Effects of atrial septal defects on the cardiac conduction system

The case report presented in this edition by Mu et al.The report presents a case of atrial septal defect(ASD)associated with electrocardiographic changes,noting that the crochetage sign resolved after Selective His Bundle Pacing(S-HBP)without requiring surgical closure.The mechanisms behind the appearance and resolution of the crochetage sign remain unclear.The authors observed the dis-appearance of the crochetage sign post-S-HBP,suggesting a possible correlation between these specific R waves and the cardiac conduction system.This editorial aims to explore various types of ASD and their relationship with the cardiac con-duction system,highlighting the diagnostic significance of the crochetage sign in ASD.

Impact of Atrial Septal Defect Closure on Mortality in Older Patients

Background:Atrial septal defect(ASD)is a common form of adult congenital heart disease that can lead to long-term adverse outcomes if left untreated.Early closure of ASD has been associated with excellent outcomes and lower complication rates.However,there is limited evidence regarding the prognosis of ASD closure in older adults.This study aims to evaluate the mortality rates in older ASD patients with and without closure.Methods:A retrospective cohort study was conducted on patients aged 40 years or older with ASD between 2001 and 2017.Patients were followed up to assess all-cause mortality.Univariable and multivariable analyses were performed to identify the predictors of mortality.A p-value of<0.05 was considered statistically significant.Results:The cohort consisted of 450 patients(mean age 56.6±10.4 years,77.3%female),with 66%aged between 40 and 60 years,and 34%over 60 years.Within the cohort,299 underwent ASD closure(201 with transcatheter and 98 with surgical closure).During the median follow-up duration of 7.9 years,51 patients died.The unadjusted cumulative 10-year rate of mortality was 3%in patients with ASD closure,and 28%in patients without ASD closure(log-rank p<0.001).Multivariable analysis revealed that age(hazard ratio[HR]1.04,95%confidence interval[CI]1.006–1.06,p=0.01),NYHA class(HR 2.75,95%CI 1.63–4.62,p<0.001),blood urea nitrogen(BUN)(HR 1.07,95%CI 1.03–1.12,p<0.001),right ventricular systolic pressure(RVSP)(HR 1.07,95%CI 1.003–1.04,p=0.01),and lack of ASD closure(HR 15.12,95%CI 5.63–40.59,p<0.001)were independently associated with mortality.Conclusion:ASD closure demonstrated favorable outcomes in older patients.Age,NYHA class,BUN,RVSP,and lack of ASD closure were identified as independent factors linked to mortality in this population.

Reliability of Echocardiographic Pulmonary Vascular Resistance to Screen for the New Definition of Precapillary Pulmonary Hypertension in Uncorrected Secundum Atrial Septal Defect

Background and Objective:The most feared complication of uncorrected secundum Atrial Septal Defect(ASD)is pulmonary arterial hypertension(PAH).Pulmonary vascular resistance(PVR)is crucial in detecting precapil-lary pulmonary hypertension(PH)to guide the need for PAH-specific therapy.There is a change in the cut-off value of PVR according to the recently updated PH guideline.How echocardiographic PVR(PVRecho)correlates to PVR by right heart catheterization(RHC)(PVRcath)according to the new guidelines has not been known.The aim of this study is to determine the reliability of PVRecho in detecting PAH in Uncorrected Ostium Secundum ASD based on the current updated guideline and to help screen the high PVR group.Methods:429 ostium secun-dum ASD in the COngenital HeARt Disease in Adult and Pulmonary Hypertension(COHARD-PH)registry was divided into three groups according to the PVR.PVRecho was calculated using Abbas’Formula and compared the its gold standard,the PVRcath.The correlation between the two methods was analyzed.The Bland-Altman plot was used to analyze the agreement between the two methods.Receiver operating characteristics(ROC)analysis was used to determine the PVRecho cut-off value for high PVR.Results:The majority of the population(63.5%)had high PVR.Female gender dominated the study population(84%).PVR_(echo) was significantly correlated with PVRcath(r=0.6225,p<0.0001).Bland-Altman plot among all groups and in subgroups analysis showed a wide range of agreement.PVRecho underestimated PVRcath 5.124 WU.In subgroup analysis,PVRecho overestimated PVRcath 0.35 WU in those with PVR<2 WU.In the second and third groups,PVR_(echo) underestimated PVRcath 0.52 and 10.77 WU,respectively.Conclusion:PVRecho is reliable in predicting high PVR in uncorrected secun-dum ASD.However,there is a wide range of agreement.PVR_(echo) cut-off value of>1.62 WU showed good dis-criminatory power in determining high PVR.

