- Email: [email protected]
Effect on right ventricular volume of percutaneous Amplatzer closure of atrial septal defect in adults
myectomy and alcohol septal ablation, there is clearly an important subgroup of patients who are unsuitable for these interventions, such as elderly patients who may have great surgical risk and patients with unsuitable coronary anatomy or distribution of hypertrophy for septal ablation. This subgroup of patients in whom medical therapy has failed may benefit from the less invasive and more accessible implantation of permanent dual-chamber pacemakers. This form of therapy has additional advantages. The device can be turned off at any time if no benefits or adverse events are observed. The implantation of a pacing device also allows more aggressive pharmacologic intervention to be initiated, such as -blocker therapy, reducing concerns over the induction of heart block. Furthermore, given the increase in therapy with implantable cardioverter-defibrillators in patients with HC, the option of implanting a combined device in patients at high risk for sudden death as well as having symptomatic LVOT obstruction has potential therapeutic advantages. An additional strategy in determining which patients were most likely to benefit from the implantation of permanent dual-chamber pacemakers in the present study was performing an acute atrioventricular pacing study. Although this may create an additional step in the evaluation process and may be associated with a small risk for complications associated with the study itself, in the small number of patients described here, this investigation seemed to select those who would most benefit; that is, all patients who had beneficial responses to acute atrioventricular pacing also had successful outcomes after permanent implantation. The acute study also pro-
vided a guide with respect to the optimal atrioventricular delay to initially set the device, although this was adjusted in some cases during follow-up. Although previous studies have demonstrated variable results from dual-chamber pacemaker therapy in patients with HC over short follow-up periods, frequently ⬍2 years,5,6 the present longer term follow-up study highlights the potential benefits and improvements in the quality of life using such therapy in selected groups of patients, such as the elderly. Dualchamber pacing therapy should also be considered in patients with HC and symptomatic LVOT obstruction at high risk for sudden death who therefore require the implantation of cardioverter-defibrillators. 1. Doolan A, Nguyen L, Semsarian C. Hypertrophic cardiomyopathy: from “heart
tumour” to a complex molecular genetic disorder. Heart Lung Circ 2004;13:15– 25. 2. Fananapazir L, Epstein ND, Curiel RV, Panza JA, Tripodi D, McAreavey D. Long-term results of dual chamber (DDD) pacing in obstructive hypertrophic cardiomyopathy. Circulation 1994;90:2731–2742. 3. McDonald KM, Maurer B. Permanent pacing as treatment for hypertrophic cardiomyopathy. Am J Cardiol 1991;68:108 –110. 4. Slade AK, Sadoul N, Shapiro L, Chojnowska L, Simon JP, Saumarez RC, Dodinot B, Camm AJ, McKenna WJ, Aliot E. DDD pacing in hypertrophic cardiomyopathy: a multicentre clinical experience. Heart 1996;75:44 – 49. 5. Maron BJ, Nishimura RA, McKenna WJ, Rakowski H, Josephson ME, Kieval RS. Assessment of permanent dual-chamber pacing as a treatment for drugrefractory symptomatic patients with obstructive hypertrophic cardiomyopathy: a randomised, double-blind, crossover study (M-PATHY). Circulation 1999;99: 2927–2933. 6. Gadler F, Linde C, Daubert C, McKenna W, Meisel E, Aliot E, Chojnowska L, Guize L, Gras D, Jeanrenaud X, et al. Significant improvement of quality of life following atrioventricular synchronous pacing in patients with hypertrophic obstructive cardiomyopathy. Pacing in Cardiomyopathy. Eur Heart J 1999;20: 1044 –1050.
