ASD Closure Research Articles

Successful occluder removal and reocclusion of an atrial septal defect after occluder immigration to aortic arch: a case report

BackgroundAtrial septal defect (ASD) is a common congenital heart disease, and currently, transcatheter intervention is the most common clinical treatment method. However, certain complications still occur during the percutaneous process, among which occluder loss and displacement are rare but serious complication. Although the probability of occluder loss and displacement is low, severe cases can endanger life.Case presentationHere, we report the case of a patient who underwent ASD closure in which the occluder fell off into the aortic arch, the detached occluder was recovered through catheter intervention, and the patient underwent ASD closure again.ConclusionsIn this case report, we highlight that although percutaneous closure of an ASD is regarded as a routine procedure, clinicians should remember the possibility of complications, especially occluder loss and displacement. Therefore, interventionist should carefully evaluate the situation before intervention closure, establish standardized interventional treatment procedures, and provide timely treatment follow-up.

A Case Study on Anesthesia for Percutaneous Closure of Large Secundum ASD in a Patient with Nemaline Myopathy Type

A Case Study on Anesthesia for Percutaneous Closure of Large Secundum ASD in a Patient with Nemaline Myopathy Type

Some Useful and Unusual Eponymous Cardiac Surgical Techniques Adopted in Chittagong Medical College Hospital

Background: Innovation is an integral part of cardiac surgery. A number of natural barriers had to be overcome by the cardiac surgery pioneers to establish open heart surgeries in the 1950s. Since then, surgeons are continuously developing and adopting various innovative techniques to ensure safety and efficacy of cardiac surgery. The Department of Cardiac Surgery of Chittagong Medical College Hospital (CMCH) has some unique characteristics as it was developed isolated from the centers of Dhaka. A few interesting methods are in practice here, which worth mentioning for the outside readers. Some of these procedures have been colloquially named in our department often after the visiting surgeon or the team who introduced those here. Methods: The unique and unusual techniques applied in CMCH were sought and discussed. The hospital records, OT operation notes and ICU log books were thoroughly searched for any clue. The local and visiting team members were interviewed for any information. All available data were compiled and analyzed. Results: Six interesting and useful named surgical techniques adopted in CMCH Cardiac Surgery Department were identified. These are: 1. Marine city ASD Closure Technique, 2. Tendolkar’s Maneuver during CPB, 3. Turkish Sling in CABG, 4. Petlar Stitch in VSD closure, 5. Pyongyang Method of LA Closure and 6. NAK-NAKA De-calcification Procedure for valve surgery. The first two were introduced with the help of visiting Indian Professor Anil Tendolkar, whereas the 3rd was introduced by a visiting Turkish team. The 4th technique was adopted from a pediatric cardiac surgeon from Dhaka. The 5th and 6th techniques have long been in practice at NICVD, which were adopted with some modification in our department. Conclusion: The above mentioned six reproducible techniques are unique and useful. Sharing and discussion of these techniques will enable other Bangladeshi surgeons to adopt these useful tips. Cardiovasc j 2024; 16(2): 86-91

Impact of 3D TEE guided ASD transcatheter closure on procedure outcome and radiation exposure

Abstract Background Transcatheter ASD device closure of secondum ASD is widely accepted in closure of ASD. Radiation exposure increases the risk of cancer for both patients and staff members, fusion of 3- D TEE and fluoroscopy has helped us decrease radiation exposure during whole procedure. Aim to assess feasibility of 3 D TEE guidance in transcatheter ASD closure and assess its value in reducing radiation exposure as compared to control patients. Methods This study was conducted on 30 patients with secundum ASD referred to cardiology department - Ain Shams University for percutaneous ASD device closure under 3D TEE guidance and 54 control patients who performed percutaneous ASD device closure using conventional method. we calculated total procedure time (min), total DAP (mGy/cm2), (FT) fluoroscopy time (min), total air kerma (mGy), maximum ASD diameter (mm) and we recorded implanted device size and device type for all the patients. Results There was no significant difference between both groups regarding FT, total air kerma, dose area product. Operative time of study group was significantly longer than control group although FT reduced significantly in last case of the study. In the last 10 cases of the study radiation exposure decreases and was significantly lower than control group. Conclusion The Use of 3 D-TEE by well-trained imaging cardiologist on tracking catheter during percutaneous ASD device closure decrease significantly radiation exposure of patients as well as medical personnel.

