Transcatheter closure of atrial septal defect in the elderly: a systematic review and meta-analysis

OBJECTIVE

Despite the establishment of transcatheter closure as the treatment of choice in adults with secundum atrial septal defects (ASDs), the effectiveness of this approach in the elderly is disputed. This systematic review and meta-analysis aims to explore the impact of transcatheter ASD closure in patients ≥60 years old.

METHODS

We systematically searched four major electronic databases (PubMed, CENTRAL (Cochrane Central Register of Controlled Trials), Scopus and Web of Science), ClinicalTrials.gov, article references and grey literature. Primary outcomes were the right ventricular end-diastolic diameter (RVEDD) and the New York Heart Association functional class change, whereas secondary outcomes included systolic pulmonary arterial pressure (sPAP), left ventricular end-diastolic diameter (LVEDD), brain natriuretic peptide (BNP), tricuspid valve regurgitation (TR) change, as well as the rate of atrial arrhythmias and all-cause mortality.

RESULTS

In total, 18 single-arm cohorts comprising 1184 patients were included. RVEDD was reduced after ASD closure (standardised mean difference (SMD) -0.9, 95% CI -1.2 to -0.7). Elderly patients had 9.5 times higher odds of being asymptomatic after ASD closure (95% CI 5.06 to 17.79). Furthermore, ASD closure improved sPAP (mean difference (MD) -10.8, 95% CI -14.6 to -7), LVEDD (SMD 0.8, 95% CI 0.7 to 1.0), TR severity (OR 0.39, 95% CI 0.25 to 0.60) and BNP (MD -68.3, 95% CI -114.4 to -22.1). There was a neutral effect of ASD closure on atrial arrhythmias.

CONCLUSIONS

Transcatheter ASD closure is beneficial for the elderly population since it improves functional capacity, biventricular dimensions, pulmonary pressures, TR severity and BNP. However, the incidence of atrial arrhythmias did not change significantly after the intervention.

PROSPERO REGISTRATION NUMBER

CRD42022378574.

Simultaneous Percutaneous Coronary Intervention and Endovascular Closure of Atrial Septal Defect in Adults

AIM

to assess clinical efficacy and expediency (appropriateness) of simultaneous single stage combined coronary stenting and closure of atrial septal defect.

MATERIALS AND METHODS

Of total number of patients who underwent endovascular correction of atrial septal defect (ASD) (n=91), in 6 (6.6 %) the procedure of endovascular repair of secondary ASD was combined with performed at same session oronary stenting. Mean age of these patients was 63±6.4 years. Mean diameter of ASD according to transesophageal echocardiography was 13.7±3.1 мм (from 10 to 17 mm). Two patients had dysplasia of atrial septum with pronounced aneurysmal protrusion in the right atrial cavity. Estimate of coronary arteries (CA) involvement SYNTAX score was 14.5±4.9.

RESULTS

At initial stage we performed coronary stenting, then ASD closure with occluder. Technical success of combined endovascular procedures was 100 %. Six ASD occluders were implanted in 6 patients. Mean occluder diameter was 21±7,3 mm. Immediately after occluder implantation complete defect closure was achieved in 5 cases, in one case small residual shunt was observed. CA stenting procedure, in one patient after successful recanalization of chronic CA occlusion, in all cases was fulfilled without complications. At control examination after 13.5±1.5 months complete closure of defects was preserved. In all cases significant reduction of right heart chambers occurred. According to echocardiography right atrial volume decreased from 48.6±5.6 to 32.6±3.3 cm3, right ventricular volume - from 45.2±5.1 to 33.4±3.8 cm3, systolic pulmonary pressure fell from 49.7±8.6 to 32.6±6.9 mm Hg. According to control coronary angiography good effect of endovascular procedures was preserved. Tolerance to exercise rose from 68.5±11.8 до 85.3±12.4 W.

CONCLUSION

Same time CA stenting and endovascular ASD closure appears to be safe and effective procedure. The strategy used was not associated with additive risk for a patient and shortened duration of hospital stay.