Effect on Right Ventricular Volume of Percutaneous Amplatzer Closure of Atrial Septal Defect in Adults Jeffrey M. Schussler, MD, Azam Anwar, MD, Sabrina D. Phillips, MD, Brad J. Roberts, RDCS, Ravi C. Vallabhan, MD, and Paul A. Grayburn, MD In adult patients with atrial septal defects (ASDs), right ventricular (RV) cavity size may return to normal after operative closure. This study demonstrated improved RV volumes and right atrial areas in 20 adult patients after successful transcatheter closure of large ASDs. RV volumes decreased by 22%, 30%, and 41% at 1 day, 1 month, and 6 months, respectively, after the procedure. Right atrial areas decreased by 5%, 23%, and 26%, respectively, over the same time. 䊚2005 by Excerpta Medica Inc. (Am J Cardiol 2005;95:993–995) From the Department of Internal Medicine, Division of Cardiology, Baylor University Medical Center, Dallas, Texas. Dr. Grayburn’s address is: Baylor Heart and Vascular Institute, 621 N. Hall St, Suite H030, Dallas, Texas 75226. E-mail: [email protected]. Manuscript received November 17, 2004; revised manuscript received and accepted December 27, 2004. ©2005 by Excerpta Medica Inc. All rights reserved. The American Journal of Cardiology Vol. 95 April 15, 2005
he surgical closure of atrial septal defects (ASDs) in adult patients ⬎40 years of age is associated T with improved survival and lessening of heart failure symptoms compared with medical therapy.1 Surgery may not result in the reversal of right ventricular (RV) dilation in such patients.2– 4 In contrast, the nonsurgical, transcatheter closure of ASDs may preserve RV function by avoiding the adverse effects of cardiopulmonary bypass on RV function.5 Transcatheter ASD closure has been shown to reduce echocardiographic RV dimensions, primarily in pediatric patients.6 –10 This study was performed to define the effect of transcatheter ASD closure using the Amplatzer Septal Occluder device (AGA Medical Corporation, Golden Valley, Minnesota) on RV volumes in adult patients. •••
The study participants were 4 men and 16 women (age range 20 to 77 years; mean 48 ⫾ 18). Rhythm was sinus in 17 patients and atrial fibrillation in 3 0002-9149/05/$–see front matter doi:10.1016/j.amjcard.2004.12.046
993
a sizing balloon ranging in diameter from 24 to 40 mm. The sizing balloon was inflated, and its waist was measured using either transesophageal (n ⫽ 10) or intracardiac (n ⫽ 10) echocardiography. An appropriately sized Amplatzer device was then selected and deployed under echocardiographic guidance. All echocardiographic data were interpreted in blinded fashion and entered into a statistical software program (StatView, SAS Institute Inc., Cary, North Carolina). Repeated-measures analysis of variance was used to calculate the F statistic for temporal changes over time. Values are reported as mean ⫾ 1 SD. A p value ⬍0.01 was considered statistically significant. FIGURE 1. Echocardiographic images from a representative patient in this study. ASD closure was successful in all Top left, large color flow jet across a secundum ASD in a short-axis view. Top right, The same view 1 day after the placement of the Amplatzer device (arrow). patients, and there were no complicaNo residual shunt is seen. Bottom right, Markedly dilated right ventricle (RV) and tions. The mean Amplatzer device size right atrium (RA) at baseline in the same patient. Bottom left, sizes of the RV and was 25 ⫾ 7 mm. One patient had 3 the right atrium RA have clearly decreased 1 day after successful ASD closure. separate defects that were closed with 3 devices (18, 12, and 4 mm).17 All other patients. Mean systolic and diastolic blood pressures patients had a single device implanted. Only 3 subwere 130 ⫾ 26 and 76 ⫾ 11 mm Hg, respectively. The jects had systolic pulmonary artery pressures ⬎60 mm mean heart rate was 78 ⫾ 13 beats/min. All patients Hg. Figure 1 shows representative echocardiograms were symptomatic and had large ASDs with significant left-to-right shunting (Qp/Qs ⱖ1.5:1) measured from a patient in the study at baseline and 1 day after ASD closure. In all patients, color flow imaging by oximetry.11 Comprehensive 2-dimensional and Doppler echo- showed either the complete eradication of the shunt or cardiograms were obtained in all subjects before ASD only a very small residual leak. All patients had the closure and at 1 day, 1 month, and 6 months thereaf- visually apparent resolution of paradoxic septal moter. Images were acquired by an experienced sonog- tion and marked reduction in RV size. Table 1 lists the rapher (BJR) using a SONOS 5500 instrument (Phil- echocardiographic values for RV volumes, RV ejecips Medical Systems, Andover, Massachusetts). RV tion fractions, right atrial areas, estimated RV systolic volumes were measured using the ellipsoidal shell pressure, and the Qp/Qs ratio. RV end-diastolic volmodel, which has been validated against cine mag- ume decreased by 22% at 1 day, 30% at 1 month, and netic resonance imaging.12,13 Briefly, a 4-chamber 41% at 6 months after the procedure. The temporal view was