Short and Mid-Term Outcome of Percutaneous Atrial Septal Defect Closure in Adults

Author Name(s): Mostafa Ahmadi, *Samad Ghafari, Bahram Sohrabi, Atooshe Rohani, Ahmad Separham, Naser Aslanabadi, Iraj Jafaripour, Ramin Khamene Bagheri, Peiman Jamshidi
Author Email: ghafaris@gmail.com

Abstract

Introduction: Percutaneous closure is considered to be the first treatment approach for a vast majority of secundum atrial septal defect (ASD) patients. Despite the frequent usage of closure devices for these treatments, there is a little level of evidences about their outcomes. The aim of our study was to determine the short and mid-term treatment outcome of patients undergoing percutaneous ASD closure with devices. Method: This cross-sectional study was conducted on patients with secondary ASD admitted to the Department of Cardiac Surgery of Shahid Madani Hospital in Tabriz, Iran during 2011 to 2014. All surgeries were performed without general anesthesia with the guidance of fluoroscopy and transthoracic echocardiography (TEE). Eight French (Fr) venous access was obtained and Initial right heart catheterization was done. A sizing balloon catheter was used for measuring the diameter of the defect, and closure device was loaded using the standard and venous sheath. Follow up at 24 hours and 6 months after surgery was completed with physical examination and TEE. Results: Eighty-seven patients (33 male/ 54 female) with a mean age of 39.1 ± 15.4 years (range 22-71 years) were studied. Device closure was done successfully in most of the patients (98.8%). One patient (1.1%) needed surgical intervention because of embolization of device. At 6 month follow up, complete closure was documented in 98.3%, of ASD patients and in 88.7% of patients with PFO. Conclusion: It seems that percutaneous closure of secundum ASD with devices is an optimal approach for treatment of adults with a very low incidence of complications.

Introduction

The ostium secundum atrial septal defect (ASD) is the most common form of ASD that increases the volume
overload of right ventricle and pulmonary arteries, resulting in dilatation in long run and finally the right ventricular failure and increased pulmonary arterial pressure (1-3). The treatment of ASD is open heart surgery in large defects and the use of septal occlude devices such as Amplatzer in relatively small defects (less than 13 mm) (4, 5). Angiography via femoral artery is employed to implement it (5). A meta-analysis of 28,142 patients across 203 studies concluded that short- and long-term septal occlude device-related mortality rates are low, at 0.01% and 0.1% respectively (6). Although the preliminary research findings of studies that have evaluated these devices were promising, their increased use has been associated with some major complications including atrial arrhythmias, cardiac erosion, conduction abnormalities, device endocarditis, nickel allergy, thromboembolic events, and valvular damage (6-9). As ASD closure is frequently performed, there is a requirement to identify the device-related complications that may have a direct impact on mortality to assist physicians to make informed decisions as to the most appropriate methods by which to treat patients; for example, choosing surgery as opposed to percutaneous intervention and selecting which devices to use (10-12). Research of this nature will also address the lack of data that is currently available relating to the adult patient population (13). The aim of the present study was to evaluate the findings, short-term and mid-term complications in the patients with the secondary atrial septal defect following the closure with cardiac catheterization.

Conclusion

The results of this study indicate that septal occlude devices can be used to close ASDs of the secundum type in an adult patient population considered for transcatheter closure. Furthermore, beside an optimal results of short- to mid-term follow-up, the technical success rate of ASD closure with septal occlude devices was very high in our series of patients. The results also revealed that over 90% of the patients that underwent closure based on echocardiographic findings were effectively treated with septal occlude devices. This finding is in line with that of previous studies, which have demonstrated that transcatheter closure with ASO achieves a success rate of 80% (1317). In fact, following a study by Spies et al.,(13) the current study included the second major series of adult patients undergoing ASDs closure with septal occlude devices. Spies et al. described how successful Amplatzer septal occluder implantation was achieved in 166 cases out of 200 of patients with hemodynamically significant ASD, representing a success rate of 83% (13). In our study, a procedurerelated complication was observed in only one case; as such, our study identified a significantly lower percentage of complication in comparison to other studies in pediatric and adult populations. In the study by Spies et al., (13) complications occurred in 11 cases (6.5%); however, as was the case with our study, none of these events were associated with long-term sequelae. A recent meta-analysis estimated that the rate of device thrombosis following ASD closure was 1.0% (6). A historic report from the Krumsdorf et al. study (18) found that the incidence of thrombus was 1.2% and that there was significant differences in thrombosis rate between different devices: the Amplatzer had the lowest incidence of thrombi (0%) followed by the CardioSeal (7.1%), Starflex (5.7), and Helex (0.8%) devices. Post-procedural atrial fibrillation was a significant risk factor for thrombus formation (18). In the majority of cases, thrombus was treated via a course of medical therapy and no clinical consequences were observed; however, in the current study, the patient who had an AF did not suffer from thrombus formation. Abaci et al. specifically examined the risk of other types of thrombolytic events, such as stroke, and found that the rate of cerebrovascular events after ASD device closure was 1.1% (6). The rate at which patients suffered from a stroke was consistent with the findings of Kotowycz study (19). Kutty et al. reported a cumulative incidence of thrombolytic events of 3% after a median duration of 8.1 years following percutaneous ASD closure (20). In our study, the rate of thrombolytic events at the six-month follow-up was somehow similar to that of previous research findings in situations in which no event was reported during the study period

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