Predictors of the Need for an Atrial Septal Defect Closure at Very Young Age

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL IMPACT

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

Risk factors for isolated atrial septal defect secundum morbidity

Atrial septal defect secundum is a common type of congenital heart defect and even more common among children born premature. The aim of this study was to assess premature birth as a potential associated risk factors for cardiac morbidity in children with isolated ASD II. In this retrospective national registry-based case-control study all children born in Sweden between 2010 and 2015 with an isolated ASD II diagnosis were included. Association between premature birth and cardiac morbidity in children with isolated ASD II was assessed by different outcomes-models using conditional logistic regression and adjustments were made for confounding factors. Overall, 11% of children with an isolated ASD II received treatment for heart failure. Down syndrome was the only independent risk factors for associated with cardiac morbidity in children with ASD II (OR = 2.25 (95%CI 1.25-4.07). Preterm birth in children was not associated with an increased risk of ASD II cardiac morbidity.

Outcomes of patent foramen ovale greater than 3 mm at birth in extremely low birthweight infants

BACKGROUND

Foramen ovale (FO) is an obligate fetal shunt that typically resolves after birth, although patency throughout life is not uncommon. The natural history of patent FO (PFO) is known in term infants, but less is known about its course in extremely preterm infants. We describe the echocardiographic changes in FO size from birth to discharge in extremely low birth weight (ELBW) infants in this retrospective study.

METHODS

Cohort was divided based on size of FO at birth. Size of FO at discharge was measured and evaluated relative to postnatal weight gain. Demographics and clinical outcomes were compared between the two groups.

RESULTS

Of the 54 ELBW infants, 50 were born with FO less than 3 mm in diameter (small), and 4 were born with FO greater than 3 mm (large). Of small defects, the majority (44/50, 88%) did not increase in size with weight gain, and minority (6/50, 12%) increased in size, and three of these 6 patients, FO grew to be slightly larger than 3 mm. In contrast, all large defects (4 of 4, 100%) nearly doubled in size with postnatal growth. These 4 ELBW infants with enlargement of FO had a flap valve evident on echocardiogram obtained prior to discharge, and subsequently closed on outpatient follow-up echocardiograms, although time to resolution was variable (6 months - 3 years). One infant had presumptive resolution because of the presence of flap valve.

CONCLUSION

No maternal or neonatal demographic characteristics were predictive of FO enlargement, although, demonstrable flap valve on discharge echocardiogram correlated with resolution of FO on outpatient follow-up echocardiogram. Therefore, based on our data, we recommend that ELBW infants born with large FO should have echocardiographic re-evaluation of the atrial septal opening prior to discharge, to specify the presence of a flap valve or lack thereof, which is an important detail that can help a neonatologist determine the need for outpatient cardiac follow-up.

Endovascular Closure of Secondary Septal Defect in Children with Low Body Weight

The aim. To assess the effectiveness and safety of transcatheter closure of a secondary atrial septal defect (ASD) using an occluder in symptomatic children weighing ≤10 kg. Materials and methods. In the period from November 2014 to June 2021, on the basis of the National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine, closure of secondary ASD using an occluder was performed in 18 patients, among them 13 women (72.2%) and 5 men (27.8%). Th e mean age of the patients was 18.94±9.44 months (the youngest patient was 12 months, the oldest was 4 years). The mean weight was 9.294±1.170 kg (6.4 kg to 10 kg), the mean Z-score was -1.7±1.5 (-4.6 to 0.46), the mean height was 80 cm (71 cm to 88 cm). According to the measurements by transesophageal echocardiography (TEE), the average size of the defects was 13.7 mm±3.6mm (the largest 18.0 mm, the smallest 6.0 mm). Results and discussion. In our publication, the effectiveness of the method was 100% (18/18), while the world statistics show 94-95%. Th e frequency of complications was 5.6% (n=1). We suggest that this is associated with the use of a sizing balloon and careful selection of the device. When choosing treatment tactics for symptomatic children weighing ≤10 kg, the decisive factor was the determination of the presence of edges and the size of the defect. Defects were considered suitable for closure, according to TEE data, when all margins of the defect were ≥4 mm, except for the aortic margin. Although the total length of the interatrial membrane was taken into account, it was not of decisive importance, since for most occluders with the presence of all edges, the fields of the implant could not interfere with the work of the anatomical structures of the heart. To determine the real size of the defect, we recommend a measuring balloon under TEE control. The following devices were used to close the defect: MemoPart ASD occluder, Amplatzer Septal Occluder, LifeTech HeartR Occluder, LifeTech HeartR Multi-Fenestrated Atrial Septal Defect (MF-ASD) Occluder.   Conclusion. After the study, we are convinced that the endovascular method of closing a hemodynamically significant secondary ASD for the treatment of children with a body weight of ≤10 kg has proven to be an effective method, with successful implantation of the occluder in 100% of cases.

Atrial Septal Defect Closure via Ministernotomy in Children

Atrial septal defect (ASD) closure is usually performed in children via a conventional sternotomy. In striving to improve the cosmetic result, we have adopted a lower ministernotomy approach with a very small skin incision. We present a single surgeon experience of 110 consecutive patients undergoing surgical closure of ASD, comparing conventional (n=55) and mini-sternotomy (n=55) approaches. Our ministernotomy technique avoids direct superior vena cava cannulation, allowing for a smaller incision, while providing adequate exposure. The ministernotomy approach is safe and provides an excellent cosmetic result.