Atrial Septal Defect Closure In Adults Research Articles

Secundum atrial septal defect closure in adults in the UK.

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, IQR 34-61) and 20.6% were surgical (40 years, 28-52). The study cohort was predominantly female (66%), with socio-ethnic profile similar to the general population.Mortality in hospital was 0.2% and at one year 1.0% (95%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-OR 0.09, 95%CI 0.02-0.46, one-year adjusted-HR 0.5, 0.3-0.9). There was excess mortality one year after ASD closure compared to 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 2 inpatient and 2 outpatient-only days) and decreased post-repair (zero inpatient and one outpatient days during the first two 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 hospitalisation even in older ages.

PROCEDURAL AND SHORT-TERM RESULTS OF PERCUTANEOUS ATRIAL SEPTAL DEFECT CLOSURE IN ADOLESCENTS AND ADULTS

Objectives: To evaluate the procedural and short-term results of percutaneous atrial septal defect (ASD) closure in adults. Methodology: We retrospectively analysed 149 consecutive patients with a secundum ASD who underwent percutaneous closure from September 2011 to January 2021. Procedural and short-term results, including arrhythmia, device embolisation and residual shunt, were assessed at 2 days and 4 weeks and 6 months after percutaneous closure of atrial septal defect. Results: The patients were 14 to 77 (37.7 ± 15.0) years old and 101 (67.8%) were female. Maximum defect size was 18.0 ± 6.3 mm measured on transoesophageal echocardiography. The device diameter used in patients who underwent closure was 21.9 ± 6.9 mm (6–38 mm). Percutaneous closure procedure success rate was 93.3%. In our study, the rates of device embolisation, arrhythmia and residual shunt were 3.6%, 1.4%, and 2.2%, respectively. Conclusion: Transcatheter closure of ASDs in adults was feasible in our centre with good short-term outcome. The procedure should be performed in experienced centres by cardiologists specialised in the treatment of structural heart diseases due to potentially severe complications.

Effectiveness and Safety of Transcatheter Atrial Septal Defect Closure in Adults with Systemic Essential Hypertension.

Concomitant systemic essential hypertension (HTN) in adults with a secundum atrial septal defect (ASD) can unfavorably affect the hemodynamics and transcatheter ASD closure (ASDC) effects. This study aims to assess the effectiveness and safety of ASDC in adults with HTN in real-world clinical practice. Right ventricular (RV) reverse remodeling (RVR) and the lack of a left-to-right interatrial residual shunt (NoRS) in echocardiography 24 h and 6 months (6 M) post-ASDC, and ASDC-related complications within 6 M were evaluated in 184 adults: 79 with HTN (HTN+) and 105 without HTN (HTN−). Compared to HTN−, HTN+ patients were older and had a greater RV size and the prevalence of atrial arrhythmias, chronic heart failure, nonobstructive coronary artery disease, diabetes, hyperlipidemia, and left ventricular diastolic dysfunction. ASDC was successful and resulted in RVR, NoRS, and a lack of ASDC-related complications in the majority of HTN+ patients both at 24 h and 6 M. HTN+ and HTN− did not differ in ASD size, a successful implantation rate (98.7% vs. 99%), RVR 24 h (46.8% vs. 46.7%) and 6 M (59.4% vs. 67.9%) post-ASDC, NoRS 24 h (79% vs. 81.5%) and 6 M (76.6% vs. 86.9%) post-ASDC, and the composite of RVR and NoRS at 6 M (43.8% vs. 57.1%). Most ASDC-related complications in HTN+ occurred within 24 h and were minor; however, major complications such as device embolization within 24 h and mitral regurgitation within 6 M were observed. No differences between HTN+ and HTN− were observed in the total (12.7% vs. 9.5%) and major (5.1% vs. 4.8%) complications. Transcatheter ASDC is effective and safe in adults with secundum ASD and concomitant HTN in real-world clinical practice; however, proper preprocedural management and regular long-term follow-up post-ASDC are required.

Evolution of blood biomarker levels following percutaneous atrial septal defect closure in adults.

