Percutaneous device closure of atrial septal defect results in very early and sustained changes of right and left heart function☆
Introduction
Atrial septal defects (ASD) are the commonest form of congenital heart disease diagnosed in adults, accounting overall for around 10% of all congenital heart defects [1]. The diagnosis and management of ASD in both paediatric and adult populations have benefited greatly from major advances over the last 10–15 years [2], including 3 dimensional and intracardiac echocardiography, as well as percutaneous device closure. Despite these advances, ASDs remain “the most underdiagnosed congenital heart disease in the adult age group”, with age at diagnosis being clearly linked to subsequent complications including the late development of pulmonary hypertension and atrial dysrhythmias [2]. While many patients with ostium secundum ASDs may be initially free from overt symptoms, many become symptomatic later in life due to chronic volume overload of the right heart. Common presenting symptoms include effort dyspnoea, fatigue, or palpitations/dysrhythmia (usually due to age-related chronic atrial stretch predisposing the patient to electrophysiological remodeling and either atrial flutter or fibrillation) [3], [4]. While surgical repair has excellent results in both the medium and long terms [5], percutaneous device closure has become the preferred method in the management of the majority of secundum ASDs, obviating the need for major cardiac surgery [6], [7]. The beneficial effect of this intervention on quality of life is accepted [8]. Percutaneous closures are not associated with impaired post-procedural systolic or diastolic cardiac dysfunction, unlike surgical ASD closures [9]. Currently, ostium primum and sinus venosus type ASDs continue to require full cardiothoracic surgical approaches for their definitive management, as do a proportion of secundum type defects which are anatomically unsuitable for device closure [10]. In experienced hands, percutaneous ASD closure is both safe (major complication rate less than 1%), clinically effective (greater than 95% success rate) and cost effective [11], [12], [13]. It can be expected that ASD closure would lead to reduced right heart volumes due to removal of left-to-right shunting. Indeed, previous authors have demonstrated that this does occur [14], [15], [16], [17], [18], [19]. Whether this improves right ventricular (RV) performance [18] or simply prevents further deterioration [20] remains controversial. In addition, the effects of ASD closure on the atria and left side of the heart are poorly characterized. We set out to study the very early effects of percutaneous ASD closure on both the right and left sides of the heart and hypothesized that early cardiac remodeling would be represented by improvement in a variety of echocardiographic parameters of right and left heart functions that have not been previously studied. We also investigated which pre‐procedural echocardiographic parameters may predict improved RV function following closure of the defect.
Section snippets
Methods
Transthoracic echocardiograms of 43 consecutive patients undergoing percutaneous closure of atrial septal defect at our institution over a 2-year period spanning June 2007 to June 2009 were retrospectively studied. Procedures were performed under general anaesthesia with transoesphageal echocardiographic and fluoroscopic guidance. The Amplatzer Septal Occluder (ASO – AGA Medical Corporation, Golden Valley, Minnesota, USA) was used in all cases. For study purposes, a series of 3 transthoracic
Results
A total of 43 patients were included in the trial, each of whom underwent 3 serial transthoracic echocardiograms according to the defined schedule above, giving a total of 129 echocardiograms for analysis. Demographic data of the enrolled patients is given in Table 1. Table 2 illustrates in detail the mean results from study group of patients.
The RV demonstrated a variety of changes in response to percutaneous ASD closure. There was a statistically significant decrease in RV diameter both
Discussion
We have undertaken a thorough evaluation of the echocardiographic effects of percutaneous ASD closure on both the left and right sides of the heart in the immediate post‐procedural period. It is clear from the results that the procedure has potentially multiple beneficial effects on cardiac anatomy and physiology as demonstrated by transthoracic echocardiography, crucially some of which appear as early as the first post-procedural day.
RV remodeling begins within 24 hours and continues at 6–8
Study Limitations
Though we employed a wide variety of echocardiographic techniques, it may be that we would have obtained a more thorough evaluation of the effects of percutaneous ASD closure on the heart if we had included further techniques such as 3D echo, speckle tracking and strain assessment. We did not have a control group to define whether or not changes occurring following percutaneous closure lead to ‘normalization’ of anatomical parameters.
Conclusion
Percutaneous ASD closure leads to very early and sustained changes in cardiac anatomy and function involving both sides of the heart. Smaller baseline RV dimensions appear to predict better RV parameters outcomes, suggesting earlier closure may be of benefit. Further studies are required to define which patients respond optimally to percutaneous ASD closure, so that such patients may receive earlier intervention and better RV outcomes.
Acknowledgement
The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology.
References (36)
- et al.
