Coronary Angiography in Patients undergoing Transcatheter Closure of Interatrial Shunt

Secundum atrial septal defect (ASD) is the most common congenital heart defect first diagnosed in adults, even late in life,¹ and it may be successfully closed percutaneously. Patent foramen ovale (PFO) is a remnant of fetal circulation present in about 20% of the normal adult population² and may require closure in cases of cryptogenic stroke due to possible paradoxical emboli.³ Since the prevalence of coronary artery disease (CAD) is increasing with age,⁴ the association of CAD and ASD or PFO may be encountered in adult patients. An adult patient may present with numerous risk factors for CAD and/or symptoms and signs of suspected coronary ischemia. Although both conditions may be successfully treated percutaneously, the techniques of ASD closure and coronary intervention are completely different. It is not established whether every adult candidate for percutaneous ASD closure should undergo coronary artery evaluation, or if concomitant percutaneous ASD closure and coronary angiography (CA) and percutaneous coronary intervention are feasible. We present our experience in patients who underwent percutaneous transcatheter ASD/PFO closure in regard to concomitant coronary assessment. Patients and Methods We reviewed all medical records of patients who underwent cardiac catheterization for secundum ASD and PFO in the Pediatric Cardiology and Adults with Congenital Heart Disease Service at the Rambam Healthcare Campus in Haifa from May 1998 to May 2006. Results From May 1998 to May 2006, 268 consecutive patients underwent catheterization and were considered for percutaneous closure of PFO or ASD. Ninety-nine patients were admitted for PFO closure due to paradoxical emboli with cerebrovascular or systemic arterial involvement. The mean age of the PFO patients was 49 ± 12 years (range 11–72 years), and 55 of them were females. Out of 169 ASD patients, 82 were > 20 years of age. The mean age of adult ASD patients was 43 ± 15 years (range 20–75 years), and 45 of them were females. The age distribution of the patients is presented in Figure 1. Ten PFO patients and 13 ASD patients underwent CA. The indications for CA were: known CAD, symptoms suggestive of CAD, positive stress test, risk factors for CAD, left ventricular segmental wall motion abnormalities on rest echocardiography, evidence of atherosclerosis in other sites (carotid, renal, peripheral, etc.) and possible candidate for surgical ASD closure > 40 years of age. In the majority of cases, the patients had more than one indication. The distribution of cardiovascular risk factors in patients who underwent CA is presented in Table 1. In all cases, CA was performed via a 6 Fr sheath inserted into the right femoral artery. CA findings had an influence on management strategy in 5 patients. Case 1. A 75-year-old female was diagnosed with a large secundum ASD and a significant (> 90%) narrowing of the right coronary artery (RCA). The patient underwent a combined procedure which included the RCA stenting and ASD closure using a 30 mm Amplatzer occluder device. Case 2. A 58-year-old male with a history of myocardial infarction (MI) and stroke was referred for percutaneous PFO closure. His CA revealed extensive CAD with total occlusion in the proximal part of the left anterior descending coronary artery (LAD), significant (> 90%) narrowing of the proximal left circumflex artery (LCX) and marked (75–90%) narrowing of the mid RCA. Left ventricular angiography showed moderately reduced systolic function with antero-apical akinesis. The patient was referred for coronary artery bypass grafting (CABG) for surgical PFO closure. Case 3. A 35-year-old female was referred for transcatheter secundum ASD closure. Transthoracic echocardiography revealed a moderate-sized secundum ASD, left ventricular segmental dysfunction with hypokinesis of the anterior wall and of the apex. In addition, color Doppler imaging showed abnormal diastolic flow in the main pulmonary artery which was interpreted as a coronary fistula. Selective CA revealed an abnormal origin of the left main coronary artery from the main pulmonary artery. The patient was referred for surgical treatment. Coronary artery bypass with left internal mammary artery (LIMA) to the LAD and surgical ASD closure were performed. Case 4.A 52-year-old male with a very large secundum ASD was referred for evaluation of percutaneous transcatheter closure of the defect. His medical history included multiple CAD risk factors: noninsulin-dependent diabetes mellitus and hypercholesterolemia and arterial hypertension. He underwent cardiac catheterization, which disclosed a huge secundum ASD with a nonstretched diameter of 45 mm and absent rims (on transesophageal echocardiography [TEE]). His CA revealed 75–90% narrowing of the mid LAD. He underwent surgical ASD closure combined with CABG (LIMA to LAD). Case 5. A 76-year-old male was admitted to the intensive coronary care unit for diaphragmatic MI with right ventricular involvement. During his hospitalization the patient developed profound hypoxemia. TEE revealed right ventricular dysfunction, severe right atrial enlargement, normal pulmonary artery pressure by tricuspid valve regurgitation jet velocity and large PFO (~12 mm) with a right-to-left shunt. The patient underwent cardiac catheterization, which revealed total proximal occlusion of the RCA not suitable for PCI and more than 90% stenosis of the proximal LAD, which was successfully dilated by stenting. The next step of the procedure was balloon sizing and temporary occlusion of the defect with an improvement in oxygenation. The PFO was successfully occluded with an Amplatzer ASD device. The postprocedural period was characterized by improvement of blood oxygenation, and the patient was successfully weaned from mechanical ventilation.