Echocardiographic Evaluation of Right Heart and Hemodynamic Changes After Transcatheter Secundum Atrial Septal Defect Closure in Adults: A Single-Center Retrospective Study

Aortic Coarctation is Right Out of Left Field: The Impact of Pulmonary Hypertension and Right Ventricular Dysfunction on Clinical Outcomes.

To examine determinants of access to treatment, outcomes, and hospital utilization in patients undergoing secundum atrial septal defect (ASD) closure in adulthood in England and Wales. Large retrospective cohort study of all adult patients undergoing secundum ASD closures in England and Wales between 2000/01 and 2016/17. Data were from population-based official data sets covering congenital heart disease procedures, hospital episodes, and death registries. Out of 6541 index closures, 79.4% were transcatheter [median age 47 years, interquartile range (IQR) 34-61] and 20.6% were surgical (40 years, 28-52). The study cohort was predominantly female (66%), with socioethnic profile similar to the general population. Mortality in hospital was 0.2% and at 1 year 1.0% [95% confidence interval (CI) 0.8-1.2%]. Risk of death was lower for transcatheter repairs, adjusting for age, sex, year of procedure, comorbidities, and cardiac risk factors [in-hospital adjusted odds ratio 0.09, 95% CI 0.02-0.46; 1-year adjusted hazard ratio 0.5, 95% CI 0.3-0.9]. There was excess mortality 1 year after ASD closure compared with matched population data. Median (IQR) peri-procedural length of stay was 1.8 (1.4-2.5) and 7.3 (6.2-9.2) days for transcatheter and surgical closures, respectively. Hospital resource use for cardiac reasons started the year before repair (median two inpatient and two outpatient-only days) and decreased post-repair (zero inpatient and one outpatient days during the first 2 years). This national study confirms that ASD closure in adults, by surgical or transcatheter methods, is provided independently of ethnic or socioeconomic differences, it is low (but not no) risk, and appears to reduce future cardiac hospitalization even in older ages.

Assessment of Pulmonary Pressures by Transthoracic Echocardiographic (TTE) and Invasive Right Heart Catheterization (RHC) in a Real-World Pulmonary Hypertension Population – Does Tricuspid Regurgitation (TR) Severity Make a Meaningful Difference?

Resolution of right heart enlargement after closure of secundum atrial septal defect with transcatheter technique

Objectives: We aimed to evaluate the effect of percutaneous atrial septal defect (ASD) closure in children using right heart indices and serum galectin-3 (Gal-3), as potential biomarkers of right heart remodeling. Methods: This case–control prospective study included 40 children with ASD and 25 control subjects. An echocardiographic evaluation was performed before the procedure, as well as 24 h, 1 month, and 6 months after intervention. Serum Gal-3 was measured before, and 1 month after the procedure. Results: Serum Gal-3 concentration, right atrial (RA) dimensions, right ventricular (RV) dimensions, indexed RA area, and right index of myocardial performance (RIMP) were significantly increased in children with ASD compared with control subjects while tricuspid annular plane systolic excursion (TAPSE) was significantly decreased. Six months after closure, RA, and RV dimensions significantly decreased and RV function improved (RIMP decreased and TAPSE increased). Gal-3 oncentration significantly decreased 1 month after ASD closure, but it did not reach normal range compared with control subjects. A positive correlation between Gal-3 and age at closure, RA area, RV dimensions, and RIMP was observed. A positive correlation was observed between the decrease in Gal-3 concentration and the decrease in RA area and RV dimensions 1 month after ASD closure. A significant negative correlation was observed between TAPSE and Gal-3 concentration before and after intervention. Conclusions: Percutaneous ASD closure can improve right-sided indices and decrease serum Gal-3 concentration. Gal-3 can be used as a sensitive biomarker of right heart remodeling, with a decrease in Gal-3 concentration suggesting reversal of maladaptive remodeling.