Long-Term Outcomes of Percutaneous Trans-catheter Device Closure of Atrial Septal Defects During Teenage Life versus Adulthood

Abstract Aim and Objectives To evaluate the long-term follow up outcome of patients who underwent percutaneous trans-catheter closure of atrial septal defects during teenage life versus adulthood. Patients and Methods The study included 100 patients with secundum type ASD were treated by transcatheter closure of their defects. Two year after the procedure patients included in the study were subjected to thorough history taking, physical examination,12 leads surface electrocardiogram and Holter. Full 2D and Doppler echocardiographic study was performed in addition to Tissue Doppler Assessment of left ventricular function. Results At the 2 years follow up of transcatheter ASD closure, the RVEDD had decreased from 22.93±5.889 mm to 18±4.06 mm(P = 0.000). By comparing 2D echocardiographic parameters between teenagers and adults there was a highly significant difference in RV basal diameter (P = 0.004), RV systolic function (P = 0.000), RA area (P = 0.030). Mean PAP decreased from 18.37±4.796 mmHg to 14.77±4.75 mmHg (P = 0.022). RVSP decreased from 28.9±4.425 mmHg to 15.83±4.17 mmHg (P = 0.000). There was statistically significant difference regarding defect size (P = 0.037), device size (P = 0.038) and Holter findings (P = 0.042) while there was no statistically significant difference between both groups regarding mPAP, device type and ECG. Defect size was larger in adult group ranged from 9 to 33 mm with mean ± SD 15.57 ± 6.57 mm than teenagers ranged from 6 to 22 mm with mean ± SD 13.06 ± 5.18 mm. Also, incidence of arrhythmia in adults was higher than teenagers as follows: PACs was in 7 patients (14 %) in adult group while 3 patients (6 %) had PACs in teenagers group and paroxsymal AF was found in 4 patients (8 %) in adult group while no patients in teenagers develop AF. All the patients had normal sinus rhythm before closure and no one developed arrhythmia until 1 year after closure. 50 % of the patients had normal RV size at the 2-year follow up. Regarding Doppler parameters, mitral E/A ratio (P = 0.000) and lateral E/e' ratio (P = 0.041) had significant difference between adults and teenagers as shown in table (8) mostly related to age. Mitral E/A ratio in adults ranged from 0.7 to 1.5 with mean ± SD 1.06 ± 0.20 while in teenagers ranged from 1.1 to 1.8 with mean ± SD 1.45 ± 0.17. Lateral E/e’ ratio in adults ranged from 3 to 7.9 with mean ± SD 5.43 ± 1.24 while in teenagers ranged from 3 to 7 with mean ± SD 4.94 ± 1.13. Conclusion Transcatheter ASD closure leads to a significant improvement in heart cavity dimensions and RV function and reversal of electrical and mechanical changes. Novel parameters for assessment of RV function are promising and appear to be helpful for the assessment of RV function and its response to correction of volume. Key words: Atrial septal defect, arrhythmia, transcatheter closure, adults, teenagers. Abbreviations and Acronyms 2D: Two-Dimensional 3D:Three-dimensional ASD(s): Atrial septal defect(s) BSA: Body surface area CHDs: Congenital heart defects ECG: Electrocardiogram EF: Ejection fraction FAC: Fractional Area Change LA: Left Atrium mPAP: mean Pulmonary Artery Pressure RA: Right Atrium RAA: Right atrial area RBBB: Right Bundle Branch Block RV : Right Ventricle TEE : TransEsophgyeal Echocardiography TTE : TransThoracic Echocardiography

The association of right ventricular-pulmonary arterial coupling and pulmonary vascular resistance in adult patients with uncorrected atrial septal defect

BackgroundAtrial septal defects (ASD) are the most common type of adult congenital heart disease (ACHD) associated with a high risk developing of pulmonary arterial hypertension (PAH). ASD closure is not recommended in patients with PAH and Pulmonary Vascular Resistance (PVR) ≥ 5 Wood Unit (WU). Noninvasive methods have been proposed to measure PVR; however, their accuracy remains low. Right Ventricle (RV) - Pulmonary Artery (PA) coupling is defined as the ability of the RV to adapt to high-resistance conditions. Tricuspid Annular Plane Systolic Excursion (TAPSE)/estimated pulmonary artery systolic pressure (ePASP) calculation using echocardiography is a noninvasive technique that has been proposed as a surrogate equation to evaluate RV-PA coupling. Currently, no research has demonstrated a relationship between RV-PA coupling and PVR in patients with ASD.MethodsThe study participants were consecutive eligible patients with ASD who underwent right heart catheterization (RHC) and echocardiography at Hasan Sadikin General Hospital, Bandung. Both the procedures were performed on the same day. RV-PA Coupling, defined as TAPSE/ePASP > 0.31, was assessed using echocardiography. The PVR was calculated during RHC using the indirect Fick method.ResultsThere were 58 patients with ASD underwent RHC and echocardiography. Among them, 18 had RV/PA Coupling and 40 had RV/PA Uncoupling. The PVR values were significantly different between the two groups (p = 0.000). Correlation test between TAPSE/ePASP with PVR showed moderate negative correlation (r= -0.502, p = 0.001). TAPSE/ePASP ≤ 0.34 is the cutoff point to predict PVR > 5 WU with sensitivity of 91.7% and specificity 63.6%.ConclusionThis study showed a moderate negative correlation between TAPSE/ePASP and PVR. TAPSE/ePASP ≤ 0.34 could predict PVR > 5 WU with good sensitivity.

