Teiji Akagi

Transcatheter closure of atrial septal defect in a geriatric population

Objectives: To evaluate the efficacy and safety of transcatheter closure of atrial septal defects (ASD) in patients over 70 years of age. Background: Transcatheter closure of ASD is an established procedure in children and young adults, but the benefits of this procedure in geriatric patients are still unclear. Methods: Between 2005 and 2010, 430 patients with ASD underwent transcatheter closure in our hospital. Among those patients, 30 consecutive patients older than 70 years of age were prospectively evaluated. Results: Mean age at procedure was 75.8 ± 3.8 years (range: 70–85 years). Mean Qp/Qs was 2.4 ± 0.7 and mean ASD diameter was 20.3 ± 6.4 mm. Nine patients (30%) had a history of hospitalization due to heart failure. ASD closure was successfully performed in 28 patients (93%) without significant complications. During the follow‐up period (mean period of 19.1 ± 11.3 months), New York Heart Association (NYHA) functional class was significantly improved in 20 patients (74%). Significant improvements of plasma BNP level, resting heart rate, and systolic pulmonary artery pressure were also observed. Improvement of tricuspid regurgitation was observed in 11 of 17 patients with moderate or severe regurgitation during the follow‐up period. Conversely, worsening of mitral regurgitation was observed in 10 of the 27 patients. Conclusion: Transcatheter closure of ASD in geriatric patients can be performed safely. This procedure contributes to significant improvement of symptoms and positive cardiac remodeling. Long‐term follow‐up is mandatory, especially for patients with mitral regurgitation.

Catheter intervention for adult patients with congenital heart disease

Adult congenital heart disease is one of the most important clinical issues not only for pediatric cardiologists but also adult cardiologists. After the introduction of catheter intervention for atrial septal defect in the pediatric population, therapeutic advantages of this less invasive procedure now focused on even geriatric patients. The most valuable clinical benefit of this procedure is the significant improvement in symptoms and daily activities, which result from the closure of left to right shunt without thoracotomy or cardiopulmonary bypass surgery. Although currently available therapeutic options for device closure for congenital heart disease in Japan are limited to atrial septal defect, patent ductus arteriosus, or some vascular abnormalities such as coronary arteriovenous fistula, various new techniques or devices such as ventricular septal defect device, pulmonary valve implantation, are going to be introduced in the near future. To perform safely and achieve good procedure success, real time imaging plays an important role in interventional procedures. Real time three-dimensional transesophageal echocardiography can provide high quality imaging for anatomical evaluation including defect size, surrounding rim morphology, and the relationship between device and septal rim. In adult patients, optimal management of comorbidities is an important issue, including cardiac function, arrhythmias, pulmonary function, and renal function. In particular, atrial arrhythmias are key issues for long-term outcome. Because the interventional procedures are not complication-free techniques, the establishment of a surgical back-up system is essential for achieving a safe procedure. Finally, the establishment of a team approach including pediatric and adult cardiologists, cardiac surgeons, and anesthesiologists is the most important factor for a good therapeutic outcome. Their roles include pre-interventional hemodynamic evaluation, good imaging technique for anatomical evaluation, management of comorbidities, and surgical back up.

Current concept of transcatheter closure of atrial septal defect in adults

After the introduction of catheter intervention for atrial septal defect (ASD) in the pediatric population, therapeutic advantages of this less invasive procedure were focused on adult through geriatric populations. The most valuable clinical benefits of this procedure are the significant improvement of symptoms and daily activities, which result from the closure of left to right shunt without thoracotomy and cardiopulmonary bypass surgery. These benefits contribute to increase the number of adult patients of this condition who have hesitated over surgical closure. In terms of technical point of view for catheter closure of ASD, the difficulties still exist in some morphological features of defect, or hemodynamic features in the adult population. Morphological features of difficult ASD closure are (1) large (≥30 mm) ASD, (2) wide rim deficiency, and (3) multiple defects. Hemodynamic features of difficult ASD are (1) severe pulmonary hypertension, (2) ventricular dysfunction, and (3) restrictive left ventricular compliance (diastolic dysfunction) after ASD closure. To complete the catheter ASD closure under these difficult conditions, various procedural techniques have been introduced. These are new imaging modalities such as real-time three-dimensional imaging, new technical modifications, and new concepts for hemodynamic evaluation. Especially, real-time three-dimensional transesophageal echocardiography can provide the high quality imaging for anatomical evaluation including maximum defect size, surrounding rim morphology, and the relationship between device and septal rim. In adult patients, optimal management for their comorbidities is an important issue, which includes cardiac function, atrial arrhythmias, respiratory function, and renal function. Management of atrial arrhythmias is a key issue for the long-term outcome in adult patients. Because the interventional procedures are not complication-free techniques, the establishment of a surgical back-up system is essential for the safe achievement of the procedure. Finally, the establishment of a team approach including pediatric and adult cardiologists, cardiac surgeons, and anesthesiologists is the most important factor for a good therapeutic outcome.