Transcatheter closure of secundum atrial septal defect in patients over 60 years old

BACKGROUND AND OBJECTIVES

Atrial septal defect (ASD) is the one of most common congenital heart diseases detected in adults. Along with remarkable development of device technology, the first treatment strategy of secundum ASD has been transcatheter closure in feasible cases. However, there are only a few publications regarding the results of transcatheter closure of ASD in elderly patients, especially those over 60 years of age. We report our results of transcatheter closure of ASD in patients over 60 years old.

SUBJECTS AND METHODS

Between May 2006 and December 2011, 31 patients over 60 years old (25 female and 6 male; mean 66.7±5.25 years old, range 61-78 years old) were referred to our center.

RESULTS

A total of 23 patients underwent therapeutic catheterization to close secundum ASD, and the closure was successful in 22 patients (95.7%). All patients who underwent the procedure survived except for one patient who expired because of left ventricular dysfunction. A small residual shunt was observed in two (9%) of 21 patients before discharge but disappeared at follow-up. All patients eventually had complete closure. There were five patients who had coronary problems. One patient underwent percutaneous coronary intervention using a stent at the same time as transcatheter closure of ASD. Atrial arrhythmias were detected in 6 of 23 patients (26.1%) before the procedure. One patient was successfully treated by radiofrequency ablation before the procedure. No patients displayed new onset arrhythmia during the follow-up period. Follow-up echocardiographic evaluation showed a significantly improved right ventricular geometry.

CONCLUSION

We conclude that transcatheter closure of ASD is a safe and an effective treatment method for patients over 60 years old if the procedure is performed under a thorough evaluation of comorbidities and risk factors.

Transcatheter closure of atrial septal defect: does age matter?

Atrial septal defect (ASD) is the most common type of common congenital heart disease (CHD) in adults. During the last decade, there has been a remarkable change in the treatment strategy of ASD, shifting the therapeutic gold standard from surgery to transcatheter closure, along with refinements and the evolution of device technology. Reports on the outcome of transcatheter ASD closure have shown an excellent efficacy as well as a low complication rate. However, the procedural details and/or outcomes of this procedure may be influenced by several factors including morphologic characteristics of the defect, co-morbid diseases, as well as individual factors including age and weight of the patient. Because the risk-benefit relationship in both the very young and the elderly subsets of the patients has not been clearly defined yet, closure of an ASD with device may be potentially subtracted from the treatment option in these patient groups. In this article, we will review the basis for device closure in small children and elderly patients with ASD and provide an overview of the frequently encountered problems.

Morphologic Characteristics and Relating Factors to the Need of Technical Modification in Transcatheter Closure of Large Atrial Septal Defect (>/=25 mm)

Background and Objectives

The rigid coupling between the delivery wire and the right atrial disk has been occasionally encountered during transcatheter closure of atrial septal defect (ASD). Therefore the device frequently makes a perpendicular angle, and the leading edge of left atrial disk slips through the defect and prolapses into right atrium (RA) before it is properly placed in the septum. The purpose of this study is to investigate relating factors to the need of technical modification in transcatheter closure of large ASD and to evaluate relevant morphologic characteristics of atrial septal rim in this situation.

Subjects and Methods

From July, 2003 to May, 2007, 312 patients underwent transcatheter occlusion of ASD with Amplatzer Septal Occluder® (ASO, AGA medical corporation, Golden Valley, MN, USA) at Yonsei Cardiovascular Center and among them 109 patients had large ASD (≥25 mm) and these patients were enrolled in our study. Patients were divided into two groups according to the deploying methods of the device (Group I: standard method, Group II: modified methods). Assessments of the defects and its surrounding rims were made by echocardiography.

Results

There were no differences between 2 groups in age, body weight and height except for balloon-stretched diameter (stop-flow technique) and device size. Group II patients with modified methods showed larger balloon-stretched diameter and device size than group I patients with standard method. The mean length of anterosuperior (AS) rim in group II was significantly shorter than group I (p<0.05). As the size of the device used in procedure increased, there was a trend towards increase in the need of modified methods.

Conclusion

This study shows that AS rim deficiency and the size of ASD may be the relating factors to the need of technical modification in transcatheter closure of ASD. Therefore, when the initial try with standard method is not successful in large ASD with deficient AS rim, we suggest that changing strategy of implantation may save time and efforts and possibly reduce the risk of complications associated with prolonged procedure.