obtained using slight angulation to maxi- decrease in RV diastolic volume was statistically mize RV cavity area, which was then traced at end- significant by repeated-measures analysis of varidiastole and end-systole. The superior RV diameter ance (F ⫽ 32.05, p ⬍0.0001). RV end-systolic volfrom the lateral tricuspid annulus to the lateral pulmo- ume also decreased significantly over time (F ⫽ nary valve annulus was measured in a modified sub- 10.48, p ⬍0.0001), decreasing by 13% at 1 day, 21% costal or parasternal short-axis view optimized to at 1 month, and 35% at 6 months. Right atrial area show each of these landmarks. RV volumes were then decreased significantly (F ⫽ 17.51, p ⬍0.0001), by calculated as 2/3 ⫻ RV area ⫻ RV diameter and 5% at 1 day, 23% at 1 month, and 26% at 6 months. indexed for body surface area. Right atrial area was The Qp/Qs ratio decreased significantly over time planimetered in an apical 4-chamber view. RV sys- (F ⫽ 22.13, p ⬍0.0001). Estimated RV systolic prestolic pressure was calculated from the velocity of the sure and RV ejection fraction decreased slightly, but tricuspid regurgitation jet (if present) and the diameter these changes were not statistically significant. Paraof the inferior vena cava and its response to rapid doxic septal motion resolved in all patients at day 1 inspiration.14 The Qp/Qs ratio was calculated from the after ASD closure and remained absent at 1- and diameters and velocity–time integrals of the aortic and 6-month follow-up. pulmonary valve annuli, as recommended by the ••• American Society of Echocardiography.15 Previous studies that have evaluated the RV reAll procedures were performed in the catheteriza- sponse to transcatheter ASD closure have been limited tion laboratory using conscious sedation. An Am- by the restriction of the study population to pediatric platzer ASD occluder device was placed through the patients, the measurement of a single RV dimension in right femoral vein using a standard technique.16 The a long- or short-axis view, or both.6 –10 RV dimension ASD was crossed with a 0.035-in J-wire, followed by does not adequately reflect the complex geometry of 994 THE AMERICAN JOURNAL OF CARDIOLOGY姞
VOL. 95
APRIL 15, 2005
TABLE 1 Echocardiographic Measurements Over Time Time After Closure Variable RV end-diastolic volume (ml) RV end-diastolic volume index (ml/m2) RV end-systolic volume (ml) RV end-systolic volume index (ml/m2) RV ejection fraction (%) Right atrial area (cm2) RV systolic pressure (mm Hg) Qp/Qs ratio
Baseline 209 120 123 70 44 28 42 2.5
⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾
60 34 54 30 14 12 21 1.0
1 Day 163 93 107 60 38 26 44 1.4
⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾
46 27 45 25 13 10 19 0.3
1 Month 146 84 97 56 37 21 40 1.2
⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾
35 22 31 19 11 8 18 0.2
6 Months
p Value
⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾
⬍0.0001 ⬍0.0001 ⬍0.0001 ⬍0.0001 0.08 ⬍0.0001 0.08 ⬍0.0001
123 71 80 46 37 20 35 1.1
32 19 27 16 12 8 13 0.2
Values are means ⫾ 1 SD.
the right ventricle, and there are no clear landmarks to ensure that this dimension is measured in the same anatomic location across serial studies. We used an ellipsoidal shell model to calculate RV volumes. This model is conceptually simple and has been validated against magnetic resonance imaging.11,12 The development of real-time 3-dimensional echocardiography might offer even more accurate assessment of right-sided chamber volumes18 but was not available to us when this study was initiated. Nevertheless, the measurement of RV volumes in this study allowed much more confidence than the measurement of a simple linear dimension. In pediatric patients, the volume overload imposed by ASDs has been present for only a few years and is expected to be reversible. In adults, RV dilation is long standing and may not resolve after surgical correction.2– 4 This study demonstrated pronounced reduction in RV volume ⬍24 hours after successful transcatheter ASD closure in adults. RV volumes continued to improve for up to 6 months, suggesting an ongoing remodeling process that is not explained solely by the prompt resolution of paradoxic septal motion. Right atrial areas also decreased significantly over time, further supporting the finding that the amelioration of the left-to-right shunt by transcatheter ASD closure results in the favorable remodeling of the right-sided volume overload. Importantly, the temporal improvement in right-sided volume overload was evident in all 20 patients in this study. However, only 3 subjects had systolic pulmonary artery pressures ⬎60 mm Hg, so further investigation is needed in patients with pulmonary hypertension. We did not follow the patients for ⬎6 months, so it is not clear whether any further temporal improvement may have occurred. 1. Konstantinides S, Geibel A, Olschewski M, Gornandt L, Roskamm H, Spillner
G, Just H, Kasper W. Comparison of surgical and medical therapy for atrial septal defect in adults. N Engl J Med 1995;333:469 – 473.
