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To the editor,
Atrial septal puncture, circumferential pulmonary vein vestibular isolation, left atrial appendage occlusion, atrial septal occlusion has become a fashion.1 But there's a problem. Atrial fibrillation.
How to solve atrial fibrillation after transcatheter closure of atrial septal defect?
The electrophysiological mechanism (focal trigger mechanism, multiple subwaves, etc.) and pathophysiological mechanism (electrical remodeling, systolic remodeling, structural remodeling, etc.) of atrial fibrillation (AF).Mechanism of AF in patients with atrial septal defect(ASD): Patients with ASD are prone to AF due to long-term excessive volume load on the atrium.The other mechanisms of AF after transcatheter closure include inflammatory reaction caused by local traction or stimulation, new reentry loop formed by occluder as electrical conduction barrier, morphological and functional changes of atrial matrix before transcatheter closure.
AF is a common complication of secundum ASD in adults. It is often caused by long-term expansion and remodeling of right atrium, and the prevalence increases with age. The presence of ASD changes the hemodynamics of the heart and leads to structural and electrical remodeling of the heart, which leads to the occurrence of AF. The occurrence of AF further aggravates the structural and electrical remodeling, forming a vicious circle.
AF often occurs in patients with atrial defect due to atrial enlargement and electrical mechanical remodeling, and the incidence of AF is still high even after atrial defect repair or interventional occlusion. Circumferential pulmonary vein isolation and fragmentation potential ablation have become the consensus of most surgeons.
Percutaneous ASD closure is a routine procedure to prevent right ventricular failure, pulmonary hypertension, or paradoxical embolism. AF is a common late complication in ASD patients even after occluder implantation.2ASD is a condition that requires early intervention because of the consequences over the right-side heart. Chronic atrial stretching promotes atrial conduction delay and the imbalance of the conduction homogeneity, which lead to the propensity to atrial arrhythmias.3Both E/e' and Left atrium volume index significantly increased immediately after device closure, but all decreased one-year later. Larger defect size and higher Tricuspid regurgitation velocity were significantly correlated with immediate E/e' elevation.4
Transcatheter ASD closure resulted in an early and persistent decrease in right ventricular systolic and diastolic function. Additionally, transcatheter ASD closure resulted in an early and sustained favourable response of left ventricular (LV) systolic function, but also in deterioration of LV diastolic function with an increase in LV filling pressure, as assessed by echocardiography.5
After transcatheter ASD closure, decrease in right ventricular size began rapidly and was followed by reduction of the QRS duration and PR interval within weeks.In both pediatric and adult ASD patients, electrocardiographic changes mainly occurred directly after ASD closure except for shortening of QRS duration and QTc interval, which occurred at later follow-up.6
It is necessary to take more active treatment strategies for patients with obvious symptoms of atrial fibrillation.Atrial septal puncture after ASD occlusion is a challenge to the experience and technique of the operator.Atrial septal puncture, thrombus and metal net fall how to do? How does puncture fail to do? Maybe biodegradable plugging umbrella can solve the problem, but what can we do when there is a large defect and a large plugging umbrella?
References
1. Zhang ZH, Yao Q, Huang HY, Zhu P, Xu X, Song ZY, et al. "One-stop shop": safety and efficacy of combining atrial septal defect occlusion and left atrial appendage closure for patients with atrial septal defect and atrial fibrillation. BMC Cardiovasc Disord. 2020 Oct 12;20(1):444.
2. Chiu SN, Wu MH, Tsai CT, Lai LP, Lin JL, Lin MT, et al. Atrial flutter/fibrillation in patients receiving transcatheter closure of atrial septal defect. J Formos Med Assoc. 2017 Jul;116(7):522-528.
3. Ortega MC, Ramos D, Novoa J, Suarez F, Ramírez FD, González MD. Impact of Transcatheter Device Closure of Atrial Septal Defect on Atrial Arrhythmias Propensity in Young Adults. Pediatr Cardiol. 2020. 41(1): 54-61.
4.Shin C, Yoon YW, Kim IS, Kim JY, Min PK, Lee BK, 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 Jan 17;2021:8846656.
5. Jin X, Hummel YM, Tay WT, Nauta JF, Bamadhaj NSS, van Melle JP, et al. Short- and long-term haemodynamic consequences of transcatheter closure of atrial septal defect and patent foramen ovale. Neth Heart J. 2021 Feb 16.
6. Kamphuis VP, Nassif M, Man SC, Swenne CA, Kors JA, Vink AS, et al. Electrical remodeling after percutaneous atrial septal defect closure in pediatric and adult patients. Int J Cardiol. 2019 Jun 15;285:32-39.