The benefit of atrial septal defect closure in elderly patients

OBJECTIVE: Closure of an atrial septal defect in elderly patients is controversial. The aim of the study was to evaluate the outcomes of transcatheter closure of secundum atrial septal defects (ASDs) in elderly patients. PATIENTS AND METHODS: From a total of 488 patients with ASDs who underwent transcatheter closure, 75 patients aged over 60 years (45 female, 30 male) with a mean age of 65.3±15.7 (60–75) years were analyzed. All patients had an isolated secundum ASD with a mean pulmonary blood flow:systemic blood flow of 2.84±1.9 (1.5–3.9). Symptom-limited treadmill exercise tests with respiratory gas-exchange analysis and transthoracic color Doppler echocardiographic study, as well as quality of life measured using the Short Form (36) Health Survey (SF-36) were repeated in all patients before the procedure and after 12 months of follow-up. RESULTS: The atrial septal device was successfully implanted in all patients (procedure time 37.7±4.5 [13–59] minutes, fluoroscopy time 11.2±9.9 [6–40] minutes). There were no major complications. The defect echo diameter was 17.7±15.8 (12–30) mm. The mean balloon-stretched diameter of ASDs was 22.4±7.9 (14–34) mm. The diameter of the implanted devices ranged from 16 to 34 mm. Significant improvement of exercise capacity was noted at 6 and 12 months after the procedure. Exercise time within 6 months of ASD closure was longer (P<0.001) compared to baseline values, and also oxygen consumption increased (P<0.001). Seven quality-of-life parameters (except mental health) improved at 12-month follow-up compared to baseline data. The mean SF-36 scale increased significantly in 66 (88%) patients, with a mean of 46.2±19.1 (5–69). As early as 1 month after the procedure, a significant decrease of the right ventricular dimension and the right atrium dimension was observed (P<0.001). The right ventricular dimension decreased in 67 patients (89.3%). CONCLUSION: Closure of ASDs in elderly patients caused significant clinical and hemodynamic improvement after percutaneous treatment, which was maintained during long-term follow-up, justifying this procedure in old age

Zamykanie ubytków międzyprzedsionkowych u chorych starszych

Ubytek w przegrodzie międzyprzedsionkowej (ASD) stanowi około 10% wszystkich wrodzonych wad serca. Wraz z coraz większą dostępnością narzędzi diagnostycznych rośnie liczba chorych starszych, u których często przypadkowo rozpoznaje się obecność ubytku międzyprzedsionkowego. Kluczowym problemem wydaje się właściwe określenie istotności wady w starszym wieku i celowości ewentualnego leczenia. Nierzadko objawy, jakie podają chorzy, wynikają z wielu obciążających chorób towarzyszących, a nie z nieistotnej często wady. Szczegółowe badanie echokardiograficzne, uwzględniające obecność cech przeciążenia objętościowego prawego serca czy cech nadciśnienia płucnego, obiektywna ocena wydolności chorych w teście spiroergometrycznym z uwzględnieniem norm wiekowych oraz wnikliwy wywiad mogą pomóc w identyfikacji chorych, którym zamknięcie ubytku przyniesie realną korzyść. Obecnie przyjęty jest pogląd, że hemodynamicznie istotne ubytki rozpoznane u dorosłych powinny być zamykane, o ile tylko opór w naczyniach płucnych nie przekracza 6–8 j. w skali Wooda. Wytyczne Europejskiego Towarzystwa Kardiologicznego przy określaniu wskazań do zamknięcia ubytku nie uwzględniają wieku chorych. Wyniki leczenia są najkorzystniejsze, jeśli jest ono przeprowadzone przed 25. rokiem życia. Niemniej w każdym wieku zamknięcie ubytku korzystnie wpływa na chorobowość (wydolność wysiłkową, duszność, niewydolność prawokomorową, jakość życia), szczególnie jeśli jest możliwe zamknięcie przezskórne. U pacjentów w podeszłym wieku z ASD niekwalifikującym się do zamknięcia przezskórnego należy starannie rozważyć ryzyko operacyjne. Kluczowym problemem u chorych z ASD w starszym wieku jest występowanie licznych schorzeń towarzyszących, w tym chorób wieku podeszłego. Identyfikacja wszystkich schorzeń towarzyszących, w tym choroby niedokrwiennej serca jest nieodzowna we właściwym kwalifikowaniu chorych do zamknięcia ASD. Najważniejsza w wieku podeszłym jest indywidualizacja podejścia do chorego z uwzględnieniem stanu biologicznego chorego.Atrial septal defect (ASD) makes up about 10% of all congenital heart defects. Because of long-term asymptomatic course atrial septal defects are frequently detected in adults. There is controversy regarding the usefulness of ASD closure in elderly patients. Hemodynamically significant ASDs should be closed in adults if pulmonary vascular resistance (PVR) does not exceed 6–8 Wood units. Nowadays significant ASD, according to the ESC Guidelines should undergo ASD closure regardless of the age. Surgical correction of ASD has been successfully used for over 50 years resulting in closure of ASD in 98% of the patients, with mortality rate being 0–3%. However, the frequency of severe complications is 10–13%, causing prolongation of rehabilitation and delaying return to normal activity. An alternative to surgical correction, especially in elderly patients who are prone to complications related to open heart surgery, is percutaneous closure of septal defect, performed under local anesthesia. Closure of ASDs in elderly patients resulted in significant clinical and hemodynamic improvement after percutaneous treatment, which requires long-term follow-up. Individualized approach to patients is necessary because of their age and frequent comorbidities. It was demonstrated significant benefits of percutaneous closure of atrial septal defects in patients over 60 years of age, which may facilitate patient selection for correction of the defect, especially in the light of divergence of opinion about the usefulness of the procedure in the elderly