Transcatheter closure of right-to-left atrial shunt in patients with platypnea-orthodeoxia syndrome associated with aortic elongation

Platypnea-orthodeoxia is a rare condition characterized by dyspnea and oxygen desaturation induced by the upright position and relieved by recumbency. The most common cause of this syndrome is right-to-left shunt through interatrial communications such as patent foramen ovale (PFO) or atrial septal defect (ASD). In addition, this syndrome can be caused by other extracardiac components, including pulmonary emphysema, pericardial disease, and prominent Eustachian valve. We experienced 3 cases of this syndrome, including 1 patient with PFO and 2 patients with ASD. Computer tomography imaging revealed aortic elongation and compression of the right atrium by ascending aorta in all of 3 patients. Transcatheter closure of PFO or ASD was successfully performed in all patients, including immediate improvements of symptoms and oxygen saturation without any complications.

Cardiac erosion after catheter closure of atrial septal defect: Septal malalignment may be a novel risk factor for erosion

Pericardial tamponade occurred 3 days after the catheter closure of an atrial septal defect (ASD) using Amplatzer Septal Occluder (St. Jude Medical, St. Paul, MN, USA). Before the closure, two-dimensional and real-time three-dimensional transesophageal echocardiography demonstrated a deficient aortic rim and atrial septal malalignment. Perforation of the right atrium toward the non-coronary sinus of the aortic root was confirmed at the emergent surgery. Cardiac erosion is one of the most catastrophic complications in ASD patients undergoing catheter closure with Amplatzer Septal Occluder. Hence, several risk factors for this complication are discussed and identified. Oversized device deployment and a deficient aortic rim are accepted factors potentially causing cardiac erosion. Besides, atrial septal malalignment, which is a morphological characteristic of ASD, may be a novel risk factor for cardiac erosion. <Learning objective: Cardiac erosion is a potentially lethal complication when catheter closure of atrial septal defects using Amplatzer Septal Occluder (St. Jude Medical, St. Paul, MN, USA) is provided to the patients. However, mechanisms of this complication remain to be completely elucidated. Atrial septal malalignment may be one of the novel risk factors for this catastrophic complication.>.

Comprehensive assessment of morphology and severity of atrial septal defects in adults by CT

BACKGROUNDnCardiac CT is an excellent tool for evaluating the anatomy of a secundum atrial septal defect (ASD). However, a comprehensive assessment of its usefulness, including measurement of the pulmonary to systemic blood flow ratio in secundum ASD patients, has not been performed.nnnOBJECTIVEnTherefore, this study was designed to evaluate the usefulness of CT for assessing the hemodynamics of secundum ASD in adults compared with transesophageal echocardiography (TEE), transthoracic echocardiography, and invasive catheterization.nnnMETHODSnFifty adult patients with secundum ASD were enrolled. Cardiac CT scans (128-slice multidetector CT instrument) were acquired. These were followed by 2-dimensional reconstruction of the secundum ASDs to determine the defect size, the rim length between the outer edge of the defect, and the pulmonary to systemic blood flow (Qp/Qs) ratio.nnnRESULTSnThe maximum sizes of the secundum ASDs derived from CT and TEE studies were comparable (21.2 ± 8.0 vs. 20.0 ± 7.3 mm; P = .41; r = 0.960; P < .001). The rim lengths for the aortic, mitral, and tricuspid valves; the inferior vena cava; and posterior atrium were also comparable between CT and TEE measurements. The mean Qp/Qs ratio that was derived from CT measurements was comparable with that found by invasive catheterization (2.3 ± 0.7 vs. 2.3 ± 0.8; P = .73; r = 0.786; P < .001).nnnCONCLUSIONnCardiac CT is feasible for assessing pathology and the severity of secundum ASD in adults.

Functional Tricuspid Regurgitation After Transcatheter Closure of Atrial Septal Defect in Adult Patients: Long-Term Follow-Up

