Patients who are older and have systolic, diastolic, and renal dysfunction may benefit from peri-interventional preload reduction therapy before implantation of larger left atrial devices, according to a study published in the Journal of Interventional Cardiology.

Patients (N=78; mean age, 49.8±15.0 years; 65% women) undergoing percutaneous device closure of an atrial septal defect (ASD) at Gangnam Severance Hospital in South Korea were recruited for this study. Patients were assessed by clinical, transesophageal, and transthoracic echocardiography at baseline, and at 1 day and 1 year after procedure.

In this cohort, the average estimated glomerular filtration rate was 99.4±20.0 mL/min, mean left ventricular ejection fraction was 66.1%±6.4%, mean left ventricular mass index was 63.3±16.3 g/m2, defects had a maximal diameter of 20.2±6.0 mm, average defect area was 2.57±1.52 cm2, and average septal occluder size was 23.8±6.4 mm. A total of 4 patients had more than 1 defect.


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E/e’ ratio and left atrial volume index were found to increase immediately after procedure (P <.001 and P =.025, respectively) but to decrease at 1-year, remaining unchanged from baseline (P =.058 and P =.600, respectively). Tricuspid regurgitation decreased at day 1 (P <.001) and continued to decline 1 year after the procedure (P =.003). Left ventricular stroke volume significantly increased at day 1 (P <.001) and continued to increase 1 year after intervention, remaining significantly elevated compared with baseline (P =.015).

Change in E/e’ ratio at day 1 was found to positively correlated with left ventricular end-diastolic elastance (r=0.480; P <.001), and changes in left atrial volume index (r=0.424; P <.001), tricuspid regurgitant velocity (r=0.332; P =.004), defect area (r=0.309; P =.008), maximal defect diameter (r=0.248; P =.032), and defect device diameter (r=0.248; P =.033), and to negatively correlate with preclosure E/e’ (r=-0.359; P =.002).

Both patients who had an increase and a decrease in pulmonary arterial systolic pressure (PASP; n=21 and n=55, respectively) immediately after the procedure still had reduced PASP 1 year after device closure compared with baseline (P =.025 and P <.001, respectively).

Patients who had decreased PASP at day 1 were significantly younger (P =.022) with lower blood urea nitrogen (P =.046) and left atrial volume index (P =.046) and significantly higher tricuspid regurgitant velocity (P =.004), e’ (P =.013), left ventricular ejection fraction (P =.015), PASP (row 19 P =.016), estimated glomerular filtration rate (P =.018), and systolic blood pressure (P =.027).

This study could not fully determine to which extent the initial increase in PASP observed in some patients was due to the device.

“In older patients with impaired LV relaxation, systolic dysfunction, renal dysfunction, or larger [left atrial] size, PASP could paradoxically increase after device closure of [atrial septal defect] due to the immediate volume overload to a noncompliant left ventricle and left atrium. Therefore, periprocedural preload manipulation, such as diuretics, is recommended in patients with these risk factors who are scheduled to close a larger defect,” concluded the study authors.

Reference

Shin C, Yoon Y W, Kim I-S, et al. Effect of Renal and Left Ventricular Function on Serial Pulmonary Arterial Pressure Changes after Device Closure of Atrial Septal Defect. J Interv Cardiol. 2021;2021:8846656. doi:10.1155/2021/8846656