⁵ All other patients had normal CAs or nonsignificant coronary artery lesions. In light of possible surgical ASD closure, 3 out of 23 patients underwent coronary angiography. In 1 of them CA revealed 1 vessel CAD (see Case 4). In the 2 remaining patients the CA was normal. Coronary angiography was uneventful in all patients. No cardiac or vascular complications were observed and no side effects of contrast media were recorded. Discussion Atrial-level shunts and CAD may coexist in adult patients. Although percutaneous techniques are available for treatment of both conditions, there is no consensus on whether these procedures should be combined or separate. Some operators state that transcatheter ASD/PFO closure should be performed as separate procedures. They claim that concomitant coronary interventions complicate the procedure and increase the combined risks.6 This may be due to the arterial access, potential complication of coronary intervention, angiographic contrast and longer radiation time. Pediatric cardiologists who are traditionally experienced with transcatheter ASD/PFO closure have less experience in coronary catheterization. On the other hand, combined procedures may obviate the need for repeated cardiac catheterizations. Furthermore, CA findings may affect the treatment strategy. In 5 of our 23 patients (21.7%) who underwent coronary angiography prior to transcatheter closure of ASD/PFO, we altered the preplanned management in view of the CA findings. One patient underwent combined coronary stenting and ASD closure, and in 2 patients, percutaneous ASD/PFO closure was abandoned and the patients were referred for cardiac surgery due to the CA findings. In the fourth case, ASD size precluded transcatheter closure of the defect, leading to surgical treatment for shunt closure. In view of the CA findings, this procedure was combined with CABG. There are scant reports in the literature related to combined percutaneous transcatheter treatment of ASD and CAD. Onorato at al described a cohort of 176 adult patients who underwent transcatheter ASD closure. In 6 of them, PCI also was performed as a separate procedure.⁷ Tomai et al⁶ described a combined procedure, which included percutaneous stenting of the proximal LAD and proximal LCX followed by transcatheter ASD closure with Amplatzer septal occluder in a 68-year-old male with a history of MI and mildly reduced left ventricular ejection fraction with severe lateral hypokinesis. The procedure was complicated by acute left heart failure, presumably as a result of an abrupt volume overload of the left ventricle due to ASD closure with a sudden interruption of the left-to-right shunt at the atrial level. The authors’ opinion was that it is necessary to defer transcatheter closure of ASDs in patients with associated ischemic heart disease suitable for coronary revascularization.⁶ We also had 2 elderly patients who underwent combined PCI and large ASD/PFO occlusion. In both cases, the procedure course and postprocedural period were uneventful. We think that meticulous hemodynamic evaluation may help to assess hemodynamic tolerance and select the optimal management to prevent complications. Coronary angiography is an important part of preoperative evaluation in patients who are referred to surgical ASD closure for detection of concomitant CAD. Ergometry and noninvasive imaging techniques, such as radionuclide scans, stress echocardiography and computer tomography may be an alternative to CA. If the results of noninvasive imaging are positive or are inconclusive, CA becomes mandatory prior to ASD/PFO closure. The analysis of our group of patients shows that concomitant coronary evaluation and intervention in patients referred for percutaneous closure of interatrial shunts is feasible and safe. Combined CA/PCI and ASD/PFO closure may avoid repeated interventional procedures and offer optimal management for selected patients. The disadvantages of the presented data analysis may be that it is retrospective and features a relatively small number of patients who underwent CA prior to ASD/PFO closure by either surgical or transcatheter techniques. It is probable that several cases of clinically silent CAD were missed. Obviously, in order to assess the true prevalence of clinically-silent CAD in patients referred for percutaneous shunt closure, all patients above a certain age limit or with cardiovascular risk factors should undergo CA, even if they show no signs or symptoms of CAD. A large multicenter, prospective study may provide more convincing answers and guidelines concerning concomitant ASD/PFO closure and invasive coronary evaluation and intervention.

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