Intelligent diagnosis of atrial septal defect in children using echocardiography with deep learning

Background Atrial septal defect(ASD)is one of the most common congenital heart diseases.The diagnosis of ASD via transthoracic echocardiography is subjective and time-consuming.Methods The objective of this study was to evaluate the feasibility and accuracy of automatic detection of ASD in children based on color Doppler echocardiographic static images using end-to-end convolutional neural networks.The proposed depthwise separable convolution model identifies ASDs with static color Doppler images in a standard view.Among the standard views,we selected two echocardiographic views,i.e.,the subcostal sagittal view of the atrium septum and the low parasternal four-chamber view.The developed ASD detection system was validated using a training set consisting of 396 echocardiographic images corresponding to 198 cases.Additionally,an independent test dataset of 112 images corresponding to 56 cases was used,including 101 cases with ASDs and 153 cases with normal hearts.Results The average area under the receiver operating characteristic curve,recall,precision,specificity,F1-score,and accuracy of the proposed ASD detection model were 91.99,80.00,82.22,87.50,79.57,and 83.04,respectively.Conclusions The proposed model can accurately and automatically identify ASD,providing a strong foundation for the intelligent diagnosis of congenital heart diseases.

Genetic Analysis of Variants of the MYH6 Gene Promoter in Congenital Atrial Septal Defects

Background:Atrial septal defect(ASD)is one of the common congenital heart diseases.The MYH6 gene has a critical role in cardiac development but the role of MYH6 promoter variants in patients with ASD has not been explored.Methods:In 613 subjects including 320 ASD patients,we investigated the MYH6 gene promoter variants and verified the effect on gene expression by using cellular functional experiments and bioinformatics analysis.Results:Eleven variants were identified in the MYH6 gene promoter,of which four variants were found only in ASD patients,and two variants(g.3434G>C and g.4524C>T)were identified for the first time.Cellular functional experiments indicated that all four variants reduced the transcriptional activity of the MYH6 gene promoter(p<0.05).Subsequent analysis through the JASPAR(A database of transcription factor binding profiles)suggests that these variants may alter transcription factor binding sites,which may in turn lead to changes in myocardin subunit expression and ASD formation.Conclusions:Our study for the first time focuses on variants in the promoter region of the MYH6 gene in Chinese patients with ASD and the discovered variants have functional significance.The study provides new insights in the role of the MYH6 gene promoter region to better understand the genetic basis of ASD formation and facilitates clinical diagnosis.

The Role of Transesophageal Echocardiography for Transcatheter Closure of Atrial Septal Defects with the Amplatzer Septal Occluder

Objective: To evaluate of the role of transesophageal echocardiography (TEE)in percutaneous closure of atrial septal defects (ASD) with the Amplatzer septal occluder. Methods:Sixty- two patients (10 to 55 years of age) were selected for percutaneous closure of ASD bytrans-esophageal echocardiography, which was also used to monitor the procedure, to select theappropriate size of the Amplatzer device, to verify its position, and to access the immediateresults of the procedure. During the follow-up, transthoracic echocardiography (TTE) or TEE was usedto evaluate the presence and magnitude of residual shunt (RS), device position, and right cardiacchamber diameters. Results: The mean ASD diameter by TTE ([19. 1 +- 5. 8] mm) was significantlysmaller (P< 0. 001) than the stretched diameter of the ASD (25. 1 +- 6. 4) mm. There are nosignificant differences between the TEE -measured value (23. 5+_6. 2) mm and the stretched diameterof the ASD (P > 0. 05). Due to proper patient selection all procedures were successful. There wasimmediate and complete closure in 61/62 patients, only one patients had trivial residual shunt.Follow- up was performed using TTE or TEE right after operation, 1 d, 1 month, 3 months, 6 monthsand yearly thereafter. Ail, patients remain asymptomatic without any clinical or technical problems.Conclusion: With the aid of TEE, percutaneous closure of ASD can be performed successfully, safely,and effectively.

