Focal scar and diffuse myocardial fibrosis are independent imaging markers in repaired tetralogy of Fallot.

AIMS: To identify the correlates of focal scar and diffuse fibrosis in patients with history of tetralogy of Fallot (TOF) repair. METHODS AND RESULTS: Consecutive patients with prior TOF repair underwent electrocardiogram, 24-h Holter, transthoracic echocardiography, exercise testing, and cardiac magnetic resonance (CMR) including cine imaging to assess ventricular volumes and ejection fraction, T1 mapping to assess left ventricular (LV) and right ventricular (RV) diffuse fibrosis, and free-breathing late gadolinium-enhanced imaging to quantify scar area at high spatial resolution. Structural imaging data were related to clinical characteristics and functional imaging markers. Cine and T1 mapping results were compared with 40 age- and sex-matched controls. One hundred and three patients were enrolled (age 28 ± 15 years, 36% women), including 36 with prior pulmonary valve replacement (PVR). Compared with controls, TOF showed lower LV ejection fraction (LVEF) and RV ejection fraction (RVEF), and higher RV volume, RV wall thickness, and native T1 and extracellular volume values on both ventricles. In TOF, scar area related to LVEF and RVEF, while LV and RV native T1 related to RV dilatation. On multivariable analysis, scar area and LV native T1 were independent correlates of ventricular arrhythmia, while RVEF was not. Patients with history of PVR showed larger scars on RV outflow tract but shorter LV and RV native T1. CONCLUSION: Focal scar and biventricular diffuse fibrosis can be characterized on CMR after TOF repair. Scar size relates to systolic dysfunction, and diffuse fibrosis to RV dilatation. Both independently relate to ventricular arrhythmias. The finding of shorter T1 after PVR suggests that diffuse fibrosis may reverse with therapy.

Long-Term Outcomes After Percutaneous Closure of Ostium Secundum Atrial Septal Defect in the Young: A Nationwide Cohort Study.

OBJECTIVES: This study sought to assess procedural characteristics, early clinical outcome, and long-term complications after transcatheter closure of atrial septal defect (ASD) in children. BACKGROUND: Transcatheter closure has become the preferred strategy in most cases of isolated secundum ASD. However, reported experience in the pediatric population is limited. METHODS: A 1998 to 2016 retrospective multicenter study was performed in 9 French tertiary institutions. All children who had an attempt of percutaneous ASD closure with an Amplatzer Septal Occluder were included. RESULTS: In 1,326 children (39% males; median age, 9 years [0.7 to 18]; weight, 29 kg [3.6 to 92]), transcatheter ASD closure was performed. Median ASD size was 15 mm (3 to 41); 254 (19.1%) patients had a large ASD (≥20 mm/m2). Procedural success rate was 95.3% (95% confidence interval: 93.9% to 96.3%). No death was observed but periprocedural complications occurred in 24 patients (1.8%). After a median follow-up of 3.5 years (range 6 months to 18 years; 173 patients [13%] followed >10 years), delayed major complications were minimal (n = 12; 1.04%) including no death and/or cardiac erosion. Periprocedural and delayed complications rates were significantly higher in children ≤15 kg (5.2% vs. 1.5%; p = 0.007 and 3.1% vs. 0.7%; p < 0.007, respectively) and those with large ASD (3.5% vs. 1.4%; p = 0.008 and 1.7% vs. 0.7%; p = 0.052, respectively). CONCLUSIONS: Transcatheter ASD closure using Amplatzer Septal Occluder is safe in children with a minimal rate of periprocedural complications and a favorable long-term outcome, especially with no death or cardiac erosion despite a substantial proportion of large defects. Children ≤15 kg and those with large ASDs had a greater risk of complications.

Percutaneous left atrial appendage closure followed by single antiplatelet therapy: Short- and mid-term outcomes.

BACKGROUND: After left atrial appendage closure (LAAC), various antithrombotic protocols have been suggested, but the optimal post-procedural antithrombotic strategy is still under debate. AIMS: To investigate the efficacy and safety of LAAC with an AMPLATZER™ Cardiac Plug (ACP) device (St. Jude Medical, Minneapolis, MN, USA) followed by single antiplatelet therapy. METHODS: Consecutive patients with non-valvular atrial fibrillation and a contraindication for oral anticoagulants who underwent LAAC with an ACP device between 2012 and 2014 in two French centres were included. Follow-up included clinical evaluation at 1, 3, 6 and 12 months, and yearly thereafter, and a cardiac computed tomography scan at 3 months to assess device position, device-related thrombus and residual leak. Single antiplatelet therapy was prescribed after the procedure for at least 12 months. RESULTS: A total of 76 patients underwent successful LAAC (mean age: 73 years; 59% men; mean CHA2DS2-VASc score 4.4±1.3; mean HAS-BLED score 3.4±0.9). Three major complications occurred during the periprocedural period (one cardiac tamponade and two access site haematomas). Device thrombosis was observed at 3 months in five (6.8%) patients who remained asymptomatic. After a mean follow-up of 13 months, the rates of death, stroke and major bleeding were 2.6%, 4.0% and 1.3%, respectively. Embolic and bleeding events were less frequent than expected from CHA2DS2-VASc (4.0% vs 9.9%; P<0.001) and HAS-BLED (1.3% vs 4.3%; P<0.001) risk scores. CONCLUSIONS: LAAC using an ACP device followed by single antiplatelet therapy could be a reasonable alternative for stroke prevention.

Extending percutaneous left atrial appendage closure indications using the AMPLATZER™ Cardiac Plug device in patients with persistent left atrial appendage thrombus: The thrombus trapping technique.

BACKGROUND: Percutaneous left atrial appendage (LAA) closure has emerged as an alternative therapeutic option for the prevention of embolic stroke in high-risk patients with non-valvular atrial fibrillation. The presence of thrombus in the LAA is currently a contraindication to the procedure. AIM: To describe a modified LAA closure technique that allows a safe procedure in patients with LAA thrombus. METHODS: Between May 2013 and October 2014, LAA closure was performed in three patients with LAA thrombus (mean age 73.6±14 years; two men), using a modified technique that avoids manipulation of catheters or angiography in the LAA. RESULTS: Two patients had persistent thrombus despite appropriate antithrombotic therapy, while the other patient had a contraindication to systemic anticoagulation. The procedure was successful using the modified implantation technique in all patients. The implanted device was the AMPLATZER™ Cardiac Plug (St. Jude Medical, Minneapolis, MN, USA) in one patient and the Amulet™ (St. Jude Medical, Minneapolis, MN, USA) in two patients. No periprocedural complications occurred. After a mean follow-up of 8±2 months, no deaths or late complications were observed. CONCLUSIONS: Thrombus trapping is a feasible and effective technique for performing LAA occlusion in patients with thrombus within the LAA. This modification of the implantation technique may allow LAA closure indications to be extended to include patients with LAA thrombus, who were formerly considered unsuitable.