A Tale of Two Balloons: Assessment of Hemodynamics with Atrial Septal Defect Temporary Balloon Occlusion

Abstract: We describe two cases in which temporary balloon occlusion (TBO) was used to determine the suitability of atrial septal defect (ASD) closure. These cases underscore the utility of TBO in select patients undergoing percutaneous closure of ASDs.

J INVASIVE CARDIOL 2012;24(5):248-249

Key words: atrial septal defect, transcatheter closure, balloon occlusion

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Temporary balloon occlusion (TBO) of an atrial septal defect (ASD) can provide important right and left heart hemodynamic information when a concomitant congenital or functional abnormality is present.^1,2 We describe two cases in which TBO was used to determine the suitability of ASD device closure.

Case 1

A 74-year-old woman with progressive dyspnea on exertion was diagnosed with a 16 mm secundum ASD and diastolic dysfunction as evidenced by elevated left ventricular filling pressures (Figure 1). Cardiac catheterization revealed Qp:Qs of 2.5:1. TBO demonstrated a rapid increase in mean pulmonary capillary wedge pressure (PCWP) to 30 mm Hg (19 mm Hg at baseline). A self-fabricated 18 mm Amplatzer cribriform atrial septal occluder (St Jude Medical) was then deployed to prevent acute volume overload of the left ventricle. Upon device closure, mean PCWP was 20 mm Hg.

Case 2

A 36-year-old woman had a 22 mm secundum atrial septal defect with concomitant infundibular pulmonic stenosis (Figure 2). Cardiac catheterization demonstrated Qp:Qs of 2.8:1 with a mean transpulmonic gradient (TPG) of 35 mm Hg. TBO decreased TPG to 18 mm Hg due to reduction in flow across the right ventricular outflow tract. After deployment of a 24 mm Amplatzer cribriform atrial septal occluder, TPG was 14 mm Hg.

Both patients were discharged post procedure day 1 with marked improvement in symptoms at 1-month follow-up.

Discussion

Hemodynamic outcomes following percutaneous closure of ASDs are generally favorable; therefore, routine assessment with TBO is not required. In certain instances, TBO may aid in the subsequent course of action, specifically in patients with left atrial hypertension, systolic/diastolic heart failure or concomitant congenital anomalies.

The risk of left atrial fluid overload from the lack of a decompression mechanism through the atrial defect does exist, specifically in patients with left ventricular dysfunction which may lead to pulmonary edema.^1,3-5 The risk of acute elevation of left atrial pressure should be acknowledged in patients with known systolic or diastolic dysfunction, baseline elevated pulmonary capillary wedge pressures, and in older populations, given the age-related decline in left ventricular compliance. TBO should be considered in these patients as a screening tool to foresee any adverse hemodynamic changes that would preclude closure of the ASD. In patients who may not tolerate the increased left-sided pressures associated with ASD occlusion, it is necessary to modify the closure devices to allow for continued decompression of the left atrium and allow the left heart to adapt over time.^6,7 In the first case, TBO was indicated as the patient was elderly and had elevated PCWP. TBO demonstrated a rapid rise in left ventricular filling pressures and therefore a fenestrated Amplatzer was employed, which preserved the offloading properties of the ASD, preventing secondary pulmonary hypertension and possible pulmonary edema. Schneider et al reported the mid-term safety and efficacy of this approach in 4 patients. At a follow-up period of up to 24 months, 3 patients had trivial left to right shunt and 1 patient had complete closure of the fenestration. An overall favorable impact on the hemodynamics was demonstrated.⁸

TBO can also be useful in the evaluation of suitability for closure of an ASD in patients with congenital lesions. Patients with hypoplastic right heart may be intolerant to ASD closure due to inability to accommodate systemic venous return.^9,10 Pulmonic stenosis also presents a diagnostic dilemma due to underestimation of the valvular area due to increased flow from the interatrial shunt. The question as to whether or not the valve lesion is severe enough to warrant surgical correction cannot formally be assessed until after ASD occlusion.² The second case highlights the importance of further evaluation of ASD closure in patients with concomitant pulmonary stenosis. The increased flow throughout the pulmonary valve due to an ASD may overestimate the valvular gradient. TBO allows adequate assessment of the resultant gradient to determine if any additional intervention to the pulmonary valve is indicated. In our case, the patient had an infundibular stenosis, which would have prompted a surgical correction had the gradient remained significantly elevated following TBO.

These cases underscore the utility of TBO test of a comprehensive hemodynamic assessment of select patients undergoing percutaneous closure of ASD.

References

1. Ewert P, Berger F, Nagdyman N, et al. Masked left ventricular restriction in elderly patients with atrial septal defects: a contraindication for closure? Catheter Cardiovasc Interv. 2001;52(2):177-180.
2. Vera JA, Nounou M, Kern M. Staged percutaneous atrial septal defect closure and pulmonic balloon valvuloplasty in an adult with congenital heart disease. Catheter Cardiovasc Interv. 2008;72(3):416-423.
3. Tomai F, Gaspardone A, Papa M, Polisca P. Acute left ventricular failure after transcatheter closure of a secundum atrial septal defect in a patient with coronary artery disease: a critical reappraisal. Catheter Cardiovasc Interv. 2002;55(1):97-99.
4. Yalonetsky S, Lorber A. Percutaneous closure of a secundum atrial septal defect in elderly patients. J Invasive Cardiol. 2007;19(12):510-512.
5. Yalonetsky S, Schwartz Y, Roguin A, Lorber A. Combined percutaneous coronary intervention and atrial septal defect closure in an adult patient. Acute Card Care. 2007;9(4):254-256.
6. Holzer R, Cao QL, Hijazi ZM. Closure of a moderately large atrial septal defect with a self-fabricated fenestrated Amplatzer septal occluder in an 85-year-old patient with reduced diastolic elasticity of the left ventricle. Catheter Cardiovasc Interv. 2005;64(4):513-518;  discussion 9-21.
7. Kenny D, Cao QL, Hijazi ZM. Fenestration of a Gore Helex Septal Occluder device in a patient with diastolic dysfunction of the left ventricle. Catheter Cardiovasc Interv. 2011;78(4):594-598.
8. Schneider HE, Jux C, Kriebel T, Paul T. Fate of a modified fenestration of atrial septal occluder device after transcatheter closure of atrial septal defects in elderly patients. J Intervent Cardiol. 2011;24(5):485-490.
9. Bass JL, Fuhrman BP, Lock JE. Balloon occlusion of atrial septal defect to assess right ventricular capability in hypoplastic right heart syndrome. Circulation. 1983;68(5):1081-1086.
10. Goh K, Sasajima T, Inaba M, Yamamoto H, Kawashima E, Kubo Y. Isolated right ventricular hypoplasia: intraoperative balloon occlusion test. Ann Thorac Surg. 1998;65(2):551-553.

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From the Division of Cardiovascular Medicine, University of California, Davis Medical Center, Sacramento, California.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr. Rogers is a consultant for Volcano, Gore, St Jude Medical, Boston Scientific, and Medtronic. The other authors report no disclosures.
Manuscript submitted November 3, 2011, provisional acceptance given November 22, 2011, final version accepted January 2, 2012.
Address for correspondence:  Jason H. Rogers, MD, 4860 Y Street, Suite 2820, Sacramento, CA 95817. Email: jason.rogers@ucdmc.ucdavis.edu