We sought to assess the effects of percutaneous atrial septal defect (ASD) closure on blood biomarker levels that possibly reflect reverse cardiac remodeling. Therefore, this study investigated temporal changes in six blood biomarkers following percutaneous ASD closure in adults. In this prospective observational cohort study, adults with ASD type II scheduled for percutaneous closure were included (2012-2016). NT-proBNP, high-sensitive troponin-T (hs-TnT), high-sensitive C-reactive protein (hs-CRP), red blood cell distribution width (RDW), growth differentiation factor-15 (GDF-15) and galectin-3 were measured one day prior to ASD closure and one day, three months and one year post ASD closure, and changes were evaluated using paired T-tests. Echocardiographic measurements were obtained. Fifty patients were included (median age 50years, 62% women, 32% NYHA II). At baseline, biomarker levels were elevated in a substantial number of patients; NT-proBNP n=22 (45%), hs-TnT n=6 (13%) hs-CRP n=19 (40%), galectin-3 n=5 (11%) and GDF n=10 (23%). One day after ASD closure, significant increases of hs-TnT (median change (Δ)=12ng/L), hs-CRP (Δ=1.9mg/L), GDF-15(Δ=129pg/mL) and RDW (Δ=0.1%) were observed, and a decrease in galectin-3 (Δ=-1.0ng/mL). Consequently, 92% had at least one abnormal biomarker directly after closure. At three months biomarker levels returned to baseline, and while echocardiographic measures 1year post closure were indicative of reverse cardiac remodeling, biomarker levels did not further decrease. Percutaneous ASD closure in adults leads to a direct increase in most blood biomarkers, in particular hs-CRP and hs-TnT. After three months, biomarkers returned to baseline levels and remained stable up to one year.

Preoperative Threshold for Normalizing Right Ventricular Volume After Transcatheter Closure of Adult Atrial Septal Defect.

The latest guidelines recommend early intervention in adult atrial septal defect (ASD) patients with signs of right ventricular (RV) enlargement. However, the criteria of RV enlargement for optimal intervention remain unclear. We investigated the preoperative determinants for normalizing the RV volume after transcatheter closure of ASD in adults.Methods and Results:We retrospectively analyzed 52 ASD patients who underwent transcatheter closure. Cardiac magnetic resonance imaging (CMR) measured RV volume before and 1 year after the closure. The patients were divided into normalized (postoperative RV end-systolic volume index [RVESVI] <47 mL/m2and end-diastolic volume index [RVEDVI] <108 mL/m2) and non-normalized (postoperative RVESVI ≥47 mL/m2or RVEDVI ≥108 mL/m2) groups. Preoperative RVESVI was significantly smaller (72 mL/m2vs. 80 mL/m2) and RVEF was higher (56% vs. 51%) in the normalized group compared with the non-normalized group. Receiver-operating characteristic analysis for the normalization of postoperative RV volume showed that the preoperative threshold value of RVESVI was 75 mL/m2. In addition, multivariate analysis showed that preoperative RVESVI was an independent predictor for normalization of RV volume. Preoperative RVESVI is an independent predictor for normalization of RV volume at 1 year after transcatheter closure of ASD in adults. Early intervention before RVESVI reaches 75 mL/m2may confer optimal timing for normalizing RV volume.

Interventional Therapy Versus Medical Therapy for Secundum Atrial Septal Defect: A Systematic Review (Part 2) for the 2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.

