Should transcatheter closure of atrial septal defects with inferior-posterior deficient rim still be attempted?

Complete Transthoracic Echocardiography for the Assessment and Guidance of Percutaneous Atrial Septal Defect Closure in Adults without Balloon Sizing: An Observed Study with a 10-Year Follow-Up

OBJECTIVES

This study aims to determine if complete transthoracic echocardiography (TTE)-guided percutaneous atrial septal defect (ASD) closure without balloon sizing could be safe and efficacious in adult patients.

METHODS

A total of 551 patients with ASDs were enrolled in this study, of which 438 patients underwent percutaneous ASD closure. Patients who received TTE-guided percutaneous ASD closure were classified into group T, and those who underwent a procedure that was guided by transesophageal echocardiography (TEE) were classified into group E. The clinical characteristics and the outcomes of the patients were analyzed.

RESULTS

The characteristics were comparable at baseline, except for the body mass index (BMI) (21.6 ± 5.3 vs. 23.8 ± 7.1, p < 0.001) between group T and group E. No significant difference was observed between the two groups regarding in-hospital outcomes, except for the duration of the procedure (29.8 ± 15.3 min vs. 41.5 ± 20.4 min), the length of stay in the hospital (2.1 ± 2.3 d vs. 2.9 ± 2.6 d), and hospital costs (USD 6233.3 ± 312.4 vs. USD 6673.7 ± 446.9). There were no significant differences in the incidences of long-term complications, cardiac chamber sizes, and tricuspid regurgitation severity between the patients in the two groups during the 10-year follow-up period.

CONCLUSION

TTE may be as safe and efficacious as TEE for the assessment and guidance of percutaneous ASD closure without balloon sizing in adult patients with lower BMIs who are commonly found in East Asia.

Sufficient versus deficient rims during percutaneous closure of ostium secundum type atrial septal defect: A systematic review and meta-analysis

BACKGROUND

The aim of this meta-analysis was to compare the efficacy and adverse events of percutaneous occlusion among patients with sufficient and deficient rims.

METHODS

A systematic review of all articles published in the Pubmed, MEDLINE and Google Scholar databases was performed. Odds ratio (OR) and 95% CI were used as a measure of effect of the combination of studies. I² with 95% CI was estimated to assess study heterogeneity. For the meta-analysis, a random effects model was used.

RESULTS

The systematic search identified ten studies which included 4355 patients; 2661 of those had sufficient rim and the remaining 1694 patients showed some rim deficiency. Implant failure rate was 4.13% CI 95% 3.53-4.72%. Compared to frequency of failures in the group with a deficient rim (5.43% CI 95% 4.35-6.50%), implant failure in patients with a sufficient rim was significantly lower (3.30% CI 95% 2.62-3.97%), OR 2.27 CI 1.34-3.83 (p 0.002). The combined adverse events were 5.19% CI 95% 4.22-6.35% vs 2.7% CI 95% 2.08-3.31% in the deficient vs sufficient rim groups respectively (OR 2.21 CI 0.93-5.29; p 0.07). Implant failures and adverse events were more frequent in patients with posterior inferior rim deficiency.

CONCLUSION

Patients presenting a posteroinferior rim deficiency are associated to both, an increased incidence of closure failure and a combined adverse events occurrence. More studies on posterior rim deficiency are necessary to ensure the feasibility and safety of the percutaneous approach.

Role of MDCT in evaluating prothesis size prior to percutaneous transcatheter closure of ostium secundum atrial septal defect

To investigate the feasibility and accuracy of cardiac multidetector computed tomography (MDCT) prosthesis sizing prior to ostium secundum atrial septal defect (ASD) percutaneous closure. Seventy consecutive patients were included in this retrospective bicentric study between May 2012 and June 2018. All underwent cardiac MDCT (primarily performed to rule out abnormal venous pulmonary return and coronary anomaly) and transesophageal echocardiography (TEE) before transcatheter closure: dimensions of the defect and peripheral rims were measured. Measurements of the defect obtained at TEE and MDCT were compared to prosthesis size. Our primary objective was the comparison of ASD maximal diameter obtained at MDCT (CT-Dmax) to prosthesis size. Intraclass correlation coefficient (ICC), Bland Altman plots and linear regression were calculated. Intra- and inter-observer agreements were calculated for MDCT defect measurements. Forty-three patients were finally included for defect measurements: 17 patients did not undergo transcatheter closure, and 10 had incomplete data. For CT-Dmax, ICC was 0.88 (CI 95% = [0.78-0.93]; p = 0.06); mean difference was - 0.8 ± 5.7 mm; regression linear equation was 0.9 × + 3.2 (p < 0.001). For maximal diameter at TEE versus prosthesis size, ICC was 0.46 (CI 95% = [0.21-0.61]; p = 0.003); mean difference was-6.0 ± 8.2 mm; regression linear equation was 0.91 × + 7.6 (p < 0.001). Intra- and inter-observer agreement for CT-Dmax were 0.97 (CI 95% = [0.95-0.98]) and 0.86 (CI 95% = [0.73-0.93]) respectively. MDCT is a reliable tool for sizing the defect of ostium secundum ASD, making it a complement or even an alternative to pre-procedural TEE.

