Prevalence and outcomes of pulmonary hypertension after percutaneous closure of atrial septal defect: a systematic review and meta-analysis

Selai Akseer; Eric Horlick; Varnita Vishwanath; Benjamin Hobbes; Ella Huszti; Susanna Mak; Douglas S. Lee; Lusine Abrahamyan

doi:10.1183/16000617.0099-2020

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FIGURE 1
Pulmonary hypertension (PH) prevalence before and after atrial septal defect closure presented in each study.
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FIGURE 2
The pooled pulmonary hypertension (PH) prevalence a) before and b) after atrial septal defect closure in cohort studies.
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FIGURE 3
Standardised mean difference in mean systolic pulmonary arterial pressure (sPAP) before and after atrial septal defect closure in a) cohort studies and b) case series. SMD: standard mean difference; PHM: pulmonary hypertension medication.
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FIGURE 4
Standardised mean difference in mean systolic pulmonary arterial pressure (sPAP) before and after atrial septal defect closure among cohort studies in a) younger patients and b) older patients.

TABLE 1

Study and patient characteristics at baseline, before atrial septal defect (ASD) closure

First author [ref].	Study design	Time period	Sample size n	Age years	Female	ASD diameter mm	NYHA class III–IV	PH assessment method	PH measure and cut-offs mmHg	Mean sPAP mmHg	PH prevalence
Veldtman [31]^#	Retrospective cohort	1997–1999	40	38 (20–71)	75	13±4	5	TEE	sPAP >35	NR	62
De Lezo [32]	Case series	NR	29	56±14	83	26±7	48	TTE/TEE	sPAP ≥40	64±23	100
Bruch [33]	Case series	NR	15	66 (48–77)	66.6	22.7±7.0 (9–34)	60	TTE/RHC	mPAP >25	58.3±15	100
Balint [34]^#,¶	Case series	1999−2004	54	59±15	76	18±7	41	TTE/TEE	sPAP 40–49 (mild), 50–59 (moderate), ≥60 (severe)	58±10	100
Yong [35]^#,¶	Prospective cohort	1999−2006	215	54±16	73	19±6	19	TTE	sPAP ≥40	Median (IQR) 30.0 (25.0–36.0)	50.2
Yalonetsky [36]^#	Retrospective cohort	1998−NR	23				NR	TTE	sPAP cut-off NR		NR
Age 40–60 years				52±6	74	19±5				39±7.7
Age 60+ years				67±5	70	18±5				53±16.2
Altindag [37]	Retrospective cohort	1999–2008	47	58±13 (40–79)	79	NR	43	TTE/TEE	NR	NR	62
Humenberger [38]^#,¶	Prospective cohort	NR						TTE/TEE	sPAP ≥40		NR
Age<40 years			78	29±6.7	61.5	Median (IQR) 23 (29–26)	1.3			31±7
Age 40–60 years			84	50±5.6	65.5	Median (IQR) 22 (17.5–26.5)	3.8			37±10
Age >60 years			74	71±6.1	82.4	Median (IQR) 22.5 (20–28)	41.4			53±17
Huang [39]^¶	Retrospective cohort	2007–2010	15	32.3±12.8	73.3	NR	NR	RHC	sPAP ≥60 (severe PAH)	51.6±9.4	100
Kefer [40]^#	Prospective cohort	1999−2009	112	46±17	71	PH: 22±5 no PH: 18±6	31	TTE	sPAP >40	47±7	28
Nakagawa [41]^¶#	Prospective cohort	2005–2010	30	75.8±3.8 (70–85)	66.6	20.3±6.4	35	TEE	mPAP ≥25	35.6±11.8	53
Mangiafico [42]^#	Prospective cohort	2008–2011			NR	NR		TTE	sPAP cut-off NR		NR
Age <40 years			10	29±7.3			0			35.1±6.6
Age >40 years			20	58±11			0			41.2±6.4
Akagi [9]^¶	Case series	2006–2014						RHC
PHM group 1			8	37±15	100	22±7	88		sPAP ≥60	60±11	100
Non-PHM group 2			14	66±13	71	23±8	21		mPAP ≥25	58±17
Wang [43]	Retrospective cohort	2000–2009	179	Median (IQR) 53 (40–81)	75.4	NR	8.9	TEE	sPAP ≥40	44.8±22.2	24
Dalvi [44]	Case series	2009–2014	6	29±8.89	83.3	28±2.09	0	RHC	mPAP ≥25	102.6±11.5	100

