Evidence of adverse ventricular interdependence in patients with atrial septal defects

doi:10.1016/j.amjcard.2004.02.033

The American Journal of Cardiology

Volume 93, Issue 11, 1 June 2004, Pages 1374-1377

https://doi.org/10.1016/j.amjcard.2004.02.033 Get rights and content

Abstract

Right ventricular (RV) volume overload is associated with left ventricular (LV) distortion and dysfunction. The availability of transcatheter device closure of secundum atrial septal defect (ASD) provides an ideal model for investigating the immediate effects of elimination of RV volume overload and avoiding the confounding effects of surgery on LV function. Echocardiograms before and after device closure of ASD were analyzed for ejection fraction, percent changes in cross-sectional area and circumference, percent changes in free wall and septal endocardial lengths, and eccentricity. We enrolled 34 patients (median age 9 years) who underwent device closure of ASD (pulmonary to systemic shunt 1.6 ± 0.4). Ejection fraction and LV end-diastolic volume, reflective of chamber preload, were significantly decreased in the presence of RV volume overload and normalized after defect closure with normalization of LV shape. Altered LV geometry secondary to RV volume overload was associated with regional variation in preload,such that diastolic circumference, a surrogate of myofiber preload, increased after closure of ASD secondary to a small increase in LV free wall arc length in conjunction with a much more significant increase in septal length. Thus, LV dysfunction associated with RV volume overload is secondary to altered chamber geometry and decreased myofiber preload. This physiology is immediately reversible and is independent of heart rate and afterload.

Section snippets

Patients

All patients between 3 and 30 years old who had device closure of an ASD at Boston Children's Hospital (Boston, Massachusetts) performed between March 1997 and March 2000 were identified. Inclusion criteria included (1) isolated secundum-type ASD ≥4 mm, (2) a transthoracic echocardiogram at our institution before the procedure and a postprocedure echocardiogram within 48 hours of device placement, (3) recording of images from the transverse apical and parasternal short-axis views adequate for

Patient characteristics

Forty-five patients met our inclusion criteria, but 11 were excluded due to no transthoracic echocardiogram before device closure at our institution (n = 4) and inadequate echocardiograms for required data (i.e., poor endocardial definition; n = 7). Table 2 lists the baseline characteristics of our study sample.

Hemodynamic characteristics

There were no significant differences in body surface area, mean heart rate, or blood pressure before and after device closure of the ASD (Table 3).

Echocardiographic measurements

Comparison of results before and

Discussion

Our study supports the occurrence of adverse ventricular interdependence associated with RV volume overload. One of the first descriptions of this relation was proposed by Dexter,12 who described the “reverse Bernheim's effect” in which the septum bulges into and encroaches on the LV cavity and leads to impairment of LV filling. The right ventricle is also more compliant than the left ventricle, so the left ventricle is relatively underfilled. This ventricular interdependence has been well