Background Optimal management of severe tricuspid regurgitation (TR) remains controversial. While right ventricular systolic function is an established prognostic marker of outcomes, the potential role of right atrial (RA) function is unknown. Purpose This study was aimed to describe RA function by 2D speckle tracking echocardiography (STE) in severe TR and to evaluate its potential association with cardiovascular outcomes Methods Consecutive patients with at least severe TR (severe, massive or torrential TR) evaluated in the Heart Valve Clinic following a comprehensive clinical protocol were included. Consecutive control subjects and patients with permanent atrial fibrillation (AF) were included for comparison. RA function was measured with 2D-STE and 3 components of RA function were calculated: reservoir (RASr), conduit (RAScd) and contractile (RASct) RA values using an automatic 2D strain analytical software (AutoStrain, Philips Medical Systems the EPIQ system, Figure 1). A combined endpoint of hospital admission due to heart failure (HF) or all-cause mortality was defined. The interobserver variability of RA strain was assessed in 30 randomly selected subjects (20 TR+5 AF+5 controls). Results A total of 176 patients with severe TR, 20 AF patients and 20 controls subjects were included in this study. Patients with at least severe TR showed lower RASr and RAScd compared to controls and to AF patients (Figure 1 and Table 1, p<0.05). After a median follow-up of 28 months (IQR: 15–48 months), n=65 patients with severe TR (37%) reached the combined endpoint. 65 (37%) were admitted for right heart failure and 8% of the population (n=14) died. Patients with events showed lower values of RASr and RAScd (p<0.01 for both). Between both parameters RASr was more strongly associated with outcomes compared to RAScd (AUC 0.74 vs. 0.65, p<0.01). RASr was an independent predictor of heart failure and all cause mortality adjusted by additional imaging prognostic parameters in a multivariable analysis (biplane vena contracta, RV end-diastolic area, and RV-free wall longitudinal strain [LR χ2: 49.7, p<0.001]). RA area or volume was not associated with outcomes. A cut-off value of RASr of <9.4% held the best accuracy to predict outcomes (adjusted HR 3.2 (1.81–5.84), p<0.001, Figure 1). Inter-observer agreements for RA strain values across the whole cohort were high (intraclass correlation coefficient for RASr, RAScd and RASct, r=0.95, r=0.86, r=0,92 respectively) Conclusions Evaluation of RA function by 2D-STE is feasible, reproducible and is an independent predictor of heart failure and all-cause mortality in patients with at least severe TR. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): INSTITUTO CARLOS III

Objectives: The aim of the study to evaluate the safety and efficacy of the transthoracic echocardiography (TTE) guided secundum atrial septal defect (ASD) closure without balloon sizing, sedation or general anesthesia in adults. Methods: We retrospectively evaluated 200 secundum ASD closure patients in the tertiary cardiology center. Transesophageal echocardiography (TEE) was performed to all the patients at least one day before the intervention by the procedure operators. The patients who were closed with a cribriform device, using more than one device, with insufficient rim (<5 mm) (other than the anterior superior rim (aortic rim)), totally flail, and complex interatrial septum anatomy were excluded from the analysis.The size of the ASD closure device was chosen according to the largest diameter measured by TEE. ASD device was selected as 4 mm larger in patients without anterior superior rim and 2 mm larger in other patients than the largest diameter measured in 2D-TEE. Results: In the remaining 166 patients, the procedure was performed with TTE and fluoroscopy guidance without balloon sizing, sedation or general anesthesia. The procedure was performed through right femoral vein. The patients age: 38.56 ± 14.72, gender: 57 male, 109 female, ASD size: 18.88 ± 5.99 mm, anterior superior rim: 5.30 ± 4.04 mm, anterior inferior rim: 14.22 ± 6.46 mm, posterior superior rim: 17.16 ± 4.96 mm, posterior inferior rim: 16.67 ± 7.48 mm. ASD device size: 23.74 ± 6.59 mm. The procedure success rate was 98.1% (163 patients). The complications; 1 patient device embolised, 2 patients device was not placed in the correct position by TTE. Conclusions: TTE and fluoroscopy-guided secundum ASD closure without balloon sizing, sedation or general anesthesia by experienced operators is a safe and effective procedure.

Symptom improvement and cachexia reversal in an 84-year-old woman after percutaneous closure of atrial septal defect.

Background/Introduction Severe tricuspid regurgitation (TR) is associated with progressive right atrial (RA) and ventricular (RV) dilation, dysfunction and increased mortality. Risk factors impacting the long-term prognosis in patients with severe TR are largely undetermined. Purpose Herein, we aimed to identify risk factors associated with long-term mortality in patients with severe TR and implement a novel risk stratification strategy based on an individual five-year mortality prediction score. Methods From January 2013 to December 2017, 1238 patients with severe functional TR were enrolled in the TRuE-registry, of which 914 with a complete dataset were included in the present study. Echocardiographic quantification of RV-function and size included measurements of tricuspid annular plane systolic excursion (TAPSE), the end-diastolic basal (RVDbasal) and longitudinal diameters (RVDlong) and the RA-volume index (RAVI). The cohort was randomly divided into a development (n=610) and validation (n=304) sample. A risk stratification model was developed using a multivariable Cox regression. Results The variables statistically significant to predict five-year-mortality, included in the final model and used as score parameters were: age, COPD, dialysis, pulmonary artery systolic pressure, RAVI, TAPSE RVDbasal, RVDlong and systolic hepatic vein flow reversal (sHVFR). Progressive enlargement of RV and RA and concomitant sHVFR was associated with higher values of hazard ratios (HR, Figure A). Based on the HR values, a risk score with 3 categories was developed (Figure B): low (0–2), intermediate (3–5), high (6–16). Among the risk groups, Kaplan Meier estimates of all-cause mortality at 5 years were 18%, 52% and 84% respectively (p<0.001; https://thetruerisk.com). The score showed good discrimination, with a concordance index of 0.75. At internal validation, a good agreement between the derivation and validation datasets indicated a good calibration of the survival curves. Implementation of a long term risk score Conclusion The present study demonstrates the prognostic impact of comorbidities and right heart remodeling on long-term mortality in patients with severe TR. The presented risk score provides an easy and accurate estimation of long-term mortality and may thus help to guide therapeutic decision-making in this difficult group of patients.