Assessing the State of Training in Congenital Interventional Cardiology: A Global Survey of Program Directors.

This study aimed to evaluate the current state of congenital interventional cardiology training worldwide, with a focus on case volumes, competency assessment, and the need for ongoing mentorship during early career stages. A survey was conducted among program directors (PDs) of congenital interventional training programs across the globe. The survey gathered data on training pathways, case volumes, types of procedures performed, trainee competency assessment, and the role of ongoing mentorship. Of the 79 PDs who completed the survey, it was observed that training pathways and case volumes varied significantly, particularly between the United States and other countries. Most PDs reported an annual laboratory case volume of >500 congenital cardiac cases, with most cases being interventional. While trainees demonstrated competency in simple procedures (diagnostic cases, simple ASD closure), complex interventions (such as patent ductus arteriosus closure in premature infants) require ongoing mentorship for graduates. PDs recommended a minimum case volume of 400 total cases for trainees, including 250 interventional cases. In addition to case volumes, assessing trainee competency was deemed important, with clinical reasoning, judgment, skillset, teamwork, and complication management being key areas of evaluation. The study highlights the variability in congenital interventional cardiology training and the need for ongoing mentorship during the early career years. External mentorship programs, facilitated by national and international societies, are proposed to provide critical support for early career interventionalists thus enhancing patient care for congenital heart disease. Ultimately, the findings of this survey may serve as a framework for future training standards and guidelines in this specialized field.

Late Presentation of Pulmonary Hypertension Crisis Concurrent with Atrial Arrhythmia after Atrial Septal Defect Device Closure

Background: ASD occurs when there is a septal defect between the right and left atria, resulting in a left-to-right shunt that increases the volume of the right heart and pulmonary circulation. Increased pulmonary resistance can lead to pulmonary hypertension (PH), resulting in progressive deterioration of right ventricular function, leading to right heart failure and death. Prolonged elevation of atrial pressure induces progressive atrial dilatation and electrophysiological remodelling. Together with autonomic modulation, this leads to atrial arrhythmias (AAs). Patients with significant shunts leading to ventricular volume overload are considered for ASD closure. However, in some cases, PH occurs after ASD closure.  Case Presentation: We report a 21 yo man diagnosed with ASD Secundum Post Closure with Device (September 1th, 2023) and Pulmonary Hypertension Crisis. The left atria (LA), right atria (RA) and right ventricle (RV) were dilated. We also found moderate mitral regurgitation, severe tricuspid regurgitation, and mild to moderate pulmonary regurgitation. There was a decline in systolic function in the right ventricle, and grade III diastolic dysfunction in left ventricle. There was a well-seated device with no residual shunt on interatrial septal. The pulmonary arteries were confluence and dilated. From ECG we found atrial flutter with variable conduction. This patient was transferred to HCU. This patient treated with digoxin, furosemide, milrinon, ceftriaxone, miniaspi, sildenafil, electrophysiology, and 3D ablation.  Conclusion: Pulmonary hypertension can occur in cases of congenital heart defects, such as ASD. The operative management of ASD is closure of the ASD, but in some unique groups, this can lead to pulmonary hypertensive crisis after its closure.

Transcatheter Closure of Atrial Septal Defects with Absent Aortic Rim and the Predictors of Right Atrial Reverse Remodeling: 5 Years Experience in China

Plain Language SummaryAtrial septal defect (ASD) is a common congenital heart disease. The transcatheter approach is not recommended for absent aortic rim ASD. However, almost 30–40% of ASD patients in China are found to have an absent aortic rim with right atrial (RA) remodeling. We evaluated the safety and efficiency of transcatheter ASD closure in patients with an absent aortic rim and the predictors of RA reverse remodeling. No major operative complications occurred in all patients with the absence of an aortic rim and a normal edge. Without coronary heart disease, a lower plasma creatinine level, and less tricuspid regurgitation before the operation were the predictive factors for the reverse of RA remodeling after treatment.