2. Richmond DE, Lowe JB, Barratt-Boyes BG. Results of surgical repair of atrial
septal defects in the middle-aged and elderly. Thorax 1969;24:536 –542. 3. St. John Sutton MG, Tajik AJ, McGoon DC. Atrial septal defect in patients
aged 60 years or older. Operative results and long-term postoperative follow-up. Circulation 1981;64:402– 409. 4. Ghosh S, Chatterjee S, Black E, Firmin RK. Surgical closure of atrial septal defect in adults: effect of age at operation. Heart 2002;88:485– 487. 5. Dhillon R, Josen M, Henein M, Redington A. Transcatheter closure of atrial septal defect preserves right ventricular function. Heart 2002;87:461– 465. 6. Du ZD, Cao QL, Koenig P, Heitschmidt M, Hijazi ZM. Speed of normalization of right ventricular volume overload after transcatheter closure of atrial septal defect in children and adults. Am J Cardiol 2001;88:1450 –1453. 7. Kort HW, Balzer DT, Johnson MC. Resolution of right heart enlargement after closure of secundum atrial septal defect with transcatheter technique. J Am Coll Cardiol 2001;38:1528 –1532. 8. Tamborini G, Pepi M, Susini F, Trabattoni D, Maltagliati A, Berna G, Onorato E, Bartorelli AL. Comparison of two- and three-dimensional transesophageal echocardiography in patients undergoing atrial septal closure with the Amplatzer septal occluder. Am J Cardiol 2002;90:1025–1028. 9. Butera G, De Rosa G, Chessa M, Rosti L, Negura DG, Luciane P, Giamberti A, Bossone E, Carminati M. Transcatheter closure of atrial septal defect in young children: results and follow-up. J Am Coll Cardiol 2003;42:241–245. 10. Santoro G, Pascotto M, Sarubbi B, Bigazzi MC, Calvanese R, Iacona C, Pisacane C, Palladino MT, Pacileo G, Russo MG, et al. Early electrical and geometric changes after percutaneous closure of large atrial septal defect. Am J Cardiol 2004;93:876 – 880. 11. Boehrer JD, Lange RA, Willard JE, Grayburn PA, Hillis LD. Advantages and limitations of methods to detect, localize, and quantitate intracardiac left-to-right shunting. Am Heart J 1992;124:448 – 455. 12. Denslow S, Wiles HB, McKellar HF, Wright NA, Gillette PC. Right ventricular volume estimation with an ellipsoidal shell model and two-plane magnetic resonance imaging. Am Heart J 1995;129:782–790. 13. Denslow S, Wiles HB. Right ventricular volumes revisited: a simple model and simple formula for echocardiographic determination. J Am Soc Echocardiogr 1998;11:864 – 873. 14. Kircher BJ, Himelman RB, Schiller NB. Noninvasive estimation of right atrial pressure from the inspiratory collapse of the inferior vena cava. Am J Cardiol 1990;66:493– 496. 15. Quinones MA, Otto CM. Stoddard M, Waggoner A, Zoghbi WA. Recommendations for quantitative Doppler echocardiography. A report from the Doppler Quantification Task Force of the Nomenclature and Standards Committee of the American Society of Echocardiography. J Am Soc Echocardiogr 2002;15:167–184. 16. Thanopoulos BD, Laskari CV, Tsaousis GS, Zarayelyan A, Vekiou A, Papadopoulos GS. Closure of atrial septal defects with the Amplatzer occlusion device: preliminary results. J Am Coll Cardiol 1998;31:1110 –1116. 17. Lander SR, Phillips S, Vallabhan RC, Grayburn PA, Anwar A. Percutaneous closure of multiple atrial septal defects with three Amplatzer septal occluder devices. Cathet Cardiovasc Interv 2004;62:526 –529. 18. Dorosz JL, Bolson EL, Weiss MS, Sheehan FH. Three-dimensional visual guidance improves the accuracy of calculating right ventricular volume with two-dimensional echocardiography. J Am Soc Echocardiogr 2003;16:675– 681.