OBJECTIVESnThis study aimed to assess the fate of tricuspid regurgitation (TR) after transcatheter atrial septal defect (ASD) closure.nnnBACKGROUNDnAlthough TR frequently occurs in patients with ASD, the change in TR during long-term follow-up after ASD closure remains unknown.nnnMETHODSnA total of 419 adult patients who underwent transcatheter ASD closure were enrolled. TR severity was graded by TR jet area on echocardiography.nnnRESULTSnAt baseline, 113 patients had severe/moderate TR and 306 patients had mild TR. Among the 113 patients with severe/moderate TR, the TR jet area significantly decreased during a median follow-up of 30 months after the procedure; this decrease was related to the improvement in right ventricular morphology. The severity of TR decreased to mild in 79xa0(70%) patients. Persistent TR, defined as severe or moderate TR after the procedure, was independently associated with the prevalence of permanent atrial fibrillation. Regarding clinical outcomes, 7 patients with severe/moderate TR andxa02 with mild TR were hospitalized because of heart failure. Patients with severe/moderate TR had the worse event-free survival rate than those with mild TR, but more than 90% of them had no cardiovascular events. Newxa0Yorkxa0Heart Association functional class and plasma B-type natriuretic peptide levels improved in patients with severe/moderate TR, similar to those with mild TR.nnnCONCLUSIONSnSignificant TR decreased during the long-term follow-up period after transcatheter ASD closure. Heartxa0failure symptoms improved in patients with severe/moderate TR. Our findings suggest that transcatheter closurexa0alone can be valuable in patients with ASD complicated with TR.

Deficient Surrounding Rims in Patients Undergoing Transcatheter Atrial Septal Defect Closure

BACKGROUNDnThe influence of deficient rims surrounding atrial septal defects (ASDs) in patients undergoing transcatheter closure has yet to be clarified. The aim of this study was to assess the influence of a deficient surrounding rim on the procedural success and clinical outcome of transcatheter ASD closure using an Amplatzerxa0septal occluder.nnnMETHODSnA total of 474 patients (mean age, 46xa0±xa022xa0years) with ostium secundum ASDs measuring ≤40xa0mm in diameter who had undergone attempted transcatheter closure using Amplatzer septal occluders from September 2007 to August 2013 were assessed. A comprehensive transesophageal echocardiographic examinationxa0was done to assess the morphologic characteristics of the defects in all patients. Subjects were classified into three groups by the extent and location of rim deficiency (<5xa0mm): patients without deficientxa0rims (sufficient group, nxa0=xa0101), patients with single deficient rims, (single group, nxa0=xa0338), and patients with multiple rim deficiencies (multiple group, nxa0=xa035).nnnRESULTSnThere was a significant difference in the maximal defect diameter among the sufficient, single, and multiple groups (15xa0±xa06, 18xa0±xa06, and 29xa0±xa07xa0mm, respectively, Pxa0<xa0.001). Transcatheter closure was successfully accomplished in 463 patients (98%). The prevalence of procedural success differed significantly among the sufficient, single, and multiple groups (100%, 98%, and 86%, respectively, Pxa0<xa0.001). There was no significant difference in the occurrence of cardiovascular events among the three groups during a mean follow-up period of 25xa0±xa019xa0months (Pxa0=xa0.926, log-rank test).nnnCONCLUSIONSnIn patients with ASDs with multiple rim deficiencies as determined by transesophageal echocardiography, successful transcatheter ASD closure using Amplatzer septal occluders is more difficult to accomplish. However, if closure is successful, rim deficiencies rarely affect intermediate-term outcomes.

Integrated 3D Echo-X-Ray Navigation Guided Transcatheter Closure of Complex Multiple Atrial Septal Defects

A 73-year-old women was referred to our institution for transcatheter closure of atrial septal defect (ASD). Three-dimensional transesophageal echocardiography (3D TEE) showed complex multiple ASDs of 26 mm (ASD1), 10 mm (ASD2), 8 mm (ASD3), and 15 mm (ASD4) ([Figurexa01A][1]). We planned to close

Catheter closure of atrial septal defect in patients with cryptogenic stroke: initial experience in Japan

A recent study has shown that cryptogenic stroke can occur even in patients with small or insignificant atrial septal defects (ASD). However, clinical experience in this field is still limited in Japan, also the efficacy and safety of catheter closure of such defects have not been identified. To evaluate the efficacy and safety of catheter closure of interatrial communication in patients with cryptogenic stroke, 13 patients who were diagnosed with cerebrovascular events due to cryptogenic embolism were included in this study. Mean age at procedure was 43xa0±xa015 (range 17–68) years. In all patients, the presence of spontaneous or provoked interatrial right-to-left shunts was demonstrated by transesophageal contrast echocardiography. Mean defect size evaluated by the balloon sizing technique was 9.2xa0±xa02.8xa0mm, and mean size of the Amplatzer Septal Occluder deployed was 9.5xa0±xa02.8xa0mm. Devices were successfully deployed in all patients, though one device migrated into the descending aorta was retrieved by a snare catheter. Complete closure was detected by transesophageal contrast echocardiography at 12xa0months after the procedure was in 11 (85%) of the 13 patients. During the follow-up period (30.1xa0±xa09.4xa0months), no recurrent thromboembolic event was observed. Catheter closure of interatrial right-to-left communications can be safely performed. This procedure may contribute to reduction or prevention of recurrent neurological events in this patient population.