Prevalence of congenital heart disease
Am Heart J
(2004) - et al.
Comparison between transcatheter and surgical closure of secundum atrial septal defect in children and adults: results of a multicenter nonrandomized trial
J Am Coll Cardiol
(2002) - et al.
Repaired and open atrial septal defects type II in adulthood: an epidemiological study of a large European cohort
Int J Cardiol
(2008) - et al.
Surgical versus percutaneous occlusion of ostium secundum atrial septal defects: results and cost-effective considerations in a low-income country
J Am Coll Cardiol
(2006) - et al.
Right ventricular form and function after percutaneous atrial septal defect device closure
J Am Coll Cardiol
(2001) - et al.
Resolution of right heart enlargement after closure of secundum atrial septal defect with transcatheter technique
J Am Coll Cardiol
(2001) - et al.
Effect on right ventricular volume of percutaneous Amplatzer closure of atrial septal defect in adults
Am J Cardiol
(2005) - et al.
Improvements in cardiac form and function after transcatheter closure of secundum atrial septal defects
J Am Coll Cardiol
(2005) - et al.
Evidence of adverse ventricular interdependence in patients with atrial septal defects
Am J Cardiol
(2004) - et al.
Usefulness of the myocardial performance index for assessing right ventricular function in congenital heart disease
Am J Cardiol
(2000)
Percutaneous closure of atrial septal defects leads to normalisation of atrial and ventricular volumes
J Cardiovasc Magn Reson
Abnormalities of left ventricular function and geometry in adults with an atrial septal defect. Ventriculographic, hemodynamic and echocardiographic studies
Am J Cardiol
Speed of normalization of right ventricular volume overload after transcatheter closure of atrial septal defect in children and adults
Am J Cardiol
Closure of atrial septal defect in the adult. Cardiac remodeling is an early event
Int J Cardiol
Early electrical and geometric changes after percutaneous closure of large atrial septal defect
Am J Cardiol
Analysis of right ventricular Doppler tissue imaging and load dependence in patients undergoing percutaneous closure of atrial septal defect
Am J Cardiol
Atrial septal defect: waiting for symptoms remains an unsolved medical anachronism
Eur Heart J
Left atrial remodelling in patients with atrial septal defects
Heart Rhythm
Cited by (26)
Long-term Outcomes of Adults With Tricuspid Regurgitation Following Transcatheter Atrial Septal Defect Closure
2022, Canadian Journal of CardiologyEvolution of blood biomarker levels following percutaneous atrial septal defect closure in adults
2020, IJC Heart and VasculatureCitation Excerpt :However, some of the patients that undergo ASD closure at adult age, still develop PAH [6]. ASD closure can lead to reverse cardiac remodeling, including improvement in left ventricular (LV) function and decreases in right ventricular dimensions and pressures [7], accompanied by an improvement in exercise capacity [8] and NYHA class [9]. However, in older patients, LV diastolic dysfunction may cause development of acute congestive left heart failure following ASD closure as a result of the sudden flow increase [10].
Electrical remodeling after percutaneous atrial septal defect closure in pediatric and adult patients
2019, International Journal of CardiologyCitation Excerpt :3) VG magnitude increased at intermediate follow-up in children and at late follow-up in adults, after an initial decrease in children; the VG direction change was most apparent in the less negative azimuth at intermediate follow-up in both groups; and VG elevation directly decreased in the adult group but did not change during follow-up in the pediatric group. Right-sided volume overload due to atrial left-to-right shunting leads to both atrial and ventricular stretch which may cause changes in the 12‑lead ECG [4,17] due to mechano-electrical coupling. RA dilatation, for example, may result in increased P-wave amplitude as well as prolonged P-wave duration and increased P-wave dispersion due to delayed atrial conduction, which are all useful markers in the prediction of atrial arrhythmias [3,12].
Successful perventricular device closure of cardiac diverticulum in an infant
2014, International Journal of CardiologyNoticeable signs of atrial septal defect: Dysphagia and headache
2014, International Journal of CardiologyAtrial septal defects
2014, The LancetCitation Excerpt :Echocardiographic indices of right ventricular function before and after defect closure have shown mixed results with some measures showing an improvement from before to after closure, whereas others show either no change or a decrease.120,123,124 Left ventricular filling improves in children and young adults.120 However, in adults with pre-existing decreased left ventricular compliance, the acute increase in preload associated with defect closure can lead to worsening left atrial and pulmonary venous hypertension and heart failure symptoms.125
- ☆
Sources of Funding: OM is funded by a charitable grant from the British Cardiovascular Society and Bristol-Myers-Squibb. There are no relationships with industry pertinent to this work.