Isolated Secundum Atrial Septal Defect Research Articles

Comparison of Short-Term Outcomes of Transcatheter versus Surgical Closure of Atrial Septum Defect at a Tertiary Cardiac Care Facility

Objective: To compare the short-term outcomes of transcatheter versus surgical closure of atrial septal defect (ASD) at a tertiary cardiac care facility in South Punjab, Pakistan.
 Study Design: Prospective comparative study.
 Place and Duration of the Study: Department of Paediatric Cardiology and Paediatric Cardiac Surgery, Chaudhary Pervez Elahi Institute of Cardiology, Multan Pakistan, from Jul 2019 to Jun 2021.
 Methodology: A total of 110 patients with moderate to large isolated secundum ASDs without severe pulmonary hypertension and planned to undergo closure of secundum ASD by either surgical approach or device closure were included. All surgical and transcatheter procedures were performed adopting standard techniques. Intra-procedural or post-procedural outcomes were noted.
 Results: In a total of 110 patients, 59(53.6%) underwent transcatheter closure of ASD, while surgical closure was done in the remaining 51(46.4%) patients. Post-procedural complications were significantly more in the Surgical Closure Group in comparison to the Transcatheter Closure Group, [14(27.5%) vs 5(8.5%) (p=0.026)]. None of the cases in the Transcatheter Closure Group required inotropes in the post-procedure period in comparison to 24(47.1%) cases (p<0.001). The total cost of treatment was significantly higher in transcatheter closure patients compared to surgical closure patients (1504±60.4 US$ versus 1448±75.4 US$, p<0.001). Overall, successful closure was noted in 108(98.2%) cases. No mortality was recorded.
 Conclusion: Overall, short-term outcomes of transcatheter ASD closure were comparable to the surgical approach, but patients with transcatheter ASD closure had significantly less duration of hospitalization and low rates of post-procedural complications.Keywords: Atrial septum defect, Mortality, Surgical closure, Transcatheter closure.

A tale of two ASDs-Compliance matters.

Key Points Patients with secundum atrial septal defects (ASDs) who have pulmonary atresia with intact ventricular septum or critical pulmonary stenosis, exhibit different ASD physiology compared to patients with isolated secundum ASDs. The indication and timing of secundum ASD closure in these patients should be made on a case‐by‐case basis. Long‐term assessment of the physiological consequences of secundum ASD closure in this group of patients should be kept in mind, as these patients have right ventricles that represent a spectrum ranging from significantly restrictive right ventricles, to right ventricles with normal compliance.

Evaluation of Arrhythmia Prevalence, Management, and Risk Factors in Patients with Transcatheter and Surgically Closed Secundum Atrial Septal Defects.

Atrial septal defect (ASD) accounts for 6-10% of all congenital heart disorders. Secundum ASD closure can be performed surgically or percutaneously. We aimed to identify the various arrhythmias that occur before, during, and after the procedure and evaluate their management. The study included a total of 427 patients aged 0-18 years who underwent transcatheter or surgical closure of isolated secundum ASD between January 2008 and January 2020. Postoperative electrocardiogram (ECG) traces, intraoperative arrhythmias, and treatments were recorded for both groups. Echocardiography and ECG were evaluated at postoperative 1 week, 1, 3, and 6 months, and annually thereafter. After transcatheter closure, follow-up basal ECG showed incomplete right bundle branch block pattern in 21 patients and sinus rhythm in 229 patients. After surgical closure, incomplete right bundle branch block pattern was detected in 23 patients, complete right bundle branch block in 3 patients, and complete AV-block (Atrioventricular Block) pattern in 1 patient. The other 150 patients showed sinus rhythm. At least one postoperative follow-up Holter ECG record could be obtained for 104 patients in the transcatheter group and 96 patients in the surgical group. Of 104 patients who underwent transcatheter closure, 97 (93.3%) had normal Holter ECG findings and 7 (6.7%) had arrhythmia. Of the 96 patients who underwent surgical closure, 85 (88.5%) had normal Holter ECG traces and 11 (11.5%) had arrhythmia. There was no statistically significant difference in the frequency of arrhythmia (P = 0.164). The higher frequency of arrhythmia in adult studies compared to the pediatric age group once again demonstrates the importance of early diagnosis and treatment of ASD in childhood. The similar incidence of arrhythmia in both groups supports the safety and effectiveness of both closure methods in eligible patients.

