Clare O’Donnell

Transcatheter Closure of Secundum Atrial Septal Defects with the Amplatzer Septal Occluder in Adults and Children—Follow-up Closure Rates, Degree of Mitral Regurgitation and Evolution of Arrhythmias

AIM To report the results of transcatheter atrial septal defect (ASD) closure with the Amplatzer septal occluder (ASO) from the single centre providing interventions for congenital heart disease in New Zealand. METHODS A single centre retrospective review of all patients 1997-2004 inclusive, undergoing planned transcatheter ASD closure was undertaken. Implantation success, complications and latest patient follow-up are described. RESULTS Percutaneous ASD closure was planned in 227 adults and children. (55% had additional medical co-morbidities.) The mean ASD size was 22+/-6 mm, and device size ranged from 5 to 40 mm. Closure was successful in 93%, unsuccessful in 5% and not attempted in 2%. There were two device embolisations, one immediately post-release and one within 24h. Minor procedural complications occurred in 5% of patients. There were no cases of suspected or proven device erosion. Ninety-two percent had documented follow-up beyond 6 months. At latest follow-up the closure rate was 98.5%. There was no significant change in the degree of mitral regurgitation. Sixteen of 24 with pre-closure arrhythmias resolved while 10 remained in atrial fibrillation. Six patients developed new arrhythmias but these were well controlled medically. CONCLUSION There is a high implantation and closure rate using transcatheter ASD closure with the Amplatzer septal occluder in children and adults avoiding the need for cardiac surgery. Follow-up at one year shows there is no progression of mitral regurgitation, and supraventricular arrhythmias have usually resolved.

Valvular Regurgitation Using Portable Echocardiography in a Healthy Student Population: Implications for Rheumatic Heart Disease Screening

BACKGROUND There is increasing use of portable echocardiography as a screening test for rheumatic heart disease (RHD). The prevalence of valvular regurgitation in healthy populations as determined using portable echocardiography has not been well defined. Minimal echocardiographic criteria for RHD have recently been clarified, but the overlap of normal and abnormal valvular regurgitation warrants further study. The aim of this study was to determine the spectrum of echocardiographic findings using portable echocardiography in children from a population with low prevalence of RHD. METHODS Screening echocardiography was conducted in 396 healthy students aged 10 to 12 years using portable echocardiographic equipment. Echocardiograms were assessed according to 2012 World Heart Federation criteria for RHD. The prevalence of physiologic valvular regurgitation was compared with that found in previous studies of children using large-platform machines. RESULTS Physiologic mitral regurgitation (MR) was present in 14.9% of subjects (95% CI, 11.7%-18.7%) and pathologic MR in 1.3% (95% CI, 0.6%-2.9%). Two percent (95% CI, 1.0%-3.9%) had physiologic aortic regurgitation, and none had pathologic aortic valve regurgitation. Physiologic tricuspid regurgitation was present in 72.7% of subjects (95% CI, 68.1%-76.9%) and physiologic pulmonary regurgitation in 89.6% (95% CI, 85.7%-91.8%). After cardiology review, no cases of definite RHD were found, but 0.5% of patients (95% CI, 0.1%-1.8%) had pathologic MR meeting World Heart Federation criteria for borderline RHD. Two percent (95% CI, 1.4%-4.6%) of the cohort had minor forms of congenital heart disease. CONCLUSIONS The spectrum of physiologic cardiac valvular regurgitation in healthy children as determined using portable echocardiography is described and is within the range of previous studies using large-platform echocardiographic equipment. The finding of two children with pathologic-grade MR, likely representing the upper limit of physiologic regurgitation, has implications for echocardiographic screening for RHD in high-prevalence regions.

Progressive Pulmonary Hypertension Post Atrial Septal Defect Device Closure—Early Symptomatic Improvement may not Predict Outcome

BACKGROUND For patients with an atrial septal defect and pulmonary hypertension it can be difficult to determine whether it is safe to intervene. With newer treatments for pulmonary hypertension and transcatheter techniques avoiding surgical stressors, it has been hoped that we can occlude previously inoperable defects safely. METHODS We undertook a subgroup analysis of outcomes for patients with mean pulmonary artery pressure (PAp) ≥30mmHg from within our database of patients undergoing transcatheter ASD closure from 1997 to 2004. RESULTS Data for 11 patients were reviewed. Mean age of the patients at intervention was 38 years (5-69 years). Eight patients have had symptomatic improvement with no evidence of progressive pulmonary hypertension. There was one death due to unrelated causes. Two patients have developed progressive pulmonary vascular disease with one death. CONCLUSIONS Despite early symptomatic improvement, adverse outcomes may occur in patients with elevated pulmonary vascular resistance undergoing transcatheter ASD closure. Careful haemodynamic evaluation is vital. Modest elevation of pulmonary vascular resistance and the presence of left to right shunt (Qp:Qs>1.5:1) are reassuring.