Secundum atrial septal defect (ASD) is the most common adult congenital heart defect and can present with wide variation in clinical findings. With the intention of preventing morbidity and mortality associated with late presentation of ASD, consensus guidelines have recommended surgical or percutaneous ASD closure in adults with right heart enlargement, with or without symptoms. The aim of the present analysis was to determine if the protective effect of secundum ASD closure in adults could be qualified by pooling data from published studies. A systematic review and meta-analysis were performed by using EMBASE, MEDLINE (through PubMed), and the Cochrane Library databases to assess the effect of secundum ASD percutaneous or surgical closure in unoperated adults ≥18 years of age. Data were pooled across studies with the DerSimonian-Laird random-effects model or a Bayesian meta-analysis model. Between-study heterogeneity was assessed with Cochran's Q test. Bias assessment was performed with the Newcastle-Ottawa Scale and the Cochrane Risk of Bias Tool, and statistical risk of bias was assessed with Begg and Mazumdar's test and Egger's test. A total of 11 nonrandomized studies met the inclusion criteria, contributing 603 patients. Pooled analysis showed a protective effect of ASD closure on New York Heart Association functional class and on right ventricular systolic pressure, volumes, and dimensions. Two additional studies comprising 652 patients were reviewed separately for mortality outcome and primary outcome of interest because they did not meet the inclusion criteria. Those studies showed that ASD closure was associated with a weak protective effect on adjusted mortality rate but no significant impact on atrial arrhythmias in patients >50 years of age. Across all studies, there was significant heterogeneity between studies for nearly all clinical outcomes. The overall body of evidence was limited to observational cohort studies, the limitations of which make for low-strength evidence. Even within the parameters of the included studies, quality of evidence was further diminished by the lack of well-defined clinical outcomes. In conclusion, pooled data analysis on the impact of secundum ASD closure in adults was notably limited because of the lack of randomized controlled trials in patients with only secundum ASD. The few cohort studies in this population demonstrated improvement in functional status and right ventricular size and function as shown by echocardiogram. However, our findings suggest that at the time of this publication, insufficient data are available to determine the impact of ASD repair on mortality rate in adults.

PCV12 - Hospitalization Outcomes For Adults In The United States With Atrial Septal Defect: Analysis Of A Multicenter Database

Atrial Septal Defect (ASD) closure in the elderly has been a topic of debate. Some experts suggest closure of ASD in the elderly, others believe risks outweigh benefits. The objectives of this study is to assess trends of ASD closure in the US between 2000 and 2012, and patient characteristics and outcomes for ASD closure in adults (16 to 59 years) and elderly adults (>60 years). The Nationwide Inpatient Sample was used to identify patients above 16 years of age who underwent transcatheter device closure (closed technique) and surgical closure (open technique) for ASD repair. ICD-9 codes were used to identify the study sample between 2000 and 2012. Risk factors for mortality in the 16-59 years age group and ≥ 60 years age group were determined based on clinical characteristics and comorbidities. Predictors for hospitalization outcomes including death, prolonged length of stay, and discharge to a skilled nursing facility were calculated. There were 11,018 cases of ASD repair in the US between 2000 and 2012. In the ≥ 60 years age group, there is a declining trend in closed technique (p <0.01) between 2006 (n = 1667) and 2012 (n = 920) and open technique (p<0.01) between 2009 (n=342) and 2012 (n=240). Unadjusted analyses revealed significant difference in mortality (0.57% vs 1.42%; p<0.05), length of stay (2.78 days vs 8.18 days; p < 0.001), and discharge to a skilled nursing facility (4.08% vs 67.14%; p<0.001) between closed technique vs open technique. Significant risk factors for mortality in closed technique included vascular complications due to procedure, previous myocardial infarction and acute kidney injury. Procedure volume of both – open technique and closed technique have increased since 2000. Mortality in open technique is three times that of closed technique (p<0.01).

Robot-assisted atrial septal defect closure in adults: first experience in Russia

