| Part One.Risk Factors of Atrial Flutter and Fibrillation Before and After Transcatheter Closure of Secundum Atrial Septal Defect and Geometric Change of Left Atrium after ClosureObjective Atrial flutter and fibrillation(AFF) is one of the most common complications in patients with atrial septal defect (ASD) aged over40years old. Open surgery is demonstrated to fail to reduce the incidence of AFF in patients aged over40years old in several researches. This article is to observe the prevalence and evaluate risk factors of AFF in patients aged40years old before and after transcatheter closure of secundum ASD within one year.Methods Between February2009and February2011,216consecutive patients aged over40years old who underwent transcatheter closure of secundum ASD in Zhongshan Hospital affliated to Fudan University were included. Perioperative data collected included basic clinical character and previous history of AFF,the result of regular12-lead electrocardiogram (ECG),24-hour dynamic electrocardiogram(Holter) and transthoracic echocardiography (TTE) parameters in right catheterization and transcatheter closure. After closure, X-ray,ECG and TTE were repeated in1day,1month,3month,6month,12month. Patients with the symptoms of palpitation but normal ECG were further checked via Holter.Risk factors for AFF were determined with uivariate and multivariate logistic regression analysis.Results Among216patients involved in the study,31(14.4%) patients had the history of AFF, including11(5.2%) patients with persistent atrial fibrillation,17patients with paroxysmal flutter(7.9%) and3patients with paroxysmal flutter(1.4%).Compared to patients without AFF, patients who had AFF before closure were older(62.1±8.7vs51.8±8.1years, p<0.001)), had higher degree of NYHA classification (p<0.001), higher incidence of hypertension(38.7%vs18.9%, p=0.013), larger diameter of left atrium (LAD)(47.6±6.9vs37.8±5.0mm, p=0.001), larger defect(23.5±8.3vs18.9±7.4mm), higher estimated systolic pulmonary arterial pressue via TTE(PAPs)(54.7±15.6vs45.2±12.2mmHg, p<0.001), higher degree of mitral regurgitation(p<0.001)and tricuspid regurgitation (p<0.001).Multivariate analysis showed that left atrial enlargement(OR5.776per10mm increment,95%CI2.363-14.124, p<0.001)were independent risk factor of AFF before closure. The incidence of AFF after closure was13.4%, insignificantly lower than the incidence before closure (P=0.781).11patients with persistant atrial fibrillation preoperatively had persistant atrial fibrillation postoperatively. Among20patients with paroxysmal AFF preoperatively,3(15%) patients turned to persistant atrial fibrillation,6(30%) patients had recurrence of paroxysmal atrial fibrillation,11(55%) patients maintained sinus rhythm. Among185patients without AFF preoperatively,7patients had AFF within6months after closure, another2patients had AFF7and8months after closure respectively. Compared to those who matained sinus rhythm in this group, patients who had AFF were older (59.6±5.9vs51.4±8.1years, p=0.003).The total216patients involved in the study were divided into2groups according to EKG or Holter postoperatively:AFF group and no AFF group. AFF group were older(62.0±7.9vs51.9±8.4years, p<0.001),had higher degree of NYHA classification(p<0.001), higher incidence of preoperative AFF (69.0%vs5.9%,P<0.001) and hypertension(44.4%vs18.7%, p=0.006), larger LAD(46.5±7.5vs37.8±5.3mm,P<0.001), larger ASD (23.4±8.6vs19.0±7.4mm,P=0.004),higher degree of mitral regurgitation(P<0.001) and tricuspid regurgitation (p<0.001),lower LVEF(64.9±5.8%vs67.7±5.4, p=0.012) higher PAPm(27.1±9.4vs18.5±6.1mmHg,P<0.001) via right heart catheterization and larger occluder(29.7±9.0vs24.9±7.5,P=0.002). Multivariate analysis showed the history of AFF(OR16.949,95%CI4.171-68.879, p<0.001) was independent predictor of AFF after closure. Both AFF and no AFF group postoperatively demonstrated no significant change of LAD within6months after closure (p=0.181,p=0.450).Conclusion Incidence of AFF was similar before and after transcatheter closure of secundum ASD in patients aged over40years. Patients postoperatively usually had AFF within6months. The enlargement of LA was independent risk factor of AFF in ASD patients aged over40years before closure. The history of AFF was independent predictor of AFF in ASD patients over40years after transcatheter closure. Both AFF and no AFF group postoperatively demonstrated no significant change of LAD within6months after closure. Part2. Efficacy and Safety of Transcatheter Closure of Secundum Atrial Septal Defect with Severe Pulmonary HypertensionObjective Transcatheter occlusion of atrial septal defect(ASD) with mild or moderate pulmonary arterial hypertension(PAH) is demonstrated to be safe and effective.This article is to evaluate the safety and efficacy of transcatheter closure of secundum ASD with severe PAH with or without combined specific drug postoperatively.Methods Between October2010and October2011,6secundum ASD patients with severe PAH were included in this study.Trial occlusion was performed in all the patients.Occluder was released in patients with positive result of trial occlusion. Vasoreactivity test by inhaled aerosolized iloprost was further performed in patients with negative result of trial occlusion.Occluder was released with significant decrease of pulmonary vascular resistance(PVR) or positive result of vasoreactivity test. Specific drugs sildenafil or(and) iloprost were administrated to patients with negative result of trial occlusion after closure. X-ray, electrocardiogram(ECG), and transthoracic echocardiography(TTE) were repeated in1day,1month,3month,6month,12month.Results Six patients,1male,5female, aged49.5±12.9, were included in this study. The diameter of ASD via TTE was28.0±5.5mm.Systolic pulmonary arterial pressure(PAPs), mean pulmonary arterial pressure(PAPm) and pulmonary vascular resistance(PVR)measeured by right heart catheterization(RHC) were91±8.4mmHg,49.5±4.2mmHg,524.3±124.6dn-s/cm5respectively.One patient with38mm ASD showed significant decrease of PAPm from46mmHg to30mmHg after trial occlusion and occluder was released directly.The other five patients with insignificant decrease or increase of PAPm during trial occlusion underwent vasoreactive test.Four patients showed positive results and one patients showed significant decrease of PVR although PAPm was still over40mmHg.ASD in these five patients were all successfully closed without complications.After closure,one patients was administrated with sildenafil and the other four with iloprost.After mean follow-up of11±6.7months,all the patients showed improved cardiac function and significant decrease of PAPs via TTE(63.8±7.2vs95.8±20.4, p<0.001)3months after closure.Conclusion Transcather closure combined with specific drugs was safe and effective in secundum ASD patients with severe hypertension under the condition of significant decrease of PVR and positive vasoreactive test after trial occlusion. |
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