Device closure of atrial septal defect with severe pulmonary hypertension in adults: Patient selection with early and intermediate term results

Abstract

Objective: To describe a subset of atrial septal defect (ASD) with severe pulmonary hypertension (PHT) that is suitable for closure.Background: As per American Heart Association/American College of Cardiology guidelines, ASD with elevated pulmonary artery pressure (PAP) and pulmonary vascular resistance (PVR) >2/3rd systemic is considered as a contraindication for closure.Methods: Patients with anatomically large ASD measuring >25 mm and a high probability of reversible pulmonary vascular disease were subjected to fenestrated device closure, despite severe PHT and elevated PVR. They were discharged on pulmonary vasodilators and were followed for 39.5 AE 8.5 months. Four patients had repeat cardiac catheterization.Results: Six patients underwent successful device closure of large ASD with severe PHT. Their basal Qp:Qs was 2.8 AE 0.3:1 while the systolic PAP and the PVR index (PVRI) were 102.6 AE 11.5 mm Hg and 9.6 AE 1.6 Wu m 2 , respectively. Post 100% oxygen inhalation, the Qp: Qs increased to 3.5 AE 0.3:1, systolic PAP remained 103.5 AE 7.6 mm Hg while the PVRI dropped to 5.4 AE 1.1 Wu m 2 . The postballoon occlusion systolic PAP decreased to 86.6 AE 8.8 mm Hg. At the last follow-up, their pulmonary artery systolic pressure by tricuspid regurgitation (TR) jet decreased from 105.6 AE 12.6 mm Hg to 45 AE 7.0 mm Hg. During follow-up cardiac catheterization (n = 4), the systolic PAP and PVRI were 55.7 AE 9.2 mm Hg and 3.2 AE 0.4, respectively.Conclusions: Patients with anatomically big defect and a large left to right shunt at baseline with a high probability of reversible PVR benefit with ASD closure and pulmonary vasodilators, despite significantly elevated PAP and PVRI.

Prevalence and outcomes of pulmonary hypertension after percutaneous closure of atrial septal defect: a systematic review and meta-analysis

“…The most common reasons for exclusion were poster presentations and/or conference proceedings (n=13), using surgical closure (n=11), and having only pooled results from paediatric and adult populations (n=10). We included a total of 15 studies in this review that met our study eligibility criteria [9,[31][32][33][34][35][36][37][38][39][40][41][42][43][44].…”

“…PH measurement and definitions 12 (80%) studies used transthoracic (TTE) or transoesophageal echocardiography (TEE) and four studies used the gold standard, RHC [9,33,39,44]. The definitions for PH varied among studies ( [39].…”

“…All cohort studies recruited patients with and without PH from the same population and all patients underwent PH measurement. Three studies used RHC to assess for PH before and after closure [9,39,44]. One study used TTE at baseline and switched to RHC at follow-up [33].…”

“…# : study-reported sPAP values derived from right ventricular systolic pressure; ¶ : study-reported values for PAH. https://doi.org/10.1183/16000617.0099-202040,43,44] or ⩾60 mmHg…”

Efficacy of treat-and-repair strategy for atrial septal defect with pulmonary arterial hypertension

“…To the best of our knowledge, this is the first study to show the efficacy of the treat-and-repair strategy for ASD complicated with PAH in a large population. Unlike previous studies, 27 28 transcatheter ASD closure was performed using non-fenestrated devices in all the patients with PAH. Our study population was in relatively good condition with predominantly left-to-right shunt at baseline prior to PAH-specific medications.…”