To analyze immediate results of minimally invasive robot-assisted atrial septal defect (ASD) closure in adults. For the period from March 2012 to November 2016 sixty patients with contraindications to endovascular procedure have undergone robot-assisted atrial septal defect closure at Meshalkin Siberian Federal Biomedical Research Center. Mean age was 34.5±11.3 years, body mass index - 24.6±4.0 kg/m2. 48 (80%) patients had NYHA class II before surgery. In 37 (61.7%) patients isolated ASD with deficiency or absence of one edge was diagnosed, isolated ASD with primary septum aneurysm - in 16 (26.7%) cases, 7 (11.6%) patients had reticulate ASD. 5 (8.3%) patients had concomitant tricuspid valve insufficiency required surgical repair (suture annuloplasty). All operations were performed under cardiopulmonary bypass with peripheral cannulation. Right-sided anterolateral mini-thoracotomy was used in the first 43 patients. Following 17 patients underwent completely endoscopic procedure. Depending on the shape, size and anatomical features of the defect we performed suturing (14 patients, 23.3%) or repair with xenopericardial patch (46%, 76.6%). Mean CPB and aortic cross-clamping time was 89.1±28.7 and 24.8±9.5 min, respectively. Postoperative variables: mechanical ventilation 3.3±1.5 hours, ICU-stay - 18.2±3.7 hours, postoperative hospital-stay - 13.4±5.7 days. There were no mortality and any life-threatening intra- and postoperative complications. Cases of conversion to thoraco-/sternotomy and postoperative bleeding followed by redo surgery were also absent. 23 patients were followed-up within 1 year, 6 patients - within 2 years, 3 patients - within 3 years. All patients were in NYHA class I-II with 100% freedom from ASD recanalization and redo surgery. According to echocardiography data there were decreased right heart, pulmonary artery pressure and preserved left ventricular function in early postoperative period and 1 year after surgery. In view of favorable course of postoperative period, no significant specific complications and encouraging immediate results we can talk about endoscopic robot-assisted ASD closure in adults as a safe and effective alternative to surgical treatment.

Fenestrated Transcatheter ASD Closure in Adults with Diastolic Dysfunction and/or Pulmonary Hypertension: Case Series and Review of the Literature.

This study aims to evaluate the safety and efficacy of transcatheter fenestrated ASD closure and to summarize the literature regarding the published techniques and outcomes of transcatheter partial ASD closure. Patients with left ventricular diastolic dysfunction (LVDD) or right ventricular (RV) dysfunction and/or pulmonary hypertension (PHT) may suffer untoward consequences of complete closure of an ostium secundum atrial septal defect (ASD). Therefore, for patients that fall under these categories we suggest partial occlusion of the defect, which may be better tolerated than complete defect closure. After obtaining IRB approval, a search for patients that have undergone percutaneous ASD closure was performed in the Ahmanson/UCLA Adult Congenital Heart Disease Center database to identify which patients received a fenestrated ASD closure device. Eight consecutive patients ranging between 22 and 83 years of age (mean 48 years) with PHT and/or LVDD or RV dysfunction who underwent fenestrated transcatheter ASD closure at UCLA were identified. None of the subjects experienced complications related to the procedure. Postprocedure clinical evaluation showed improvement in symptoms and exercise capacity. Available follow-up transthoracic echocardiography data (mean 4 months, range 0-20 months) demonstrated patent fenestrations in four of eight patients. None of the patients had thromboembolic or infectious complications and there were no device migrations, erosions or embolizations. Partial ASD occlusion in patients with diastolic dysfunction or RV dysfunction and/or PHT is safe and may be better tolerated than complete ASD closure in selected patients.

First Comprehensive Analysis of Outcomes in Adult Patients after Percutaneous Closure of Isolated Secundum Atrial Septal Defects.

Secundum atrial septal defect (ASD) is a common congenital heart defect in adults. If untreated, ASD leads to right ventricular (RV) failure, atrial arrhythmias, and pulmonary hypertension. The aim of this study is to analyze published data on outcomes and complications of percutaneous ASD closure in adults. PubMed searches performed for published literature on percutaneous ASD closure using the terms ASD, ASD closure or repair, and percutaneous or transcatheter closure. A total of 23 studies, 1958 patients, were analyzed. Baseline characteristics showed mean age of 49.1 ± 1.7 years, Qp:Qs of 2.2 ± 0.05, defect size 19.4 ± 1 and device size 24.0 ± 0.7. The percentage of patients in NYHA class I, II and III was 42.4 ± 6.3, 40.0 ± 6.5, and 9.3 ± 3.0, respectively. Mean follow-up was 12.6 ± 4.9 months with a closure rate of 96.9% ± 1.4. Echocardiographic parameters of improvement included decrease in RV volume from 157.2 to 100.2 mL (p = 0.02), RV end-diastolic dimensions from 40.8 to 32.4 mm (p < 0.0001) and pulmonary artery systolic pressures from 42.2±2.2 to 34.4±2.4 (p < 0.0001). The percentage of patients in NYHA class II and III decreased from 55±7.5 to 15.9±4.4 (p = 0.0013). At the end of follow-up, complications included 1% mortality rate, 0.8% device embolization, 5.8% new onset arrhythmias and 1.2% need for surgical closure. Our study confirms that percutaneous ASD closure in adults with moderate pulmonary hypertension and RV dilation is safe and effective with reverse remodeling and better functional capacity. Prospective studies are needed to evaluate efficacy of percutaneous ASD closure in adults with large defects, higher shunt ratios, and severe pulmonary hypertension.