Abstract 15278: Transcatheter Closure of Atrial Septal Defect Over the Age of 60

Introduction: The long-term benefits of transcatheter device closure of a secundum atrial septal defect (ASD) over 60 remain controversial. The aim of the study was to assess the predictors of death late after device closure in these elderly patients. Methods: This retrospective study enrolled 87 patients with successful ASD transcatheter closure over 60 and at least 1 year follow-up after closure. The mean age was 73.3±5 years, and 74 of them were female (85%). All patients had an isolated secundum ASD with a mean defect size of 18±4 (9-30) mm. At the time of closure 10 patients were known with pulmonary hypertension (11%), 52 with atrial arrhythmia (61%), 56 with heart failure (64%), and 15 with coronary artery disease (17%). Demographic, clinical and echo data were compared between values at the time of closure, and at the last follow-up. Predictors of death were analyzed with multivariate Cox regression. Results: After the mean follow-up of 5±4 years 11 patients developed high LV filling pressure, 15 patients had new atrial arrhythmia and 10 patients right heart failure. At the last FU a significant decrease in right ventricular (45±5 vs 38±8 mm, p=0.032) and right atrium dimension (62±10 vs. 59 ±10mm, p=0.045) were seen, together with right ventricular systolic pressure improvement (51±18 vs. 40±19 mmHg, p=0.038). The left atrium showed significant further dilatation after closure (60±9 vs. 62±9.5, p=0.048). The presence of pulmonary hypertension, right ventricular dilatation and tricuspid regurgitation correlated with the right heart failure after closure, and the atrial dimension, tricuspid regurgitation, and high filling pressure with new atrial arrhythmia. Fourteen patients died during follow-up. On multivariate analysis the main predictor of death was right heart failure (HR: 10; 95% CI 2,15-41). Conclusions: In terms of right heart remodeling, elderly patients still benefit from late ASD catheter closure. However, those who develop right heart failure after closure are at a high risk of death (HR:10). Diastolic dysfunction after the defect closure was not a predictor of death.

Can Right Infra-Axillary Vertical Thoracotomy Make a Big Difference in Surgical Technique Preference?

Minimally invasive techniques in the surgical treatment of congenital heart diseases have gained popularity recently. Right infra-axillary vertical thoracotomy (RIAVT) is one of these techniques. The aim of this study is to investigate the postoperative morbidity and cosmetic results of the right infraaxillary thoracotomy technique and compare them with the results in the literature. All patients who had undergone cardiac surgery using RIAVT at the Ankara City Hospital Pediatric Cardiovascular Surgery Clinic between 2019 and 2021 were enrolled in the study. Preoperative echocardiographic diagnoses, intraoperative surgical data and postoperative morbidity data of the patients was obtained. In addition, surgical incision length was measured and recorded for the evaluation of cosmetic outcome. This data was then compared with data from similar studies in the literature. Between January 2019 and December 2021, 59 patients were operated on using RIAVT. Of the RIAVT patients, 45 (76%) were female and 14 (24%) were male. The mean weight of the patients was 22.38±12.48 kg. Although the youngest patient was a 5-month-old infant weighing 4 kg, the oldest one was 15-years-old weighing 57 kg. Isolated secundum atrial septal defect (ASD) repair (primary or patch) was performed in 47 patients. One (1) patient with Primum ASD and mitral cleft, 1 patient with secundum ASD and perimembranous ventricular septal defect (VSD) repair, nine patients with high venosum ASD and PAPVC, and one patient with a discrete subaortic membrane were operated on. The surgical incision length was between 4 to 5 cm. RIAVT is an important surgical alternative to median sternotomy in selected cases with certain pathologies. It can be performed safely in various congenital heart anomalies and provides excellent functional and cosmetic results in the long-term when compared to other surgical methods.