Background Optimal management of severe tricuspid regurgitation (TR) remains controversial. While right ventricular systolic function is an established prognostic marker of outcomes, the potential role of right atrial (RA) function is unknown. Purpose This study aimed to describe RA function by 2D speckle tracking echocardiography (STE) in at least severe TR and to evaluate its potential association with cardiovascular outcomes. Methods Consecutive patients with at least (≥) severe TR (severe, massive or torrential TR) evaluated in the Heart Valve Clinic following a comprehensive clinical protocol were included. Consecutive control subjects and patients with permanent isolated AF were included for comparison (control and AF group respectively). RA function was measured with 2D-STE and RA reservoir strain (RASr) was calculated in all subjects (figure 1, AutoStrain, Philips Medical Systems the EPIQ system). The interobserver variability of RA strain was assessed in 30 randomly selected subjects (20 TR+5 AF+5 controls). A combined endpoint of hospital admission due to heart failure (HF) or all cause mortality was defined. Results A total of 227 patients with severe TR, 20 AF patients and 20 controls subjects were included in this study. Patients with at least severe TR showed lower RASr compared to controls and to AF patients (p<0,05). After a median follow-up of 26 months (IQR: 15-48 months), n=83 patients with severe TR (37%) reached the combined endpoint. Patients with events showed lower values of RASr (p<0,01 for both). RASr was an independent predictor of heart failure and all cause mortality adjusted by additional imaging prognostic parameters in a multivariable analysis (biplane vena contracta, RV end-diastolic area, and RV- free wall longitudinal strain [LR Chi2 : 49,7, p<0,001]). RA area or volume was not associated with outcomes. A cut-off value of RASr of <10% held the best accuracy to predict outcomes (adjusted HR 3,8 (2,4-6,1), p<0,001, figure 2). Inter-observer agreements for RA strain values across the whole cohort were high (intraclass correlation coefficient for RASr, RAScd and RASct, r= 0,95, r=0,86, r=0,92 respectively). Conclusions Evaluation of RA function by 2D-STE is feasible, reproducible and is an independent predictor of heart failure and all-cause mortality in patients with at least severe TR.LA STRAINKaplan Meier Curves

Opinions vary widely regarding the effectiveness of transcatheter atrial septal defect (ASD) closure in adults, especially in elderly patients. The purpose of this study was to evaluate and compare the hemodynamic changes after transcatheter ASD closure in two groups of patients, one aged 40-59 years (group 1) and one 60 years of age and older (group 2). Retrospective analysis of patient files. Forty-six patients were evaluated (23 in each group). Older patients had a higher prevalence of cardiovascular risk factors and established coronary artery disease. There was no statistically significant difference between the two groups in Qp/Qs values, ASD diameter and occluder size. The elderly patients had significantly higher baseline systolic pulmonary artery pressure (PAp) levels -53 +/- 16.2 vs. 39 +/- 7.7 mm Hg, P = 0.003. One year following the procedure, the mean reduction in PAp values was 11.3% in group 1 and 19% in group 2 (P = 0.099). While significant baseline tricuspid regurgitation (TR) was more frequent in the elderly patients, no significant TR was observed in either group 1 year following the procedure. Transcatheter ASD closure resulted in significant hemodynamic improvement in all patients, but was even more beneficial in the elderly patient cohort.

Mitral Annular Plane Systolic Excursion: An Early Marker of Mortality in Severe COVID-19

We determined the prevalence and factors associated with tricuspid regurgitation (TR) in adults with repair of right ventricular (RV) outflow obstruction. A total of 256 patients (128 males) were studied at 25.7 ± 7.2years after surgery, of whom 179 had repaired tetralogy of Fallot (TOF), 31 had pulmonary atresia with intact ventricular septum (PAIVS), and 46 had pulmonary stenosis (PS). The mitral and tricuspid annulus diameters, maximum right atrial (RA) area, RV end-systolic and end-diastolic areas, and tricuspid and pulmonary regurgitation were assessed using echocardiography. The prevalence of moderate-to-severe TR was 20.7%. Subgroup analysis revealed that prevalence was greater in patients with repaired TOF (20.7%) and PAIVS (35.5%) than PS patients (10.9%). As a group, severity of TR was found to be correlated with RA area (r = 0.35, p < 0.001), RV end-diastolic (r = 0.28, p < 0.001) and end-systolic (r = 0.22, p = 0.001) areas, and tricuspid valve annulus diameter (r = 0.15, p = 0.022). Moderate-to-severe TR was associated with development of cardiac arrhythmias with an odds ratio of 2.9 (95% CI 1.1 to 8.1, p = 0.031). Multivariate analysis revealed maximum RA area (β = 0.36, p = 0.016) as an independent determinant of severity of TR. Moderate-to-severe TR occurs in about one-fifth of adults with repaired TOF, PAVIS, and PS and is associated with RA dilation and risk of development of cardiac arrhythmias.