Data are presented as mean (range), %, mean±sd or mean±sd (range), unless otherwise stated. NYHA: New York Heart Association; PH: pulmonary hypertension; sPAP: systolic pulmonary artery pressure; TEE: transoesophageal echocardiography; TTE: transthoracic echocardiography; RHC: right heart catheterisation; NR: not reported; mPAP: mean pulmonary artery pressure; PAH: pulmonary arterial hypertension; PHM: pulmonary hypertension medication. ^#: study-reported sPAP values derived from right ventricular systolic pressure; ^¶: study-reported values for PAH.

TABLE 2

Study-reported outcomes at follow-up

First author [ref.]	Sample size n	Mean follow-up time months	PH assessment method	Mean sPAP after closure mmHg	Mean sPAP reduction mmHg	PH prevalence	NYHA class III–IV
Veldtman [31]	27	NR (1–12)	TTE	NR	10^#	28.5	0
De Lezo [32]	28	21±14	TTE	34±11	14^#	100	0
Bruch [33]	13	10±4	RHC	49.9±17.8	NR	92	0
Balint [34]^¶	39	31±15	TTE/TEE	44±16	14^#	NR	20
Yong [35]^¶	186	Median (IQR) 15 (8–43)	TTE	Median (IQR) 25.0 (24–49)	Median (IQR) 5 (1–13)	26	3.7
Yalonetsky [60]	NR	NR (1–12)	TTE		NR	NR	NR
Age 40–60 years				26
Age >60 years				33.5
Altindag [37]	41	15±15	TTE/TEE	NR	NR	38	5
Humenberger [38]^¶		28±19	TTE			NR
Age <40 years	75			26±5	5±8		0
Age 40–60 years	84			30±6	8±9		0
Age >60 years	74			43±14	9±14		4
Huang [39]^¶,+	7	23.4±9.7	RHC/TTE	21.0±3.8	16^#	13	NR
Kefer [40]	112	60±34	TTE	31±11	7^#	5.4	8
Nakagawa [41]^¶	27	19.1±11.3	TEE	27.2±7.3	NR	NR	4
Mangiafico [42]		NR (1–12)	TTE			NR
Age <40 years	10			28±2.8	7.1^#		0
Age >40 years	20			28.4±6.5	12.8^#		0
Akagi [9]^¶			TTE		NR	NR
PHM group 1	8	19±27 (3–83)		40±9			0
non-PHM group 2	14	19±16 (4–61)		38±10			0
Wang [43]	176	45.6±25.2	TEE	NR	NR	7	1.7
Dalvi [44]	4	39.5±8.5	RHC	55.7±9.2	12.8^#	NR	0

Data are presented as mean±sd, mean (range) or %, unless otherwise stated. PH: pulmonary hypertension; sPAP: systolic pulmonary artery pressure; NYHA: New York Heart Association; PHM: pulmonary hypertension medication; NR: not reported; TTE: transthoracic echocardiography; RHC: right heart catheterisation; TEE: transoesophageal echocardiography. ^#: when mean sPAP reductions were not reported, we calculated (mean sPAP before closure (mmHg)) – (mean sPAP after closure (mmHg)); ^¶: study reported values for pulmonary arterial hypertension; ⁺: study reported mean values as mPAP.

Supplementary Materials

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