Transcatheter closure of atrial septal communication : impact on P-wave dispersion, duration and arrhythmia in mid-term follow-up

Background: Atrial septal communications (ASCs) include atrial septal defects (ASDs) and patent foramen ovale (PFO). Aim: The purpose of this study was to assess P-wave dispersion (PWD) and the prevalence of arrhythmia in patients before and after ASC closure. Methods: We analysed the clinical history and performed 12-lead electrocardiograms, echocardiograms, and 24-h Holter electrocardiograms in patients with ASC, before and six months after ASC closure. Results: We included patients with ASD (n = 56) and PFO (n = 73). PWD before percutaneous ASC closure was predicted by right ventricular outflow tract (RVOT) proximal diameter, left atrial area, ASD, smoking, and paroxysmal dyspnoea, R2 = 0.67; p &lt; 0.001. RVOT proximal diameter was an independent predictor of PWD, both in patients with ASD and PFO. Six months after successful closure of ASC, a reduction in PWD was observed in the whole group of patients as well as in patients with ASD and PFO considered separately. A decrease in PWD was associated with reduction of maximum P-wave duration. At the same time, in the whole group, we noticed a reduction in the number of supraventricular and ventricular extrasystolic beats and fewer atrial fibrillation (AF) episodes, p &lt; 0.04 for all variables. Postprocedural AF episodes in patients with ASD were predicted by PWD of 80 ms. Conclusions: Percutaneous closure of ASC is associated with a reduction of PWD and fewer arrhythmia episodes six months after the procedure. PWD predicts AF episodes after ASD closure

Is it worth closing the atrial septal defect in patients with insignificant shunt?

Introduction: Closure of the atrial septal defect in patients with insignificant shunt is controversial. Aim: To evaluate the outcomes of transcatheter closure of atrial septal defect (ASD) in symptomatic patients with borderline shunt. Material and methods: One hundred and sixty patients (120 female, 40 male) with a mean age of 30.1 ±16.2 (20–52) years with a small ASD who underwent transcatheter closure were analyzed. All patients had a small ASD with Qp : Qs ratio ≤ 1.5, mean 1.2 ±0.9 (1.1–1.5) in echo examination. Cardiopulmonary exercise tests, clinical study, transthoracic echocardiographic study as well as quality of life (QoL) (measured using the SF36 questionnaire (SF36q)) were repeated in all patients before and after the procedure. Results: The devices were successfully implanted in all patients. After 12 months of ASD closure, all the patients showed a significant improvement of exercise capacity (oxygen consumption – 21.9 ±3.1 vs. 30.4 ±7.7, p > 0.001). The QoL improved in 7 parameters at 12-month follow-up. The mean SF36q scale increased significantly in 141 (88.1%) patients of mean 43.2 ±20.1 (7–69). A significant decrease of the right ventricular area (20.3 ±1.3 cm2 vs. 18.3 ±1.2 cm2, p < 0.001) and the right atrial area (15.2 ±1.9 cm2 vs. 12.0 ±1.6 cm2, p < 0.001) was observed at 12-month follow-up. Conclusions: Closure of ASD in the patients with insignificant shunt resulted in significant durable clinical and hemodynamic improvement after percutaneous treatment

Intragenomic diversity of Rhizobium leguminosarum bv. trifolii clover nodule isolates

BACKGROUND: Soil bacteria from the genus Rhizobium are characterized by a complex genomic architecture comprising chromosome and large plasmids. Genes responsible for symbiotic interactions with legumes are usually located on one of the plasmids, named the symbiotic plasmid (pSym). The plasmids have a great impact not only on the metabolic potential of rhizobia but also underlie genome rearrangements and plasticity. RESULTS: Here, we analyzed the distribution and sequence variability of markers located on chromosomes and extrachromosomal replicons of Rhizobium leguminosarum bv. trifolii strains originating from nodules of clover grown in the same site in cultivated soil. First, on the basis of sequence similarity of repA and repC replication genes to the respective counterparts of chromids reported in R. leguminosarum bv. viciae 3841 and R. etli CFN42, chromid-like replicons were distinguished from the pool of plasmids of the nodule isolates studied. Next, variability of the gene content was analyzed in the different genome compartments, i.e., the chromosome, chromid-like and 'other plasmids'. The stable and unstable chromosomal and plasmid genes were detected on the basis of hybridization data. Displacement of a few unstable genes between the chromosome, chromid-like and 'other plasmids', as well as loss of some markers was observed in the sampled strains. Analyses of chosen gene sequences allowed estimation of the degree of their adaptation to the three genome compartments as well as to the host. CONCLUSIONS: Our results showed that differences in distribution and sequence divergence of plasmid and chromosomal genes can be detected even within a small group of clover nodule isolates recovered from clovers grown at the same site. Substantial divergence of genome organization could be detected especially taking into account the content of extrachromosomal DNA. Despite the high variability concerning the number and size of plasmids among the studied strains, conservation of the location as well as dynamic distribution of the individual genes (especially replication genes) of a particular genome compartment were demonstrated. The sequence divergence of particular genes may be affected by their location in the given genome compartment. The 'other plasmid' genes are less adapted to the host genome than the chromosome and chromid-like genes