Transcatheter closure of atrial septal defect using intracardiac echocardiography: a two-center, retrospective study.

AIMS: We present the experience and long-term results of intracardiac echocardiography (ICE)-guided closure of ostium secundum atrial septal defects (ASDs) in two Italian centers and investigate its systematic applicability as the gold standard in routine clinical practice. METHODS: We retrospectively evaluated all consecutive patients who underwent an ASD percutaneous closure procedure from March 2008 to February 2020. All patients underwent a preprocedural transesophageal echocardiography (TEE) evaluation. The closures were carried out under fluoroscopic and ICE guidance. A follow-up visit was performed at 1, 3 and 12 months, followed by telephone evaluations approximately every 2 years. RESULTS: Sixty-six patients (29% male individuals), mean age 43 ±â€Š16 years, were treated. In 15 cases, the TEE defect diameter was less than 10 mm, and in 8 of these patients, the ICE intraprocedural sizing increased the maximum diameter by more than 5 mm. Sizing balloon of the defect was performed in 51 cases; 2 patients received an ASD 38 mm device. Eight patients had multiple defects; in three of these, it was necessary to apply two devices. Four patients showed nonsignificant residual shunt; no complications related to the use of ICE were observed. One patient presented the migration of the ASD device into the abdominal aorta, percutaneously retrieved with a snare. No major complications were recorded during the entire follow-up period. CONCLUSION: This study confirms that ICE monitoring during ASD percutaneous closure is well tolerated and effective; it might be achievable as a routine gold standard by operators willing to use ICE systematically in all transcatheter closure interventions of interatrial communications.

Detection and prognostic impact of renal dysfunction in patients with chronic heart failure and normal serum creatinine.

BACKGROUND: Accurate identification of renal dysfunction (RD) is crucial to risk stratification in chronic heart failure (CHF). Patients with CHF are at special risk of having RD despite normal serum creatinine (SCr), owing to a decreased Cr generation. At low levels of SCr, the equations estimating renal function are less accurate. This study was aimed to assess and compare the prognostic value of formulas estimating renal function in CHF patients with normal SCr. METHODS: We studied 462 patients with systolic CHF and normal SCr. Creatinine clearance was estimated by the Cockcroft-Gault (eCrCl) and glomerular filtration rate by the 4-variable MDRD equation (eGFR); eCrCl normalized for body-surface area (eCrCl(BSA)) was calculated. The primary outcome was all-cause mortality at 2 years. RESULTS: Seventy five patients died. At multivariate Cox regression analysis, only eCrCl(BSA) was significantly associated with mortality (p = 0.006); eGFR (p = 0.24), eCrCl (p = 0.09) and BUN (p = 0.14) were not statistically significant predictors. The patients in the lowest eCrCl(BSA) quartile had an adjusted 2.1-fold (CI: 1.06-4.1) increased risk of mortality, compared with those in the referent quartile. Two-year survival was 70.4% in the lowest eCrCl(BSA) quartile and 89.7% in the referent quartile. Other independent predictors of mortality were ischemic etiology (RR: 2.16 [CI: 1.3-3.5], p = 0.0017), NYHA III/IV class (RR: 2.45 [CI: 1.51-3.97], p = 0.0003), LVEF <0.25 (RR: 3.38 [CI: 1.69-6.75], p = 0.014), and anemia (RR: 1.86 [CI: 1.16-2.99], p = 0.009). CONCLUSIONS: A sizeable proportion of CHF patients have prognostically significant RD despite normal SCr. Such patients represent a high-risk subgroup and can more accurately be identified by the CG formula corrected for BSA than the MDRD.

Prognostic value of formulas estimating excretory renal function in the elderly with systolic heart failure.

BACKGROUND: reduced renal excretory function (REF) is increasingly being appreciated as a potent prognostic factor in chronic heart failure (CHF). The Cockroft-Gault (CG) and the simplified Modification of Diet in Renal Disease (MDRD) equations have been recommended to estimate REF. However, limitations for both formulas have been reported in the elderly. Their prognostic performance in older CHF patients has not been investigated. OBJECTIVES: to assess the factors independently associated with all-cause mortality and compare the prognostic value of formulas estimating REF in CHF patients aged > or =70 years. DESIGN: a longitudinal study with a median follow-up of 859 days. The end-point was all-cause mortality. SETTING: Division of Cardiology and Cardiac Rehabilitation. SUBJECTS: two hundred and sixty-six patients aged > or =70 years with systolic CHF. METHODS: REF was estimated using the CG (eCrCl(CG)) and the MDRD (eGFR(MDRD)) formulas. Cox proportional hazards model was used to assess the factors independently associated with mortality and compare the prognostic value of estimating formulas. Receiver-operating characteristic (ROC) curve analysis was also performed. RESULTS: Kaplan-Meier estimates of the rates of death at 1 and 2 years were 85% and 73%, respectively At multivariate analysis, eCrCl(CG) <50 mL/min (P = 0.005), anaemia (P = 0.012), non-prescription of beta-blockers (P = 0.006) and left ventricular ejection fraction (P = 0.03) were the only independent predictors of mortality. On ROC analysis, the eCrCl(CG) was significantly more accurate than the eGFR(MDRD). CONCLUSIONS: among CHF patients aged > or =70 years, reduced REF is the most powerful independent predictor of survival. The excess in risk conferred by reduced REF is better appraised by means of the CG than the MDRD equation.