Monday, 2 April 2018

Percutaneous Closure of Adult Atrial Septal Defects in Adults: Short- and MediumTerm Results



Patients aged 40 years and older with an ASD with a percutaneous closure indication. Indications for closure were: an important left to right shunt (signs of right ventricular overload) regardless of the presence of symptoms, patients with severe pulmonary vascular disease (pulmonary resistances > 5 units Wood), after a vaso-reactivity test or after a targeted treatment. Were not considered for the percutaneous closure, patients with a septal defect diameter exceeding 38 mm (on transesophageal echocardiography (TEE)) or after using a calibration balloon) and those with inadequate morphology (insufficient shorelines, Multiple defects, complex aneurysm, association of other important lesions).

Complete transthoracic echocardiography (TTE), including M mode, 2D, continuous, pulsed colour Doppler were performed prior to surgery and on each follow-up visit. TEE was routinely performed in all patients proposed for percutaneous closure in order to evaluate the ASD morphology and exclude additional lesions, such as pulmonary venous return abnormality. The right ventricle size was studied by measuring its diastolic diameter on the parasternal long axis view (RVTDD), and systolic pulmonary arterial pressure (SPAP) was estimated from the tricuspid regurgitation rate. The ratio of flow rates (Qp/ Qs) was obtained by measuring the time-velocity, as well as the diameters of the pulmonary artery and the left ventricular ejection pathway.

An invasive assessment was performed before surgery when the SPAP estimated in ultrasound was greater than 50% of the systemic pressure or 60 mmHg. In these patients, pulmonary vascular resistance (PVR) had been carefully evaluated. Only patients with PVR ≤ 5 units Wood -either spontaneously or after a vaso-reactivity test with nitrogen monoxide-were considered for the ASD percutaneous closure. In patients with left atrial pressure greater than 15 mmHg during invasive assessment, ASD balloon occlusion was performed and pressure measurement was repeated. In patients with an increased left atrial pressure of more than 10 mm Hg, treatment of heart failure was initiated prior to ASD closure to reduce after surgery left heart failure risk. 

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