HLH in a patient with post-surgical Ebstein’s anomaly: Case report

This case was interesting as it presents a rare complication in a rare congenital anomaly. We present it to raise awareness about serious fatal complications that could occur in a CHD postoperative patient which may not be related to their surgery. The heart surgery was successful but the patient passed away from complications which arose postoperatively. A 34-year-old male with Ebstein’s anomaly and severe tricuspid regurgitation status post ASD closure, atrialized ventricular plication and tricuspid annuloplasty at 6 years old presented with symptoms of congestive heart failure. He underwent tricuspid valve replacement and insertion of epicardial dual chamber pacemaker. Patient developed recurrent high fevers on the first night following surgery that were unresponsive to antibiotics and antipyretics. Evaluation revealed hyperferritinemia, thrombocytopenia, anemia and splenomegaly consistent with Hemophagocytic Lymphohistiocytosis (HLH). EVB titers were found to be elevated as a possible inciting infection. He was treated with Dexamethasone, Etoposide and Cyclopsorine, however he developed Heparin Induced Thrombocytopenia (HIT) followed by Disseminated Intravascular Coagulopathy (DIC) and died from a presumed pulmonary embolism. Conclusion: Surgical intervention outcomes in complex congenital heart disease patients can be complicated by infectious and hematological complications. If more cases of cardiac bypass related HLH are identified, the presence or absence of cold agglutinins as a factor should be studied. Timely recognition will prevent unnecessary mortality and morbidity.

Reversibility and outcome of fenestrated surgical closure in adult patients with congenital left-to-right shunts and pulmonary hypertension: a result of cohard-ph registry

Abstract Background Uncorrected congenital heart disease in the adults often come with a complication of pulmonary hypertension (PH) , resulting in high mortality and low quality of life due to right heart failure and arrythmias. Shunt closure in those patients has been shown to reduce such complications. However, in patients who develop PH, total shunt closure posseses risk that increase mortality. ESC guidelines recommend avoidance of ASD closure and careful evaluation of VSD and PDA closure in those with PVRI>5 WU. Nevertheless, some Asian countries reported good outcome in LtoR shunt closure in patients with PVRI>5. Congenital Heart Disease in Adults and Pulmonary Hypertension (COHARD-PH) Registry is a single tertiary center registry in Indonesia. The data showed that among congenital LtoR shunts, PAH occurred in 66.9% patients and Eisenmenger Syndrome in 18.7%. In this study we aim to evaluate the outcome and the PH reversibility of adult patients underwent fenestrated closure in this registry. Methods Patients with intracardiac shunts who underwent surgical closure with atrial septal fenestration on January 2019-July 2022 were recruited and the follow-up data was obtained within 6 months after surgery. Results Thirty-eight patients underwent surgical fenestrated closure were identified. Age was ranging between 19-70 (mean 39) years-old and 81.6% were female. Thirty patients (30%) were ASD, 7 (18.4%) were VSD, and 1 patient (2.6%) was incomplete AVSD. All patients underwent 4-5 mm atrial septal fenestration despite the repair of their anatomical lesion. Hemodynamic measurement before surgery showed that the average Qp/Qs was 3.2; mPAP 51±17 mmHg and the mean pulmonary vascular resistance index (PVRI) was 7.2±4.4 WU before surgery. We performed acute vasoreactivity test (AVT) to 21 patients and showed positive result, while the rest of the patients did not have AVT due to PVRI of 4 WU or less. Short and mid-term follow up reveal a mean SICU length of stay was 2.5 days and mean total hospital stay was 9 days. Three patients died during their hospital stay after discharged from the SICU due to post operative sepsis. On 6 month follow up, the remaining 35 subjects have no remaining symptoms. The reversibility of PH was assesed by echocardiography and showed that mean TVG was reduced from 78 to 36 (by 54%). None of these patients showed signs of heart failure or pulmonary hypertension on follow up. Conclusion Atrial septal fenestration in patients with adult congenital left to right shunt undergoing surgical closure might be considered in selected patients with pulmonary hypertension including those with positive acute vasoreactivity test. Further study with larger subjects is warranted to evaluate the current guidelines.