Missense mutations in CSX/NKX_(2.5)are associated with atrial septal defects

Objective ：To study the gene mutations of homeobox transcription factor （CSX/NKX2.5） associated with a Chinese family with secundum atrial septal defect （ASD）. Methods ：Polymerase chain reaction and DNA sequencing were used to check all the members in the family with ASD, and single strand conformation polymorphism analysis （SSCP） was used to check 126 normal control people for detecting the mutations of CSX/NKX2.5 gene. Results： Three mutations, G270A（Glu32Lys ）, G378A （Glu68Lys）andG390A （Glu72Lys）were identified in CSX/NKX2.5 gene of ASD patients. However, the other members in the family with ASD and the control did not have such gene mutations. Conclusion：These mutations of CSX/NKX2.5 gene, which were identified in a Chinese family, may be one of the secundum ASD etiologic causes .

Transcatheter to Close the Patent Duetus Arteriosus and Atrial Septal Defects in Children

Objective: To evaluate the therapeutic effect, safety and complications oftranscathetering Amplatzer device in the closure of patent ductus arteriosus (PDA) and atrial septaldefects (ASD) in children. Methods: Patients with PDA (n = 25) and ASD ( n = 16), confirmed byechocardiography, were treated by transcatheterization. Amplatzer occluder device was placed by thetranscatheterization with the image support of X-ray and transthoracic echocardiography ( TTE) . TheTTE, ECG and X-ray examination were engaged to evaluate the therapeutic results on the time pointsof 24 h , 1, 3 , 6, 12 months after the operation, and all these cases were engaged to the follow-upexamination. Results: The cardioangiographic diameter was 13.0-28.0 mm ([19.3+-4.9] mm) in ASD and2.0-7.7 mm ([3.9+-1.5] mm) in PDA . The diameter of the Amplatzer occluder selected were 13.0-30.0mm ( [20.6+-5.1] mm) in ASD and 4.0-12.0 mm ([6.6+-1.9] mm) in PDA , respectively. All the Amplatzeroccluders were placed successfully. There were no complications during and after the operation.Very small residual shunt was still found soon after the operation in 10 cases , and there were noresidual or recanalization after three months of the operation. The pulmonary artery pressure andheart size were significantly decreased in follow-up examination . Conclusion: Transcatheteringclosure with Amplatzer device is an effective, simple and safe technique in the treatment of ASD andPDA in children.

Percutaneous closure of secundum type atrial septal defects:More than 5-year follow-up

AIM: To investigate long-term efficacy of two different devices more than five years after percutaneous atrial septal defect(ASD) closure in adults.METHODS: All patients who underwent percutaneous closure of an ASD in the St. Antonius Hospital, Nieuwegein, The Netherlands, between February 1998 and December 2006 were included. Percutaneous closure took place under general anaesthesia and transesophageal echocardiographic moni toring. Transthoracic echocardiography(TTE) was performed 24 h post-procedure to visualize the device position and to look for residual shunting using color Doppler. All complications were registered. All patients were invited for an outpatient visit and contrast TTE more than 5-years after closure. Efficacy was based on the presence of a residual right-to-left shunt(RLS), graded as minimal, moderate or severe. The presence of a residual left-to-right shunt(LRS) was diagnosed using color Doppler, and was not graded. Descriptive statistics were used for patients' characteristics. Univariate analysis was used to identify predictors for residual shunting.RESULTS: In total, 104 patients(mean age 45.5 ± 17.1 years) underwent percutaneous ASD closure using an Amplatzer device(ASO) in 76 patients and a Cardioseal/Starflex device(CS/SF) in 28 patients. The mean follow-up was 6.4 ± 3.4 years. Device migration occurred in 4 patients of whom two cases occurred during the index hospitalization(1 ASO, 1 CS/SF). The other 2 cases of device migration occurred during the first 6 mo of follow-up(2 CS/SF). The recurrent thrombo-embolic event rate was similar in both groups: 0.4% per follow-up year. More than 12 mo post-ASD closure and latest follow-up, new-onset supraventricular tachyarrhythmia's occurred in 3.9% and 0% for the ASO and CS/SF group, respectively. The RLS rate at latest follow-up was 17.4%(minimal 10.9%, moderate 2.2%, severe 4.3%) and 45.5%(minimal 27.3%, moderate 18.2%, severe 0%) for the ASO- and CS/SF groups, respectively. There was no residual LRS in both groups.CONCLUSION: Percutaneous ASD closure has good long-term safety and efficacy profiles. The residual RLS rate seems to be high more than 5 years after closure, especially in the CS/SF. Residual LRS was not observed.

