Acute Changes on Pulmonary Pressure Following Percutaneous Closure of Secundum Atrial Septal Defect

Pulmonary hypertension is a common complication of congenital heart disease due to systemic – pulmonary circulation shunt which if left uncorrected leads to increased pulmonary artery pressure, vascular remodeling and further increase of pulmonary vascular resistance. Percutaneous closure of the defect interrupts this shunt thus reducing right heart and pulmonary circulation load and pulmonary artery pressure. In this paper we present two cases of percutaneous secundum atrial septal defect closure complicated by pulmonary hypertension along with echocardiographic evaluation of cardiopulmonary hemodynamic changes before and shortly after device closure. Forty years old and thirty three years old females presented to our clinics with classical symptoms of atrial septal defects, assessment revealed TVG of 37 mmHg and 30 mmHg,shortly after the procedure patient was re-evaluated and revealed TVG of 39 mmHg and 23 mmHg respectively. From these cases we conclude that changes in pulmonary artery pressure is not constantly found after device closure. However both patients display improvements in functional capabilities.


INTRODUCTION
Pulmonary Hypertension (PH) can be found in 9 to 35% of patients with atrial septal defect (ASD).It is a consequence of increased left to right shunt resulting in volume overload of
the right heart and pulmonary circulation.Reduced hemoglobin saturation stimulates bone marrow production of red blood cells (erythrocytosis).This can cause hyperviscosity manifesting as fatigue, headache, and stroke due to cerebrovascular occlusion.Hemoptysis may occur in case of pulmonary artery infarct/ rupture. 11,12When Eisenmenger syndrome developed, there is no remedies to turn back the disease process, although some treatment strategies can be applied, the only effective long-term strategy for severely affected patients is lung / heart-lung transplantation. 12However this is limited to the scarcity of donor organs and lack of organ specificity in developing countries. 11rtunately, with early detection and correction of congenital heart defects, Eisenmenger syndrome has become less common. 12all defects often close spontaneously within the first few years of life.However, ASO is one of the commonly used device, safe, easy to use and has high success rate(98.4%).
On comparison, success rate for both surgical or transcatheter device closure is not statistically different.However, complication rate was lower and length of stay was shorter in device closure patients. 14 Aside from that, RA pressure estimation can be used to evaluate right heart hemodynamics.
Estimation of RA pressure can be made with IVC diameter and degree of inspiratory collapse. 1,16,17e first case displayed no changes in TVG while having increased clinical performance.This could be caused by a long standing pulmonary hypertension leading to pulmonary vascular remodeling causing increased pulmonary vascular resistance and reduced compliance. 18 because of the reduced compliance of the left ventricle in comparison to right ventricular compliance. 19Meanwhile, the second case

CONCLUSION
From the cases above, acute hemodynamic changes of the pulmonary artery is not constantly found subsequent to percutaneous closure of atrial septal defect.Even so, without significant changes of pulmonary artery pressure, our patients had improved functional capabilities.
However due to limitations regarding the small sample size, this conclusion is prematurely made, thus further study is required.

Figure 4 .Figure 3 .
Figure 4. Case 2 Post ASO evaluation. A. Atrial Septal Defect.B. Transvalvular Gradient significant ASD (Qp/Qs of > 1.5) seldom do, therefore they are closed surgically or by interventional catheter techniques before school age or at the time of diagnosis later in life. 13Closure of interatrial septal defects closes the left to right shunt, resulting in reduction of volume overload on the right heart and pulmonary circulation.Thus pulmonary vascular disease might be prevented or reversed with early correction of the defects. 1 Surgical closure of the defects has been practiced for over 45 years, but over the past three decades transcatheter device closure has evolved and is increasingly used in recent years.A wide variety of device has been developed for transcatheter closure of ASD, in this study we demonstrate the use of Amplatzer septal occluder (ASO) device.
displayed changes in TVG after device closure and clinical improvements.This difference in TVG evaluation result might be caused by a ten year age difference.Studies have shown that aging correlates with increased pulmonary systolic arterial pressure. 20In older patients, ASD closure resulted in further deterioration of LV relaxation impairment and increased LV stiffness. 21Despite the difference in PH changes after percutaneous ASD closure, both patients display clinical improvements.