Transcatheter closure of atrial septal defect: does age matter?

Long-Term Outcomes After Atrial Septal Defect Transcatheter Closure by Age and Against Population Controls

OBJECTIVES

The long-term outcomes after transcatheter closure of atrial septal defects (ASD) in adults are reported and compared between age groups and against population control patients.

BACKGROUND

ASD is the second most common lesion in congenital heart disease. Comprehensive data on long-term outcomes after ASD closure are limited.

METHODS

This retrospective cohort study enrolled adult patients with secundum ASD closure between 1998 and 2016. Information from a detailed clinical registry was linked to population-based administrative databases to capture outcomes. The population control cohort was matched using important prognostic characteristics.

RESULTS

The cohort included 1,390 ASD patients of whom 32% were <40 years of age, 45% were 40 to 60 years of age, and 23% were >60 years of age at closure. The median follow-up was 10.6 years (interquartile range: 6.2 to 14.0 years). New-onset atrial fibrillation (AF) was the most frequent outcome overall (14.9%). The incidence of adverse cardiac and cerebrovascular events was higher in the >60 years of age group than in the younger groups. In adjusted analysis, patients >60 years of age continued exhibiting higher risk of all-cause (hazard ratio [HR]: 8.54; 95% confidence interval [CI]: 93.40 to 21.43) and cardiovascular (CV)-specific mortality compared with the <40 years of age group. The risk of new-onset AF (HR: 3.73; 95% CI: 2.79 to 4.98) and any AF hospitalization (HR: 1.55; 95% CI: 1.28 to 1.89) was higher in the ASD than in the control population, whereas there was no difference in all-cause and CV-specific mortality.

CONCLUSIONS

As expected, rates of adverse events post-ASD closure are higher in older age groups, but long-term mortality was comparable to that of a population control cohort. The high rates of AF necessitate future investigations.

The changes in biventricular remodelling and function after atrial septal defect device closure and its relation to age of closure

Background

The trans-catheter closure of atrial septal defect (ASD) usually has a rapid impact on biventricular remodelling and functions. Whether the transcatheter closure of ASD at early childhood or at adulthood age would affect the improvement in biventricular dimensions and functions remains an area of active research.

Results

This prospective observational study enrolled 70 subjects (50 ASD cases and 20 control subjects). Tissue Doppler imaging (TDI) and strain (S) were performed for the control group and ASD patients at baseline and at 24 h and 1 month after ASD device closure. The total ASD group was subdivided into two subgroups: group-1—children and adolescent with ASD, who underwent transcatheter closure at age ≤ 19 years; group-2—adult who underwent ASD device closure at age > 19 years old. The right and left ventricular global longitudinal systolic strain (RV/LV-GLS) and RV free wall longitudinal strain (RV free wall LS) showed a significant decline after 24 h of device closure (RVGLS-P = 0.001, LVGLS-P = 0.048, RV free wall LS-P < 0.001). However, after a 1-month follow-up, the LVGLS increased in comparison with 24 h changes after device closure (P = 0.038). The baseline mean value of RV free wall LS of G2 was significantly lower than G1 value (P < 0.001). There was no statistically significant difference between the 2 age subgroups regarding biventricular GLS and RV free wall LS changes after device closure. The changes in LV diastolic function immediately and after 1 month of device closure showed a statistically significant change in e′ and its delta change value in group-2 in comparison with its baseline values and to group-1 delta changes (P = 0.002, P = 0.011, P = 0.019, respectively).

Conclusion

The ASD transcatheter closure reduced biventricular global and RV free wall longitudinal systolic strain within 1 day of intervention and was associated with a short-term improvement in the LV-GLSS after a 1-month duration. The progressive increase in LV preload results in its strain growth and reduction in diastolic function after transcatheter ASD closure. The older age at the time of ASD device closure was associated with a significant decrease in the RV free wall LS and septal e′ velocity towards abnormality.

Immediate and Short-Term Outcome of Percutaneous Atrial Septal Defects Closure in Adult Patients

Background

Atrial septal defect secundum (ASD II) is the commonest of the congenital heart diseases in the adult population and the closure of ASD II causes a significant improvement in hemodynamics and the clinical status of the patient. However, it carries certain risks, especially the development of post-closure pulmonary edema and congestive cardiac failure, which may lead to death. Therefore, this study was designed to share our experience and to evaluate the immediate and short-term outcomes of percutaneous closure of ASD II in adult patients presenting at a tertiary care cardiac center in Karachi, Pakistan.

Methodology

In this study, we included 30 adult (≥ 40 years) patients who underwent percutaneous ASD II closure at the pediatric cardiology department of the National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan, between June 1, 2017, and July 31, 2019. Data for this study were extracted from a prospectively collected departmental database. Extracted data for this study consisted of demographic profile, comorbid conditions, echocardiographic findings, cardiac catheterization data, pre and post six-month electrocardiographic findings, and New York Heart Association (NYHA) Functional Classification (FC).