“Treat-Repair-Treat”:Management of Left Main Coronary Compression by a Pulmonary Artery Aneurysm in a Patient with Atrial Septal Defect and Significant Pulmonary Hypertension

Left main coronary compression syndrome(LMCS)may complicate pulmonary artery aneurysms(PAA),usually developed in the context of pulmonary arterial hypertension(PAH).We report the case of a 51-year-old female patient with an atrial septal defect(unsuitable for device closure)complicated by a PAA generating a 90%left main stenosis.The significant PAH held us back from immediate surgery.After specific dual PAH-targeted therapy(sildenafil and bosentan),the atrial septal defect could be closed with a unidirectional valved patch;the PAAinduced LMCS was treated by reductive arterioplasty.The postoperative course was uneventful.Follow-up showed clinical improvement,but PAH treatment was still needed.After three months,coronary angiography showed only an insignificant residual left main stenosis,proving that reductive pulmonary arterioplasty was effective in treating LMCS.Any PAA requires further evaluation for LMCS,a dangerous but treatable complication.The“treat-repair-treat”strategy and shunt-closure with a unidirectional valved patch can both improve surgical prospects of LMCS with shunt-related PAH.

The Effect of Atrial Septal Defect Closure on Cardiac Volumetric Changes in Adults, Transcatheter Versus Surgical Closure, a Pilot Cardiac Magnetic Resonance Study

Background:Closure of an atrial septal defect(ASD)reduces right-side heart volumes by abolishing shunting with simultaneous improvement of the left ventricle(LV)filling and functions due to ventricular interdependence,thereby improving symptoms.Furthermore,studies conducted on atrial volume changes after ASD closure are limited.Cardiac magnetic resonance(CMR)is considered as the gold standard method for measuring cardiac volume and mass.Objective:We aimed to study the effect of transcatheter and surgical closure of secundum ASD on cardiac volumes and systolic functions as well as the fate of tricuspid regurgitation(TR),using CMR analysis.Methods:We prospectively enrolled 30 adult patients with isolated secundum ASD who were referred to ASD closure.CMR evaluation of cardiac chambers indexed volumes,systolic function,myocardial mass index,and tricuspid regurgitant fraction were done at before and 6 months after closure.Results:RV volumes decreased in both groups when compared to baseline(p-value 0.001),the device group had more reduction in volumes and more improvement in RV function after closure(p-value 0.001)when compared to the surgical arm.The changes in the RV mass index were insignificant between both groups(p-value 0.31).Functional TR improved to the same extent in both groups.Left ventricular end diastolic volume index(LVEDVI)and LV mass index increased sig-nificantly in both groups when compared to baseline in both groups but with no difference between groups p-value 0.01),left ventricular end systolic volume index(LVESVI)changes were insignificant.LV systolic function improved in patients who underwent device closure only(63.53±3.85 vs.67.13±4.34,p-value 0.01).There was a significant reduction in right atrial(RA)volumes and an insignificant decrease in left atrial(LA)volumes,with no difference between groups.Conclusion:Transcatheter and surgical secundum ASD closure resulted in volumetric changes in some cardiac chambers with better improvement in bi-ventricular systolic function in the transcatheter arm and no difference in the TR reduction between the two groups at 6 months follow-up by CMR.

Clinical Value of Stereoscopic Three-dimensional Echocardiography in Assessment of Atrial Septal Defects: Feasibility and Efficiency

Stereoscopic three-dimensional echocardiography（S-3DE） is a novel displaying technol-ogy based on real-time 3-dimensional echocardiography （RT-3DE）. Our study was to evaluate the feasibility and efficiency of S-3DE in the diagnosis of atrial septal defect （ASD） and its use in the guidance for transcatheter ASD occlusion. Twelve patients with secundum ASD underwent RT-3DE examination and 9 of the 12 were subjected to transcatheter closure of ASD. Stereoscopic vision was generated with a high-performance volume renderer with red-green stereoscopic glasses. S-3DE was compared with standard RT-3D display for the assessment of the shape, size, and the surrounding tis-sues of ASD and for the guidance of ASD occlusion. The appearance rate of coronary sinus and the mean formation time of the IVC, SVC were compared. Our results showed that S-3DE could measure the diameter of ASD accurately and there was no significant difference in the measurements between S-3DE and standard 3D display （2.89±0.73 cm vs 2.85±0.72 cm, P〉0.05; r=0.96, P〈0.05）. The appearance of coronary sinus for S-3DE was higher as compared with the standard 3D display （93.3% vs 100%）. The mean time of the IVC, SVC for S-3DE monitor was slightly shorter than that of the standard 3D display （11.0±3.8 s vs 10.3±3.6 s, P〉0.05）. The mean completion time of interven-tional procedure was shortened with S-3DE display as compared with standard 3D display （17.3±3.1 min vs 23.0±3.9 min, P〈0.05）. Stereoscopic three-dimensional echocardiography could improve the visualization of three-dimensional echocardiography, facilitate the identification of the adjacent structures, decrease the time required for interventional manipulation. It may be a feasible, safe, and efficient tool for guiding transcatheter septal occlusion or the surgical interventions.