BRIEF REPORTS
995
vided a guide with respect to the optimal atrioventricular delay to initially set the device, although this was adjusted in some cases during follow-up. Although previous studies have demonstrated variable results from dual-chamber pacemaker therapy in patients with HC over short follow-up periods, frequently ⬍2 years,5,6 the present longer term follow-up study highlights the potential benefits and improvements in the quality of life using such therapy in selected groups of patients, such as the elderly. Dualchamber pacing therapy should also be considered in patients with HC and symptomatic LVOT obstruction at high risk for sudden death who therefore require the implantation of cardioverter-defibrillators. 1. Doolan A, Nguyen L, Semsarian C. Hypertrophic cardiomyopathy: from “heart
tumour” to a complex molecular genetic disorder. Heart Lung Circ 2004;13:15– 25. 2. Fananapazir L, Epstein ND, Curiel RV, Panza JA, Tripodi D, McAreavey D. Long-term results of dual chamber (DDD) pacing in obstructive hypertrophic cardiomyopathy. Circulation 1994;90:2731–2742. 3. McDonald KM, Maurer B. Permanent pacing as treatment for hypertrophic cardiomyopathy. Am J Cardiol 1991;68:108 –110. 4. Slade AK, Sadoul N, Shapiro L, Chojnowska L, Simon JP, Saumarez RC, Dodinot B, Camm AJ, McKenna WJ, Aliot E. DDD pacing in hypertrophic cardiomyopathy: a multicentre clinical experience. Heart 1996;75:44 – 49. 5. Maron BJ, Nishimura RA, McKenna WJ, Rakowski H, Josephson ME, Kieval RS. Assessment of permanent dual-chamber pacing as a treatment for drugrefractory symptomatic patients with obstructive hypertrophic cardiomyopathy: a randomised, double-blind, crossover study (M-PATHY). Circulation 1999;99: 2927–2933. 6. Gadler F, Linde C, Daubert C, McKenna W, Meisel E, Aliot E, Chojnowska L, Guize L, Gras D, Jeanrenaud X, et al. Significant improvement of quality of life following atrioventricular synchronous pacing in patients with hypertrophic obstructive cardiomyopathy. Pacing in Cardiomyopathy. Eur Heart J 1999;20: 1044 –1050.
Effect on Right Ventricular Volume of Percutaneous Amplatzer Closure of Atrial Septal Defect in Adults Jeffrey M. Schussler, MD, Azam Anwar, MD, Sabrina D. Phillips, MD, Brad J. Roberts, RDCS, Ravi C. Vallabhan, MD, and Paul A. Grayburn, MD In adult patients with atrial septal defects (ASDs), right ventricular (RV) cavity size may return to normal after operative closure. This study demonstrated improved RV volumes and right atrial areas in 20 adult patients after successful transcatheter closure of large ASDs. RV volumes decreased by 22%, 30%, and 41% at 1 day, 1 month, and 6 months, respectively, after the procedure. Right atrial areas decreased by 5%, 23%, and 26%, respectively, over the same time. 䊚2005 by Excerpta Medica Inc. (Am J Cardiol 2005;95:993–995) From the Department of Internal Medicine, Division of Cardiology, Baylor University Medical Center, Dallas, Texas. Dr. Grayburn’s address is: Baylor Heart and Vascular Institute, 621 N. Hall St, Suite H030, Dallas, Texas 75226. E-mail: [email protected]. Manuscript received November 17, 2004; revised manuscript received and accepted December 27, 2004. ©2005 by Excerpta Medica Inc. All rights reserved. The American Journal of Cardiology Vol. 95 April 15, 2005
he surgical closure of atrial septal defects (ASDs) in adult patients ⬎40 years of age is associated T with improved survival and lessening of heart failure symptoms compared with medical therapy.1 Surgery may not result in the reversal of right ventricular (RV) dilation in such patients.2– 4 In contrast, the nonsurgical, transcatheter closure of ASDs may preserve RV function by avoiding the adverse effects of cardiopulmonary bypass on RV function.5 Transcatheter ASD closure has been shown to reduce echocardiographic RV dimensions, primarily in pediatric patients.6 –10 This study was performed to define the effect of transcatheter ASD closure using the Amplatzer Septal Occluder device (AGA Medical Corporation, Golden Valley, Minnesota) on RV volumes in adult patients. •••