Results

Out of 30 adult patients, 18 (60%) were female. The mean age of the patients at the time of ASD closure was 51.43 ± 7.09 years, ranging between 40 and 67 years. None of the patients had any post-intervention complications. Mean systolic pulmonary artery pressure (SPAP) on cardiac catheterization pre-implantation was 49.8 ± 16.3 mmHg range was 20-90 mmHg while SPAP immediately after device implantation was 37 ± 11.4 range 20 to 65 mmHg with p<0.001. Mean SPAP on pre-catheterization echocardiography was 58.8 ± 14.3, range 30-95 mmHg, while after six months, the mean SPAP was 34.5 ± 7.2, range 20-45 mmHg, with p<0.001 in 28 (93.3%) patients (in two patients, there was no TR). There was no mortality up till six months after the intervention. The functional class (FC) after six months of the procedure improved in most, 90% (27), of the patients.

Conclusion

There were no complications immediately after the procedure. After six months, post-procedure SPAP decreased to < 50 mmHg in the majority of patients (96.6%). Functional class (FC) improved in most (90%) of the adult (≥ 40 years) patients undergone percutaneous atrial septal defects closure. Therefore, percutaneous closure of ASD II is a safe and effective procedure for adult patients.

Percutaneous atrial septal defect closure in infant weighing <10 kg and having a bilateral superior vena cava: a case report

Percutaneous closure has become a preferred treatment for secundum atrial septal defect (ASD). However, this approach remains challenging in treating small infant weighing <10 kg because of procedure-related complications. The closure of ASD in other congenital anomalies, such as a bilateral superior vena cava (SVC), should be cautiously conducted. A 15-month-old boy with a body weight of 8 kg was diagnosed with secundum ASD (9–11 mm in diameter), residual pulmonary stenosis, and bilateral SVC. Transcatheter closure of ASD was successfully performed by using a 12 mm CeraFlex occluder device (Lifetech Scientific Corporation). Post-procedural examination showed good results without any impingement to the adjacent structure. Therefore,the transcatheter closure of ASD in infant weighing <10 kg and having bilateral SVC is technically feasible and safe.

Risk factors for adverse events within one year after atrial septal closure in children: a retrospective follow-up study

INTRODUCTION

Secundum atrial septal defect is one of the most common congenital heart defects. Previous paediatric studies have mainly addressed echocardiographic and few clinical factors among children associated with adverse events. The aim of this study was to identify neonatal and other clinical risk factors associated with adverse events up to one year after closure of atrial septal defect.

METHODS

This retrospective case-control study includes children born in Sweden between 2000 and 2014 that were treated surgically or percutaneously for an atrial septal defect. Conditional logistic regression was used to evaluate the association between major and minor adverse events and potential risk factors, adjusting for confounding factors including prematurity, neonatal sepsis, neonatal general ventilatory support, symptomatic atrial septal defects, and pulmonary hypertension.

RESULTS

Overall, 396 children with 400 atrial septal defect closures were included. The median body weight at closure was 14.5 (3.5-110) kg, and the median age was 3.0 (0.1-17.8) years. Overall, 110 minor adverse events and 68 major events were recorded in 87 and 49 children, respectively. Only symptomatic atrial septal defects were associated with both minor (odds ratio (OR) = 2.18, confidence interval (CI) 95% 1.05-8.06) and major (OR = 2.80 CI 95% 1.23-6.37) adverse events.

CONCLUSION

There was no association between the investigated neonatal comorbidities and major or minor events after atrial septal defect closure. Patients with symptomatic atrial septal defects had a two to four times increased risk of having a major event, suggesting careful management and follow-up of these children prior to and after closure.

Impact of hospital volume on outcomes of percutaneous ASD/PFO closure in pediatric patients

BACKGROUND

We investigated the effect of hospital volume on percutaneous closure of atrial septal defect/patent foramen ovale (ASD) among pediatric patients.

METHODS

We identified patients undergoing percutaneous closure of ASD with device using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) procedure code 35.52 from the National Inpatient Sample, years 2002-2011. Patients with age ≤ 18 years and primary diagnosis code 745.5 for ASD were included. Hospital volume was calculated using unique identification numbers and divided into tertiles for analysis. Multivariate regression analysis was performed to determine independent predictors of procedure-related complications which were coded using specific codes released by Healthcare Cost and Utilization Project.

RESULTS

6162 percutaneous ASD closure procedures were analyzed. There was no mortality associated with percutaneous ASD closure. Cardiac complications (9.5%) were most common. On multivariate analysis, age increment of 3 years decreased the odds of developing complications (OR 0.83, 95% CI 0.79-0.87, P < 0.001). Odds of developing complications in the 2nd (OR 0.74, 95% CI 0.62-0.89, P = 0.007) and 3rd tertiles (OR 0.34, 95% CI 0.27-0.42, P < 0.001) were lower as compared to the 1st tertile of hospital volume.

CONCLUSION

Increasing annual hospital volume is an independent predictor of lower complication rates in percutaneous ASD closure cases with no associated mortality in pediatric patients.

