Persistent Atrial Septal Defect Research Articles

Abstract 16093: Hemodynamic Implications of Transseptal Access for Ventricular Tachycardia Ablation in Patients With Left Ventricular Assist Devices

Introduction: Ventricular tachycardia (VT) is common in patients with left ventricular assist devices (LVAD), and catheter ablation can be an effective treatment strategy. Although transseptal approach for LV mapping and ablation is often preferred, iatrogenic atrial septal defect (ASD) after transseptal access may theoretically result in clinically significant right-to-left shunting. The short- and long-term implications of transseptal puncture, including hemodynamic changes in LVAD patients, remain uncertain. Methods and Results: From 2013-2023, 15 LVAD patients (age 68.5±12 years; 2 women) underwent 18 VT ablation procedures with single transseptal access for LV ablation without ASD closure afterwards. Clinical VT was eliminated in 83%. No patients had prior PFO/ASD; Mean RVSP was 45mmHg, 6 (40%) had pulmonary hypertension, and 8 (53.3%) had moderate or severe RV dysfunction. All patients had previously failed at least 1 antiarrhythmic drug (amiodarone 100%; sotalol 33%; mexiletine 94%). Procedural complications occurred in 3 procedures (all related to vascular access, none directly related to transseptal access; 1 patient with interrupted IVC requiring transhepatic access had bleeding due to transection of intercostal artery requiring arterial embolization). Post-procedure echocardiograms (n=14; mean time to echo 90±116 days) showed no intra-cardiac shunting or persistent ASD. Right heart catheterization (pre: n=12; post: n=8, at mean follow-up 187±243 days) showed similar pre- and post-ablation RA pressures (11.6 vs 14.9 mmHg, p =0.24) and wedge pressures (14.9 vs 20.4 mmHg, p =0.8) with absence of significant shunting based on pre- and post-ablation arterial (95.2% vs 97.7%, p =0.06) and PA oxygen saturations (56.5% vs 51.3%, p =0.29). No episodes of clinically significant hypoxia occurred after ablation. Conclusion: Transseptal access for VT ablation can be safely performed in LVAD patients and is unlikely to result in clinically or hemodynamically significant residual shunting over long-term follow-up. Therefore, empiric ASD closure after transseptal access in all LVAD patients is likely unnecessary.

TCT-554 Comparison of Transcatheter and Surgical Repair of Atrial Septal Defect: Analysis from Nationwide Inpatient Sample

Atrial septal defect (ASD) belongs to one of the most common congenital cardiac lesion. ASD repair is definitive treatment preventing major complications of persistent ASD. Alongside standard open surgical ASD repair (OSR), transcatheter/closed procedure (TCP) is an attractive modality applied in

Invited Commentary

Invited Commentary

Percutaneous left atrial decompression in patients supported with extracorporeal membrane oxygenation for cardiac disease.

Left atrial decompression using cardiac catheterization techniques has been described at centers with extracorporeal membrane oxygenation programs. Left atrial decompression can decrease cardiogenic edema, minimize ventricular distension, and allow myocardial recovery. We describe Boston Children's Hospital's experience with percutaneous left atrial decompression techniques, acute outcomes, and clinical impact of left atrial decompression in extracorporeal membrane oxygenation patients. Patients supported with extracorporeal membrane oxygenation undergoing percutaneous left atrial decompression were identified and assigned to two groups 1) myocarditis/suspected myocarditis or 2) nonmyocarditis cardiac disease. Three techniques including vent placement, static balloon dilation, and stent implantation were used. Change in left atrial pressure and severity of pulmonary edema on chest radiography pre and post procedure, impact of timing and technique of left atrial decompression on resolution of left atrial hypertension, and extracorporeal membrane oxygenation survival were evaluated. Furthermore, we evaluated the presence of residual atrial septal defect during follow-up. Percutaneous left atrial decompression was performed in 44 of 419 extracorporeal membrane oxygenation cases (10.5%) and was frequently used for myocarditis (22 of 44 patients; 50%). Techniques included 25 vents, 17 static balloon dilations, and two stents. All techniques were equally successful and significantly reduced left atrial pressure and pulmonary edema. Survival to hospital discharge was not associated with extracorporeal membrane oxygenation duration prior to left atrial decompression, change in left atrial pressure, or technique used. Persistent atrial septal defect was noted in five surviving patients (excluding transplant recipients and deceased), two required closure. Left atrial decompression can be performed effectively in children on extracorporeal membrane oxygenation using various percutaneous techniques. Reduction in pulmonary venous congestion is usually evident by chest radiography within 48 hours of intervention. Persistent atrial septal defect may require closure at the time of extracorporeal membrane oxygenation decannulation or during long-term follow-up.

Atrial septal defect after percutaneous mitral balloon valvuloplasty: Immediate results and follow-up

Percutaneous mitral balloon valvuloplasty was performed in 150 patients. There were 124 women and 26 men (mean age 53 +/- 1 years). A left to right shunt through the created atrial communication was present in 28 patients (19%) after valvuloplasty. The pulmonary to systemic flow ratio was greater than or equal to 2:1 in 4 patients and less than 2:1 in 24. Univariate predictors of left to right shunting after valvuloplasty included older age (p less than 0.01), lower cardiac output before mitral valvuloplasty (p less than 0.01), higher New York Heart Association functional class before valvuloplasty (p less than 0.05), presence of mitral valve calcification under fluoroscopy (p less than 0.01) and higher echocardiographic score (p less than 0.05). Multiple stepwise logistic regression analysis identified the presence of mitral valve calcification (p less than 0.02) and lower cardiac output (p less than 0.02) as the independent predictors of a left to right shunt through the atrial communication after balloon valvuloplasty. Follow-up (10 +/- 1 months) of patients with an atrial septal defect after valvuloplasty showed that 1) 6 patients died (3 in the hospital and 3 at 2, 16 and 18 months, respectively, after valvuloplasty); 2) an atrial septal defect was demonstrated in 3 of 6 patients who underwent mitral valve replacement (6 +/- 0.8 months after valvuloplasty); and 3) 13 patients were in functional class I, 2 patients were in class II and 1 patient was in class III at 13 +/- 1 months after valvuloplasty.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical implications of atrial septal defect complicating aortic balloon valvuloplasty

An 80-year-old man underwent percutaneous transluminal balloon valvuloplasty for critical aortic stenosis. The procedure was performed by the antegrade atrial transseptal approach and was complicated by a persistent atrial septal defect. Symptoms recurred 6 months later, restenosis of the aortic valve was confirmed, and the atrial septal defect yielded a substantially greater left-to-right shunt. This complication of percutaneous transluminal balloon valvuloplasty poses important problems in hemodynamic assesment and operative management of patients who undergo subsequent aortic valve replacement.