Diagnostic chest X-ray in atrial septal defects

A 66-year-old woman with lower limb edema and exertional dyspnea presented to the emergency department.Posteroanterior chest X-ray revealed a Fleischner’s sign in both lungs(Figure 1A)suggesting a pulmonary hypertension.A subsequent transthoracic echocardiogram revealed a 24 mm diameter secundum atrial septal defect(ASD)(Figure 1B)with a dilated right heart and a mean pulmonary pressure of 68 mmHg.Fleischner’s sign refers to a prominent central pulmonary artery that can be commonly caused either by pulmonary hypertension or acute pulmonary embolism.This radiological finding is very rare in patients with secundum ASD unless the defect remains undiagnosed till the elderly.Chest X-ray remains fundamental in making diagnosis of cardiovascular disease.

TRANSCATHETER CLOSURE OF LARGE SECUNDUM ATRIAL SEPTAL DEFECTS WITH AMPLATZER~ SEPTAL OCCLUDER

Objective To evaluate the safety and feasibility of transcatheter closure of large secundum atrial septal defects(ASDs)with Amplatzer~ septal occluder(ASO).Methods A total of 26 patients(age 16 to 67 years,median 43 years;body weight 52 to 102 kg,median 67 kg)with large ASDs underwent an attempted transcatheter closure using ASO.Large ASD was defined as those with a balloon-stretched diameter of ≥30 mm.Another 81 patients with small-to-moderate ASD during same period who underwent closure served as controls.Results In patients with large ASDs,the ASD dimension means were(22.1±3.2)mm(range from 16 to 30 mm)and(23.8±2.6)mm(range from 18 to 31mm)assessed by transesophageal echocardiography(TEE)and transthoracic echocardiography(TTE),respectively.The mean balloon-stretched diameter of the ASD was(31.9±2.1)mm(range from 30 to 37mm).The size of device was(32.0±1.9)mm(range from 30 to 36mm).The transcatheter procedure was successful in all patients(100%).Seventeen deployments were performed using the conventional left atrium approach,and remaining 9 patients required the right upper pulmonary vein approach.Immediately after deployment,TEE revealed that complete closure rate was 73%.Procedure-related complications were recorded in 3 patients(12%),including device embolization in one patient,pericardial effusion in one patient,and large hematoma at puncture site in one patient.During follow-up,the complete closure rate increased to 88% at 24h after procedure and 100% at 6 months.The procedural success rates,immediate TEE results and TTE results at 24h and 6 months after procedure,were not significantly different between patients with large ASDs and those with small-to-moderate ASDs.Conclusion Transcatheter closure of large ASDs using ASO is technical feasible and relatively safe.Proper care selection and specific technique modification such as the right upper pulmonary vein approach is vital for the implantation success.

Delayed cardiac tamponade after simultaneous transcatheter atrial septal defect closure and left atrial appendage closure device implantation: a particular case report

Percutaneous left atrial appendage(LAA)occlusion evolved as an alternative treatment to the patients who are contraindicated or cannot tolerate oral anticoagulants with nonvalvular atrial fibrillation(AF)at risk of stroke or systemic embolism.[1]Abnormal hemodynamic changes in elder atrial septal defect(ASD)patients cause remodeling of the left atrium,which eventually leads to right heart failure.[2]As the ASDs elderly are associated with a higher incidence of AF,simultaneous transcatheter ASD and LAA closure has become a new effective therapeutic strategy.However,only a limited number of articles involving cardiac tamponade complications have been published in the literature.What’s more,previous studies involving early hemodynamically irrelevant pericardial effusion after the procedure attribute to multiple repositioning attempts of LAA occluder or delivery sheath injured the atrial wall.