BackgroundIn precapillary pulmonary hypertension (PH), the incidence of different tricuspid regurgitation (TR) degree is poorly defined. The impact of TR severity on pulmonary artery pressure (PAP) assessment and clinical risk stratification in precapillary PH remains unclear.MethodsA total of 207 patients diagnosed precapillary PH who underwent right heart catheterization (RHC) and echocardiography within 3 days were included. The severity of TR was graded as trace, mild, moderate and severe. Pearson correlation analysis was performed to evaluate the correlation between systolic PAP by echocardiography (sPAPECHO) and mean PAP by RHC (mPAPRHC) in different TR degree groups. The impact factors on risk stratification of precapillary PH were analyzed by logistic regression analysis.ResultsThe proportion of None, Trace, Mild, Moderate and Severe TR group was 2.4%, 23.7%, 39.1%, 28.5% and 6.3% respectively. Right atrium (RA) area increased gradually with TR aggravation (p < 0.001). Moderate and Severe TR group had higher N-terminal pro-B-type natriuretic peptide (p < 0.001), right atrial pressure (RAP) (p = 0.018), right ventricular basal diameter (RVD)/left ventricular basal diameter (LVD) ratio (p < 0.001), larger right ventricle (RV) (p < 0.001) and lower tricuspid annular plane systolic excursion (p = 0.006) compared with Trace and Mild group. TR-sPAPECHO in Moderate TR group had the greatest correlation coefficient with mPAPRHC (0.742, p < 0.001) followed by Mild (0.635, p < 0.001) and severe group (0.592, p = 0.033), while there was no correlation in Trace TR group (0.308, p = 0.076). Multivariate logistic regression showed three significant independent echocardiography predictors of high-risk precapillary PH: RVD/LVD ratio (OR = 5.734; 95%CI1.502–21.889, p = 0.011), RA area (OR 1.054; 95% CI 1.004–1.107, p = 0.035) and systolic annular tissue velocity of the lateral tricuspid annulus (S’) (OR 0.735, 95% CI 0.569–0.949, p = 0.018).ConclusionsPrecapillary PH was not necessarily accompanied by significant TR. None or Trace TRaccounted for 26% in our population and TR-sPAPECHO was not applicable to estimate PAP in these patients. RVD/LVD ratio, RA area and S’ can independently predict the high-risk patients with precapillary PH. TR may play an indirect role in risk stratification by affecting these indicators.

Surgical indications for moderate to severe tricuspid regurgitation (TR) during atrial septal defect (ASD) closure are still unclear. Additional tricuspid valve annuloplasty (TVP) can be beneficial to avoid postoperative persistent TR. Therefore, we compared the results of surgical ASD closure with or without additional TVP in patients who presented with moderate-to-severe TR. Between November 2009 and June 2016, 103 patients with ASD and moderate-to-severe TR underwent surgical ASD closure without (n = 76, group 1) and with additional TVP (n = 27, group 2). Clinical outcomes and echocardiographic data were analyzed. There was no mortality. Postoperative outcomes were similar despite significantly longer aortic clamping time in group 2 (P = .003). Mean TR grade, right atrial diameter, right ventricular end-diastolic diameter, pulmonary artery pressure, and Qp/Qs ratio decreased significantly in both groups (P < .05). Mean follow-up time was 5.3 months (range: 1 month-6.2 years) in group 1 and 6.1 months (range: 1 month-4.1 years) in group 2 (P = .66). Echocardiography results showed significant decrease in TR grade in both groups (P = .93). The incidence of persistent moderate to severe TR was higher in isolated ASD closure group (14.4% vs 3.7%, P = .086). Additional TVP provided greater regression in TR grade (-1.49 ± 0.9 vs -1.89 ± 0.8, P = .041). Despite TVP being associated with longer ischemic time, postoperative outcomes were comparable to ASD closure alone. Both approach demonstrated an effective decrease in TR, but TVP provided greater regression and lower incidence of persistent TR. Therefore, additional TVP should be considered in patients undergoing ASD closure with moderate-to-severe TR.