Left ventricular diastolic function in adult patients with an atrial septal defect and its age-dependent changes over time after transcatheter closure of the defect
Authors: Kovalchuk Il'ya A. , Rafaeli Ionatan R. , Kryukov Vladislav A. , Rogatova Anna N. , Azarov Alexey V. , Kurnosov Sergey A. , Ioseliani David G. 
Published: May 2023

Background: There are no echocardiographic (echoCG) criteria to predict whether adult patients with an atrial septal defect (ASD) will develop post-procedural left ventricular (LV) failure after the defect closure.
Aim: To evaluate the LV diastolic function before and after the intervention in ASD patients depending on their age and, based on this, to identify potential echoCG risk factors for the development of acute heart failure immediately after the ASD closure.
Materials and methods: This retrospective study included 69 patients with the mean age of 44.2 14.5 years and 57 (82.6%) being women. The patients were divided into 2 age groups: group 1 included 39 (56.5%) patients aged 18 to 49 years (mean SD, 35.4 9.4 years) and group 2, 30 (43.5%) patients aged 50 to 74 years (mean SD, 60.1 6.1 years). The characteristics of the ASD, heart chambers and LV diastolic function were assessed with transthoracic and transesophageal echoCG. The indexed indicators of the left atrial (LA) and LV volumes were measured before the intervention and in the postoperative period and compared. LV diastolic function was assessed by the e lateral (determined by tissue Doppler imaging, TDI) and E/e ratio (reference values 10 cm/s and 8, respectively).
Results: The indexed LA volume at baseline in the second group was slightly higher than in the first one (27.6 9.8 ml/m2 and 25.4 7.1 ml/m2; p = 0.311), whereas there was no between-group difference in the baseline indexed LV volume parameters (41.8 7.9 ml/m2 and 42.4 8.6 ml/m2, respectively; p = 0.768). Immediately after the closure of the ASD, LV diastolic function deteriorated. In the patients below 50 years of age, this difference was non-significant, despite significant changes in the E/e values (from 7.6 3.6 to 9.9 4.1; p = 0.012). In the second age group, this parameter increased significantly (from 9.2 5.7 to 13.1 4.3, respectively; p = 0.005). The TDI index (e lateral) decreased in both groups: in the group 1, from 11.9 2.5 to 9.1 2.2 (p 0.001) and in the group 2, from 9.3 3.6 to 7.9 1.6 (p = 0.061). Two patients of the elderly group, in whom sings of LV failure were identified immediately after the defect closure, by echoCG showed the lowest TDI values (е lateral) (7.8 and 8.0 cm/sec before closure and 6.4 and 7.0 cm/sec thereafter), as well as the highest values E/e before closure (13.4 and 13.1, respectively). In the long-term (12.5 6.5 months on average), the E/e index decreased in both age groups, compared to that in the early postoperative period, approaching the preoperative parameters (group 50 years of age: 7.6 3.6 9.9 4.1 8.7 4.8, group 50 years of age, 9.2 5.7 13.1 4.3 10.8 5.6). The TDI e indicators also shifted close to their initial values, increasing from 9.1 2.2 to 11.6 1.9 in the group 50 years of age and from 7.9 1.6 to 8.9 2.8 in the group 50 years of age. In the long-term, the LA volume index in both groups was unchanged, compared to its baseline values. The indexed LV end diastolic volume and end diastolic diameter increased significantly at one year after the ASD closure in both groups; however, they did not fall outside the reference ranges, and the LV systolic function indicators remained at the same level.
Conclusion: LA volumes and LV function demonstrated the expected positive remodeling after the transcatheter ASD closure. Potential echoCG risk factors for the development of acute heart failure immediately after the ASD closure were identified. These were low baseline rates of early diastolic velocity of the mitral ring (TDI e lateral) of less than 8.0 cm/sec and high LV filling pressure (E/e) of more than 13 in the patients with ASD.