Impaired left and right systolic ventricular capacity in corrected atrial septal defect patients

Resting right ventricular (RV) systolic function has in some studies been shown to be impaired after correction of an atrial septal defect (ASD) whereas impairment of left ventricular (LV) systolic function is uncertain. In the present study we examine the LV and RV systolic response to exercise in patients with a previously corrected ASD in order to investigate the myocardial capacity. Thirty-six adult ASD patients with a corrected isolated secundum ASD and eighteen adult age-matched controls underent a semi-supine exercise stress echocardiographic examination. At rest, LV parameters were comparable between groups, and RV global longitudinal strain (RV-GLS) was lower for the ASD group (−18.5%, 95% CI −20.0—−17.0%) compared with controls (−24.5%, 95% CI −27.7—−22.4%, p < 0.001). At peak exercise, LV ejection fraction (LVEF) was lower for ASD patients (61%, 95% CI 58–65%) compared with controls (68%, 95% CI 64–73% p = 0.01). Peak LV global longitudinal strain (LV-GLS) was borderline significantly lower (ASD: -18.4%, 95% CI −20.2—−16.6%, controls: −21.3%, 95% CI −23.6—−19.0%, p = 0.059). Both RVEF (ASD: 64%, 95% CI 60–68%, controls: 73%, 95% CI 65–80%, p = 0.05) and tricuspid annular plane systolic excursion (TAPSE) (ASD: 2.5 cm, 95% CI 2.3–2.7 cm, controls: 3.2 cm, 95% CI 2.9–3.6 cm, p < 0.001) at peak exercise were lower for ASD patients. Exercise assessed peak oxygen uptake was comparable between groups (ASD: 32.8 mL O2/kg/min, 95% CI 30.3–35.5 mL O2/kg/min, controls: 35.2 mL O2/kg/min, 95% CI 31.6–38.8 mL O2/kg/min, p = 0.3). Corrected ASD patients demonstrate a reduced LV and RV systolic exercise response decades after ASD correction whereas resting parameters of LV and RV systolic function were within normal range. The presence of subclinical systolic myocardial dysfunction during exercise might be associated with the long-term morbidities documented in this patient group.

Elevated Left and Right Atrial Pressures Long-Term After Atrial Septal Defect Correction: An Invasive Exercise Hemodynamic Study.

BackgroundDespite correction of the atrial septal defect (ASD), patients experience atrial fibrillation frequently and have increased morbidity and mortality. We examined physical capacity, cardiac performance, and invasive hemodynamics in patients with corrected ASD.Methods and ResultsThirty‐eight corrected patients with isolated secundum ASD and 19 age‐matched healthy controls underwent right heart catheterization at rest and during exercise with simultaneous expired gas assessment and echocardiography. Maximum oxygen uptake was comparable between groups (ASD 32.7±7.7 mL O2/kg per minute, controls 35.2±7.5 mL O2/kg per minute, P=0.3), as was cardiac index at both rest and peak exercise. In contrast, pulmonary artery wedge v wave pressures were increased at rest and peak exercise (rest: ASD 14±4 mm Hg, controls 10±5 mm Hg, P=0.01; peak: ASD 25±9 mm Hg, controls 14±9 mm Hg, P=0.0001). The right atrial v wave pressures were increased at rest but not at peak exercise. The transmural filling pressure gradient (TMFP) was higher at peak exercise among patients with ASD (10±6 mm Hg, controls 7±3 mm Hg, P=0.03). One third of patients with ASD demonstrated an abnormal hemodynamic exercise response defined as mean pulmonary artery wedge pressure ≥25 mm Hg and/or mean pulmonary artery pressure ≥35 mm Hg at peak exercise. These patients had significantly elevated peak right and left atrial a wave pressures, right atrial v wave pressures, pulmonary artery wedge v wave pressures, and transmural filling pressure compared with both controls and patients with ASD with a normal exercise response.ConclusionsPatients with corrected ASD present with elevated right and in particular left atrial pressures at rest and during exercise despite preserved peak exercise capacity. Abnormal atrial compliance and systolic atrial function could predispose to the increased long‐term risk of atrial fibrillation.Registration Informationclinicaltrials.gov. Identifier: NCT03565471.

