Postoperative supraventricular arrhythmias in atrial septal defects]

Before operation as well as over a mean postoperative period of 8.9 years 222 adults with atrial septal defects underwent a follow-up examination concerning frequency and clinical significance of supraventricular dysrhythmias. Thereby disturbances of the formation of stimuli were found before the operative procedure in 60 patients and after the correction in 115 patients. Disturbances of the sinoatrial and atrioventricular conduction were registered preoperatively in 53 cases and postoperatively in 81 cases. Within these statistically significant increases in particular the significant forms of dysrhythmia elevated after the atrial septal defect closure. Thus the tachycardiac atrial dysrhythmias increased from 7 to 28%, complex arrhythmias even from 2 to 16%. Of dysrhythmias to be taken seriously patients with IAVC and supraventricular defect are significantly more frequently affected than those with interatrial septal defects. Size of the defect, shunt volume and pressure of the pulmonary artery did not show any connections with the frequency of dysrhythmia. On the other hand, when accompanying cardiac anomalies, symptoms of a manifest heart insufficiency were present and at an operation age over 40 years arrhythmias were proved more frequently. The complaints of the patients did not correlate with the endangering, but are imprinted by the haemodynamics and its postoperative normalization. By the established profile of complaints and a decrease of frequency from 76% pre- to only 40% postoperative the patient with atrial septal defect cannot estimate his individual risk and needs an adapted long-term concept for his cardiological care.     

Catheter closure of atrial septal defects

Following the pioneering work of King, Rashkind and their associates in the mid 1970s, a number of devices have been designed and tested in animal models and human subjects. Some devices have been discontinued and others were modified followed by further clinical trials. At the time of this writing, only one device, ASO, was approved by the FDA for general clinical use to occlude atrial defects. There are a number of other devices which are in clinical trials, including the CardioSeal/StarFlex, COD buttoned, Helex and transcatheter patch devices. The preceding paper reports on the utility of ASO in occluding atrial defects in adult patients: the results appear good with extremely rare major complication and little need re-intervention during follow-up. It is envisioned that several other devices will be approved by the regulatory authorities in the foreseeable future so that an appropriate device for a given type of atrial septal defect may be selected by the practicing interventional cardiologist.     

Functional closure of atrial septal defects

Three patients with left to right shunts at the atrial level and clinical findings of atrial septal defect were studied at 8 months to 2 years of age. The subsequent clinical course of these children indicated that the atrial defect had closed. The second heart sound became normal although systolic ejection murmurs remained. Hemodynamic studies confirmed the functional closure of the atrial septal defect although probe patency of the foramen ovale was still present in 2 patients. Although functional closure of atrial septal defects may not be a common occurrence, the possibility should be kept in mind and elective surgery should not be undertaken during the first few years of life.     

Transcatheter closure of atrial septal defects

The first transcatheter closure of an atrial septal defect (ASD) was performed by King and Mills in 1976. The Lock Clamshell occluder and the buttoned device are the latest devices to undergo clinical trials. Successful transcatheter closure has been possible with minimal morbidity and mortality. Small residual shunts may remain, however, in up to 20% of patients 1 year after the procedure. The clinical significance and natural history of these small residual atrial communications remains to be determined. This article reviews the history and development of the current ASD closure techniques, with emphasis on the experience with the Lock Clamshell occluder and the buttoned device.     

Sizing of atrial septal defects in adults

In a retrospective study of 51 consecutive patients undergoing transcatheter closure of secundum type atrial septal defects (ASDs), we examined the reliability of transesophageal echocardiography (TEE) prior to catheterization and compared the diameter with that obtained by balloon measurement during catheterization. The TEE diameter was 16.3+/-4.6 mm compared with 22.5+/-6.0 mm for the stretched diameter obtained during catheterization (p<0.001). There was no gender difference. The degree of left-to-right shunting correlated poorly with the size of the defect. We conclude that although TEE is accurate for diagnosis of an ASD, the measurement of its size to determine the size of the closure device is at best inaccurate.     

Echocardiographic assessment of atrial septal defects

Echocardiography has become the method of choice for the assessment of patients with a known or suspected atrial septal defect. The majority of patients with defects can be identified by this method. In patients with inconclusive transthoracic studies, transesophageal echocardiography is useful for identification or exclusion of a defect. Echocardiography is useful for quantification of left-to-right shunting, identification of associated anomalies, and estimation of pulmonary pressure. Cardiac catheterization can be reserved for patients who require measurement of pulmonary vascular resistance, those who have a significant risk of coronary artery disease, and those with complex congenital heart disease.     