Predictors of mid-term functional tricuspid regurgitation after device closure of atrial septal defect in adults: Impact of pre-operative tricuspid valve remodeling

BackgroundFunctional TR occurs in adults with congenital atrial septal defect (ASD) due to left-to-right inter-atrial shunting and enlarged right heart. The prevalence and the predictors of TR following ASD closure in adults remain unknown. Moreover, whether preoperative anatomical parameters of tricuspid valve related to TR after ASD closure is understudied. MethodsComprehensive transthoracic echocardiography was performed in 64 consecutive secundum ASD patients before and at 3months after device closure. Tricuspid valve parameters [annulus diameter (TAD), tenting area, tenting height, distal tricuspid septal leaflet angle (TSLA)], right ventricular (RV) function, pulmonary arterial pressures and severity of TR were recorded. Post-closure TR was defined as PISA radius ≥6mm at 3months. ResultsThe TR severity was reduced after ASD closure with post-closure TR in 31 patients (48%) at follow-up. TR patients had larger ventricles, more TR, greater TAD, and larger tenting area/height and TSLA but similar RV long-axis function and pulmonary pressures at baseline. Pre-closure TAD [odds ratio (OR): 6.076, p=0.032] and TSLA (OR: 1.218, p=0.001) were the independent predictors for TR. A TAD >3.5cm and a TSLA >30° had sensitivity, specificity, and area under the curve of 97%, 76%, and 0.82 and 100%, 78%, and 0.84, respectively. Assessment of TSLA showed an incremental value over TAD for predicting TR after closure (χ2=21.3 vs. 9.9, p<0.001). ConclusionNearly half of adults had TR following device closure of ASD. It was related to the excessive pre-operative structural remodeling in tricuspid valve rather than changes in RV.

Closure of secundum atrial septal defects in the adult and elderly patients†

Treatment of atrial septal defect (ASD) in adults is still controversial, and with older age the likelihood of treatment is decreased. The aim of this study was to investigate the effect of ASD closure in adults and especially in the elderly in our institution in a retrospective review. Adult patients (n = 220) underwent surgical or catheter closure for an isolated ASD at Aarhus University Hospital from 1990 to 2008. Eleven were lost to follow-up and 13 had cardiac comorbidity, and thus 196 were eligible for analysis in the study. Hospital records were reviewed and symptoms and echocardiographic findings registered preoperatively and at 3-month follow-up. Patients were divided into Group I (n = 117): between 18 and 50 years old and Group II (n = 79): older than 50 years. Symptoms and echocardiographic findings before and 3 months after closure were compared within and between the two groups. One patient (0.5%) died during follow-up. Complications occurred in 16% in Group I and 22% in Group II. There was an absolute risk reduction of -62 and -52%, respectively in right ventricle (RV) dilation after operation. Atrial fibrillation was noticed preoperatively in 6% of the young and 47% of the elderly, with an absolute risk reduction after treatment of -20% in Group II (P < 0.0001). Subjective symptoms occurred in 75% in Group I and 99% in Group II with a postoperative reduction to 43 and 67%, respectively. In Group I, 70% felt an improvement of symptoms while this was true for 89% in Group II. Symptoms and RV dilation are more pronounced in the elderly (>50 years), but reversibility is the same as in the young (<50 years) patients. The elderly benefit substantially from ASD closure. Based on these data, ASD closure is recommendable even after the fifth decade.