Abstract 13708: Analyzing Outcomes of Atrial Septal Defect Closure in Patients With Ischemic Stroke and Thrombophilia

Introduction: Evidence on outcomes of ASD closure after a stroke in patients with thrombophilia is limited.: We illustrate differences in long-term outcomes amongst patients diagnosed with a stroke and thrombophilia, who underwent ASD closure up to 3 months after the stroke versus those who did not. Methods: We queried the TriNetX research database to identify adult patients with thrombophilia and ASD who had an ischemic stroke from 2016 to 2021. Patients were divided into two groups: those undergoing percutaneous transcatheter ASD closure within 3 months of the stroke and those who received medical therapy only. Subgroup analyses was performed comparing ASD closure with patients who received either anticoagulation or antiplatelets, and of those with a specific diagnosis of PFO. Propensity score matching (PSM) was used to control for age, sex, hypertensive diseases, CKD, diabetes, dyslipidemias, ischemic heart disease, and tobacco use. Outcomes were measured from 1 month to 3 years after the index event and included all-cause mortality, new onset Atrial fibrillation/flutter, arterial embolism, and services associated with stroke/arterial embolism namely thrombolysis, thrombectomy, and imaging (CT, CTA, MRI, MRA) of head and neck. Results: Patients with thrombophilia undergoing ASD closure after a stroke had lower all-cause mortality compared to medical therapy [HR 0.35, 95%CI 0.165 - 0.764]. This association persisted on subgroup analysis comparing ASD closure to antiplatelet use only [HR 0.392, 95% CI 0.163,0.947] (Table 1). Conclusions: ASD closure was associated with lower mortality in patients with thrombophilia and ischemic stroke. There was no statistical difference in incidence of A.fib/flutter, arterial embolism, or services associated to stroke/embolism. There were no differences in outcomes in patients with a specific diagnosis of PFO.

Mid-Term Electrical Remodeling after Percutaneous Atrial Septal Defect Closure with GCO Device in a Pediatric Population.

The GORE® CARDIOFORM (GCO) septal occluder is an atrial septal defect/patent foramen ovale closure device with theoretical advantages over other commercialized devices thanks to its softness and anatomical compliance. Our aim was to evaluate the short- and medium-term electrocardiographic changes after percutaneous ASD closure with GCO in a pediatric population. We enrolled 39 patients with isolated ASD submitted to trans-catheter closure from January 2020 to June 2021. ECG was performed before, at 24 h and 6 months after the procedure. P wave dispersion, QTc and QTc dispersion were calculated. ECG Holter was recorded at 6 months after implantation. Patients' age and body surface area (BSA) were 8.2 ± 4.2 years and 1.0 ± 0.3 m2 respectively. At the baseline, mean P wave dispersion was 40 ± 15 msec and decreased at 24 h (p < 0.002), without any further change at 6 months. At 24 h, PR conduction and QTc dispersion significantly improved (p = 0.018 and p < 0.02 respectively), while the absolute QTc value considerably improved after 6 months. During mid-term follow-up, QTc dispersion remained stable without a significant change in PR conduction. The baseline cardiac frequency was 88.6 ± 12.6 bpm, followed by a slight reduction at 24 h, with a further amelioration at 6 months after the procedure (87.3 ± 14.2, p = 0.9 and 81.0 ± 12.7, p = 0.009, respectively). After device deployment, two patients developed transient, self-limited junctional rhythm. One of them needed a short course of Flecainide for atrial ectopic tachycardia. No tachy/brady-arrhythmias were recorded at the 6-month follow-up. ASD closure resulted in a marked decrease in right heart volumes and diameters at 6 months after percutaneous closure. Percutaneous ASD closure with the GCO device results in significant, sudden improvement of intra-atrial, atrio-ventricular and intraventricular electrical homogeneity. This benefit persists unaltered over a medium-term follow-up. These electrical changes are associated with a documented positive right heart volumetric remodeling at mid-term follow-up.

Complications Associated with Transcatheter Device Closure of Atrial Septal Defect Cases in Pediatric Cardiology Center of Combined Military Hospital Dhaka, Bangladesh

Background: In Bangladesh, ASD device closure has been started in various centers for about a decade. Still, to date, few studies concern the complications associated with transcatheter device closure of ASD. Material &amp; Methods: From January 2016 to December 2016, patients with suspected and confirmed ASD cases reported to the Department of Paediatric Cardiology Center of Combined Military Hospital, Dhaka, Bangladesh were evaluated. Osteum second ASD cases that were suitable for device closure were selected. Data of patients who underwent device closure were recorded in a predesigned data collection sheet. Results: During the study period, a total of 48 patients were found with second ASD and tried for transcatheter device closure, and 46 (95.83%) were successfully closed. There were 6/46 (13.04%) complications, of which 2 were major, and 4 were minor. The only major complication was device embolization occurring in 2/46 (4.37%) cases; 1 (2.1%) required surgical retrieval, while in the remaining case, the device was retrieved by catheter technique. Another important complication is the formation of a thrombus on the device. Among minor complications, arrhythmia was most common and occurred in 2/46 (4.34%) of cases. In one of these 2, atrial fibrillation required electrical cardioversion, and the other one recovered spontaneously. Post-procedural lower respiratory tract infection occurred in 1/46 (2.17%) patients, for which no apparent reason was found. Transient hypoxemia occurred in one case, 1/46 (2.17%), which also recovered spontaneously. Conclusion: In summary, it is stated that transcatheter ASD device closure is a safe and effective procedure.

