Effectiveness of percutaneous device occlusion for atrial septal defect in adult patients with pulmonary hypertension

Abstract

Background Adult patients with atrial septal defect (ASD) and pulmonary hypertension have a more advanced degree of disease, frequently having functional class deterioration and atrial arrhythmias when they are aged >40 years. Surgery at this age prolongs life expectancy and limits functional deterioration. Although percutaneous ASD device occlusion is an accepted alternative to surgery, there is limited information on the immediate and long-term effects of device occlusion in middle-aged and elderly patients with ASD and pulmonary hypertension.Methods From a total of 101 patients with secundum ASD who were receiving treatment with percutaneous device occlusion, we selected for analysis 29 adult patients (mean age 56+/-14 years) with a baseline peak pulmonary pressure of >40 mm Hg (mean 65+/-23 mm Hg). Three of the patients had suprasystemic pulmonary pressure and a bidirectional shunt. Six patients were asymptomatic at treatment. The remaining 23 had different degrees of dyspnea; 14 of them had an advanced New York Heart Association functional class (III-IV). Twelve patients had chronic atrial fibrillation. At cardiac catheterization, the mean ratio of pulmonary to systemic flow was 1.8+/-0.5, and the pulmonary-to-systemic pressure ratio was 0.66+/-0.22. The mean diameter of the defect, as evaluated by the stretching balloon method, was 26+/-7 mm: All patients received an Amplatzer septal occluder (Golden Valley, Minn). Seven patients had combined therapeutic procedures for associated anomalies before the implant: mitral balloon valvuloplasty (n=1), stent coronary revascularization (n=1), stent in pulmonary vein stenosis (n=1), and internal catheter defibrillation (n=4). After treatment, patients were followed up by clinical and echocardiographic Doppler studies every 6 months.Results Immediately after the implantation, the peak systolic pulmonary pressure significantly decreased to 54+/-21 mm Hg (P<.001). A clear improvement in functional status was observed after the treatment in all symptomatic patients, especially in those with refractory heart failure. There were no major complications. Six patients who had atrial fibrillation at baseline study recovered to a stable sinus rhythm after treatment, and it was maintained at discharge. Complete ASD occlusion by echocardiographic Doppler at discharge was observed in 28 patients (97%). After a mean follow up of 21 +/- 14 months, clinical improvement persisted in all previously symptomatic patients, and the peak systolic pulmonary pressure, obtained by echocardiographic Doppler, further decreased to 31 +/- 11 mm Hg (P<.001) compared with baseline and immediately after hemodynamic measurements.Conclusions Our findings suggest that percutaneous device occlusion of ASD in adult patients with pulmonary hypertension is safe and effective and provides significant and prolonged relief.