The study participants were 4 men and 16 women (age range 20 to 77 years; mean 48 ⫾ 18). Rhythm was sinus in 17 patients and atrial fibrillation in 3 0002-9149/05/$–see front matter doi:10.1016/j.amjcard.2004.12.046
993
a sizing balloon ranging in diameter from 24 to 40 mm. The sizing balloon was inflated, and its waist was measured using either transesophageal (n ⫽ 10) or intracardiac (n ⫽ 10) echocardiography. An appropriately sized Amplatzer device was then selected and deployed under echocardiographic guidance. All echocardiographic data were interpreted in blinded fashion and entered into a statistical software program (StatView, SAS Institute Inc., Cary, North Carolina). Repeated-measures analysis of variance was used to calculate the F statistic for temporal changes over time. Values are reported as mean ⫾ 1 SD. A p value ⬍0.01 was considered statistically significant. FIGURE 1. Echocardiographic images from a representative patient in this study. ASD closure was successful in all Top left, large color flow jet across a secundum ASD in a short-axis view. Top right, The same view 1 day after the placement of the Amplatzer device (arrow). patients, and there were no complicaNo residual shunt is seen. Bottom right, Markedly dilated right ventricle (RV) and tions. The mean Amplatzer device size right atrium (RA) at baseline in the same patient. Bottom left, sizes of the RV and was 25 ⫾ 7 mm. One patient had 3 the right atrium RA have clearly decreased 1 day after successful ASD closure. separate defects that were closed with 3 devices (18, 12, and 4 mm).17 All other patients. Mean systolic and diastolic blood pressures patients had a single device implanted. Only 3 subwere 130 ⫾ 26 and 76 ⫾ 11 mm Hg, respectively. The jects had systolic pulmonary artery pressures ⬎60 mm mean heart rate was 78 ⫾ 13 beats/min. All patients Hg. Figure 1 shows representative echocardiograms were symptomatic and had large ASDs with significant left-to-right shunting (Qp/Qs ⱖ1.5:1) measured from a patient in the study at baseline and 1 day after ASD closure. In all patients, color flow imaging by oximetry.11 Comprehensive 2-dimensional and Doppler echo- showed either the complete eradication of the shunt or cardiograms were obtained in all subjects before ASD only a very small residual leak. All patients had the closure and at 1 day, 1 month, and 6 months thereaf- visually apparent resolution of paradoxic septal moter. Images were acquired by an experienced sonog- tion and marked reduction in RV size. Table 1 lists the rapher (BJR) using a SONOS 5500 instrument (Phil- echocardiographic values for RV volumes, RV ejecips Medical Systems, Andover, Massachusetts). RV tion fractions, right atrial areas, estimated RV systolic volumes were measured using the ellipsoidal shell pressure, and the Qp/Qs ratio. RV end-diastolic volmodel, which has been validated against cine mag- ume decreased by 22% at 1 day, 30% at 1 month, and netic resonance imaging.12,13 Briefly, a 4-chamber 41% at 6 months after the procedure. The temporal view was obtained using slight angulation to maxi- decrease in RV diastolic volume was statistically mize RV cavity area, which was then traced at end- significant by repeated-measures analysis of varidiastole and end-systole. The superior RV diameter ance (F ⫽ 32.05, p ⬍0.0001). RV end-systolic volfrom the lateral tricuspid annulus to the lateral pulmo- ume also decreased significantly over time (F ⫽ nary valve annulus was measured in a modified sub- 10.48, p ⬍0.0001), decreasing by 13% at 1 day, 21% costal or parasternal short-axis view optimized to at 1 month, and 35% at 6 months. Right atrial area show each of these landmarks. RV volumes were then decreased significantly (F ⫽ 17.51, p ⬍0.0001), by calculated as 2/3 ⫻ RV area ⫻ RV diameter and 5% at 1 day, 23% at 1 month, and 26% at 6 months. indexed for body surface area. Right atrial area was The Qp/Qs ratio decreased significantly over time planimetered in an apical 4-chamber view. RV sys- (F ⫽ 22.13, p ⬍0.0001). Estimated RV systolic prestolic pressure was calculated from the velocity of the sure and RV ejection fraction decreased slightly, but tricuspid regurgitation jet (if present) and the diameter these changes were not statistically