Images: Raghib complex

Raghib complex:
Persistent LSVC to LA
Absent Coronary sinus (considered unroofed)
ASD at the inferior part of atrial septum
JACC 2022;57:e15 (Images in Cardiology)

Cath lab: Outcome of ASD created by Transseptal puncture

The Incidence and Long-Term Clinical Outcome of Iatrogenic Atrial Septal Defects Secondary to Transseptal Catheterization with a 12Fr Transseptal Sheath

1. Sheldon M. Singh1*,
2. Pamela S. Douglas2 and
3. Vivek Y. Reddy1

1. ¹ Mount Sinai School of Medicine, New York, NY;
2. ² Duke Clinical Research Institute, Durham,

Abstract

Background—Studies assessing the presence of a residual iatrogenic atrial septal defect (iASD) after transseptal catheterization with 8Fr transseptal sheaths have suggested that the majority of these iASD close within 6 months. However, these studies have been limited by small patient numbers and short follow-up. Additionally, there are a number of novel catheter procedures in interventional cardiology and electrophysiology that employ larger transseptal sheaths. The objective of this study was to assess the incidence of and complications associated with iASD in a large cohort of patients undergoing transseptal catheterization with a 12Fr transseptal sheath.

Methods and Results—253 patients without a pre-existing inter-atrial shunt undergoing WATCHMAN implantation as part of the PROTECT AF study were included in this current study. Patients underwent transesophageal echocardiography (TEE) with echo-contrast immediately post-procedure, 45-days, 6 months, and 12 months. 87% of patients had an iASD immediately post-procedure, the majority of which sealed by 6 months (incidence of iASD - 34% at 45 days, 11% at 6 months, 7% at 12 months). While the majority of iASDs were >3mm in diameter immediately post-procedure, the minority of iASD were >3mm during the follow-up period. Additionally, inter-atrial shunting was predominantly left-to-right when an iASD was present. There was no significant difference in the rate of stroke and/or systemic embolism during the follow up period in patients with or without iASD.

Conclusions—Transseptal catheterization procedures with a large diameter transseptal sheath have a high spontaneous closure rate of iASD, and is not associated with an increased rate of stroke / systemic embolization during long-term follow-up.

• Received July 29, 2010.
• Accepted December 20, 2010.

Closure of ASD in adults

Benefit of Atrial Septal Defect Closure in Adults: Impact of Age
Humenberger M, Rosenhek R, Gabriel, et al.
Eur Heart J 2010;Oct 12:[Epub ahead of print].

Comments (3)Study Question:
What is the effect of age on the clinical benefit of atrial septal defect (ASD) closure in adults?
Methods:
A cohort of 236 patients undergoing transcatheter ASD closure at a single center was studied. Patients were divided into three groups based on age.
Group A included patients younger than age 40 (n = 78),
Group B included patients ages 40-60 (n = 84), and
Group C included patients older than 60 years (n = 74).
Pulmonary pressures, right ventricular size, and symptoms were assessed before and after device closure.

Results:
The mean age for the entire cohort was 49 ± 18 years. There was no difference in defect size (median 22 mm; interquartile range, 19-26 mm) or shunt ratio (Qp:Qs 2.2; interquartile range, 1.7-2.9). Pulmonary pressure and right ventricular size were significantly related to age. Right ventricular size (by two-dimensional echocardiogram measures) decreased in all groups. Post-procedure, the systolic pulmonary artery pressure (PAP) decreased from 31 ± 7 to 26 ± 5 mm Hg in group A, 37 ± 10 to 30 ± 6 mm Hg in group B, and 53 ± 17 to 43 ± 14 mm Hg in group C (p < 0.0001). Absolute changes in right ventricular size and PAP did not differ between the groups. Symptoms were present in 13%, 49%, and 83% of patients prior to the procedure, and 3%, 11%, and 34% of patients after the procedure in groups A, B, and C, respectively. Functional status was related to PAP.
Conclusions:
At any age, ASD closure is followed by symptomatic improvement, and decrease in right ventricular size and PAP.

Perspective:
Closure of ASD in adults of advancing age has long been an area of controversy in congenital cardiology. Most studies comparing defect closure with conservative management were done in the era of surgical closure and did not convincingly demonstrate a survival benefit. Most studies, including this one, demonstrate significant improvement in symptoms after closure of ASD. The impact on atrial arrhythmias is less clear. The minimal mortality and overall low complication rate of device closure make it an attractive option for older adults who may have multiple comorbidities. This study supports closure of ASDs in older adults, particularly for symptomatic relief. As patients with long-standing ASD may not appreciate their level of symptomatology, all patients with significant ASD should be strongly considered for device closure.
Author(s):
Timothy B. Cotts, M.D., F.A.C.C.

Echo: 3D imaging of ASD & Right Atrium

Anatomy of Right Atrial Structures by Real-Time 3D Transesophageal Echocardiography
Francesco F. Faletra, Siew Y. Ho, and Angelo Auricchio
J Am Coll Cardiol Img 2010;3 966-975

3D Echocardiography of the Atrial Septum: Anatomical Features and Landmarks for the Echocardiographer
Kuberan Pushparajah, Owen I. Miller, and John M. Simpson
J Am Coll Cardiol Img 2010;3 981-984