Latent pulmonary hypertension in atrial septal defect: Dynamic stress echocardiography reveals unapparent pulmonary hypertension and confirms rapid normalisation after ASD closure

Abstract

ObjectiveClosure of atrial septal defects (ASD) prevents pulmonary hypertension, right heart failure and thromboembolic stroke. The exact timing for ASD closure is controversial.MethodsIn a prospective study to address the question whether unapparent pulmonary hypertension can be revealed prior to right ventricular (RV) remodelling, patients were investigated before and 6, 12, and 24 months after ASD closure using exercise stress echocardiography (ESE) and ergospirometry (n = 24).ResultsAt rest, RV systolic pressure (RVSP) was normal in 58.8 %, slightly elevated in 26.5 %, and moderately elevated in 11.8 %. One patient showed severe pulmonary hypertension. During ESE, all patients with normal RVSP at rest exhibited an increase (25.7 ± 1.2 mmHg vs. 45.3 ± 2.3 mmHg, p < 0.001). After closure the RVSP was lower, both at rest and ESE. RV diameters decreased too. Tricuspid annulus plane systolic excursion (TAPSE) at rest remained lower after closure (24.0 ± 0.9 vs. 22.0 ± 0.9 mm, p < 0.05). TAPSE in ESE was elevated, and stayed stable after closure (30.1 ± 1.8 mm vs. 29.3 ± 1.6 mm). Before closure, RV systolic tissue velocities (sa) at rest were normal and decreased after closure (14.0 ± 1.0 cm/s vs. 11.5 ± 0.7 (6 month) vs. 10.6 ± 0.5 cm/s (12 month), p < 0.05). During ESE, sa velocity was similar before and after closure (23.0 ± 1.3 cm/s vs. 23.3 ± 1.9 cm/s). Maximal oxygen uptake (VO2/kg) did not differ between baseline and follow-ups.ConclusionLatent pulmonary hypertension may become apparent in ESE. ASD closure leads to a significant reduction in this stress-induced pulmonary hypertension and to a decrease in the right heart diameters indicating reverse RV remodelling. RV functional parameters at rest did not improve. The VO2/kg did not change after ASD closure.

Interventional Closure of Secundum Type Atrial Septal Defects in Infants Less Than 10 Kilograms: Indications and Procedural Outcome

“…ASD closure in patients without an increase in PVR prevents and reduces pulmonary hypercirculation and hypertension and decreases right heart diameters and averts right ventricular remodeling and failure. 31,32 Periprocedural anesthesia influences invasive PAP measurement and at the same time non invasive "estimation" of RV pressures by calculating velocity of the jet of tricuspid regurgitation does often not correlate strongly with invasive PAP measurements. During the interventional ASD closure procedure and preliminary hemodynamic assessment only 6 of our patients showed elevated pulmonary artery pressure (PAP >25 mmHg) measured invasively, and 4 of those showed an increased PVR, defined >3Wood Units/m 2 BSA.…”

Secundum atrial septal defect in adults: a practical review and recent developments

“…Closure of the ASDII results in right-sided volume unloading and reduction in RA and RV size. The remodelling process and associated increase in cardiopulmonary function commence immediately after closure and continue for several years [ 10 , 35 , 36 ]. Decreased RV volume improves ventricular interaction and LV filling.…”

Association between pulmonary hypertension and an atrial septal defect

“…In the study by Lange et al 59 ‘asymptomatic’ patients, with haemodynamically relevant primum and secundum type ASD (shunt fraction 1.7), were included [1]. Twenty-four percent suffered from atrial fibrillation and three patients had a history of stroke.…”

“…In this Journal, Lange et al describe the use of exercise echocardiography to identify pulmonary hypertension in the presence of an atrial septal defect (ASD) [1]. …”