Percutaneous device closure of atrial septal defect results in very early and sustained changes of right and left heart function

Abstract

Objectives

To investigate the echocardiographic effects of percutaneous closure of secundum atrial septal defect (ASD) in adults and assess which pre-closure parameters predict good response to closure.

Background

ASD is a common congenital heart disease often undiscovered until adulthood. ASD closure has been revolutionized by the use of percutaneous devices. The effects of these procedures on echocardiographic parameters are not well characterized.

Methods

Patients undergoing percutaneous device closure of ASD between June 2007 and June 2009 had 3 sequential echocardiograms reviewed: pre-procedure, immediate post-procedure (24 hours) and 6–8 weeks post-procedure. Significant changes from baseline were investigated using paired t-test/1-way ANOVA. Pearson correlation (2-tailed) tests were used to categorize patients as ‘good responders’ to closure in terms of selected parameters.

Results

129 echocardiograms in 43 consecutive patients were included. Remodeling of both ventricles occurred immediately following ASD closure and was sustained. Right ventricular (RV) diameter in diastole decreased by 13.5% and 19.3% compared to baseline at 24 hours and 6–8 weeks post‐closure, respectively (p < 0.05); Left ventricular (LV) diameter in diastole increased by 8.5% and 15.6%, respectively (p < 0.05). Functional parameters of the RV also demonstrated early and sustained decreases (TAPSE decreased by 8.3% and 17% compared to baseline at 24 hours and 6–8 weeks post‐closure, respectively (p < 0.05)). Smaller RV baseline diameter appeared to predict good response to closure.

Conclusions

Percutaneous ASD closure has immediate, sustained benefits on multiple echocardiographic parameters. Good responders have smaller RV at baseline, suggesting early closure is preferable.

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.