Elsevier

Journal of Cardiac Failure

Volume 17, Issue 11, November 2011, Pages 957-963
Journal of Cardiac Failure

Review Article
Left Ventricular Function in Adult Patients With Atrial Septal Defect: Implication for Development of Heart Failure After Transcatheter Closure

https://doi.org/10.1016/j.cardfail.2011.07.003Get rights and content

Abstract

Despite advances in device closure for atrial septal defect (ASD), post-closure heart failure observed in adult patients remains a clinical problem. Although right heart volume overload is the fundamental pathophysiology in ASD, the post-closure heart failure characterized by acute pulmonary congestion is likely because of age-related left ventricular diastolic dysfunction, which is manifested by acute volume loading with ASD closure. Aging also appears to play important roles in the pathophysiology of heart failure through several mechanisms other than diastolic dysfunction, including ventricular systolic and vascular stiffening and increased incidence of comorbidities that significantly affect cardiovascular function. Recent studies suggested that accurate assessment of preclosure diastolic function, such as test ASD occlusion, may help identify high-risk patients for post-closure heart failure. Anti–heart failure therapy before device closure or the use of fenestrated device appears to be effective in preventing post-closure heart failure in the high-risk patients. However, the long-term outcome of such patients remains to be elucidated. Future studies are warranted to construct an algorithm to identify and treat patients at high risk for heart failure after device closure of ASD.

Section snippets

LV Function in ASD

Because ASD represents a hemodynamic abnormality of right ventricular (RV) volume overload induced by left-to-right shunt at the atrial level, LV function has been studied less extensively than the RV function. Nonetheless, a number of previous studies provided important information about LV mechanics in this disease that could be relevant to the mechanism(s) involved in the development of heart failure after device closure (Table 1).

Because the symptoms of heart failure after ASD closure are

LV Function after ASD Device Closure

Assessment of LV function after ASD device closure allows the identification of those factors that contribute to the impaired filling capacity in ASD and their importance in the pathophysiology of post-closure heart failure. To date, studies were limited to those factors related to changes in relaxation, but there seem to be some disagreement in their results.

Transesophageal echocardiography immediately before and after ASD device closure showed no significant changes in the early diastolic

Heart Failure After ASD Closure

As discussed previously, although reduced LV filling capacity appears to play a central role in the development of heart failure after device closure of ASD, diastolic function, both before and after ASD closure, is not necessarily uniform, and as such, heart failure after ASD closure does not occur in all patients. Therefore, it is important to identify patients at high risk of postprocedural heart failure before such procedure for a better management of such patients. The following section

Risk Factors of Post-closure Heart Failure and Their Detection

Based on the premise that LV diastolic dysfunction is an etiological factor in post-closure heart failure, it is reasonable to assume that the risk of development of post-closure heart failure increases with increased severity of the diastolic dysfunction. In this regard, our group demonstrated previously that the baseline e′ value (before ASD closure) is an independent predictor of brain natriuretic peptide levels after ASD closure.8 We also reported that 2 patients with the lowest e′ values

Management of High-risk Patients of Post-closure Heart Failure

After high-risk patients are identified, how should we manage them? Current management options of the high-risk patients for post-closure heart failure include anti–heart failure therapy before ASD closure and the use of fenestrated device. Schubert et al reported the usefulness of anti–congestive conditioning therapy, which consists of dopamine, milrinone, and intravenous furosemide, over 48 to 60 hours before definite ASD closure for patients with LV restriction, which was defined as mean

Summary

In a subgroup of aged patients, ASD closure is followed by pulmonary congestion, which is mainly the result of aging-related LV diastolic dysfunction, comprising increased diastolic stiffness and delayed relaxation. Advanced age per se also increases the risk of development of heart failure after ASD closure through changes in cardiovascular properties other than diastolic dysfunction, as well as increased incidence of comorbidities that potentially affect cardiovascular function. The extremely

Disclosures

None.

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  • Cited by (0)

    A national grant (no. 8025127) from the Japan Society for the Promotion of Science and Medical Research (H.S.), grants from Nipro Corporation (H.S.), Kawano Memorial Foundation (H.S.), Saitama Medical University Internal Grant (No. 212208, H.S.), and Tenshindo Medical Institution (Dr. Senzaki). Supported by grants from Nipro Corporation (H.S.), Kawano Memorial Foundation (No. 10-3, H.S.), Saitama Medical University Internal Grant (No. 212208, H.S.), and Tensindo Medical Institution (H.S.).

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