The Risk Factors of Mitral Regurgitation Deterioration After Secundum Atrial Septal Defect Closure

Background

Association between secundum Atrial Septal Defect (ASD) and mitral valve (MV) disease has been recognized for decades. Secundum ASD closure can reduce mitral regurgitation (MR) degree. However, in some patients, deterioration of MR after ASD closure has been observed. We aimed to identify the risk factors of MR deterioration after ASD closure.

Methods

This was an observational retrospective cohort study. Data were collected from the registry and echocardiogram report. We evaluated all patients with ASD closure by surgery and transcatheterization without MR intervention from January 2012 until June 2021 at Dr. Sardjito General Hospital, Yogyakarta. We excluded patients with multiple ASD and ASD with severe MR requiring MV intervention. Risk factors for MR deterioration were evaluated using multivariate logistic regression.

Results

A total of 242 patients who underwent post-secundum ASD closure were included. In multivariate analysis, ASD closure by surgery, large left atrial (LA) diameter (>40 mm), low left ventricular ejection fraction (LVEF; <55%), and MV regurgitation degree were significant risk factors for MR worsening after ASD closure, with OR of 2.103 (95% CI 1.124-3.937); 2.871 (95% CI 1.032-7.985); 5.531 (95% CI 1.368-22.366); and 2.490 (95% CI 1.339-4.630) respectively.

Conclusion

ASD closure by surgery, large LA diameter (>40 mm), low LVEF (<55%), and MV regurgitation degree are independent significant risk factors for MR deterioration in post-secundum ASD closure patients. In adult ASD patients with reduced LV function, it is recommended to perform balloon testing and consider fenestrated closure, as low LVEF <55% has the highest risk of causing new or deteriorating MR.

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.

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.

Retrograde dye perfusion of the proximal aorta - A postmortem technical study

Introduction

Multiple cardiovascular conditions can lead to unexpected fatality, which is defined as sudden cardiac death. One of these potentially underlying conditions is aortic regurgitation, which can be caused by discrete changes of the geometry of the proximal aorta. To analyze aortic valve competency and furthermore to elucidate underlying pathological alterations of the coronary arteries and the vasa vasorum a perfusion method to simulate a diastolic state was designed.

Material and methods

A postmortem approach with retrograde perfusion of the ascending aorta with methylene blue was applied to three bodies. The procedure comprised cannulation of the brachiocephalic trunk, clamping of the aortic arch between brachiocephalic trunk and left carotid artery, infusion of 250 ml of methylene blue, and optical clearing of the superficial tissue layers after perfusion. Organs were examined directly following perfusion and after optical clearing.

Results

Assessment and visualization of aortic valve competency and the vasa vasorum were possible in all three instances. Visualization of the coronary perfusion was impaired by postmortem thrombus formation. Optical clearing did not provide additional information.

Discussion

The method presented here is a time- and cost-efficient way of visualizing aortic valve competency and the vasa vasorum. The visualization of the vasa vasorum highlights the potential of this method in basic research on diseases of the great arteries and coronaries. However, for a time-efficient functional analysis of the coronaries, other methods must be applied.

Prevalence and Hemodynamic Consequences of Mitral Valve Abnormalities in Atrial Septal Defect

Background: Atrial septal defect (ASD) is a common congenital heart disease in adults. Concomitant mitral valve disease in patients with ASD could have significant hemodynamic effects whit a great impact on managing this congenital defect. Objectives: This study evaluated the prevalence of mitral valve abnormalities and the hemodynamic burden associated with different types of ASD. Methods: This retrospective study reanalyzed 1,006 consecutive patients referred to Rajaie Heart Center in Tehran from March 2019 to February 2022. We evaluated adult patients with the diagnosis of a shunt at the atrial level. Diagnoses were made with 2D and 3D transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE). 3D analysis was performed with 3D zoom, mitral valve navigation (MVN), and full-volume and multi-planar reconstruction (MPR) modalities. We performed statistical analysis by SPSS version 22.0. The qualitative data were expressed as frequency and percentage. Data were compared between subgroups via Mann-Whitney U/Kruskal-Wallis tests for the interval variables, Pearson's chi-square test for nominal variables, and chi-square for trends test for ordinal variables. Results: The distribution of different ASD types was ostium secundum in 88.8% of cases, primum ASD in 0.9%, SVC-type sinus venosus ASD in 9%, IVC-type sinus venosus in 0.4%, and unroofed coronary sinus in 0.9%. We found mitral valve abnormalities in 21.1% of cases, and the most common mitral valve abnormality were prolaptic lesions (17.4%). Conclusions: Age, ASD size, estimated Systolic Pulmonary Artery Pressure (SPAP), and severity of mitral regurgitation (MR) were markedly higher were markedly higher among patients with MV anomalies, more over left ventricular ejection fraction (LVEF) was significantly lower among this group (P-value < 0.05).