Atrial Septal Defect Repair in Adolescent and Adult Patients, a Cross Sectional Study at Jordan University Hospital, a Tertiary Hospital in a Developing Country

Objective

We aim to report our heart team's experience in repair of Secundum atrial septal defect (ASD) in adolescent and adult patients at Jordan University Hospital (JUH).

Methodology

A retrospective observational study of 44 patients who underwent secundum ASD closure by transcatheter closure (TCC) or Minimally Invasive Cardiac Surgery (MICS) at JUH. Patients who were treated at an age of 14 years or older regardless of the age of diagnosis were included. SPSS and Microsoft Excel were used to analyze the data.

Results

A total of 44 patients with secundum ASD were treated during the period of (January 2015 and December 2019). The mean age was 34.1 (±14.3) years. Thirty-four patients underwent TCC, 9 underwent surgical closure and one had a hybrid procedure. We had no mortality and 2 minor morbidities. After a mean follow-up period of 13.2-/+13.6 months, most patients experienced improved symptoms, and there was a significant reduction of right ventricular dimension from 33.1 (±8.74) to 24 (±4.67) mm (p=0.0001).

Conclusion

ASD closure whether TCC or MICS is a safe procedure with very low morbidity. A heart team approach is a necessity in the era of advances in both MICS surgery and TCC approach. A heart team provides the patients with a variety of safe and cosmetic solutions that allow the patients to have a fast management and recovery phase in rapid time through providing the merits and avoiding the complications of each modality, the team allows low volume centers in developing countries to achieve an excellent outcome.

Transcatheter Device Therapy and the Integration of Advanced Imaging in Congenital Heart Disease

Transcatheter device intervention is now offered as first line therapy for many congenital heart defects (CHD) which were traditionally treated with cardiac surgery. While off-label use of devices is common and appropriate, a growing number of devices are now specifically designed and approved for use in CHD. Advanced imaging is now an integral part of interventional procedures including pre-procedure planning, intra-procedural guidance, and post-procedure monitoring. There is robust societal and industrial support for research and development of CHD-specific devices, and the regulatory framework at the national and international level is patient friendly. It is against this backdrop that we review transcatheter implantable devices for CHD, the role and integration of advanced imaging, and explore the current regulatory framework for device approval.

Transcatheter closure of atrial septal defect with deficient posterior-inferior or inferior vena cava rim under echocardiography only: a feasibility and safety analysis

BACKGROUND

The safe closure of atrial septal defect with deficient posterior-inferior or inferior vena cava rim is a controversial issue. Few studies have been conducted on the closure of atrial septal defect with deficient posterior-inferior or inferior vena cava rim without fluoroscopy. This study evaluated the feasibility and safety of echocardiography-guided transcatheter closure of atrial septal defect with deficient posterior-inferior or inferior vena cava rim.

METHODS

The data of 136 patients who underwent transcatheter atrial septal defect closure without fluoroscopy from March 2017 to March 2020 were retrospectively analysed. The patients were classified into the deficient (n = 45) and sufficient (n = 91) posterior-inferior or inferior vena cava rim groups. Procedure and the follow-up results were compared between the two groups.

RESULTS

Atrial septal defect indexed diameter and the device indexed diameter in the deficient rim group were both larger than that in the sufficient rim group (22.12 versus 17.38 mm/m2, p < 0.001; 24.77 versus 21.21 mm/m2, p = 0.003, respectively). There was no significant difference in the success rate of occlusion between two groups (97.78% in the deficient rim group versus 98.90% in the sufficient rim group, p = 1.000). During follow-up, the incidence of severe adverse cardiac events was not statistically significant (p = 0.551).

CONCLUSIONS

Atrial septal defect with deficient posterior-inferior or inferior vena cava rim can safely undergo transcatheter closure under echocardiography alone if precisely evaluated with transesophageal or transthoracic echocardiography and the size of the occluder is appropriate. The mid-term results after closure are similar to that for an atrial septal defect with sufficient rim.

Renaissance of Cardiac Imaging to Assist Percutaneous Interventions in Congenital Heart Diseases:The Role of Three-Dimensional Echocardiography and Multimodality Imaging

Percutaneous interventions have completely refashioned the management of children with congenital heart diseases (CHD) and the use of non-invasive imaging has become the gold standard to plan and guide these procedures in the modern era. We are now facing a dual challenge to improve the standard of care in low-risk patients, and to shift our strategies from the classic open chest surgery to imaging-guided percutaneous interventions in high-risk patients. Such rapid evolution of ultrasound technologies over the last 20 years have permitted the integration of transthoracic, transesophageal and intracardiac echocardiography into the interventional workflow to improve image guidance and reduce radiation burden from fluoroscopy and angiography. Specifically, miniaturization of transesophageal probe and advances in three-dimensional (3D) imaging techniques have enabled real-time 3D image guidance during complex interventional procedure, In addition, multimodality and fusion imaging techniques harness the strengths of different modalities to enhance understanding of anatomical and spatial relationship between different structures, improving communication and coordination between interventionalists and imaging specialists. In this review, we aim to provide an overview of 3D imaging modalities and multimodal fusion in procedural planning and live guidance of percutaneous interventions. At the present times, 3D imaging can no longer be considered a luxury but a routine clinical tool to improve procedural success and patient outcomes.