Comparison of Transcatheter Atrial Septal Defect Closure in Children, Adolescents and adults: Differences, Challenges and Short-, Mid- and Long-Term Results

Background and Objectives

This study aims to compare the characteristics, effectiveness and results of transcatheter closure of atrial septal defect between children, adolescents, and adults.

Subjects and Methods

In this study, 683 patients who underwent atrial septal defect closure in the last 10 years were divided into three groups: children (age <12), adolescents (age 12 to 16), and adults (age >16) as group 1, group 2 and group 3, respectively.

Results

The average defect size and incidence of complex atrial septal defect were higher in group 3 (p=0.0001 and 0.03 respectively). While the average size of the devic was higher in adults (22.6±6.4 mm vs. 18.5±4.9 mm; p=0.0001), the ratio of the device size/total septum was higher in both children and adolescents (Group 1 and 2). In the child and adolescent groups and patients with only complex atrial septal defect, the use of techniques, other than standard deployment, was similar in all three groups (p=0.86 and 0.41, respectively). The ratio of the residual shunt was similar in all three groups. Major complications were seen in 5 cases (4 cases with migration, and 1 case with dislocation) in group 3 and 1 case (migration) in group 1.

Conclusion

Depending on the complexity of the defect and age of the patient, transcatheter closure of atrial septal defect might have certain difficulties and complications. Patients must be evaluated in detail to avoid major complications and possible problems during the procedure.

Surgical correction of atrial septal defect in the elderly

Introduction

Atrial septal defects (ASDs) are one of the most common congenital malformations in adults. Correction of ASDs in advanced age remains controversial, even though beneficial effects in this patient group were found in recent studies. In older patients, less invasive transcatheter closure of ASDs has been recommended.

Aim

The aim of this study was to analyze our advanced age ASD surgical cohort: early and late results.

Material and methods

Retrospective analysis of 32 patients operated on at an age of ≥ 60 years (i.e. age 66.13 ± 4.8, range from 60 to 78) in our center between 2001 and 2011 was carried out. We reviewed our experience of surgical ASD closure in elderly patients over a 10-year period to assess the effects of this type of treatment on early postoperative and long-term survival, early and late complications, preoperative and postoperative clinical status (New York Heart Association [NYHA] functional class), pulmonary hypertension (PH) and atrial arrhythmias. The patients were divided into two groups according to age.

Results

The frequency of comorbidities was lower in younger age group patients (11 [61%] vs. 13 [93%], p < 0.05). Atrial fibrillation/flutter was found in 21 (66%) of all patients. Late postoperative mortality was higher in the older patient group (3 [21%] vs. 1 [5.6%]). Despite this, we observed significant improvement of symptoms and functional ability in the older population after surgical ASD closure (group I, n = 10 [56%] vs. group II, n = 12 [86%]).

Conclusions

Surgical correction of clinically significant ASD is effective even in older patients with comorbidities.

Comprehensive understanding of atrial septal defects by imaging studies for successful transcatheter closure

Transcatheter closure of atrial septal defects has become a popular procedure. The availability of a preprocedural imaging study is crucial for a safe and successful closure. Both the anatomy and morphology of the defect should be precisely evaluated before the procedure. Three-dimensional (3D) echocardiography and cardiac computed tomography are helpful for understanding the morphology of a defect, which is important because different defect morphologies could variously impact the results. During the procedure, real-time 3D echocardiography can be used to guide an accurate closure. The safety and efficiency of transcatheter closures of atrial septal defects could be improved through the use of detailed imaging studies.

Balloon occlusive diameter of non-circular atrial septal defects in transcatheter closure with amplatzer septal occluder

Background and Objectives

The aim of this study was to investigate the balloon occlusive diameter (BOD) of non-circular defects in the transcatheter closure of atrial septal defect (ASD).

Subjects and Methods

A total of 67 patients who had undergone transcatheter closure of an ASD were reviewed retrospectively. A non-circular defect was defined as the ratio of the short diameter to the long diameter of the defect on the en-face image less than 0.75. The BOD was compared with the long diameter of the defect and then compared between the two groups.

Results

There were 22 patients with circular defects and 45 patients with non-circular defects. The difference in BOD measuring from the long diameter of the defect was quite different between the two groups and significantly smaller in non-circular morphology (0.1±4.0 vs. 2.3±2.1, p=0.006). The difference in BOD measurement from the long diameter of ASD showed a positive correlation with the ratio of the short diameter to the long diameter of ASD (b/a) (r²=0.102, p=0.008). In the non-circular morphology of ASD, the difference in BOD measured from the long diameter had a significant negative correlation with the long diameter of ASD (r²=0.230, p=0.001), whereas in circular ASD, no significant correlation was found between the difference in BOD and the long diameter of ASD (p=0.201).

Conclusion

The BOD compared with the long diameter measured from three-dimensional transesophageal echocardiography was smaller in non-circular ASD than in circular ASD. This difference was much smaller in non-circular ASD with a large long diameter.

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.