Assessment of Left Ventricular Function and Mitral Regurgitation Severity Early After Percutaneous Device Closure of the Atrial Septal Defect

BACKGROUND

Atrial septal defect (ASD) is one the most prevalent forms of congenital heart disease in adults. Closure of ASDs eliminates left-to-right shunt and reduces right heart volumes, but the effects of ASD closure, on the left ventricle (LV) and mitral valve competence are somewhat inconsistent. Therefore, we designed this study to evaluate the early effect of percutaneous closure of ASD on LV function and mitral regurgitation (MR) severity.

METHODS

In this prospective study, we enrolled 32 patients with ASD secundum who underwent percutaneous device closure in Tehran Heart Center. We used transthoracic and transesophageal echocardiography (TEE) before the procedure and TTE 24 hours after the procedure, then compared obtained LV parameters before and after the procedure.

RESULTS

LV end-diastolic diameter (LVEDD) increased significantly from 44.8 ± 2.4 to 45.8 ± 2.8 (P < 0.001). LV end-systolic diameter (LVESD) also increased but was statistically insignificant (P = 0.063) and LV ejection fraction (LVEF) remained nearly unchanged. Highest alteration was in right ventricular systolic pressure (12.4% decrease; P < 0.001) and mitral early Doppler/tissue Doppler velocity ratio (E/E') (9.7% increase; P = 0.010). The change in MR severity was insignificant using Wilcoxon signed-rank test (P = 0.157).

CONCLUSIONS

We concluded that systolic functions do not change immediately. However, LVEDD and E/E' will increase immediately, resulting from the passage of all blood from the LA into the LV in the early diastole just after closure. We also observed the positive effect of device closure on reducing right ventricular systolic pressure, and at least it does not worsen MR early after the procedure.

A case of progressive dyspnea: Atrial septal device-related functional mitral regurgitation after myocardial infarction

Transcatheter device closure is a common treatment option of atrial septal defect. Mitral regurgitation has been reported with comorbid mitral valve prolapse and atrial septal defect. However there is no consensus regarding the pathogenesis of mitral regurgitation after closure. We are reporting a patient with functional mitral regurgitation associated with both an oversize closure device and wall motion abnormality after inferior myocardial infarction.

Mitral regurgitation detected during the intraoperative period after atrial septal defect closure: a case report

Background

Atrial septal defect (ASD) is a congenital cardiac defect often diagnosed in adult patients. Mitral regurgitation (MR) observed in ASD patients mostly improves after ASD closure. However, a subset of adult ASD patients present new-onset MR or aggravation of preexisting MR after ASD closure. Intraoperative MR aggravation after surgical ASD closure is a rare occurrence which has not been reported in the literature to date.

Case presentation

A 54-year-old woman was referred to our center due to large secundum ASD with a diameter of 17 mm which was incidentally detected on pre-operative echocardiography at a local clinic. Surgical repair of ASD under mini-thoracotomy was performed. After completion of the operation, intra-operative transesophageal echocardiography showed newly developed Grade II MR which subsequently deteriorated to severe level on postoperative day 3. Because the patient was asymptomatic, we decided to observe closely and treat conservatively with diuretics. Thereafter, echocardiography was evaluated on postoperative day 10 and MR disappeared to trivial level.