significant. Paraof the inferior vena cava and its response to rapid doxic septal motion resolved in all patients at day 1 inspiration.14 The Qp/Qs ratio was calculated from the after ASD closure and remained absent at 1- and diameters and velocity–time integrals of the aortic and 6-month follow-up. pulmonary valve annuli, as recommended by the ••• American Society of Echocardiography.15 Previous studies that have evaluated the RV reAll procedures were performed in the catheteriza- sponse to transcatheter ASD closure have been limited tion laboratory using conscious sedation. An Am- by the restriction of the study population to pediatric platzer ASD occluder device was placed through the patients, the measurement of a single RV dimension in right femoral vein using a standard technique.16 The a long- or short-axis view, or both.6 –10 RV dimension ASD was crossed with a 0.035-in J-wire, followed by does not adequately reflect the complex geometry of 994 THE AMERICAN JOURNAL OF CARDIOLOGY姞
VOL. 95
APRIL 15, 2005
TABLE 1 Echocardiographic Measurements Over Time Time After Closure Variable RV end-diastolic volume (ml) RV end-diastolic volume index (ml/m2) RV end-systolic volume (ml) RV end-systolic volume index (ml/m2) RV ejection fraction (%) Right atrial area (cm2) RV systolic pressure (mm Hg) Qp/Qs ratio
Baseline 209 120 123 70 44 28 42 2.5
⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾
60 34 54 30 14 12 21 1.0
1 Day 163 93 107 60 38 26 44 1.4
⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾
46 27 45 25 13 10 19 0.3
1 Month 146 84 97 56 37 21 40 1.2
⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾
35 22 31 19 11 8 18 0.2
6 Months
p Value
⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾
⬍0.0001 ⬍0.0001 ⬍0.0001 ⬍0.0001 0.08 ⬍0.0001 0.08 ⬍0.0001
123 71 80 46 37 20 35 1.1
32 19 27 16 12 8 13 0.2
Values are means ⫾ 1 SD.
the right ventricle, and there are no clear landmarks to ensure that this dimension is measured in the same anatomic location across serial studies. We used an ellipsoidal shell model to calculate RV volumes. This model is conceptually simple and has been validated against magnetic resonance imaging.11,12 The development of real-time 3-dimensional echocardiography might offer even more accurate assessment of right-sided chamber volumes18 but was not available to us when this study was initiated. Nevertheless, the measurement of RV volumes in this study allowed much more confidence than the measurement of a simple linear dimension. In pediatric patients, the volume overload imposed by ASDs has been present for only a few years and is expected to be reversible. In adults, RV dilation is long standing and may not resolve after surgical correction.2– 4 This study demonstrated pronounced reduction in RV volume ⬍24 hours after successful transcatheter ASD closure in adults. RV volumes continued to improve for up to 6 months, suggesting an ongoing remodeling process that is not explained solely by the prompt resolution of paradoxic septal motion. Right atrial areas also decreased significantly over time, further supporting the finding that the amelioration of the left-to-right shunt by transcatheter ASD closure results in the favorable remodeling of the right-sided volume overload. Importantly, the temporal improvement in right-sided volume overload was evident in all 20 patients in this study. However, only 3 subjects had systolic pulmonary artery pressures ⬎60 mm Hg, so further investigation is needed in patients with pulmonary hypertension. We did not follow the patients for ⬎6 months, so it is not clear whether any further temporal improvement may have occurred. 1. Konstantinides S, Geibel A, Olschewski M, Gornandt L, Roskamm H, Spillner
G, Just H, Kasper W. Comparison of surgical and medical therapy for atrial septal defect in adults. N Engl J Med 1995;333:469 – 473.
2. Richmond DE, Lowe JB, Barratt-Boyes BG. Results of surgical repair of atrial
septal defects in the middle-aged and elderly. Thorax 1969;24:536 –542. 3. St. John Sutton MG, Tajik AJ, McGoon DC. Atrial septal defect in patients
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