Automated measurements based on artificial intelligence software in pediatric echocardiography: a feasibility study

Abstract Funding Acknowledgements Type of funding sources: None. Background Transthoracic echocardiography is the first-line non-invasive investigation for assessing pediatric patients' cardiac anatomy, physiology, and hemodynamics, based on its accessibility and portability, but complete anatomic and hemodynamic assessment is time-consuming. The study aimed to determine the accuracy and reliability of a new automated artificial intelligence software initially developed for adults for analyzing the main echocardiographic parameters in pediatric patients. Materials and Methods The study was performed at the University Hospital of Bordeaux between August and September 2022 and included 45 patients who underwent a 2D transthoracic echocardiographic examination, mainly for murmur (n=8), post ASD closure evaluation(N=5), chest pain, or arrhythmia as we aimed to have a homogeneous group of patients with normal or near normal heart architecture. We compared AI automatic measurements with manual measurements performed by a senior and junior pediatric cardiologist. Pearson correlation and Bland and Altman analysis were used. As the AI software has been developed for adults, we decided to subclassify our patients into two subgroups: the first group (patients aged between 0–8 years) and the second group (patients over 8 years). The decision was made because pediatric anatomy differs from adults and to see if the dedicated artificial intelligence soft for adults has better reproducibility for pediatric patients older than 8 years. Results The median age was 8.9 years. Comparison between senior and junior pediatric cardiologists for all subgroups was significant (Pearson correlation &amp;gt;0,7 for most measurements performed). For younger patients (&amp;lt;8 years old), we found excellent correlations (Pearson correlation &amp;gt;0.8) for heart chambers measurements measured from A4CH and A2CH views (LV end-diastolic volume, LV end-systolic volume, RV end-diastolic area, and RV area) between AI software and both junior and senior pediatric cardiologist, but poor correlation for the measurements performed from parasternal long axis view (r=0.06 for STJ measurement). We achieved stronger correlations for the measurements evaluation of patients over 8 years old ( r&amp;gt;0.8 for aortic annulus, STJ, E, A, S waves, LV end-diastolic volume in A4CH, LV end-systolic volume in A4CH) for both junior and senior cardiologist in relation to AI measurements. Conclusion In this preliminary study, we found that automated artificial intelligence software provided promising results for measuring mainly volumes (LV end-diastolic volume, LV end-systolic volume) in A4CH and A2CH. The software requires improvements for automated measurements within the parasternal long-axis section to achieve better accuracy. Results obtained with the AI software for patients over 8 years old were significantly improved compared to those obtained for those under 8 years of age.

The Prevalence of and Predisposing Factors for Late Atrial Arrhythmias after Transcatheter Closure of Secundum Atrial Septal Defects in Children.

A 24 h Holter study in children after transcatheter secundum ASD (ASD II) closure was conducted to detect the prevalence of defects and/or device-related late atrial arrhythmias (LAAs). ASD II closure with an Amplatzer septal occluder (ASO) is an established procedure. Little is known about LAAs after device implantation. The eligible participants were children who had undergone ASO implantation, with a follow-up of ≥5 years, as well as one pre- and at least one post-procedural Holter ECG. In total, 161 patients (mean age: 6.2 ± 4.3 years), with a mean follow-up of 12.9 ± 3.1 years (range 5-19), were included. A median of four Holter ECGs per patient were available. LAAs occurred before intervention in four patients (2.5%), and it was peri-interventional in four patients (2.5%), sustained in three patients (1.9%), and developed in three patients (1.9%). In patients with pre- and peri-interventional LAAs, the Qp/Qs ratio was higher (6.4 ± 3.9 vs. non-AA: 2.0 ± 1.1 (p = 0.002)) and the IAS/ASO ratio was lower (1.18 ± 0.27 vs. non-AA: 1.7 ± 0.4 (p < 0.001)). The patients with LAAs differed from those without LAAs in their Qp/Qs (6.8 ± 3.5 vs. 2.0 ± 1.3; p < 0.0001) and IAS/ASO ratios (1.14 ± 0.19 vs. 1.73 ± 0.45; p < 0.001). The patients with LAAs had a Qp/Qs ratio ≥2.94:1, and those who developed LAAs had an IAS/ASO ratio <1.15. LAAs occurred in 1.9% of patients and were sustained in another 1.9% of patients but persisted in those with large shunt defects and large occluders in relation to the atrial septal length. The predisposing factors for LAAs after ASD closure were a high Qp/Qs ratio, pre-existing atrial arrhythmias, and a low IAS/ASO ratio.