Dynamic Characteristic Mechanism of Atrial Septal Defect Using Real-Time Three-Dimensional Echocardiography and Evaluation of Right Ventricular Functions

The dynamic characteristics of the area of the atrial septal defect（ASD） were evaluated using the technique of real-time three-dimensional echocardiography（RT 3DE）, the potential factors responsible for the dynamic characteristics of the area of ASD were observed, and the overall and local volume and functions of the patients with ASD were measured. RT 3DE was performed on the 27 normal controls and 28 patients with ASD. Based on the three-dimensional data workstations, the area of ASD was measured at P wave vertex, R wave vertex, T wave starting point, and T wave terminal point and in the T-P section. The right atrial volume in the same time phase of the cardiac cycle and the motion displacement distance of the tricuspid annulus in the corresponding period were measured. The measured value of the area of ASD was analyzed. The changes in the right atrial volume and the motion displacement distance of the tricuspid annulus in the normal control group and the ASD group were compared. The right ventricular ejection fractions in the normal control group and the ASD group were compared using the RT 3DE long-axis eight-plane（LA 8-plane） method. Real-time three-dimensional volume imaging was performed in the normal control group and ASD group（n=30）. The right ventricular inflow tract, outflow tract, cardiac apex muscular trabecula dilatation, end-systolic volume, overall dilatation, end-systolic volume, and appropriate local and overall ejection fractions in both two groups were measured with the four-dimensional right ventricular quantitative analysis method（4D RVQ） and compared. The overall right ventricular volume and the ejection fraction measured by the LA 8-plane method and 4D RVQ were subjected to a related analysis. Dynamic changes occurred to the area of ASD in the cardiac cycle. The rules for dynamic changes in the area of ASD and the rules for changes in the right atrial volume in the cardiac cycle were consistent. The maximum value of the changes in the right atrial volume occurred in the end-systolic period when the peak of the curve appeared. The minimum value of the changes occurred in the end-systolic period and was located at the lowest point of the volume variation curve. The area variation curve for ASD and the motion variation curve for the tricuspid annulus in the cardiac cycle were the same. The displacement of the tricuspid annulus exhibited directionality. The measured values of the area of ASD at P wave vertex, R wave vertex, T wave starting point, T wave terminal point and in the T-P section were properly correlated with the right atrial volume（P〈0.001）. The area of ASD and the motion displacement distance of the tricuspid annulus were negatively correlated（P〈0.05）. The right atrial volumes in the ASD group in the cardiac cycle in various time phases increased significantly as compared with those in the normal control group（P=0.0001）. The motion displacement distance of the tricuspid annulus decreased significantly in the ASD group as compared with that in the normal control group（P=0.043）. The right ventricular ejection fraction in the ASD group was lower than that in the normal control group（P=0.032）. The ejection fraction of the cardiac apex trabecula of the ASD patients was significantly lower than the ejection fractions of the right ventricular outflow tract and inflow tract and overall ejection fraction. The difference was statistically significant（P=0.005）. The right ventricular local and overall dilatation and end-systolic volumes in the ASD group increased significantly as compared with those in the normal control group（P=0.031）. The a RVEF and the overall ejection fraction decreased in the ASD group as compared with those in the normal control group（P=0.0005）. The dynamic changes in the area of ASD and the motion curves for the right atrial volume and tricuspid annulus have the same dynamic characteristics. RT 3DE can be used to accurately evaluate the local and overall volume and functions of the right ventricle. The local and overall volume loads of the right ventricle in the ASD patients increase significantly as compared with those of the normal people. The right ventricular cardiac apex and the overall systolic function decrease.

Cryoballoon pulmonary vein isolation and left atrial appendage occlusion prior to atrial septal defect closure: A case report

