Morse Andrew, Kapadia Samir, Eleid Mackram, Kodali Susheel K, McCabe James M, Krishnaswamy Amar, Smalling Richard, Reisman Mark, Mack Michael J, O'Neill William W, Bapat Vinayak N, Leon Martin B, Rihal Charanjit S, Makkar Raj R, Guerrero Mayra E, Whisenant Brian K, Rodriguez Evelio
Structural Heart & Heart Valve Clinic, Ascension Saint Thomas Heart West, Nashville, Tennessee.
Miller Family Heart, Vascular & Thoracic Institute, Tomsich Family Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio.
J Soc Cardiovasc Angiogr Interv. 2025 Jun 17;4(6):102636. doi: 10.1016/j.jscai.2025.102636. eCollection 2025 Jun.
Iatrogenic atrial septal defects (iASD) are created during transseptal (TS) mitral valve-in-valve (MViV) implantation to facilitate access. Although most iASD remain untreated, the outcomes of closing iASD during TS MViV are unclear. This study evaluates outcomes of concomitant iASD closure during TS MViV.
Patients undergoing TS MViV with SAPIEN 3/Ultra/Resilia valves from June 2015 to September 2023 were identified using the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. To reduce patient selection bias in the primary analysis, MViV patients without iASD closure were chosen from sites that did not perform iASD closures. Propensity score matching accounted for baseline characteristics, and analyses evaluated procedural success, complications, and 1-year clinical outcomes.
Among 5363 TS MViV patients, 472 (8.8%) underwent iASD closure at 173 of 494 sites (35.0%). Propensity matching yielded 468 patient pairs (34% male, 66% female). No significant differences were observed in procedural success, complications, stroke (3.3% vs 5.2%; = .26), or mortality (18.8% vs 17.3%; = .54). Rates of New York Heart Association class III/IV and heart failure rehospitalization were also similar. However, in patients with severe pulmonary hypertension (mean pulmonary artery pressure, 47.4 ± 8.6 mm Hg), iASD closure was associated with higher 30-day mortality (9.7% vs 3.9%; = .03) and 1-year cardiac readmission rates (14.1% vs 4.1%; = .008).
Iatrogenic atrial septal defect closure during the index hospitalization for TS MViV patients is a well-tolerated procedure when performed in carefully selected individuals. However, no significant clinical benefits were observed in the iASD closure group. Additionally, patients with significant pulmonary hypertension did not demonstrate any clinical advantage from iASD closure, and the procedure may even pose potential harm in this subgroup.
医源性房间隔缺损（iASD）是在经房间隔（TS）二尖瓣瓣中瓣（MViV）植入过程中为便于操作而造成的。尽管大多数iASD未得到治疗，但在TS MViV期间关闭iASD的结果尚不清楚。本研究评估了TS MViV期间同时关闭iASD的结果。
使用胸外科医师协会/美国心脏病学会经导管瓣膜治疗注册中心确定2015年6月至2023年9月期间接受使用SAPIEN 3/Ultra/Resilia瓣膜进行TS MViV的患者。为了在初步分析中减少患者选择偏倚，未进行iASD关闭的MViV患者选自未进行iASD关闭的机构。倾向评分匹配考虑了基线特征，分析评估了手术成功率、并发症和1年临床结局。
在5363例TS MViV患者中，472例（8.8%）在494个机构中的173个（35.0%）进行了iASD关闭。倾向匹配产生了468对患者（男性34%，女性66%）。在手术成功率、并发症、中风（3.3%对5.2%；P = 0.26）或死亡率（18.8%对17.3%；P = 0.54）方面未观察到显著差异。纽约心脏协会III/IV级和心力衰竭再住院率也相似。然而，在重度肺动脉高压（平均肺动脉压，47.4±8.6 mmHg）患者中，iASD关闭与30天死亡率较高（9.7%对3.9%；P = 0.03）和1年心脏再入院率较高（14.1%对4.1%；P = 0.008）相关。
对于精心挑选的个体，在TS MViV患者的首次住院期间进行医源性房间隔缺损关闭是一种耐受性良好的手术。然而，在iASD关闭组中未观察到显著的临床益处。此外，重度肺动脉高压患者未从iASD关闭中显示出任何临床优势，并且该手术在该亚组中甚至可能带来潜在危害。
