The frequency of development of atrial fibrillation/atrial flutter and its associated conditions in long-term follow-up after percutaneous closure in patients with atrial septal defect and patent foramen ovale

Aim: Transcatheter treatment of secundum type atrial septal defects (ASD) and patent foramen ovale (PFO) has been carried out with success, especially in the last two decades. Our knowledge of atrial fibrillation (AF) and atrial flutter (AFL) development, which is the major cause of morbidity in this population, is limited. The balloon sizing technique applied to determine the diameter of the device to be used during the ASD and PFO closure process via transcatheter has been accepted as the basic technique for many years. Publications in recent years have shown that the device diameter can be determined successfully without using the balloon sizing technique. The aim of our study is to evaluate the development frequency and associated conditions of atrial fibrillation and atrial flutter in short and long-term follow-up after percutaneous closure in patients with the atrial septal defect and patent foramen ovale. Method: Between January 2011 and December 2019, patients aged 18 years and older who underwent secundum-type ASD and PFO with transcatheter closure were screened retrospectively. Patients with sinus rhythm before the procedure were included in the study. Patients with atrial fibrillation or atrial flutter in the early or late postoperative period were identified. Our cases were analyzed retrospectively. The effects of different methods used in the procedure on the success and complications of the procedure and especially on the development of atrial tachyarrhythmia were examined. Findings: In one of 183 patients (0.52%) whose secundum type ASD and PFO were closed successfully, device embolization was observed in the left ventricular outlet of the device in the early period (at the 1st-month control) after the procedure. In four (2.1%) of these patients, insignificant-minimal residual shunts were observed. No major complications were observed in patients during follow-up. Atrial tachyarrhythmia (atrial fibrillation or atrial flutter) was observed at any time during the follow-up period in 34 (18.6%) of 183 patients included in the study. In terms of the development of atrial tachyarrhythmia, no significant difference was observed in the gender factor with those who had sinus rhythm, and a significant difference was observed with the age of the closure of the defect. Patients who developed atrial tachyarrhythmia were found to have a higher defect closure age (p = 0.001). When echocardiographic parameters were considered, a significant difference was found in patients with sinus rhythm and atrial tachyarrhythmia in the left ventricular ejection fraction (LVEF), before and after the procedure, left atrium (LA) diameter, post-procedure RV diameter and PAB measurements (respectively p<0,05; p=0,05; p<0,01; p<0,05; p<0,001). When we look at the technical difference applied in the procedure, atrial tachyarrhythmia was observed in 18.1% of 116 patients without balloon sizing and in 19.4% of 67 patients with balloon sizing. There was no statistically significant difference in terms of atrial tachyarrhythmia with or without balloon sizing. When all patients were analyzed, the average diameter of the Amplatzer Septal Occluder (ASO) closure device used in the procedure was 24.6mm ± 7.2mm (min-max: 10mm-40mm), while the averege device diameter of patients with sinus rhythm was 24.1 ± 7.1mm and the averege device diameter of atrial tachyarrhythmia patients was 25,5mm ± 6.8mm. No significant relationship was found between the device diameter and the incidence of atrial tachyarrhythmia development. When we examined the fluoroscopy recording times during the procedure due to technical differences, we found that the mean fluoroscopy time was 22 ± 12.4 minutes in the balloon sizing group and 10.7 ± 15.9 minutes in the non-performed group. Using the balloon sizing technique significantly increases the duration of fluoroscopy (p <0.001). Results and Conclusion: In our study, we demonstrated that the age of defect closure, increased left atrium and right ventricular diameter, and increased pulmonary artery pressure are important among cases associated with the development of atrial tachyarrhythmia in the follow-up of patients with transcatheter closure with secundum type ASD and PFO. At the same time, when we look at the technical differences of the procedure, we showed that performing balloon sizing does not make a difference in terms of the success of the procedure, but it significantly increases the duration of the procedure and fluoroscopy. Our study supports the view that it is not necessary to use the balloon sizing technique in the process, which has become controversial in recent years, and suggests that it can only be successfully and reliably performed under TEE guidance.