Yasufumi Kijima

Application of Real-Time Three-Dimensional Transesophageal Echocardiography Using a Matrix Array Probe for Transcatheter Closure of Atrial Septal Defect

BACKGROUND The aim of this study was to demonstrate the utility of real-time three-dimensional (3D) transesophageal echocardiography (RT3D-TEE) using a matrix array 3D transesophageal echocardiographic probe for morphologic evaluation and guidance of transcatheter closure of atrial septal defects (ASDs). METHODS Forty-eight consecutive patients scheduled for the intervention were included. Two-dimensional (2D) transesophageal echocardiography (2D-TEE) and RT3D-TEE were performed before and during the procedures. Measurements of maximal ASD diameter and surrounding rims obtained on RT3D-TEE were compared with those obtained on 2D-TEE. RESULTS In 46 patients (96%), optimal 3D images for the morphologic evaluation of ASDs were obtained. RT3D-TEE facilitated the evaluation of ASD morphology and surrounding rims and was able to provide intraprocedural information clearly. A Bland-Altman plot showed a mean maximal diameter difference of -0.12 mm between the means (95% limits of agreement, -2.2 to 2.5 mm). CONCLUSION RT3D-TEE is a clinically useful, complementary option to 2D-TEE for evaluation of ASD morphology and for interventional guidance.

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.

Long-Term Outcome After Transcatheter Closure of Atrial Septal Defect in Older Patients Impact of Age at Procedure

OBJECTIVES This study assessed long-term outcome after transcatheter atrial septal defect (ASD) closure in older patients, especially those older than 75 years of age. BACKGROUND The clinical benefits of transcatheter ASD closure in this aged population are controversial. METHODS A total of 244 patients older than 50 years of age were divided into 3 groups according to age at procedure (50 to 59 years: n=69; 60 to 74 years: n=120; 75 years and older: n=55). The primary endpoint was defined as all-cause mortality and hospitalization due to heart failure or stroke. Improvements in functional capacity and cardiac remodeling after the procedure were also assessed. RESULTS During a median follow-up of 36 months, mortality and hospitalization due to heart failure or stroke occurred in 18 patients (7%). Among patients older than 75 years of age, 2 died of noncardiovascular disease, 2 were hospitalized due to heart failure, and 1 had a stroke. More than 90% of patients older than 75 years of age did not experience these events. Kaplan-Meier analysis showed that the event-free survival rate was not different among the 3 age groups (log-rank test, p=0.780). New York Heart Association functional class and right ventricular/left ventricular end-diastolic diameter ratio improved in patients older than 75 years of age, similar to the other age groups. CONCLUSIONS Long-term outcome after transcatheter ASD closure in patients older than 75 years of age is similar to that in the other, relatively younger age groups. This suggests that transcatheter ASD closure can be considered a valuable therapeutic option in patients older than 75 years of age.

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.

Torn Atrial Septum during Transcatheter Closure of Atrial Septal Defect Visualized by Real-Time Three-Dimensional Transesophageal Echocardiography

Transcatheter closure of atrial septal defects (ASDs) has become an accepted and reliable procedure. Although various complications have been recognized, tear of the atrial septal rim is a rare complication. We report a case of atrial septal rim tear that was diagnosed during the procedure by real-time three-dimensional transesophageal echocardiography (TEE). The device was successfully implanted 3 months after the initial intervention. RT3D TEE is more useful for displaying the entire shape of the defect and its spatial relationship (RT3D) with its neighboring structures compared with conventional two-dimensional echocardiography. By using both two-dimensional and RT3D TEE images, especially in cases with complicated ASD morphology, both the echocardiologist and interventionalist gain valuable information on the morphology of the ASD before and during the procedure.

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.>.

Catheter closure of coronary sinus atrial septal defect using Amplatzer Septal Occluder

Coronary sinus defect is a rare type of atrial septal defect. We report two patients who had a coronary sinus atrial septal defect without persistent left superior caval vein, where the orifice of the coronary sinus was closed using the Amplatzer Septal Occluder. The procedure was successful, without any complications including conduction disturbance.

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

BACKGROUND Cardiac 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. OBJECTIVE Therefore, 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. METHODS Fifty 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. RESULTS The 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). CONCLUSION Cardiac CT is feasible for assessing pathology and the severity of secundum ASD in adults.

Acute Pericarditis Unmasks ST-Segment Elevation in Asymptomatic Brugada Syndrome

A 26‐year‐old man was admitted to our hospital because of acute pericarditis. The current patient had a saddle‐back type ST‐segment elevation shortly after the onset of acute pericarditis. Interestingly, it converted into a coved type ST‐segment elevation, subsequently regressed gradually as acute inflammation improved. After 3 months, right ventricular rapid pacing induced ventricular fibrillation, and intravenous sodium channel blocker induced a coved type ST‐segment elevation. The current case implies that a Brugada‐type ST‐segment elevation, which is thought to be false in acute pericarditis, may be true in some patients with asymptomatic Brugada syndrome.

Fate of Mitral Regurgitation after Transcatheter Closure of Atrial Septal Defect in Adults

Although the volume overload of pulmonary circulation improves after atrial septal defect (ASD) closure, the increasing left ventricular preload may contribute to mitral regurgitation (MR) deterioration. We aimed to evaluate the impact of MR after transcatheter ASD closure on clinical outcomes in adults. A total of 288 consecutive patients who underwent transcatheter ASD closure were enrolled. Changes in MR were assessed at 1 month after the procedure. The end point was defined as cardiovascular events. After the procedure, MR ameliorated in 3 patients and unchanged in 253, whereas MR deteriorated in 32. During a median follow-up of 24 months, patients with MR deterioration had no cardiovascular events, and the event-free survival rate was not different between patients with MR deterioration and those with MR amelioration or no-change (p = 0.355). Even in patients with MR deterioration, the New York Heart Association functional class improved after the procedure, with no cases of worsening functional class. Multivariate logistic regression analysis showed that MR deterioration was independently related to advanced age and female gender. The degree of enlargement of mitral valve annulus diameter after the procedure was greater in patients with MR deterioration than in those with MR amelioration or no-change, and it was correlated with the degree of MR deterioration. In conclusion, MR deterioration occurs in a minority of adult patients after transcatheter ASD closure; however, it is not linked with adverse outcomes. MR deterioration may be provoked by geometric changes in mitral valve annulus, especially in women with advanced age.