Transcatheter ASD closure improves tricuspid regurgitation, heart failure symptoms

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Transcatheter closure of the atrial septal defect (ASD) resulted in significant reductions in tricuspid regurgitation (TR) and improvements in right ventricular dimensions, according to a new study in JACC: Cardiovascular Interventions.

The study included 419 patients who underwent transcatheter ASD closure, including 113 who had severe or moderate TR at baseline. TR was reduced to mild in 70 percent of those severe/moderate cases an average of 30 months later, and the proportion of patients with severe TR dropped from 32 percent to 5 percent. There were no patients who progressed from moderate to severe.

“TR gradually decreased during the long-term follow-up period after transcatheter ASD closure, in parallel with right ventricular reverse remodeling,” wrote lead investigator Yoichi Takaya, MD, with the department of cardiovascular medicine at Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science in Okayama, Japan, and colleagues.

“Transcatheter closure resulted in good clinical courses in patients with significant TR. Our findings suggest that transcatheter closure alone can be valuable in adult patients with ASD complicated with significant TR.”

The researchers determined the severity of TR by measuring the TR jet area via transthoracic echocardiography: less than five square centimeters was considered mild, five to 10 square centimeters was moderate and greater than 10 square centimeters was severe. They conducted patient checkups at one, three, six and 12 months post-procedure, and annually afterward.

Persistent TR—present in 30 percent of the patients after the procedure—was associated with age, prevalence of permanent atrial fibrillation, New York Heart Association functional class and plasma B-type natriuretic peptide (BNP) levels. The mean age of all patients was 54 and 62 percent of them were female.

After ASD closure, two-thirds of patients who were New York Heart Association functional class II or III at baseline improved their functional class. In addition, more than 90 percent of patients with severe/moderate TR at baseline survived without hospitalization for heart failure during follow-up.

Takaya et al. noted this was an important finding because significant cases of TR have been associated with adverse cardiovascular events and worsening heart failure.

“Although patients with severe/moderate TR had worse condition of heart failure, such as NYHA functional class, plasma BNP levels, the prevalence of atrial fibrillation, and a history of hospitalization for heart failure, most of them had no cardiovascular events during the follow-up period,” they wrote. “Heart failure symptoms improved in patients with severe/moderate TR, leading to an improvement in quality of life.”

Surgical ASD closure may show similar benefits, Takaya and colleagues pointed out, and robotic technology has been demonstrated to improve quality of life and reduce postoperative pain for those procedures. Still, “adult patients tend to refuse or hesitate to undergo surgical closure,” they wrote. “Compared with surgical closure, transcatheter closure has therapeutic advantages, such as less invasiveness, fewer complications, and shorter hospital stay. … Thus, adult patients may prefer transcatheter closure even with significant TR.”

In an accompanying editorial, Gary D. Webb, MD, and Alexander R. Opotowsky, MD, said the research by Takaya et al. helped answer another important question—whether ASD closure alone can improve TR or if tricuspid valve repair (or replacement) is necessary.

“We believe the relatively widespread improvement in TR severity after percutaneous ASD closure observed in the current study provides adequate counterweight to the weak argument in favor of more aggressive surgical intervention to address the tricuspid valve issue,” Webb and Opotowsky wrote.