Catheter closure of atrial septal defects and patent foramen ovale in patients with an atrial septal aneurysm using different devices

BACKGROUND: Atrial septal aneurysm is frequently associated with patent foramen ovale (PFO) and atrial septal defects (ASD). Moreover, a relationship between atrial septal aneurysm and embolic cerebrovascular events has been suggested. The aims of this study were to analyze morphological and functional characteristics of atrial septal aneurysm in PFO and ASD patients and to assess the feasibility and efficacy of different devices for transcatheter closure and the influence of atrial septal aneurysm. METHODS: Between March 1997 and May 2000 transcatheter ASD or PFO closure was attempted in 63 patients (mean age 47 +/- 13 years) with an atrial septal aneurysm using one of the following devices: Angelwings (n = 3), Cardioseal (n = 5), Cardioseal-Starflex (n = 7), Amplatzer (n = 11), Amplatzer-PFO (n = 5), PFO-Star (n = 25), or Helex (n = 7). RESULTS: Implantation was primarily successful (after the first or second attempt) in all patients. One PFO-Star device embolized 12 hours after the procedure. During follow-up (0.6-37 months, mean 10.4 +/- 9.2) a residual shunt could be detected by transesophageal echocardiography after 2 weeks in four patients and after 6 months in one patient. Three PFO patients had cerebrovascular events after implantation. Two patients had a transient ischemic attack (TIA) and one patient a stroke. A thrombus formation on the device detected in three patients disappeared after antithrombotic therapy. CONCLUSION: We conclude that ASDs and PFOs with an associated atrial septal aneurysm can be closed with different available devices. There seem to be no additional risks compared with patients without atrial septal aneurysm.     

Amplatzer封堵器治疗房间隔缺损(附9例报告)

目的 应用Amplatzer封堵器治疗继发孔型房间隔缺损（ASD）并评价其疗效。方法 9例患者,男3例,女6例,年龄8～52（33.0±5.2）岁,体重22 kg以上。经临床、心电图、x线胸片和经超声心动图（TEE）检查诊断继发孔型ASD,导管法测定肺动脉收缩压24～46（24.4±5.5）mmHg（1mmHg=0.133 kPa）,经心内球囊测定法测定ASD直径11～30（23.3±6.2）mm。手术在X线透视和TEE监视下进行。用10F、11F或12F导管装载Amplatzer封堵器经皮穿刺插入封堵治疗ASD。术后24h、1、3、6个月行胸壁超声心动图和X线胸片评价效果。结果 手术全部获得成功,8例术后即时做TEE检查示ASD立即关闭,次日病人即能下床活动。1例有残余微量分流,1个月后仍然存在,6个月时分流消失。1例在术中发生脑栓塞,经及时用尿激酶溶栓治疗痊愈。结论 Amplatzer封堵器治疗继发孔型ASD是一种有效的非手术治疗方法,具有安全、操作简便、成功率高的特点。     

Transcatheter closure of atrial septal defects in adults with the Amplatzer septal occluder

OBJECTIVE—To assess the efficacy and complications of device occlusion of atrial septal defects in adults, using the Amplatzer septal occluder (ASO).
DESIGN—A prospective interventional study.
SETTING—Paediatric cardiology departments in two European teaching hospitals.
PATIENTS—The first 20 patients accepted for atrial septal defect device occlusion, on the basis of transoesophageal echocardiography. Sixteen patients had larger defects with right heart dilatation, while the primary indication for closure in four was a history of early paradoxical embolism.
INTERVENTIONS—Transcatheter atrial septal defect occlusions performed under transoesophageal echocardiography and fluoroscopic guidance between December 1996 and June 1998.
OUTCOME MEASURES—Success of deployment of ASO devices, procedure and fluoroscopic times, complications, and symptoms.
RESULTS—The ASO device was successfully implanted in all 20 patients (14 female), median age 44.2 years, with no complications. Of the 16 patients with right heart dilatation, the median Qp:Qs was 2.5:1. Defects measured 11-22 mm (median 18) on transoesophageal echocardiography, with balloon sized diameter (and device size) of 13-28 mm (median 20). For all 20 patients, the procedure time ranged from 38-78 minutes (median 61), and fluoroscopy 8.4-24.7 minutes (median 15.2). There were residual shunts in three patients at the end of the procedure, which were trivial ( 1 mm) as assessed by transoesophageal echocardiography, and persisted for more than six months in only one patient. Follow up ranged from 0.1-1.5 years (median 0.7). There have been no late complications.
CONCLUSIONS—The ASO device can be used successfully to close selected oval fossa defects in adults, with minimal procedural morbidity and excellent early results.


Keywords: atrial septal defect; interventional cardiac catheterisation; Amplatzer septal occluder