Comparison of the early cardiac electromechanical remodeling following transcatheter and surgical secundum atrial septal defect closure in adults

BackgroundSecundum atrial septal defect (ASD) closure leads to electrical and mechanical remodeling that occurs early after shunt disappearance. The relationship between electromechanical remodeling using electrocardiogram (ECG) and cardiac magnetic resonance (CMR) after percutaneous and surgical closure has not yet been recorded in prospective studies.ObjectiveWe thought to study right atrium (RA) and right ventricle (RV) changes by CMR 3 months after transcatheter and surgical closure and their comparison with electrical remodeling by ECG.ResultsWe prospectively evaluated 30 consecutive adult patients with isolated secundum ASD who were referred for (transcatheter and surgical) ASD closure.There was significant reduction in all of the electrical parameters within the same group as compared to the baseline values, except P wave dispersion (Pd). (P max was 97.33 ± 16.67 (pre closure) to 76 ± 15.49 (post closure) in the device group and 97.33 ± 12.79 (preclosure) to 73.33 ± 16.32 (post closure) in the surgical group, QRS complex was 104 ± 18.82 (preclosure) to 80 ± 18.51 (post closure) in the device group and 106.67 ± 14.47 (preclosure) to 86.67 ± 17.99 (post closure) in the surgical group. QTc maximum was 478.53 ± 36.79 (preclosure) to 412.53 ± 38.03 (post closure) in the device group and 470.53 ± 65.70 (preclosure) to 405.93 ± 63.08 (post closure) in the surgical group, and QTc dispersion was 70.33 ± 24.04 (preclosure) to 60.26 ± 28.56 (post closure) in the device group and 80.73 ± 30.38 (preclosure) to 60.27 ± 28.57 (post closure) in the surgical group).There was no significant difference between two groups indicating that transcatheter and surgical closure had led to equivalent value of electrical remodeling.In CMR study, we measured RA maximal volume and right ventricle end diastolic volume (RVEDV), RA maximal volume decreased significantly as compared to the base line values post closure in both groups (P value < 0.001). The reduction in RA max volume was more in the transcatheter closure group; however, this difference was not statistically significant when compared with the surgical arm (P value = 0.5).RVEDV decreased significantly in both groups as compared to the baseline values (P value < 0.001). Transcatheter closure resulted in more significant reduction in the RVEDV than the surgical closure (P value = 0.03).ConclusionOur study showed early significant electromechanical reverse remodeling in most of the study parameters from the baseline values after ASD closure. We found no significant differences in all of the electrical and RA mechanical remodeling parameters with significantly better mechanical remodeling of RV in the device group.

Cost-Minimization Analysis of Transcatheter versus Surgical Closure of Secundum Atrial Septal Defect in Children

Objective: Secundum atrial septal defect (ASD) is one of the congenital heart diseases commonly found in children, which can be treated by transcatheter closure as a standard treatment or by surgical treatment. Few studies have analyzed the cost of these two strategies. The present study is aimed to compare the short-term cost-minimization of both procedures. Materials and Methods: A retrospective single-center study analyzed all children aged 1 to 18 years, diagnosed with isolated secundum atrial septal defect, who were entirely treated by transcatheter or surgical ASD closure at Ramathibodi Hospital, Mahidol University between January 2005 and August 2016. The baseline characteristics, total hospital days, cost per case, clinical outcomes, and complications between these two procedures are compared. Results: Thirty-five patients were enrolled in the present study, divided into two groups, with 43% in the transcatheter group and 57% in the surgical group. The baseline characteristics of the transcatheter and surgical groups were not significantly different except for weight, which was 28.6 kg versus 16.5 kg (p=0.045), and for medical history of asymptomatic, which was seven versus 16 patients (p=0.04), respectively. Patients with transcatheter procedures had a shorter length of hospital stay at 2.3 days versus 8.1 days (p&lt;0.001), respectively. The direct medical cost per case of surgical procedure was less than the transcatheter procedure at 116,993 Baht or 3,878 US Dollar versus 206,204.7 Baht or 6,835 US Dollar (p&lt;0.001), respectively. The major complication of the transcatheter procedure was bleeding from the puncture site while it was intraoperative arrhythmia for the surgical procedure. Conclusion: The short-term clinical outcomes of the transcatheter and the surgical ASD closure were excellent. The cost analysis suggests that surgical procedures may incur fewer costs than transcatheter procedures from the hospital’s perspective. Surgical ASD closure may be a less costly strategy for Ramathibodi pediatric patients. Keywords: Atrial septal defect, ASD, Transcatheter, Cost-minimizing analysis, Device, Surgery