BACKGROUND In patients who suffer from both atrial fibrillation(AF)and atrial septal defect(ASD),cryoballoon pulmonary vein isolation(PVI),sequential left atrial appendage(LAA)occlusion and ASD closure could be a strategy for effective prevention of stroke and right heart failure.CASE SUMMARY A 65-year-old man was admitted to our institution due to recurrent episodes of palpitations and shortness of breath for 2 years,which had been worsening over the last 48 h.He had a history of AF,ASD,coronary heart disease with stent implantation and diabetes.Physical and laboratory examinations showed no abnormalities.The score of CHA2DS2VASc was 3,and HAS-BLED was 1.Echocardiography revealed a 25-mm secundum ASD.Pulmonary vein(PV)and LAA anatomy were assessed by cardiac computed tomography.PV mapping with 10-pole Lasso catheter was performed following ablation of all four PVs with complete PVI.Following the cryoballoon PVI,the patient underwent LAA occlusion under transesophageal echocardiographic monitoring.Lastly,a 34-mm JIYI ASD occlude device was implanted.A follow-up transesophageal echocardiography at 3 mo showed proper position of both devices and neither thrombi nor leakage was found.CONCLUSION Sequential cryoballoon PVI and LAA occlusion prior to ASD closure can be performed safely in AF patients with ASD.

Should we consider patent foramen ovale and secundum atrial septal defect as different steps of a single anatomo-clinical continuum？

1 Introduction Isolated atrial septal defects （ASD） represent 7% of all cardiac anomalies and can present at any age. Adolescents and adults with simple congenital heart disease such as isolated atrial septal defects are more likely to reach adult age without being diagnosed. Secundum ASD （sASD） is by far the most common type, occurring in 1/1500 live births, with 65% to 75% involving females, On the other hand, patent foramen ovale （PFO） represents an endemic variant in the normal population with a prevalence of 25%-27%. These two entities appear so different that is difficult to fred a conjunction ring： nevertheless we use the same philosophy for the treatment, Indeed, device-based closure has been proved to be effective in both settings.

Evaluation of Left Ventricular Rotation and Twist Using Speckle Tracking Imaging in Patients with Atrial Septal Defect

Speckle tracking imaging （STI） was employed to investigate the effect of right ventricular （RV） volume and pressure overload on left ventricular （LV） rotation and twist in 35 patients with atrial septal defect （ASD）, 18 of which with pulmonary hypertension, and 21 healthy subjects serving as controls. The peak rotations of 6 segments at the basal and apical short-axises and the average peak rotation and interval time of the 6 segments in the opposite direction during early systolic phase were measured respectively. LV twist versus time profile was drawn and the peak twist and time to peak twist were calculated. LV ejection fraction （EF） was measured by Biplane Simpson. Compared to ASD patients without pulmonary hypertension and healthy subjects, the peak rotations of posterior, inferior and postsept walls at the basal level were lower （P〈0.05）, and the average counterclockwise peak rotation of 6 segments at the basal level during early systolic phase was higher （P〈0.05）, and the average interval time was delayed （P〈0.05）. LV peak twist was also lower （P〈0.05）, and had a significant negative correlation with pulmonary arterial systolic pressure （r=-0.57, P=0.001）. No significant differences were found in LVEF among the three groups. It was suggested that although RV volume overload due to ASD has no significant effects on LV rotation and twist, LV peak twist is lower in ASD patients with pulmonary hypertension. Thus LV twist may serve as a new indicator of the presence of pulmonary hypertension in ASD patients.

Outcomes of Three Different Minimal Invasive Approaches for Secundum Atrial Septal Defect Closure: A Single Institute Experience

Objective:The aims of this retrospective study were to investigate and evaluate the safety and efficacy of three approaches for closure of secundum atrial septal defect(ASD).Methods:In this study,we reviewed clinical data for transcatheter occlusion(TCO,n=63),transthoracic occlusion(TTO,n=55),and right anterolateral minithoracotomy(RALT,n=60)techniques used for ASD closure.We compared the safety and efficacy of the three approaches.Results:ASD size in the TTO group was similar to that in the RALT group(P=0.645)and significantly larger than that in the TCO group(P<O.OO1).The RALT group had more non-central types of ASD than the TTO and TCO groups(P=O.019 and P<O.OO1).The operative time in the TTO group was shorter than that in the TCO and RALT groups(P<O.OO1 and P<0.001).The ventilation time and intensive care unit duration were shorter in the TTO group than in the RALT group(P<O.OO1 and P<O.OO1).Hospital duration in the TCO group was shorter than that in the TTO and RALT groups(P<O.OO1 and P<O.OO1).There were no residual shunt and mortality in any group in hospital or during follow-up.There was no significant difference in the incidence of total complications among the three groups(P=0.738).Conclusion:TCO,TTO,and RALT can be performed with favorable cosmetic and clinical results for closing ASD.Appropriate patient selection is an important factor for successful closure.These techniques are promising alternatives to standard median sternotomy and merit additional study.