Conclusions

Intraoperative MR aggravation is a rare complication following ASD closure. The possibility of MR aggravation should be evaluated in all ASD patients prior to surgery. This case highlights the importance of mitral leaflet examination after ASD closure for early detection of MR.

Feasibility, safety and midterm follow-up of patients after nonsurgical closure of atrial septal defects using very large 40-46 mm nitinol septal occluders

OBJECTIVES

To study the feasibility of closure of large atrial septal defects (ASDs) using occluder devices >38 mm and assess the midterm complications.

BACKGROUND

Feasibility and safety of large occluders >38 mm and their follow-up are largely unknown.

METHODS

All patients with ASDs closed using devices >38 mm were retrospectively analyzed. Since outcome of patients receiving 40 mm devices were known before, patients receiving 40 mm devices were compared with those receiving 42-46 mm devices on demographic, hemodynamic parameters and procedural characteristics.

RESULTS

A total of 17 patients with 40-mm device and 31 patients with >40-mm device formed the cohort. The mean echocardiographic defect size was 36.3 ± 3.7 mm. In total 19 patients had deficient retroaortic margin; inferior margin was deficient in one. Larger defects needed special deployment techniques more often. There was acute technical success in all patients. Two procedures failed; one device embolization next day in a patient with deficient inferior margin needed surgery. Another elderly patient with restrictive left ventricular physiology died of multiorgan dysfunction. Two late deaths on follow-up were unrelated to the procedure. All other patients had symptom improvement. There were no erosions, thromboembolism or valvar regurgitation at a median follow-up of 39 (1-60) months. Apart from late-onset atrial flutter in one, there were no arrhythmias on follow-up.

CONCLUSIONS

Occluders larger than 38 mm in appropriately selected patients are feasible, successful and safe in majority and often require special deployment techniques. Complications during and after the procedure were infrequent. Very large defects with any deficient margin except retroaortic rim should be excluded from device closure.

Congenital Double-Orifice Mitral Valve in Asymptomatic Patients

Congenital double-orifice mitral valve (DOMV) is a rare malformation that may affect both mitral valve and apparatus, and it is usually associated with other cardiac disorders. Asymptomatic DOMV is extremely rare. We present two similar cases of asymptomatic congenital double-orifice mitral valve. Both cases presented functionally normal mitral valve apparatus with two equally sized orifices, which were formed by a central fibrosis. In addition, final confirmatory diagnosis was made using three-dimensional (3D) echocardiography in both cases.

Incidence and Predictors of Aggravation of Mitral Regurgitation After Atrial Septal Defect Closure

BACKGROUND

The association between atrial septal defect (ASD) and mitral regurgitation (MR) is well known. However, data about the predictors of changes in MR after ASD closure are limited. The purpose of this study was to clarify the chronological changes in MR after ASD closure and the predictors of aggravation of MR.

METHODS

In this single-center cohort study, we retrospectively investigated 129 consecutive adult patients (mean age, 53 ± 14 years) who underwent surgical ASD closure between 1987 and 2014. The MR grade was qualitatively classified as none, mild, moderate, or severe by echocardiography. Aggravation of MR was defined as an increase by two or more grades after ASD closure. Clinical factors and echocardiographic and catheterization data were evaluated.

RESULTS

The mean follow-up period was 77 months. Aggravation of MR after ASD closure occurred in 16 patients (12%). The rate of perioperative atrial fibrillation was higher (odds ratio, 5.89), the anterior mitral leaflet was thicker (odds ratio, 1.91), and the posterior mitral leaflet length was shorter (odds ratio, 1.58) in patients with aggravation of MR than in the remaining 113 patients. The mechanism of aggravated MR was poor coaptation associated with annular dilatation, thickened anterior mitral leaflet, and shortened posterior mitral leaflet.

CONCLUSIONS

A thickened anterior mitral leaflet and shortened posterior mitral leaflet, combined with mitral annular dilation associated with atrial fibrillation and restored left ventricular geometry, may aggravate MR after ASD closure. Careful follow-up is needed for patients with atrial fibrillation, a thickened anterior mitral leaflet, or a shortened posterior mitral leaflet.