Limited Utility of Surveillance Echocardiograms in Pediatric Patients with Isolated Secundum Atrial Septal Defects

Atrial septal defects (ASDs) are the third most common form of congenital heart defects worldwide.1 Most otherwise healthy pediatric patients with hemodynamically significant ASDs remain asymptomatic throughout childhood. Pulmonary vascular disease or atrial arrhythmias associated with long-standing ASDs rarely occur before late adolescence or early adulthood.2 In the absence of failure to thrive or frequent respiratory infections, most patients undergo elective ASD repair in early childhood (2-5 years of age).

The benefit of atrial septal defect closure in the elderly patients

Abstract Objective Closure of the atrial septal defect in the elderly patients is controversial. The aim of the study was to evaluate the outcomes of transcatheter closure of secundum atrial septal defect (ASD) in elderly patients. Methods From a total of 650 pts with ASD who underwent transcatheter closure 120 pts over 60 years (70 F, 50 M) with a mean age of 66.7±18.1 (60–78) were analyzed. All patients had an isolated secundum ASD with a mean Qp:Qs: 2.79±1.8 (1.5–3.9). A symptom-limited treadmill exercise tests with respiratory gas exchange analysis and transthoracic color Doppler echocardiographic study as well as Quality of life (QoL) measured using the SF36 questionnaire (SF36q) were repeated in all pts before procedure and after 12 months of follow-up. Results The device was successfully implanted in all pts (procedure time 30.1±9.9 (10–59) minutes, fluoroscopy time 10.1±7.2 (6–40) minutes). There were no major complications. The defect echo diameter was 19.5±15.4 (12 - 34) mm. The mean balloon stretched diameter of ASD was 22.0±7.8 (14 - 36) mm. The diameter of the implanted devices ranged 16 - 38 mm. After 12 months of ASD closure, all the pts showed a significant improvement of exercise capacity parameters. Seven QoL parameters (except mental health) improved at 12 months follow up compared to their baseline data. The mean SF36q scale increased significantly in 96 (80.2%) pts of mean 41.6±26.1 (4–71). The right ventricular dimension decreased in 101 pts (84.2%) (Table 1). Conclusions Closure of ASD in elderly patients caused a significant clinical and hemodynamic improvement after percutaneous treatment, which is maintained to long-term follow-up what justified this procedure in old age. Funding Acknowledgement Type of funding source: None

Surveillance Echocardiograms Have Minimal Clinical Utility in Pediatric Patients with Isolated Secundum Atrial Septal Defects

Purpose Secundum atrial septal defects (ASDs) are among the most common forms of congenital heart disease. Hemodynamically significant ASDs cause right-sided enlargement and may precipitate atrial arrhythmias and pulmonary hypertension in adulthood. Most patients with ASDs are asymptomatic, and elective closure is planned between 2-5 years of age. Transthoracic echocardiography is the gold standard for diagnosis and treatment planning. Herein, we evaluated the clinical utility of surveillance echocardiograms on clinical management on pediatric patients diagnosed with isolated secundum ASDs. Methods An IRB-approved retrospective study was completed on pediatric …

Surveillance Echocardiograms Have Minimal Clinical Utility in Pediatric Patients with Isolated Secundum Atrial Septal Defects

Surveillance Echocardiograms Have Minimal Clinical Utility in Pediatric Patients with Isolated Secundum Atrial Septal Defects

Intraoperative localization of cardiac conduction tissue regions using real-time fibre-optic confocal microscopy: first in human trial.

