Fluid challenge and balloon occlusion testing in patients with atrial septal defects
Author(s)
Type
Journal Article
Abstract
Introduction:
Careful, stepwise assessment is required in all atrial septal defect (ASD) patients to exclude pulmonary vascular or left ventricular (LV) disease. Fluid challenge and balloon occlusion may unmask LV disease and post-capillary pulmonary hypertension, but their role in the evaluation of patients with ‘operable’ ASDs is not well established.
Methods:
We conducted a prospective study in 3 Italian specialist centres between 2018 and 2020. Patients selected for percutaneous ASD closure underwent assessment at baseline and after fluid challenge, balloon occlusion and both.
Results:
Fifty patients (46[38.2,57.8] years, 72% female) were included. All had a shunt fraction >1.5, pulmonary vascular resistance (PVR) <5 WU and pulmonary arterial wedge pressure (PAWP) <15 mmHg. Individuals with a PVR ≥2 WU at baseline (higher PVR group) were older, more symptomatic, with a higher baseline systemic vascular resistance (SVR) than the lower PVR group (all p<0.0001). Individuals with a higher PVR experienced smaller increases in pulmonary blood flow following fluid challenge (0.3[-0.1,0.5] vs. 2.0[1.5,2.8] L/min, p<0.0001). Balloon occlusion led to a more marked fall in SVR (p<0.0001) and a larger increase in systemic blood flow (p=0.024) in the higher PVR group. No difference was observed in PAWP following fluid challenge and/or balloon occlusion between groups; 4(8%) patients reached a PAWP≥18 mmHg following the addition of fluid challenge to balloon occlusion testing.
Conclusions:
In adults with ASD without overt LV disease, even small rises in PVR may have significant implications on cardiovascular haemodynamics. Fluid challenge may provide additional information to balloon occlusion in this setting.
Careful, stepwise assessment is required in all atrial septal defect (ASD) patients to exclude pulmonary vascular or left ventricular (LV) disease. Fluid challenge and balloon occlusion may unmask LV disease and post-capillary pulmonary hypertension, but their role in the evaluation of patients with ‘operable’ ASDs is not well established.
Methods:
We conducted a prospective study in 3 Italian specialist centres between 2018 and 2020. Patients selected for percutaneous ASD closure underwent assessment at baseline and after fluid challenge, balloon occlusion and both.
Results:
Fifty patients (46[38.2,57.8] years, 72% female) were included. All had a shunt fraction >1.5, pulmonary vascular resistance (PVR) <5 WU and pulmonary arterial wedge pressure (PAWP) <15 mmHg. Individuals with a PVR ≥2 WU at baseline (higher PVR group) were older, more symptomatic, with a higher baseline systemic vascular resistance (SVR) than the lower PVR group (all p<0.0001). Individuals with a higher PVR experienced smaller increases in pulmonary blood flow following fluid challenge (0.3[-0.1,0.5] vs. 2.0[1.5,2.8] L/min, p<0.0001). Balloon occlusion led to a more marked fall in SVR (p<0.0001) and a larger increase in systemic blood flow (p=0.024) in the higher PVR group. No difference was observed in PAWP following fluid challenge and/or balloon occlusion between groups; 4(8%) patients reached a PAWP≥18 mmHg following the addition of fluid challenge to balloon occlusion testing.
Conclusions:
In adults with ASD without overt LV disease, even small rises in PVR may have significant implications on cardiovascular haemodynamics. Fluid challenge may provide additional information to balloon occlusion in this setting.
Date Issued
2022-05-12
Date Acceptance
2021-08-10
Citation
Heart, 2022, 108 (11), pp.848-854
ISSN
1355-6037
Publisher
BMJ Publishing Group
Start Page
848
End Page
854
Journal / Book Title
Heart
Volume
108
Issue
11
Copyright Statement
© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.
Subjects
Science & Technology
Life Sciences & Biomedicine
Cardiac & Cardiovascular Systems
Cardiovascular System & Cardiology
congenital heart disease
atrial septal defect
pulmonary arterial hypertension
cardiac catheterisation
FOLLOW-UP
EXERCISE
DISEASE
AGE
atrial septal defect
cardiac catheterisation
congenital heart disease
pulmonary arterial hypertension
Adult
Balloon Occlusion
Female
Heart Septal Defects, Atrial
Hemodynamics
Humans
Male
Prospective Studies
Vascular Resistance
Humans
Heart Septal Defects, Atrial
Balloon Occlusion
Prospective Studies
Vascular Resistance
Adult
Female
Male
Hemodynamics
Cardiovascular System & Hematology
1102 Cardiorespiratory Medicine and Haematology
1103 Clinical Sciences
Publication Status
Published
Date Publish Online
2021-08-19