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Quantitative assessment of biventricular function in atrial septal defect (ASD) patients before and after closure remains debatable. This study aimed to assess the global biventricular strain in ASD patients before and 24 h and one month after transcatheter and surgical closure.
Standard Two-Dimensional (2D)-echocardiography and strain imaging were done for sixty ASD patients before, and 24 h and one month after correction by surgery or transcatheter intervention. Also, all echocardiographic and strain parameters for twenty age-matched controls were included. 2D- Strain (S) imaging was measured by speckle tracking analysis.
Right ventricle global longitudinal systolic strain (RV GLSS) was significantly reduced after 24 h of ASD closure in both device and surgical groups. The reduction in RV GLSS was greater in the surgical group (8.00 ± 1.76% vs 2.60 ± 0.72%, P = 0.004). Left ventricle global longitudinal systolic strain (LV GLSS) showed a statistically significant decline after 24 h of device closure (from −24.47 ± 0.57% to −23.14 ± 0.65%, p = 0.048) followed by a significant increase in LV GLSS (from-23.14 ± 0.65% to −24.15 ± 0.75%, p = 0.038) after 1 month.
The ASD closure had a rapid impact on geometric and functional changes of both ventricles regardless of the way of closure. Interestingly, the rate of improvement in LV-GLSS was higher after device closure than a surgical one within one month follows.
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Citation Excerpt :
One study confirmed an association between myocardial fibrosis and supraventricular arrhythmias in this population and suggests that chronic RV volume overload contributes to the development of said fibrosis.15 Characterized by a large ventricular septal defect with overriding aorta, obstruction of pulmonary blood flow, and RV hypertrophy, TOF is among the most common cyanotic congenital cardiac defects.6 Among the first lesions to be corrected surgically, TOF represents a model not only of the impact of abnormal physiology of the defect, but also of repair physiology.
Assessment of right atrial function with speckle tracking echocardiography after percutaneous closure of an atrial septal defect
2017, Revista Portuguesa de Cardiologia
Speckle tracking echocardiography (STE) for two-dimensional (2D) strain analysis is a new tool to assess myocardial function. The aim of this study was to assess right atrial (RA) function using STE in patients with an atrial septal defect (ASD) before and one month after percutaneous closure.
We prospectively examined 32 consecutive patients (nine male, 23 female) who underwent percutaneous transcatheter closure of a secundum ASD between June 2013 and December 2015. Echocardiography was performed on admission, prior to cardiac catheterization and then one month after ASD closure. Peak global RA longitudinal strain was analyzed by 2D-STE.
Patients’ mean age was 34.6±8.2 years. The mean diameter of the occlusive devices was 18.5±7.5 mm. Right ventricular (RV) end-diastolic diameters were significantly increased but decreased significantly after ASD closure (43±5 vs. 38±4 mm, p<0.05). Left atrial (LA) diameters (40±8 vs. 37±6 mm, p<0.05) decreased significantly after the intervention, whereas left ventricular (LV) end-diastolic diameters (45±5 vs. 46±4 mm, NS) remained unchanged. Tricuspid annular plane systolic excursion increased significantly (17.6±5.4 vs. 22.3±8.1 mm, p<0.05). After closure of the defect, a significant increase was observed in longitudinal RA strain (26.5±9.6% vs. 35.3±10.5%, p<0.001).
After percutaneous transcatheter closure of a secundum ASD, there was an increase in RA longitudinal strain. 2D-STE strain analysis appears to be helpful for the assessment of RA function and of response to correction of volume overload after percutaneous transcatheter closure of a secundum ASD.
O speckle tracking por ecocardiograma (STE) ou a avaliação do strain em 2 D são novas ferramentas para a avaliação da função miocárdica. O objetivo deste estudo foi avaliar a função da aurícula direita (AD) com o uso de STE em doentes com comunicação interauricular antes e um mês após o encerramento percutâneo.
Avaliamos prospetivamente 32 doentes consecutivos (nove homens, 23 mulheres) submetidos a encerramento percutâneo de comunicação interauricular (CIA) do tipo ostium secundum, entre junho de 2013 e dezembro de 2015. O ecocardiograma foi feito previamente ao procedimento e um mês após o encerramento da CIA. Foi avaliado o strain longitudinal global da AD (RALS) por 2D-STE.
A idade média dos doentes foi de 34,6±8,2 anos. O diâmetro médio dos dispositivos empregados foi de 18,5±7,5 mm. Os diâmetros telediastólicos do ventrículo direito (VD) eram significativamente maiores e diminuíram após encerramento da CIA (43±5 versus 38±4 mm, p<0,05). O diâmetro da aurícula esquerda (AE) diminuiu significativamente após a intervenção (40±8 versus 37±6 mm, p<0,05), enquanto que o diâmetro telediastólico do ventrículo esquerdo permaneceu igual (45±5 versus 46±4 mm, NS). O TAPSE aumentou significativamente (17,6±5,4 versus 22,3±8,1 mm, p<0,05). Observamos ainda uma subida significativa do strain longitudinal da AD (26,5±9,6% versus 35,3±10,5%, p<0,001).
Após encerramento percutâneo de CIA ostium secundum, observou-se um aumento significativo do strain longitudinal global da AD.
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Current preclinical models of pulmonary arterial hypertension do not reproduce the clinical characteristics of congenital heart anomalies. Aortocaval shunt is relevant to a variety of clinical conditions. The pathophysiology and possible determination of pulmonary hypertension in this model are still undefined.
A method to create a standardized and reproducible aortocaval shunt was developed in rats. After creation of the shunt, the animals were followed up for 20 weeks and a sham laparotomy was used as a control. The chronic effects of volume overload on the right and left ventricles and pulmonary hemodynamic modifications were evaluated by biventricular catheterization, echocardiography, and magnetic resonance. Pulmonary vascular changes were defined by histology.
An increased right ventricular end-diastolic area was confirmed by echocardiography. Left ventricular overload and decreased biventricular ejection fraction were demonstrated by magnetic resonance after 20 weeks in the shunt group compared with the controls (left ventricle, 50% ± 5% vs 62% ± 3%, P = .029; right ventricle, 53% ± 2% vs 65% ± 2%, P = .036). Preload recruitable stroke work of left and right ventricles decreased after 20 weeks in shunt rats (left ventricle: 36 ± 7 vs 98 ± 5, P = .004; right ventricle: 19 ± 2 vs 32 ± 9, P = .047). At the same time point, catheterization showed that effective pulmonary arterial elastance was increased only in the shunt group (1.29 ± 0.20 vs 0.14 ± 0.06 mm Hg/μL; P = .004). Histology showed medial hypertrophy, small artery luminal narrowing, and occlusion.
The aortocaval shunt model reliably produces right ventricular volume overload and secondary pulmonary hypertension. Due to a combination of left ventricular dysfunction and pulmonary overflow, the pulmonary hypertension produced shows features similar to those found in patients with chronic atrial-level shunt.
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Evidence of adverse ventricular interdependence in patients with atrial septal defects

Abstract

Section snippets

Patients

Patient characteristics

Hemodynamic characteristics

Echocardiographic measurements

Discussion

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