ASD prevalence at birth found to be 1 to 2 per 1000 live births but it’s distribution by nations is still a study subject (2, 3). Female and male ratio in community was found to be 2:1 (8). In our study we also determined that female ASD prevalence was higher than male but our ratio was 1,5:1.
Infants and adolescents with isolated ASD are frequently asemptomatic and presenting with murmur (8, 9). ASDs may be symptomatic rarely in children and may cause growth retardation, tachypnea, recurrent upper reaspiratory system infections and heart failure (9). Thirty-eight (18,3%) of our patients had active complaints on admission even literature stated that most of ASD patients are asymptomatic.
In our study the mean age at hospital admission was 80,99 ± 58,24 months and median age was found 74 months. Youngest patient admitted to our clinic was 3 days old. The mean age at diagnosis of ASD was found 4.5 years in literature (10). We believe that the reason for our clinic has the older patients in admission, is patients were referred from other clinics for procedure.
As reports of familial clusters of secundum ASDs have noted different modes of inheritance, secundum defects also encountered in genetic syndromes. Exposure to several substances has also been associated with ASDs (11). A study stated that 19% of patients with ostium secundum atrial septal defect had at least one relative with congenital heart disease (12). The list of genes associated with isolated heart diseases is rapidly expanded (13). ASDs can be related with genetic syndromes like Holt-Oram syndrome, Down syndrome and Kabuki syndrome (14). In our study, 6 of our patients had diagnosed with Down syndrome and 11 patients in total had diagnosed different syndromes like Kabuki syndrome, Marfan syndrome and Kleinefelter syndrome. Only one patient had diagnosed situs intersus totalis which is rarely accompanied by ASDs (15).
Children diagnosed with isolated secundum ASD are often asymptomatic and the only finding on physical examination is cardiac murmur. Isolated secundum ASDs rarely develop heart failure and only 3.4% of our patients developed heart failure so our results were compatible with literature (16). Seven child in our study had heart failure and three of them were classified as severe heart failure due to their need for combined medical treatment. Even heart failure in infancy is rare in patients with isolated secundum ASD; all patients need to be evaluated for heart failure.
In our study defect sizes that calculated by TTE, TEE and balloon-sizing was statistically correlated. But some studies state that the ASD size could be overestimated by oblique passage of the balloon through the ASD. On the other hand some studies are standing on that balloon sizing might not be essential for transcathatery closure of ASD and TEE-guided sizing is presented as a successful alternative to balloon sizing (17). In recent studies intracardiac echocardiography guided closure is suggested for closure of ASDs without balloon sizing (18).
Twenty-two of the procedures canceled in procedure room mainly due to total interseptum deficiency or IVC rim deficiency. Amedro P. et al (19) emphasized in their study that transcathatery closure of ASDs with posterior-inferior rim deficiency cannot be recommended.
Abacı A. et al (20) stated their success of transcathatery closure of ASD as 96.9% while ours was 95,7% which is very close to that number and compatible with literature. Chessa M. et al (21) carried out a similar study with adults and major complication indicated as divice embolization just like in our study and the study that Abacı A. et al conducted (20). In four cases the device embolised and in one patient shunt developed after procedure which were major complications in our study group.
Atrio-ventricular block and arrhythmias are the most frequent types of complications on adults after transcathatery ASD closure which might lead to need of heart pace. In our study we evaluated arrhythmias as minor complication which was the second most frequent complication in our study and encountered in 3 patients. All of our patients responded well to medical therapy and none of them needed heart pace. On the other hand Alnasser S. et al (22) evaluated long term complications on adults and atrial arrhythmia occured in 6,5% and atrial fibrillation in 4,9%.
Kato Y. et al (23) indicated new onset migrane after transcathatery closure of ASD in their patient likewise two of our patients developed headaches after procedure and diagnosed as migrane by child neurology consultans. On the other hand Motelmans K. et al (24) found transcathatery closure of ASD was not realated to a decrease on prevalance of migraine but in a subgroup, patients who suffered from typical migraine before ASD closure, the frequency of migraine attacks decreased significantly.
Patients received prophylactic heparin treatment before the procedure but one patient had stroke due to mid-cerebral artery thrombosis despite prophylaxis. Though the patient consulted to Division of Pediatric Haematology of Istanbul University and treatment of the patient started immediately, muscle weakness of the patient was permanent. Thromboembolism is a rare complication of transcathatery ASD closure procedure but may lead to serious results and permanent damages in patients which is more oftenly seen in adult patients. Abacı A. et al (20) indicated thromboembolic diases as the most common complication of transcathatery ASD closure complication and in their study 1,3% of adult patients had cerebrovascular disease after procedure.
Pericardial effusion that responds well to anti-inflammatory drugs were seen in one patient and categoried as minor complication. The patients was full recovered after a year of medical therapy. Wilson N. J. et al (25) studied 227 patients which included both adults and children also remarked one patient with pericardial effusion. Some studies in literature also indicated complications like haematoma in procedure area, press on sciatic nerve, nicel hypersensitivity, atrio-ventricular fistula, cardiac tamponade, cardiac perforation; which none of them were seen in our patients. (12, 25, 26)
The brands of the devices used for the procedure are Amplatzer”, “Occlutech”, “Solysafe”, “Sera Occluder” and “Biostar”. The most used brands in our clinic are “Amplatzer” and “Occlutech”. We compared the complications rates of each brands with each other and there was no statistical significance. Also in another clinical study compromised on 110 chilren “Occlutech” compared with “Amplatzer” and assesed similar results both with each two brands (27).
The mean follow up period of patients in total and after procedure in our clinic were 57,38 ± 50,83 months and 36,58 ± 34,20 respectively; also maximum follow-up durations were 208 months and 117,1 months respectively. A group of patients who were consulted for procedure from other clinics, continued their follow-ups in the clinics they referred from after the procedure. That’s why the follow-up periods after procedure is calculated shorter. There was no other study included only child patients as broad in scope as ours in literature. Thats’s why we couldn’t compare the follow-up periods with other researches.
The defect diameters calculated by ECO, TEE and balloon sizing were statistically positively correlated with each other and there were no statistically significant difference between genders. Also there were no statistical difference between gender specific complication rates. Major and minor complication rates in both genders were similar.
In literature we came across to plenty of studies which compared the brands of ASD closure devices, their performance on large defects and complication rates. However most of these studies were supported or sponsored by the device brands. In our study five different device brands were used in the procedures of 186 cases. In his review, Daniel De Wolf (28) stated that “CardioSEAL/STARflex” devices has higher risk of device embolisation which is supported by our study too. In another study Kim A. Y. et al. (29) compared “Amplatzer” with “Occlutech” and “Gorehelex” devices and their mid-term experiences and they found “Occlutech” and “Gorehelex” devices were safe as “Amplatzer” devices. Complication rates of the devices in this study were close to our study and there were no statistically significant difference between brands. Roymanee S. et al. (30) compared succes rates and complications of “Amplatzer” and “Occlutech” devices in their study and both of these brands were the most frequently used devices in our study too. They found both devices safe and effective for transcathatery closure of ASD like we did.
Our study also has some limitations; as our study is a retrospective, some of patient files were unavailable or soma data was missing so these patients excluded from the study.
All in all our study is uniqeu as our study has one of largest child population in literature. Also we reviewed the literature and we found no studies which has only child case population and has long follow-up period as long as like ours.