Comparison of zero fluoroscopy versus fluoroscopy guided ablation for atrial fibrillation: A single center experience

Abstract Funding Acknowledgements Type of funding sources: None. Background With advances in mapping equipment and increased use of intracardiac echocardiography (ICE), atrial fibrillation (AF) ablations can be safely performed without fluoroscopy. Benefits include no radiation exposure to patient and staff and reduced long-term orthopedic complications related to use of lead aprons for staff. Published data comparing zero fluoroscopy ablation (ZFA) and conventional fluoroscopy guided ablation (CFA) for AF is limited to small case series and meta-analysis. Aim To evaluate the safety and procedural outcomes of a simplified ZFA approach, comparing it to standard of care (CFA). Methods Consecutive AF cases from 03/2021 to 09/2022 at our institution were included. 120 cases underwent ZFA (RF ablation, ICE and 3D mapping guided) and 155 cases underwent CFA (Cryo or RF ablation, fluoroscopy, ICE and 3D map guided). For the ZFA group, a simplified ICE based map of relevant anatomical structures was created, in order to guide trans-septal (TS) access and left -sided ablation (See figure) and no pre-procedural imaging was obtained. All CFA cases had pre-procedural cardiac CT or MRI to evaluate left atrial anatomy. Redo ablation cases represented 17% of the ZFA and 23% of the CFA patients. All cases were performed by operators with &amp;gt;12 years of experience, and all cases underwent general anesthesia. Only two ZFA cases required a brief period of fluoroscopy (under 2 min each) to achieve safe trans-septal access (including one case with a prior ASD closure device). Results Mean age was 67 for ZFA and 69 for CFA groups respectively (p=NS). 69% of ZFA and 71% of CFA cases were men. Persistent AF cases more frequently underwent posterior wall isolation in the ZFA group (98% vs 68%, P&amp;lt;0.01), but despite this, procedural times were similar for both groups (168±55 min ZFA vs 172±51 min CFA, P=NS). Procedural success (pulmonary vein isolation ± posterior wall isolation) was achieved in all ZFA and 99% of CFA cases. At a mean follow up 12 months, Freedom for AF was 81% for paroxysmal AF and 74% for persistent AF cases in the ZFA group, and 79% for paroxysmal AF cases and 71% for persistent AF cases in the CFA group (p=NS). Procedural complications included one TIA in the ZFA group and 2 pericardial effusions in the CFA group (p=NS). Use of antiarrhythmic drugs post ablation did not differ between the ZFA and the CFA groups (23% vs 27%, p=NS). Conclusion Our ZFA approach for AF was safe, effective and produced similar outcomes compared to a traditional CFA approach. ZFA has considerable health benefits for personnel and patients without compromising procedural outcomes. The cost of ICE catheters may be offset by eliminating the need for pre-procedural imaging (CT or MRI) commonly used prior to AF ablations. Our study adds to the growing literature supporting the safety of catheter ablation in a non-fluoroscopy environment.

P113 TRANSCATHETER CORRECTION OF RESIDUAL INFERIOR SINUS VENOSUS DEFECT AFTER SURGICAL CLOSURE

Abstract A 21–year old male who underwent surgical closure of an isolated inferior type sinus venosus atrial septal defect (SV–ASD) at 6 years of age was admitted to our institute for acute superior limb hypotonia and dysarthria, with brain computed tomography scan positive for an ischaemic event. The contrast transcranial Doppler (CTD) was positive for right–to–left shunt (RLS). The transesophageal echocardiogram (TOE) revealed a small ASD (3.8 mm) near the inferior vena cava (IVC) with a small baseline left–to–right shunt and severe RLS after Valsalva’s Manovre (&amp;gt;20 bubbles) (fig.A–B). No clear intra–cardiac source of embolization was detected on workup. After a multidisciplinary discussion, percutaneous closure of residual ASD was planned. The main challenge was represented by inadequate inferior–posterior rim towards the IVC (&amp;lt;5 mm). A Figulla Flex II ASD Occluder with the smallest waist of 4 mm was implanted with no evidence of residual intraprocedural shunt; no intraprocedural complications were observed (fig.C). The 1 month follow–up CTD was negative for RLS. Conclusions Residual ASD is a rare late complication after surgical closure of the ASD(1). We describe the case of a successful transcatheter closure of a small ASD in the presence of a deficient posterior–inferior rim which, in general, is considered an unfeasible anatomy for percutaneous procedure (2). The appropriate choice of treatment for a residual ASD should be carefully considered on a case–by–case basis. Reference 1) S. Ogura;Y.Takaya1; T. Akagi; K. Nakagawa; H. Ito.Percutaneous closure of residual atrial septal defect after surgical closure. Cardiovascular Intervention and Therapeutics (2021) 36:256–259 2) M. Chessa; G. Butera; A. Giamberti; R. M. Bini; M.Carminati. Transcatheter Closure of Residual Atrial Septal Defects After Surgical Closure. Journal of Interventional Cardiology vol.15, No. 3,2002

