Incidence and predictors of asymptomatic pericardial effusion after transcatheter closure of atrial septal defect

Prognostic Utility of Pericardial Effusion in the General Population: Findings From the STAAB Cohort Study

BACKGROUND

The incidental finding of a pericardial effusion (PE) poses a challenge in clinical care. PE is associated with malignant conditions or severe cardiac disease but may also be observed in healthy individuals. This study explored the prevalence, determinants, course, and prognostic relevance of PE in a population-based cohort.

METHODS AND RESULTS

The STAAB (Characteristics and Course of Heart Failure Stages A/B and Determinants of Progression) cohort study recruited a representative sample of the population of Würzburg, aged 30 to 79 years. Participants underwent quality-controlled transthoracic echocardiography including the dedicated evaluation of the pericardial space. Of 4965 individuals included at baseline (mean age, 55±12 years; 52% women), 134 (2.7%) exhibited an incidentally diagnosed PE (median diameter, 2.7 mm; quartiles, 2.0-4.1 mm). In multivariable logistic regression, lower body mass index and higher NT-proBNP (N-terminal pro-B-type natriuretic peptide) levels were associated with PE at baseline, whereas inflammation, malignancy, and rheumatoid disease were not. Among the 3901 participants attending the follow-up examination after a median time of 34 (30-41) months, PE was found in 60 individuals (1.5%; n=18 new PE, n=42 persistent PE). Within the follow-up period, 37 participants died and 93 participants reported a newly diagnosed malignancy. The presence of PE did not predict all-cause death or the development of new malignancy.

CONCLUSIONS

Incidental PE was detected in about 3% of individuals, with the vast majority measuring <10 mm and completely resolving. PE was not associated with inflammation markers, death, incident heart failure, or malignancy. Our findings corroborate the view of current guidelines that a small PE in asymptomatic individuals can be considered an innocent phenomenon and does not require extensive short-term monitoring.

Case report of worsening of preexisting pericardial effusion after ASD device closure: is it calamitous?

Background

Secundum-type atrial septal defects (ASD) constitute 8% to 10% of congenital heart defect. Secundum ASDs can be closed either percutaneously or surgically. However, ASD device closure has proven to be technically safe and feasible; it is not free of complications. These complications include device embolization/malposition which have been reported in 3.5% of cases, arrhythmia, and pericardial effusion in 2.6% and 0.5–1.5% respectively, device thrombus, residual shunting, and impingement of the device on the adjacent structures.

Case presentation

We introduce three patients with secundum ASD who had preexisting pericardial effusion, device closure was performed for them, and after the procedure, the effusion size progressed significantly. We used multimodality imaging to diagnose the cause of pericardial effusion (PE). Cardiac erosion was diagnosed in one of the patients that managed surgically. We did not found any specific procedure-related cause for worsening the pericardial effusion in the other two patients.

Conclusion

Several reasons include procedure-related complication and other systemic causes should be considered in patients who develop pericardial effusion after trans catheter closure of ASDs.

Completed atrioventricular block induced by atrial septal defect occluder unfolding: A case report

BACKGROUND

An atrial septal defect is a common condition and accounts for 25% of adult congenital heart diseases. Transcatheter occlusion is a widely used technique for the treatment of secondary aperture-type atrial septal defects (ASDs).

CASE SUMMARY

A 30-year-old female patient was diagnosed with ASD by transthoracic echocardiography (TTE) 1 year ago. The electrocardiogram showed a heart rate of 88 beats per minute, normal sinus rhythm, and no change in the ST-T wave. After admission, TTE showed an atrial septal defect with a left-to-right shunt, aortic root short-axis section with an ASD diameter of 8 mm, a parasternal four-chamber section with an ASD diameter of 9 mm, and subxiphoid biatrial section with a diameter of 13 mm. Percutaneous occlusion was proposed. The intraoperative TTE scan showed that the atrial septal defect was oval in shape, was located near the root of the aorta, and had a maximum diameter of 13 mm. A 10-F sheath was placed in the right femoral vein, and a 0.035° hard guidewire was used to establish the transport track between the left pulmonary vein and the inferior vena cava. A shape-memory alloy atrial septal occluder with a waist diameter of 20 mm was placed successfully and located correctly. TTE showed that the double disk unfolded well and that the clamping of the atrial septum was smooth. Immediately after the disc was revealed, electrocardiograph monitoring showed that the ST interval of the inferior leads was prolonged, the P waves and QRS waves were separated, a junctional escape rhythm maintained the heart rate, and the blood pressure began to decrease. After removing the occluder, the elevation in the ST segment returned to normal immediately, and the sinus rhythm returned to average approximately 10 min later. After consulting the patient’s family, we finally decided to withdraw from the operation.

CONCLUSION

Compression of the small coronary artery, which provides an alternative blood supply to the atrioventricular nodule during the operation, leads to the emergence of a complete atrioventricular block.

Percutaneous Atrial Septal Defect Closure Using the Occlutech Figulla Device in Adults: More than 800 Patient-Years of Follow-Up

Purpose

The Occlutech Figulla occluder has been proven safe and effective at midterm follow-up after percutaneous atrial septal defect (ASD) closure. We describe the safety and efficacy at long-term follow-up in adults.

Methods

All consecutive adult patients that underwent ASD closure between 2008 and 2015 were included. All complications were registered. Residual left-to-right shunt (LRS) was diagnosed using color-Doppler transthoracic echocardiography (TTE). Right-to-left shunting was diagnosed using contrast TTE. Successful closure was defined as no LRS at follow-up.

Results

In total, 166 patients (mean age 56.7 ± 16.1 years; 62% female) underwent percutaneous ASD closure using the Occlutech Flex I (70%) or Flex II (30%) device (diameter 24 mm; range 10-40 mm) under general anaesthesia and transoesophageal echocardiographic guidance. Long-term follow-up data were available for 144 patients (87%) with a mean follow-up of 5.9 ± 2.6 years, a total of 814 patient-years. During hospitalization, device embolization occurred in three patients (1.8%) with successful extraction in all. During the long-term follow-up, 15 patients (9.8%) suffered new-onset atrial fibrillation and stroke occurred in 2.1%. There was no residual LRS at 12-month follow-up. No device embolization occurred during the long-term follow-up.

Conclusion

Percutaneous ASD closure using the Occlutech device appears to be safe at long-term follow-up with a high successful closure rate at one year.

A Very Late Life-Threatening Complication After Percutaneous Closure of an Atrial Septal Defect

Percutaneous closure is widely recognized as the first therapeutic option in the majority of cases of secundum atrial septal defect (ASD) because of its high effectiveness and safety. Nonetheless, with the progressive increase of implanted devices and follow-up duration, several adverse events, some of them potentially life-threatening, have been reported. We report the case of an asymptomatic aortic erosion that occurred 13 years after the procedure. The main feature of our case is the very late occurrence of a life-threatening asymptomatic complication of ASD percutaneous closure, which should prompt lifelong surveillance in this population.