveillance. We sought to compare spontaneous closure rates and need for intervention for ASDs in TNs/near term (≥ 36 weeks) versus PNs (< 36 weeks). We included all TNs and PNs who underwent echocardiography at ≤ 1 month between 2010 and 2018 in our institution with an ASD ≥ 3 mm, without major congenital heart disease, and with repeat echocardiogram(s). Spontaneous resolution was defined as size diminution to < 3 mm or closure. We included 156 TNs (mean gestational age at birth 38.6 ± 1.4 weeks) and 156 PNs (29.6 ± 3.7 weeks) with a mean age at follow-up of 16 ± 19 and 15 ± 21 months, respectively (p = 0.76). Based on maximum color Doppler diameter, in TNs, ASD resolution occurred in 95% of small (3-5 mm), 87% of moderate (5.1-8 mm), and 60% of large (> 8 mm) defects; whereas, in PNs, resolution occurred in 79% of small, 76% of moderate, and 33% of large ASDs. There was a significant association between size and ASD resolution in TNs (p = 0.003), but not PNs (p = 0.17). Overall, ASD resolution rate was higher in TNs (89%) versus PNs (78%) (p = 0.009), and fewer TNs (1%) compared to PNs (7%) required ASD intervention (p = 0.02). Most ASDs identified in TNs and PNs spontaneously resolve. PNs, however, demonstrate lower ASD resolution and higher intervention rates within all size groups. These data should inform follow-up of affected neonates.

[Incidence and evolution of congenital heart disease in Spain from 2003 until 2012]

INTRODUCTION AND OBJECTIVES

Congenital heart disease (CHD) represents the most common congenital malformation. The objective of this study was to analyse the incidence of CHD in Spain, and it is the first nationwide study so far.

METHODS

A retrospective observational study was performed in order to evaluate the incidence of CHD in Spain. The administrative database (minimum basic data set) from 2003 to 2012 was analysed in children less than one year old admitted to hospital with codes of CHD (International Classification of Diseases, 9th Revision, clinical modification). Cumulative incidence, Incidence relative risk, and standardised incidence ratio were calculated to study geographic variations.

RESULTS

There were 64,831 infants with CHD among the 4,766,325 births analysed during the period studied, with an incidence of 13.6‰. The incidence excluding atrial septal defect was 7.29 ‰.The most frequent CHD were atrial septal defect (6.31‰), ventricular septal defect (3.48‰), patent ductus arteriosus (2.71‰), coarctation of the aorta (0.55‰), pulmonary stenosis (0.50‰), transposition of the great arteries (0.49‰), atrioventricular septal defect (0.45‰), and tetralogy of Fallot (0.41‰). Castilla and Leon, together with Extremadura, showed the highest risks for severe and very severe CHD, while Madrid and Cantabria showed the lowest.

CONCLUSIONS

An increase of mild CHD was observed during the period analysed. This could have been influenced by improvements in diagnostic techniques, extended use of echocardiography, and the International Classification of Diseases, 9th Revision, clinical modification coding system, and to a decrease in very severe CHD, which is less influenced by external factors. Significant geographical differences were found in the incidence of severe and very severe CHD.

The Clinical Course of Patients With Atrial Septal Defects

BACKGROUND

Atrial septal defect (ASD) is a common congenital heart disease.

OBJECTIVES

The aim of this study was to assess the clinical course of ASD, as well as its frequency of spontaneous closure and regression of diameter.

METHODS

In a study conducted from 2000 to 2011, 192 consecutive patients with an isolated ASD were followed up regularly with periodic echocardiographic evaluations according to a standardized protocol. The study was conducted in two series of patients: infants and children and adults. Infants were classified into three groups based on ASD diameter: small (≤ 5 mm), medium (6 - 9 mm), and large (> 9 mm). In the same manner, the ASD size in children and adults was categorized into three groups: small (≤ 10), medium (10 - 20 mm), and large (> 20 mm).

RESULTS

The patients consisted of 76 (39.6%) males and 116 (60.4%) females. The mean age of patients at diagnosis was 16.12 ± 15.66 years (range 1 week - 75 years). The mean follow-up duration was 70 ± 9 months (range: 25 - 119 months). The most prevalent age group was adult patients (> 20 years), and most ASDs were of medium size (1 - 2 cm). The most common complication was mild pulmonary hypertension (31 cases, 16.2%), and Eisenmenger phenomenon was the rarest complication (2 cases, 1%). Overall spontaneous closure of ASD occurred in 42 (21.9%) cases. Spontaneous closure in cases with small defects occurred in 18 of 22 (81%) infants and 24 of 81 children > 1 years of age. Regression of ASD size occurred in 2 (9.5%) infants and 3 (3.7%) children. No spontaneous closure was observed in cases with a defect size > 10 mm, and no spontaneous occlusion was detected in adolescents or adults. Seventy-two percent (n = 139) of patients needed surgical repair or transcatheter closure of the ASD.