P406 LAUBRY–PEZZI SYNDROME: EVERYTHING IS NOT AS IT SEEMS

Abstract Introduction Laubry–Pezzi syndrome is a congenital heart disease characterized by the prolapse of an aortic valve cusp into a subjacent ventricular septal defect (VSD), mostly supracristal, leading to severe aortic regurgitation (AR). It has been reported nearly always in childhood, the Venturi effect is the predominant factor and onset symptoms may be variable. Case Report A 61–years–old male was admitted to our intensive case unit for chest pain radiated to interscapular region and exertional dyspnea. Hemodynamic parameters were normal. At ECG sinus rytm with heart rate 92 bpm and non–specific repolarization abnomalities were reported. Hs troponin I was 276 ng/L, myoglobin 30.2 ng/mL and BNP 325 pg/mL. Transthoracic echocardiography showed a dilated left ventricle (LV EDV 107 mL/m2) with normal ejection fraction (55%), severe AR without aortic root dilation and a suspicious shunt left to right at level of interventricular septum. Therefore, transesophageal echocardiography was performed and confirmed severe AR by probable bicuspid valve and right cusp prolapse, in absence of calcifications and/or vegetations by endocarditis, restrictive perimembranous VSD (maximum diameter 0.6 cm) and ostium secundum ASD with shunt L–R. Right chambers were not dilated and non invasive systolic pulmonary artery pressure was 43 mmHg. Coronary angiography was performed and showed a significant stenosis of distal left anterior descending (LAD) artery and of proximal circumflex artery. Right heart catetherization excluded significant high values of pulmonary pressures (mPAP=18 mmHg), of pulmonary capillary wedge pressure (9 mmHg), with a mild increase of pulmonary vascular resistances (1.16 HRU; nv &amp;lt; 96). Coronary artery bypass grafting (left internal mammary artery on LAD and Y–graft radial artery on obtuse marginal artery), aortic valve replacement with bioprothesis (Inspiris Resilia 23 mm), ASD closure by direct suture and VSD closure with pericardial patch were performed. No post–surgical complications were reported. Interestingly, during the replacement of aortic valve, it resulted tricuspid, confirming the suspicion of Laubry Pezzi syndrome. Conclusions our case was object of great debate because restrictive VSD and severe AR were not previously known, were diagnosed in middle age and until then paucisymptomatic. Laubry–Pezzi syndrome is a very rare disease that may explain controversial cases of severe AR.

P51 PERCUTANEOUS CLOSURE OF PATENT FORAMEN OVALE IN CHILDREN :SINGLE CENTER EXPERIENCE

Abstract Background Transcatheter patent foramen ovale (PFO) closure is a validated strategy to prevent recurrent cerebral events in adult patients; limited data are available for children. Methods This is a retrospective analysis including pediatric population underwent to percutaneous treatment of PFO in our center. Results From 2006 to 2021, 21 transcatheter PFO closures have been performed in children (mean age: 14 +3 years; female: 58%, weight: 59 + 20 kg). Indications for the closure of PFO consisted in the occurrence of cryptogenic ischemic events for 18 patients (86%), in disabling migraine symptoms for 2 patients (9,5%) and in prophylactic measure to prevent paradoxical embolism in high risk abdominal surgery for 1 patient (4,5%). Transcatheter PFO closure was performed under general anesthesia with transesophageal ultrasound guidance. Complex anatomies of PFO included atrial septal aneurysm in 4 cases (with accessory fenestration of atrial membrane in 2 of these cases) and long and stiff PFO tunnel in one case. Single device was used in 20 procedures. ASD closure device was required for 5 cases because of anatomic characteristics of PFO. In one case of large multifenestrated atrial septal aneurysm, percutaneous treatment was performed using both PFO closure device and ASD closure device. No peri and/or post procedural complications have been reported . All patients were treated with Acetylsalicylic acid and Clopidogrel for the first six months after the procedure. Conclusions Transcatheter PFO closure is a safe procedure in pediatric patients in high volume center that should be used for preventing recurrent cerebral events also in children.