The aim of this study was to evaluate the feasibility and safety of fibre-optic confocal microscopy (FCM) using fluorescein sodium dye for the intraoperative location of conduction tissue regions during paediatric heart surgery. The pilot study included 6 patients undergoing elective surgery for the closure of isolated secundum atrial septal defect aged 30 days to 21 years. FCM imaging was integrated within the normal intraoperative protocol for atrial septal defect repair. Fluorescein sodium dye was applied on the arrested heart. FCM images were acquired at the atrioventricular node region, sinus node region and right ventricle (RV). Total imaging time was limited to 3 min. Any adverse events related to the study were recorded and analysed. Subjects received standard postoperative care. Trained reviewers (n = 9) classified, de-identified and randomized FCM images (n = 60) recorded from the patients as presenting striated, reticulated or indistinguishable microstructures. The reliability of reviewer agreement was assessed using Fleiss' kappa. The FCM imaging instruments were integrated effectively into the cardiac surgery operating room. All adverse events found in the study were deemed expected and not related to FCM imaging. Reticulated myocardial microstructures were found during FCM imaging at atrioventricular node and sinus node regions, while striated microstructures were observed in RV. Reliability of agreement of reviewers classifying the FCM images was high (Fleiss' kappa: 0.822). FCM using fluorescein sodium dye was found to be safe for use during paediatric heart surgery. The study demonstrates the potential for FCM to be effective in identifying conduction tissue regions during congenital heart surgery. NCT03189134.

Value of P wave dispersion in pediatric patients with secundum atrial septal defect

Objective:Ostium secundum defect is the common cause of RA enlargement. The aim in this study is to evaluate P wave dispersion in children to the size of atrial septal defect.Method:Forty–one children with isolated secundum atrial septal defect (and 41 age-matched controls evaluated. Using the same 12 lead ECG device in resting position, P maximum and P dispersion measured.Results:Mean P dispersion in atrial septal defect children is prolonged compare to the controls (P dispersion: 29.1±10.1 vs. 25.3±5.5 ms, P=0.009). And children with right atrial dilation had significantly longer P maximum (101.2±14.1 vs. 81.7±12.3 ms, P<0.001) and larger P dispersion (35.0±11.4 vs. 26.5±8.3 ms, P=0.003) compared to those without right atrial dilation.Conclusion:Children with moderate to large sized ASD are valuable to have prolonged. Atrial conduction time in the form of P duration and P dispersion. Also, it’s a good tool for diagnosing ASD in places where echocardiography imaging is not available. We can also differentiate between small ASD and large one based on P dispersion.

P1800The benefit of atrial septal defect closure in patients with borderline shunt

Abstract Objective Closure of atrial septal defect in patients with borderline shunt is controversial. The aim of the study was to evaluate the outcomes of transcatheter closure of secundum atrial septal defect (ASD) in the patients with the borderline shunt. Methods 215 pts (126 F,89 M) with a mean age of 31.9±18.2 (16–58) years with a small ASD who underwent transcatheter closure were analyzed. All patients had an isolated secundum ASD with pulmonary to systemic blood flow Qp:Qs ratio≤1.5, mean 1.2±0.6 (1.1–1.5). A symptom-limited treadmill exercise test with respiratory gas exchange analysis, transthoracic color Doppler echocardiographic study and Quality of life (QoL) (using the SF36 questionnaire (SF36q)) were repeated in all pts before and 36 months after the procedure. Results The device was successfully implanted in all pts (procedure time 19.1±5.2 (8–38) minutes, fluoroscopy time 8.1±4.4 (6–13) minutes). There were no major complications. The defect echo diameter was 7.7±3.9 (5 - 15) mm. The diameter of the implanted devices ranged from 6 to 18 mm. After 36 months of ASD closure, all the pts showed a significant improvement of exercise capacity. 7 QoL parameters (except mental health) improved at 36 months of follow-up compared with baseline. The mean SF36q scale increased in 168 (78.1%) pts of mean 40.2±20.1 (9–72). The right ventricular dimension decreased in 173 pts (80.4%) (Table 1). Table 1 Parameter Before ASD closure 36 months after ASD closure p value Time of exercise (min) 12.1±5.2 18.6±4.3 &lt;0.001 VO2 peak (ml/kg/min) 10.2±4.7 14.8±4.2 &lt;0.001 SF36q scale 0–100 37.3±22.3 79±29.5 &lt;0.001 Right atrial area (cm2) 20.1±1.7 14.7±1.5 &lt;0.001 Right ventricular area (cm2) 18.1±1.4 12.2±1.5 &lt;0.001 Conclusions ASD closure in patients with borderline shunt resulted in a significant and long-term clinical and hemodynamic improvement after percutaneous treatment.