Prevalence and Determinants of Incomplete Right Atrial Reverse Remodeling After Device Closure of Atrial Septal Defects

Whether the relief of chronic right atrial (RA) volume load by device closure of an atrial septal defect (ASD) normalizes RA size is unknown. The present study evaluated the prevalence and determinants of incomplete RA reverse remodeling (RAR) after ASD closure in adults. Transthoracic echocardiography was performed in 44 consecutive patients with secundum ASD (age 43 ± 17 years, 10 men) without a history of atrial arrhythmia shortly before and at 3 months after device closure of ASD. The pulmonary/systemic flow ratio was derived using invasive oximetry. The RA size had significantly decreased at 3 months of follow-up (RA volume index [RAVI] 52 ± 29 to 27 ± 17 ml/m(2), p <0.001). Incomplete RAR (defined as a RAVI of ≥21 ml/m(2)) was detected in 25 patients (57%) after closure. They were older, had a larger pulmonary/systemic flow ratio, a higher pulmonary arterial systolic pressure, more tricuspid regurgitation, and larger RA, left atrial, and right ventricular sizes before closure than those with a normalized right atrium. Before closure, RAVI was the only independent determinant for incomplete RAR (odds ratio 1.115, 95% confidence interval 1.019 to 1.220; p = 0.018). A cutoff value of RAVI of ≥40 ml/m(2) has a sensitivity of 84% and specificity of 72% in the receiver operating characteristic curve. The preclosure RAVI correlated moderately with the shunt-duration index, calculated by multiplying the age to pulmonary/systemic flow ratio (r = 0.64, p <0.01). In conclusion, incomplete RAR occurred in >1/2 of the adult patients at 3 months after ASD device closure and was related to excessive preclosure RA dilation.

Long-term outcome of percutaneous closure of secundum-type atrial septal defects in adults

Transcatheter closure of the secundum-type atrial septal defect (ASD) is widely practised. We report complications and efficacy of percutaneous ASD closure in adults using the Amplatzer ASD occluder and the Cardioseal/Starflex device during long-term follow-up. Between 1996 and 2008 percutaneous ASD closure was performed in 133 patients (mean age 46.8 ± 16.9 years; 36 men) by using the Amplatzer(r) device in 104 patients and the Cardioseal/Starflex device in 29. During a mean follow-up of 3.4 ± 2.8 years the occurrence of major complications was higher in patients with the Cardioseal/Starflex compared to patients with the Amplatzer(r) devices (17.2 vs. 2.9%, log rank, P=0.005), due to a higher embolisation rate (13.8 vs. 1.0%, log rank, P=0.002). In univariable analysis, the implantation of a Cardioseal/Starflex device (OR 6.0 (CI 1.4-25.2); P=0.01) and a larger device diameter (OR 1.1 (CI 1.0-1.2); P=0.04) were found to be predictors of the occurrence of major complications. Minor complications occurred in 10.5%, recurrent thrombo-embolism in 2.3% and residual shunting at six months was 13.9% without differences between devices. NYHA class improved from 1.8 ± 0.6 before to 1.2 ± 0.4 after closure (P<0.001) without differences between devices. During long-term follow-up, percutaneous ASD closure in adults is safe and effective when using the Amplatzer(r) device. Larger Cardioseal/Starflex devices are related to a higher embolisation rate. Randomised trials are needed.

Not too old to be closed….

Not too old to be closed….

Atrial myocardial pathoelectrophysiology in adults with a secundum atrial septal defect is unaffected by closure of the defect. A study using high resolution signal-averaged orthogonal P-wave technique

Background In patients with atrial septal defect (ASD) the P-wave is prolonged as a marker of delayed atrial conduction which is associated with atrial fibrillation. The study aim was to analyse the impact of ASD closure in adults on P-wave duration and morphology by means of signal-averaged P-waves (PSA-ECG) and to investigate potential mechano–electrical interactions. Methods PSA-ECG was obtained before and 8 ± 6 months after ASD closure in 35 adult patients (age 53 ± 15 years). Heart chamber sizes and pulmonary artery pressure levels were assessed by echoDopplercardiography. Results P-wave duration and morphology did not change after ASD closure (148 ± 16 vs 144 ± 16 ms, P = 0.07). P-wave duration did not relate to age at repair, preclosure atrial sizes or pulmonary artery pressure. Pre- or postclosure atrial fibrillation propensity was associated with longer P-wave duration both before and after ASD closure. Conclusion Atrial conduction disturbances in middle-aged patients with ASD, manifested as a prolonged P-wave duration, do not change after ASD closure and are not related to the dilatation of the right and left atria. It is suggestive that atrial conduction disturbance associated with ASD develop early and early intervention is required to prevent the development of late atrial fibrillation.

