| Background:Atrial Septal Defect(ASD)is one of the most common adult congenital heart diseases(CHD)in clinical practice,accounting for about 20% ～ 30% of adult CHD,of which the vast majority are ostium secundum ASD.Previous studies have shown that the incidence of Atrial Fibrillation(AF)in ASD patients is high,and the incidence of AF in ASD patients over 40 years old is as high as over 20%.However,what is the occurrence of AF after ASD occlusion?The literature is less reported.In addition,AF in adult ASD patients not only affects the patient’s cardiac function,but also significantly increases the incidence of cardiogenic stroke.Left Atrial Appendage Closure(LAAC)is a new technology to prevent the occurrence of non-valvular AF stroke,and numerous clinical studies in recent years have confirmed that LAAC is safe and effective in preventing stroke in patients with non-valvular AF.For patients with ostium secundum ASD combined with AF,is it feasible to perform the "one-stop" treatment of ostium secundum ASD occlusion and LAAC at the same time? What about postoperative antithrombotic therapy? It’s not entirely clear.The purpose of this study was to investigate the incidence and related risk factors of AF in patients with ostium secundum ASD before and after transcatheter occlusion through retrospective analysis of hospitalized cases in our department,and to explore the safety,effectiveness and postoperative antithrombotic treatment strategies of ostium secundum ASD occlusion plus LAAC "one-stop" treatment.Method:This study was divided into two parts,with specific research methods as follows:1.Patients over 40 years old with ostium secundum ASD who were admitted to our hospital from August 2014 to June 2021 and received transcatheter interventional occlusion were selected as the study objects.General information and related examination data of patients were collected from the hospital medical record database for statistical analysis.They were divided into ASD with AF group and ASD sinus rhythm group according to whether there was AF before interventional occlusion.According to whether there was any new-onset AF during the follow-up period,the patients were divided into the new new-onset AF group and the sinus rhythm group.The clinical data of ASD with AF group,new-onset AF group after ASD occlusion and corresponding sinus rhythm group were compared.2.Patients admitted to our department from September 2015 to June 2021 and receiving ostium secundum ASD occlusion plus "one-stop" LAAC treatment were selected as the study group,and AF patients of the same gender,similar age(±5 years old)and similar postoperative antithrombotic therapy who received LAAC treatment in our hospital during the same period were selected as the control group.Both groups underwent Transesophageal Echocardiography(TEE)detection within 3 days before occlusion and 45 to 60 days after occlusion.Follow-up was conducted at 45-60 days,3,6,and 12 months after closure,and then annually.Electrocardiogram(ECG)and Transthoracic Echocardiogram(TTE)should also be performed during follow-up in addition to routine physical examination.The relevant clinical data,occluder size,exposed occluder area,postoperative antithrombotic drug and follow-up results were compared between the two groups.Result:1.Analysis of AF incidence and related factors in patients with ostium secundum ASD before and after interventional occlusion:(1)A total of 280 patients with ostium secundum ASD over 40 years old were included in this study,including 75 males(26.79%)and 205 females(73.21%),whose mean age was54.51±10.02(40-83)years old.(2)The incidence of AF before ASD intervention was 16.07%(45/280).Analysis of the factors related to the occurrence of AF showed that: Compared with ASD sinus rhythm group,Patients with ASD and AF were older(P < 0.001),more male(P=0.004),less platelet count(P < 0.001),lower total cholesterol level(P=0.008),lower HDL cholesterol level(P=0.033),and significantly higher proportion of NYHA patients with cardiac function grade Ⅱ or above(P=0.004),increased Left Atrium(LA)internal diameter(P < 0.001),increased Right atrium(RA)internal diameter(P<0.001),Left Ventricular Ejection Fraction(LVEF)was significantly decreased(P< 0.001),and Right Ventricular Systolic Pressure(RVSP)was significantly increased(P< 0.001).Logistic regression analysis indicated that age,the dilated LA,NYHA cardiac function grade ≥Ⅱ,and the increase of RVSP were the risk factors for AF.