VENTRICULAR COMPRESSION OF LEFT LOWER LOBE BRONCHUS MASQUERADING AS LOWER LOBE COLLAPSE

SESSION TITLE: Monday Fellow Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: There have been reports of tracheobronchial compression from vascular enlargements such as that seen in pulmonary hypertension of the pulmonary artery. Severe aortic aneurysms or congenital abnormalities of the pulmonary artery and descending aorta have been reported to cause compression of the left main stem bronchus. We present a rare case of compression of the left main and lower lobe bronchus from an enlarged left ventricle (LV). CASE PRESENTATION: 61 year old man with history of non-ischemic cardiomyopathy who presented with a ST elevation myocardial infarction (MI) to an outside hospital. He underwent percutaneous intervention and was noted to have a thrombus in the left anterior descending artery (LAD). Balloon dilation, thrombectomy and TPA instillation were performed, however, given severe cardiogenic shock, patient required mechanical circulatory support with an impella device and was intubated for respiratory failure. His stay was complicated by ventricular tachyarrhythmia cardiac arrest. After return of circulation was achieved, patient was transferred to our facility for further management. On arrival, he was alert, had decreased breath sounds at the left lung base with rhonchi throughout, soft abdomen, pulses present throughout all extremities, with pitting edema of the lower extremities, and appropriate flows at 3.5L on the impella. He developed fevers soon after arrival, concerning for sepsis. On chest x-ray, patient was noted to have left lower lobe collapse, with thick foul smelling sputum. Hence we performed bronchoscopy which showed minimal secretions and extrinsic compression at the level of the left secondary carina. No significant mucous plugging was noted. On echo, patient had a severely dilated left ventricle with impella in appropriate position and a mildly dilated right ventricle. DISCUSSION: Vascular enlargements in the mediastinum causing tracheobronchial compression have been reported in case reports and case series, however LV enlargement leading to compression of left main stem bronchus is rare. After ruling out usual causes of white out of the left lower lobe on chest xray including obstruction (often mucous plugging), consolidation, pleural effusion, atelectasis, in patients with severe LV dilation and dysfunction, enough to warrant mechanical circulatory support, LV compression of the left lower lobe should be considered as well. CONCLUSIONS: Left lower lobe collapse in a patient with cardiogenic shock and severe LV dysfunction may be secondary to LV dilation causing compression of the left main-stem or left lower lobe bronchus. Further studies are needed to determine whether decompression of the LV relieves this bronchial compression. Reference #1: Jaijee SK, Ariff B, Howard L, et al. Left main bronchus compression due to main pulmonary artery dilatation in pulmonary hypertension: two case reports. Pulm Circ. 2015;5(4):723-5. Reference #2: Park SH, Park SY, Kim NK, et al. Bronchial compression in an infant with isolated secundum atrial septal defect associated with severe pulmonary arterial hypertension. Korean J Pediatr. 2012;55(8):297-300. DISCLOSURES: No relevant relationships by Bindu Akkanti, source=Web Response No relevant relationships by Maryam Kaous, source=Web Response

Transcatheter and intraoperative device closure and surgical repair for atrial septal defect

BackgroundTranscatheter and intraoperative device closure for atrial septal defect (ASD) are widely applied to reduce the incision size and the potential for injury during cardiopulmonary bypass (CPB) in conventional surgical repair. No studies had been conducted to compare the safety and efficiency of these three treatments.MethodsFrom January 2018 to April 2018, 87 patients with an isolated ASD who had undergone transcatheter device closure (n = 45), intraoperative device closure (n = 22) and surgical repair (n = 20) were retrospectively reviewed and further analyzed to compare these three treatments.ResultsThe successful closure rate was similar in the three groups. There was a significant difference in aortic cross-clamping time, CPB duration and operative time between the surgical group and the device groups. The length of intensive care unit stay, postoperative mechanical ventilation time and length of hospital stay were shorter in the two device groups than in the surgical group. The incision was the most extended in the surgical group. Regarding major adverse events, no significant differences were found among the three groups.ConclusionsTranscatheter and intraoperative device closure and surgical repair for ASD are all safe and effective. Considering their respective disadvantages and advantages, the transcatheter approach may be the first choice for an isolated secundum ASD, the intraoperative approach may be the second choice, and surgical repair may be the last resort.

