Fate of iatrogenic atrial septal defects following mitral transcatheter edge-to-edge repair - a subanalysis of the MITHRAS trial

Stephan Blazek, Matthias Unterhuber, Karl-Philipp Rommel, Karl-Patrik Kresoja, Tobias Kister, Christian Besler, Karl Fengler, Sebastian Rosch, Ingo Daehnert, Holger Thiele, Philipp Lurz, Maximilian von Roeder, Stephan Blazek, Matthias Unterhuber, Karl-Philipp Rommel, Karl-Patrik Kresoja, Tobias Kister, Christian Besler, Karl Fengler, Sebastian Rosch, Ingo Daehnert, Holger Thiele, Philipp Lurz, Maximilian von Roeder

Abstract

Persisting iatrogenic atrial septal defects (iASD) after transcatheter mitral edge-to-edge repair (M-TEER) are associated with impaired outcomes. We investigated the natural history of relevant iASDs with left-to-right shunting post-M-TEER, predictors of spontaneous closure of iASD between 1 and 6 months post-M-TEER, and outcomes (heart failure [HF] hospitalization) in patients with spontaneous closure versus those with persistent iASD 6 months post-M-TEER. Patients with a relevant iASD 1-month post-M-TEER, who were treated conservatively in the randomized controlled MITHRAS trial, underwent clinical follow-up including transesophageal echocardiography 6 months post-M-TEER. Overall, 36 patients (median 77 [interquartile range 65-81] years; 36% women) completed the 6-months follow-up. Six (17%) patients had a spontaneous closure of the iASD. The eccentricity index of the iASD 1-month after M-TEER was the strongest predictor for spontaneous closure (Odds ratio 3.78; 95% confidence interval 1.26-11.33, p = 0.01) and an eccentricity index of < 1.9 provided a sensitivity of 77% at a specificity of 83% for iASD persistence (Area under the curve 0.83, p < 0.001) within 6-months post M-TEER.At follow-up, a numerical difference in the endpoint of HF hospitalization between the spontaneous closure and the residual shunt group (0% vs. 20%, p = 0.25) was observed. The eccentricity of the iASD was the strongest predictor for spontaneous closure at 1-months and an eccentricity index of < 1.9 is associated with a high persistence rate for 6 month after M-TEER. Clinical Trial Registration ClinicalTrials.gov https://ichgcp.net/clinical-trials-registry/NCT03024268 Identifier: NCT03024268. a (red) is reflecting the mayor lengthwise dimension and b (blue) the mayor oblique dimension. The eccentricity index is calculated by dividing a through b. (Open circle) is depicting an example for a round iASD and (Open rhombus) an example for an eccentric iASD 1 month after M-TEER.

Keywords: Atrial septal defect; Closure; Heart failure; Shunt; Transcatheter mitral valve edge-to-edge repair.

Conflict of interest statement

The authors declare no competing interests.

PL has received institutional fees and research grants from Abbott Vascular, Edwards Lifescience, Medtronic, ReCor and Occlutech. The other authors have nothing to disclose.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
Comparison of echocardiographic characteristics of the iASD 1 month after M-TEER between the spontaneous iASD closure and iASD persistence group. Differences in transesophageal echocardiographic iASD characterization 1 month after M-TEER between patients with spontaneous iASD closure vs. iASD persistence at 6 months post-M-TEER p-values derived from ANOVAs or Mann Whitney U tests. Abbreviations: iASD: iatrogenic atrial septal defect, Qp: pulmonary perfusion, Qs: systemic perfusion, M-TEER: mitral transcatheter edge-to-edge repair
Fig. 2
Fig. 2
Receiver-operator curves on eccentricity index for iASD persistence. An eccentricity index of 

Fig. 3

Kaplan–Meier survival curves for endpoint…

Fig. 3

Kaplan–Meier survival curves for endpoint of heart failure hospitalization at 6-month follow-up post…

Fig. 3
Kaplan–Meier survival curves for endpoint of heart failure hospitalization at 6-month follow-up post M-TEER. Kaplan–Meier estimated event rates in the spontaneous iASD closure and the residual shunt group for the time to the endpoint of heart failure hospitalization. Abbreviations: iASD: iatrogenic atrial septal defect
Fig. 3
Fig. 3
Kaplan–Meier survival curves for endpoint of heart failure hospitalization at 6-month follow-up post M-TEER. Kaplan–Meier estimated event rates in the spontaneous iASD closure and the residual shunt group for the time to the endpoint of heart failure hospitalization. Abbreviations: iASD: iatrogenic atrial septal defect

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