Transcatheter Closure of Atrial Septal Defects in Adults ≥40 Years of Age: Immediate and Follow‐Up Results

Controversy still exists regarding closure of atrial septal defects (ASDs) in patients >40 years of age who are largely asymptomatic or do not have large shunts (LS). If left unrepaired, the majority of patients will experience symptoms and will have a shorter life span compared to patients who undergo repair. This study presents the outcomes of closure of ASDs in adults >40 years using the Amplatzer septal occluder. A total of 113 patients (79F/34M) with a mean age of 57.9 years (SD 11.9) who had indications for closure (right ventricular [RV] enlargement by echocardiograpy, clinically symptomatic) underwent an attempt of transcatheter closure. The mean size of ASD as measured by transesophageal echocardiography (TEE) (30 patients) or intracardiac echocardiography (83 patients) was 17.2 mm (SD 7.3) with mean Qp:Qs of 2.2:1 (SD 1.1). Follow-up at 24 hours, 6 month, and yearly thereafter included physical examination, TEE, and/or transthoracic echocardiography; furthermore, chart review (n = 112) as well as telephone interviews (n = 56) were conducted to determine clinical symptomatic status. The procedure was successful in 112 patients and 1 patient failed due to the presence of a large defect (44 mm). One hundred four patients had a single device implanted, 7 had two, and 1 had three. Following the procedure, 96 patients had immediate complete closure (CC), 3 had trivial shunt (TS), 11 had small shunt (SS), and 2 had moderate shunt (MS). At 24 hours postprocedure, 100 patients had CC, 7 had TS, 3 had SS, 1 had MS, and 1 had LS. Four patients had complications: one had device migration within 24 hours, two had atrial arrhythmias (supraventricular tachycardia, atrial tachycardia), and one had large hematoma. At 6 months postprocedure, 100 patients had CC, 6 had TS, 5 had SS, and 1 had MS. At 6-month follow-up, the right ventricle end-diastolic dimension decreased from 35.3 mm (SD 7.6) preprocedure to 23.8 mm (SD 6.6) (P < 0.001) and the majority of patients reported improvement in their symptoms. ASD closure is safe and effective in patients over 40 years of age with minimal complications. The procedure resulted in a decrease in the RV size that was accompanied by improvement in clinical symptoms. Our findings suggest that device closure of ASDs in adult patients >40 years of age should be the first option of management.

Intracardiac echocardiography guided device closure of atrial septal defects

ObjectivesThis study was designed to determine the feasibility and accuracy of intracardiac echocardiography (ICE) in guiding percutaneous closure of atrial septal defects (ASD). BackgroundIntracardiac echocardiography is a novel imaging technique that might be used to guide interventional procedures. The sensitivity and specificity of ICE, compared to standard imaging techniques, in detecting potentially adverse procedural events and guiding remedial action will be an important consideration in its use. MethodsIn a prospective study, 24 patients underwent device closure of ASD using ICE as the primary echocardiographic imaging modality. Feasibility was expressed as proportion of cases in which complete diagnostic ICE imaging was achieved. Accuracy was expressed as the percent agreement between ICE and simultaneously performed transesophageal echocardiography (TEE). ResultsHigh-quality ICE images were acquired in all patients, though images were limited in two patients with aneurysmal septa. Intracardiac echocardiography successfully guided closure of 24 out of 25 ASDs (96%) in 23 patients. There was close agreement between ICE and TEE in their assessment of device position and the adequacy of septal capture before device release (98%) and in identifying the presence of significant residual shunts. Intracardiac echocardiography detected all potentially adverse events, including four malpositions, and guided appropriate remedial action. ConclusionsIntracardiac echocardiography guided device closure of secundum ASDs is feasible in the majority of patients and provides diagnostic data comparable to TEE. These data indicate that ICE may be used to guide routine closure of ASDs in adults without the need for TEE and general anesthesia.