(3)There were 235 patients with ASD of sinus rhythm before interventional occlusion,and 15 patients(6.38%)were newly diagnosed with AF during the average follow-up period of 42.40±23.98 months after occlusion.Compared with sinus rhythm group,the newly diagnosed AF patients after interventional occlusion showed that they were older(P < 0.001),had a larger internal diameter of LA(P=0.008),had a larger internal diameter of RA(P=0.003),and had a larger internal diameter of Right ventricular(RV).LVEF was lower(P=0.004).Logistic regression analysis indicated that age was the main risk factor for new-onset AF after interventional occlusion in ASD patients.2.Ostium secundum ASD occlusion +LAAC "one-stop" treatment research:(1)A total of 67 patients in the "one-stop" occlusion treatment group were included in this study,including 31 males(46.27%)and 36 females(53.73%),with an average age of60.94±10.69 years.67 LAAC patients with the same gender and similar age were selected as the control group,including 31 males(46.27%)and 36 females(53.73%),with an average age of 61.60±10.73 years.(2)There was no significant difference in the basic data between the two groups.(3)Comparison of preoperative TTE and TEE examination data between the two groups:Compared with LAAC alone,the internal diameter of LA was smaller(P=0.004)and left ventricular(LV)internal diameter was smaller(P<0.001).The RA diameter was larger(p=0.046),the RV diameter was larger(P<0.001)and the estimated Pulmonary Artery Systolic Pressure(PASP)was larger(P< 0.001).(4)Comparison of intraoperative data between the two groups: patients in the "one-stop" treatment group had a higher RVSP(P=0.027)and a larger total area of exposed occluder(p <0.001)than those in the LAAC group alone.(5)Postoperative antithrombotic drug use and follow-up results in 2 groups:(1)Postoperative antithrombotic regiments of the two groups were similar: 16 cases(23.88%)of warfarin,20 cases(29.85%)of non-vitamin k inhibitor oral anticoagulant(NOAC)regiments,31 cases(46.27%)of dual antiplatelet regiments.In the "one-stop" treatment group,DRT was observed on the surface of the LAA occluder in 1 patient(1.49%)who received oral NOAC anticoagulant therapy after occlusion.In the LAAC group alone,DRT was observed on the surface of the LAA occluder in 2 patients(2.98%)during follow-up,1 patient was treated with oral rivaroxaban and the other with oral warfarin anticoagulation(the INR is not up to standard).(2)The TTE test data at 3 months after "one-stop" occlusion showed that the RA diameter decreased(P<0.001),RV diameter decreased(P<0.001)and estimated PASP decreased(P=0.001)at 3 months after the operation.The inner diameter of LV increased(P=0.002)and LVEF increased(P=0.017),while the inner diameter of LA was slightly larger,but there was no statistical significance.TTE test data at 6 months after "one-stop" occlusion showed that RA diameter decreased(P<0.001),RV diameter decreased(P<0.001)and estimated PASP decreased(P<0.001)at 6months after the operation.The inner diameter of LV increased(P<0.001)and LVEF increased(P=0.017),while the inner diameter of LA was slightly larger,but there was no statistical significance.Conclusion:1.The incidence of AF was higher in patients with ostium secundum ASD over 40 years old before and after interventional occlusion.Older age,enlarged atrial inner diameter,higher NYHA cardiac function grade and increased RVSP may be risk factors for the occurrence of AF,among which age is the main risk factor for new-onset AF after interventional occlusion in ASD patients.Therefore,ASD should be detected,diagnosed and treated as early as possible.2.The "one-stop" treatment of ASD occlusion combined with LAAC is feasible for patients with ostium secundum ASD at the same time,which can simplify the treatment strategy and has good clinical effect.Postoperative antithrombotic therapy can be used with warfarin,NOAC or dual antiplatelet drugs,but an individualized antithrombotic program should be developed according to the specific clinical characteristics of patients. |
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