Prevalence of Deficient Retro-Aortic Rim and Its Effects on Outcomes in Device Closure of Atrial Septal Defects

Abstract

Background Deficient retro-aortic rim is of concern as a risk factor for aortic erosion following device closure of atrial septal defects (ASD). However, its prevalence and contribution to technical failure and adverse outcomes has not been delineated. Methods A single-center retrospective cohort study of children and adults undergoing cardiac catheterization for device occlusion of ASD from 1/1/1999 to 4/1/2012 was performed. Risk factors for technical failure and early adverse outcome were assessed using multivariate logistic regression. Results Four-hundred forty-five consecutive subjects of median age 5.9 years (range: 0.8–80 years) underwent catheterization during the study period. Of subjects with reviewable echocardiograms, 60% had deficient retro-aortic rim. No attempt was made at device closure in 3.6% of subjects. Of the remaining 429 subjects, 96% underwent successful device occlusion. Major early adverse events occurred in 1.2% (95% CI: 0.4–2.7%) of cases, all either device embolization or malposition. Deficient retro-aortic rim was not a risk factor for composite outcome of technical failure or early major adverse event. No deaths, late re-interventions, or erosion events occurred over 2,395 total person-years of follow-up (median 5.8 years). Deficient retro-aortic rim was associated with increased risk of device impingement on the aorta, but no association was seen between device impingement or deficient retro-aortic rim and the development of new/progressive aortic insufficiency. Conclusion Deficient retro-aortic rim is highly prevalent but did not increase risk of adverse outcomes. Its contribution to the risk of aortic erosion could not be addressed by this study.

Increasing propensity to pursue operative closure of atrial septal defects following changes in the instructions for use of the Amplatzer Septal Occluder device: An observational study using data from the Pediatric Health Information Systems database

“…To date, the single consistent risk factor for device erosion is deficient retro-aortic rim(10,38). However, deficient retro-aortic rim is extremely prevalent in pediatric patients (between 40–60%)(30,39–41), and it is not clear that the current definition of deficient retro-aortic rim discriminates the patients at highest risk of device erosion. There is recent evidence that patients with larger defects relative to body size and septal length and oversizing the device to the defect are more prevalent in erosions than in matched-controls(38).…”

Assessment of atrial septal defects rims on transesophageal echocardiogram at Shahid Gangalal National Heart Centre, Kathmandu, Nepal

“…9 On the other hand, O'Byrne et al found that deficient aortic rim is highly prevalent but does not seem to increase the risk of adverse outcomes. 10 Another group found that procedural failure mainly occurs with extremely large defects (≥40 mm), regardless of whether an aortic rim of septal tissue was present. 11 Deficient or floppy posterior rims are the second most common variation in ASD rims.…”

Relative Risk Factors for Cardiac Erosion Following Transcatheter Closure of Atrial Septal Defects

“…That modification had the potential to alter the therapeutic landscape for ASDs dramatically, because 17% to 60% of patients undergoing device closure have been found to have a deficient anterior-superior rim. 17,22,23 In addition, the recommendation to use multiple views to evaluate the aortic rim was often confusing to implanters who used intracardiac echocardiography for ASD closure, because this was not necessarily routine practice. Understandably, these IFU modifications raised a number of questions within the interventional cardiology community and led to variable changes in practice.…”