Transcatheter closure of secundum atrial septal defects: has fear of device erosion altered outcomes?

BACKGROUND Transcatheter device closure has become the established standard of care for suitable atrial septal defects. Device erosion has been a recent focus and has prompted changes in the Instructions for Users documentation released by device companies. We reviewed our entire local experience with atrial septal defect device closure, focussing on the evolution of this procedure in our centre and particularly on complications. METHODS We carried out a retrospective review of 581 consecutive patients undergoing attempted transcatheter device closure of an atrial septal defect in Auckland from December 1997 to June 2014. We reviewed all complications recorded and compared our outcomes with the current literature. We sought to understand the impact of the evolution in recommendations and clinical practice on patient outcomes in our programme. RESULTS There were a total of 24 complications (4.1%), including 10 device embolisations (1.7%), nine arrhythmias (1.5%), two significant vascular access-related complications (0.3%), one device erosion (0.2%), one malposed device (0.2%), and one probable wire perforation of the left atrial appendage (0.2%). There was one mortality related to device embolisation. All device embolisations occurred following the change in Instructions for Users after publication of the first device erosion report in 2004. This increase in embolisation rate was statistically significant (p-value 0.015). CONCLUSIONS In our series, the incidence of device embolisation was higher than that anticipated, with a significant increase following changes to the Instructions for Users. This highlights the need for ongoing data collection on complication incidence and for ongoing review of the impact of changes in clinical practice on complication rates.

Hybrid Procedure for Acute Severe Aortic Regurgitation in an Uncorrected Adult Tetralogy of Fallot

Adult survivors of surgically uncorrected complex tetralogy of Fallot [TOF] with multiple aorto-pulmonary coronary arteries [MAPCAs] are unusual and the development of severe aortic regurgitation [AR] due to endocarditis is a rare and difficult problem to manage. We report a successful hybrid approach utilising temporary balloon occlusion of the collaterals during the cross-clamp time as a strategy to allow adequate brain perfusion and safe aortic root replacement.

Adult Congenital Heart Disease in Australia and New Zealand A Call for Optimal Care

BACKGROUND Adult congenital heart disease (ACHD) is a relatively new subspecialty in the cardiology field. The prevalence of ACHD is estimated at ∼ 3,000 per million adult population. The ACHD patient group is estimated to grow at ∼ 5% per year and in the next decade it is forecast that 1 in 150 young adults will carry some form of ACHD diagnosis. These estimates translate to ∼ 72,000 ACHD patients in Australia and ∼ 14,000 in New Zealand, although no current numbers are available. The Cardiac Society of Australia and New Zealand (CSANZ) has recently published Recommendations for Standards of Care for Adult Congenital Heart Disease (ACHD) in 2016. There is currently no long-term plan or proposal to address this huge health care burden within the federal government. This document details the size of the problem insofar as it is known and recommends solutions to be implemented. METHODS This document was developed by the Adult Congenital Heart Disease Working Group of the Paediatric and Congenital Council (the Congenital Heart Alliance of Australia and New Zealand) as a response to the chronic under resourcing in this area, the risk this poses to patients and clinicians, and the clear need for long-term planning to develop safe care pathways. RESULTS These issues were raised with the CSANZ Board in December 2015 and the document was developed in response to the Boards request for more information. The current iteration was finalised on 14 November 2017. CONCLUSIONS The authorship group comprised participants in the CSANZ adult CHD standards of care recommendations from 2013 with the inclusion of some newly trained ACHD cardiologists, who represented most states and territories across ANZ. None of the authors has any academic or professional conflict of interest.

Multiple atrial thrombi in a neonate presenting with supraventricular tachycardia

Case report A 21-day-old female term neonate presented to a regional hospital in New Zealand with a 2-day history of poor feeding and jaundice. Antenatal period was unremarkable, including no history of fetal tachycardia. At presentation, tachycardia was noted and a 12-lead electrocardiogram confirmed SVT at a rate of 240 beats per minute (Figure 1). Cold water immersions and adenosine boluses of up to 300 mcg/kg produced a transient response; however, SVT persisted. An intravenous amiodarone infusion was started and the baby was air-transferred to our pediatric intensive care unit. The rhythm was still SVT at a rate of 240 beats per minute on arrival; therefore, oral digoxin was added at 5 mcg/kg daily (half standard dose). A focused echocardiogram on arrival demonstrated severe biventricular dysfunction (ejection fraction 23%, fractional shortening 17%). Eight hours after arrival, the rhythm reverted to sinus rhythm. There was no pre-excitation on the 12-lead electrocardiogram (Figure 1). A complete echocardiogram to reassess ventricular function and exclude structural heart disease was performed on day 3 of admission in the pediatric intensive care unit and revealed mobile hyperechoic masses