Long-Term Outcomes After Percutaneous Closure of Ostium Secundum Atrial Septal Defect in the Young: A Nationwide Cohort Study

ObjectivesThis study sought to assess procedural characteristics, early clinical outcome, and long-term complications after transcatheter closure of atrial septal defect (ASD) in children. BackgroundTranscatheter closure has become the preferred strategy in most cases of isolated secundum ASD. However, reported experience in the pediatric population is limited. MethodsA 1998 to 2016 retrospective multicenter study was performed in 9 French tertiary institutions. All children who had an attempt of percutaneous ASD closure with an Amplatzer Septal Occluder were included. ResultsIn 1,326 children (39% males; median age, 9 years [0.7 to 18]; weight, 29 kg [3.6 to 92]), transcatheter ASD closure was performed. Median ASD size was 15 mm (3 to 41); 254 (19.1%) patients had a large ASD (≥20 mm/m2). Procedural success rate was 95.3% (95% confidence interval: 93.9% to 96.3%). No death was observed but periprocedural complications occurred in 24 patients (1.8%). After a median follow-up of 3.5 years (range 6 months to 18 years; 173 patients [13%] followed >10 years), delayed major complications were minimal (n = 12; 1.04%) including no death and/or cardiac erosion. Periprocedural and delayed complications rates were significantly higher in children ≤15 kg (5.2% vs. 1.5%; p = 0.007 and 3.1% vs. 0.7%; p < 0.007, respectively) and those with large ASD (3.5% vs. 1.4%; p = 0.008 and 1.7% vs. 0.7%; p = 0.052, respectively). ConclusionsTranscatheter ASD closure using Amplatzer Septal Occluder is safe in children with a minimal rate of periprocedural complications and a favorable long-term outcome, especially with no death or cardiac erosion despite a substantial proportion of large defects. Children ≤15 kg and those with large ASDs had a greater risk of complications.

Long-term outcomes after percutaneous closure of isolated secundum atrial septal defect in the young: A nationwide cohort study

Transcatheter closure has become the preferred treatment strategy in most cases of secundum atrial septal defect (ASD). However, reported experience in the pediatric population is limited. To assess procedural characteristics, early clinical outcome and long-term device-related complications after transcatheter closure of ASD in children. A 1998–2014 retrospective multicenter study was performed in 9 French tertiary institutions. All children in whom a percutaneous ASD closure was attempted during the study period were included. In total, 1326 children (39% males, age: 9 years (0.7–18.0), weight: 29 kg [3.6–92]) were included. Median ASD size was 15 mm (3–41). Large ASDs ≥ 20 mm/m 2 were present in 254 (19%) patients. The procedure was performed under fluoroscopic guidance in all cases, assisted with TEE imaging in 856 cases (65%) and TTE in 470 cases (35%). Procedural success rate was 95.3%. Periprocedural complications occurred in 30 (2.2%) patients (including 15 device embolization but no death). After a median follow-up of 4 years (6 months–18 years), no death was observed. The rate of delayed complications 1.04% (95% confidence interval [0.5%–1.6%] including cardiac arrhythmias (n = 8), pulmonary hypertension ( n = 2) and transient ischemic attack (n = 2). No cardiac erosion nor endocarditis were reported. Periprocedural and delayed complications rates were significantly higher in children < 15 kg (6.2% vs 1.9%, P = 0.007; 3.1% vs 0.6%, P < 0.007, respectively) and those with large ASD (3.9% vs 1.8%, P = 0.008 and 1.9% vs 0.4%, P = 0.052, respectively). Our large-scale pediatric cohort confirms that transcatheter closure of isolated secundum ASDs is a safe procedure in children, with a favorable long-term outcome and no life-threatening delayed complication. Children ≤ 15 kg and those with large ASDs had an increased risk of both periprocedural and delayed complications.