CONCLUSIONS

It is concluded that atrial septal defects < 6 mm typically close spontaneously, and ASDs measuring 6 - 9 mm may regress in infants and children. An ASD > 1 cm has little chance of spontaneous closure and may need surgical or device closure. ASD diameter and age at diagnosis are the most important predictors of spontaneous closure and the need for possible surgical or device closure.

Prevalence of congenital heart disease at live birth: an accurate assessment by echocardiographic screening

AIM

To determine the true prevalence of congenital heart disease (CHD) at live birth using echocardiographic screening.

METHODS

A total of 5190 consecutive newborns from two secondary hospitals were included. Each neonate had a complete clinical evaluation with echocardiographic diagnosis at average 47 h of age. Newborns with persistent CHD underwent at least 4 months of follow-up, and the temporal trend of prevalence of mild CHD was assessed.

RESULTS

Overall live birth prevalence of CHD was 26.6‰ (severe 3.5‰, moderate 5.4‰ and mild 17.7‰), and prevalence of CHD that could be detected by clinical evaluation was 12.1‰. The most common CHD was ventricular septal defect (VSD, 17.3‰), followed by atrial septal defect (ASD, 6.2‰), patent ductus arteriosus (PDA, 1.3‰), tetralogy of Fallot (TOF, 0.4‰), single ventricle (SV, 0.4‰), atrioventricular septal defect (AVSD, 0.2‰) and double outlet right ventricle (DORV, 0.2‰). Female predominance was observed in mild CHD (VSD, ASD), and male predominance was observed in severe CHD. The prevalence of CHD was reduced to 19.5‰ at the 4-month follow-up, which was largely caused by spontaneous closure rate of muscular VSD.

CONCLUSION

Prevalence of CHD determined by echocardiography screening was higher but more accurate than that obtained from birth defect registries.

Intracardiac shunting and stroke in children: a systematic review

In adults, patent foramen ovale or other potential intracardiac shunts are established risk factors for stroke via paradoxical embolization. Stroke is less common in children and risk factors differ. The authors examined the literature on intracardiac shunting and stroke in children, identifying the methods employed, the prevalence of detectible intracardiac shunts, associated conditions, and treatments. PubMed searches with keywords related to intracardiac shunting and stroke in children identified articles of interest. Additional articles were identified via citations in these articles or in reviews. The authors found that studies of intracardiac shunting in children with stroke are limited. No controlled studies were identified. Detection methods vary and the prevalence of echocardiographically detectible intracardiac shunting appears lower than reported in adults and autopsy studies. Defining the role of intracardiac shunting in pediatric stroke will require controlled studies with unified detection methods in populations stratified by additional risk factors for paradoxical embolization. Optimal treatment is unclear.

Single pediatric center experience with multiple device implantation for complex secundum atrial septal defects

OBJECTIVES

We analyzed the efficacy and complications of placing multiple transcatheter devices to correct complex ASD in a primarily pediatric population.

BACKGROUND

Limited pediatric information exists regarding the safety and efficacy of using multiple devices for secundum atrial septal defects (ASD) when multiple defects are present.

METHODS

Cath lab, echo, and clinical data were reviewed for 238 patients who underwent device closure of secundum ASD from 2000 to 2007 at a single pediatric center. Of those requiring multiple devices (n = 15), residual shunting and complications were assessed.

RESULTS

238 patients (mean age 12 yrs; 80% < 16 yrs) underwent transcatheter ASD closure. 34 (14%) had multiple ASD, but only 15 received multiple devices (2 devices in 14 and 3 devices in 1). The mean age and weight (12 yrs; 35 kg) represent a younger population than previously reported. Only 3 were > 15 yrs, with a median age of 10.8 yrs (range 2-31). There was no compromise or obstruction to surrounding structures, and no device embolization or erosion was noted. A tiny thrombus was observed on the right sided screw of one device with no clinical sequelae. One patient (age 31 yrs) died at home 30 days post procedure from cardiac tamponade. Autopsy revealed the 3 intact devices in stable position without evidence of erosion. Latest available echo follow-up for the group revealed functional resolution of atrial level shunting in all patients.

CONCLUSION

Multiple devices can safely and effectively be implanted in the pediatric population to close complex ASD.