Morphological assessments of deficient posterior-inferior rim for transcatheter closure of atrial septal defect

OBJECTIVES

This study aimed to determine morphological characteristics of deficient posterior-inferior rim for transcatheter atrial septal defect (ASD) closure success.

BACKGROUND

The feasibility of transcatheter closure of ASD with deficient posterior-inferior rim remains unclear.

METHODS

Of 869 patients with ASD who were scheduled transcatheter closure, 121 with posterior-inferior rim of <5 mm were included. Posterior-inferior rim morphologies were evaluated by transesophageal echocardiography.

RESULTS

One hundred six patients successfully underwent transcatheter closure, while 15 patients failed. These 15 patients had complete deficient posterior-inferior rim of 0 mm and/or a large defect of ≥38 mm. Multivariate logistic regression analysis showed that transcatheter closure failure was independently related to complete deficient posterior-inferior rim and a large defect of ≥38 mm. Incomplete deficient posterior-inferior rim of >0 to <5 mm was observed in 84 patients. All these patients successfully underwent transcatheter closure, except two patients with a large defect of ≥38 mm. Complete deficient posterior-inferior rim was observed in 37 patients. The frequency of complete deficient posterior-inferior rim was higher in patients who failed transcatheter closure (87% vs. 23%, p < .01), but transcatheter closure was performed successfully if the range of complete deficient rim was ≤30°. After the procedure, no adverse events occurred during a median follow-up of 24 months.

CONCLUSIONS

Most patients with deficient posterior-inferior rim successfully underwent transcatheter closure. Transcatheter closure could be performed even in patients with complete deficient posterior-inferior rim if the range was partial. Our findings can help to identify candidates for transcatheter closure.

Transcatheter Closure of Atrial Septal Defects with Cardiac Computed Tomography Sizing: Eight-Year Single-Center Practice

INTRODUCTION

An accurate evaluation of atrial septal defect (ASD) is important for the success of interventional treatment. Cardiac computed tomography (CT) has unique advantages for ASD assessment, although transesophageal echocardiography (TEE) remains the accepted method.

OBJECTIVE

This study aimed to evaluate the safety and feasibility of transcatheter closure of ASD with cardiac CT sizing but without TEE measurement.

METHODS

Among 134 patients undergoing transcatheter closure, 13 underwent TEE in addition to a cardiac CT examination, and 121 underwent only cardiac CT. Propensity score matching was used to analyze the outcomes of the groups treated with (group 1) or without (group 2) TEE examinations. The success rate and complications among the 121 ASD patients with only cardiac CT sizing were recorded and analyzed. The maximal diameters of the defects remeasured on CT images were compared to the echocardiography results and correlated with the device size by Student t test and Pearson's linear regression analysis, respectively.

RESULTS

No significant differences (p > 0.05) were found between groups 1 and 2 in the success rate, complications, or ratio of the device size to the maximum diameter of the defect measured by cardiac CT. In group 1, the maximum diameters of the ASD derived from cardiac CT and TEE were comparable (22.08 ± 9.68 vs. 21.50 ± 10.24; p = 0.351). The success rate among the 121 patients who underwent transcatheter closure with only cardiac CT sizing was 99.2%; however, within 1 month of follow-up, 2 patients had arrhythmia, 1 patient had residual shunting, 1 patient had an infection, and 1 patient had a hematoma, but all patients recovered within a short time.

CONCLUSIONS

Cardiac CT seems to be comparable to TEE in the assessment of ASD, and transcatheter closure of ASD based on CT sizing alone is safe and feasible.

Transcatheter closure of a residual shunt with posteroinferior deficient rim after surgical closure of an ASD: a case report

BACKGROUND

There are few reports in the literature of device closure of residual shunts following initial surgical closure of an atrial septal defect (ASD). This case study reports one such case. We describe here a case of secundum type ASD that was initially closed surgically, followed by device closure of a residual shunt with a posteroinferior deficient rim.

CASE PRESENTATION

A 7-month-old boy was admitted to our hospital for elective surgery to surgically correct a secundum type ASD. Unfortunately, a residual shunt 3.5 mm in diameter appeared before discharge and was enlarged at1-year follow-up. The cause of this residual shunt was dehiscence at the posteroinferior aspect, and the posteroinferior rim was 3.7 mm. After careful discussion and preparation, we proceeded with an interventional procedure. A 16 mm ASD occluder (AGA Medical Corp, Plymouth, Minnesota) was deployed successfully with no residual shunt. In some cases of ASD, interventional therapy is not considered due to the size and position of the defect, but we show here, a successful case of interventional therapy for a residual shunt with a deficient rim.

CONCLUSION

We have presented a case in which a postoperative residual shunt with a deficient rim was successfully closed with interventional therapy.