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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
European Respiratory Review 2020 29: 200099; DOI: 10.1183/16000617.0099-2020
Selai Akseer
1Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
2Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, ON, Canada
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  • ORCID record for Selai Akseer
Eric Horlick
3Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre (PMCC), University Health Network, Toronto, ON, Canada
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Varnita Vishwanath
3Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre (PMCC), University Health Network, Toronto, ON, Canada
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Benjamin Hobbes
3Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre (PMCC), University Health Network, Toronto, ON, Canada
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Ella Huszti
2Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, ON, Canada
4Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
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Susanna Mak
5Division of Cardiology, Mount Sinai Hospital, Toronto, ON, Canada
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Douglas S. Lee
1Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
2Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, ON, Canada
6ICES, Toronto, ON, Canada
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Lusine Abrahamyan
1Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
2Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, ON, Canada
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  • For correspondence: lusine.abrahamyan@utoronto.ca
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  • FIGURE 1
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    FIGURE 1

    Pulmonary hypertension (PH) prevalence before and after atrial septal defect closure presented in each study.

  • FIGURE 2
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    FIGURE 2

    The pooled pulmonary hypertension (PH) prevalence a) before and b) after atrial septal defect closure in cohort studies.

  • FIGURE 3
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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.

  • FIGURE 4
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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.

Tables

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  • TABLE 1

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

    First author [ref].Study designTime periodSample size nAge yearsFemaleASD diameter mmNYHA class III–IVPH assessment methodPH measure and cut-offs mmHgMean sPAP mmHgPH prevalence
    Veldtman [31]#Retrospective cohort1997–19994038 (20–71)7513±45TEEsPAP >35NR62
    De Lezo [32]Case seriesNR2956±148326±748TTE/TEEsPAP ≥4064±23100
    Bruch [33]Case seriesNR1566 (48–77)66.622.7±7.0 (9–34)60TTE/RHCmPAP >2558.3±15100
    Balint [34]#,¶Case series1999−20045459±157618±741TTE/TEEsPAP 40–49 (mild), 50–59 (moderate), ≥60 (severe)58±10100
    Yong [35]#,¶Prospective cohort1999−200621554±167319±619TTEsPAP ≥40Median (IQR) 30.0 (25.0–36.0)50.2
    Yalonetsky [36]#Retrospective cohort1998−NR23NRTTEsPAP cut-off NRNR
     Age 40–60 years52±67419±539±7.7
     Age 60+ years67±57018±553±16.2
    Altindag [37]Retrospective cohort1999–20084758±13 (40–79)79NR43TTE/TEENRNR62
    Humenberger [38]#,¶Prospective cohortNRTTE/TEEsPAP ≥40NR
     Age<40 years7829±6.761.5Median (IQR) 23 (29–26)1.331±7
     Age 40–60 years8450±5.665.5Median (IQR) 22 (17.5–26.5)3.837±10
     Age >60 years7471±6.182.4Median (IQR) 22.5 (20–28)41.453±17
    Huang [39]¶Retrospective cohort2007–20101532.3±12.873.3NRNRRHCsPAP ≥60 (severe PAH)51.6±9.4100
    Kefer [40]#Prospective cohort1999−200911246±1771PH: 22±5
    no PH: 18±6
    31TTEsPAP >4047±728
    Nakagawa [41]¶#Prospective cohort2005–20103075.8±3.8 (70–85)66.620.3±6.435TEEmPAP ≥2535.6±11.853
    Mangiafico [42]#Prospective cohort2008–2011NRNRTTEsPAP cut-off NRNR
     Age <40 years1029±7.3035.1±6.6
     Age >40 years2058±11041.2±6.4
    Akagi [9]¶Case series2006–2014RHC
     PHM group 1837±1510022±788sPAP ≥6060±11100
     Non-PHM group 21466±137123±821mPAP ≥2558±17
    Wang [43]Retrospective cohort2000–2009179Median (IQR) 53 (40–81)75.4NR8.9TEEsPAP ≥4044.8±22.224
    Dalvi [44]Case series2009–2014629±8.8983.328±2.090RHCmPAP ≥25102.6±11.5100

    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 nMean follow-up time monthsPH assessment methodMean sPAP after closure mmHgMean sPAP reduction mmHgPH prevalenceNYHA class III–IV
      Veldtman [31]27NR (1–12)TTENR10#28.50
      De Lezo [32]2821±14TTE34±1114#1000
      Bruch [33]1310±4RHC49.9±17.8NR920
      Balint [34]¶3931±15TTE/TEE44±1614#NR20
      Yong [35]¶186Median (IQR) 15 (8–43)TTEMedian (IQR) 25.0 (24–49)Median (IQR) 5 (1–13)263.7
      Yalonetsky [60]NRNR (1–12)TTENRNRNR
       Age 40–60 years26
       Age >60 years33.5
      Altindag [37]4115±15TTE/TEENRNR385
      Humenberger [38]¶28±19TTENR
       Age <40 years7526±55±80
       Age 40–60 years8430±68±90
       Age >60 years7443±149±144
      Huang [39]¶,+723.4±9.7RHC/TTE21.0±3.816#13NR
      Kefer [40]11260±34TTE31±117#5.48
      Nakagawa [41]¶2719.1±11.3TEE27.2±7.3NRNR4
      Mangiafico [42]NR (1–12)TTENR
       Age <40 years1028±2.87.1#0
       Age >40 years2028.4±6.512.8#0
      Akagi [9]¶TTENRNR
       PHM group 1819±27 (3–83)40±90
       non-PHM group 21419±16 (4–61)38±100
      Wang [43]17645.6±25.2TEENRNR71.7
      Dalvi [44]439.5±8.5RHC55.7±9.212.8#NR0

      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.

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      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
      European Respiratory Review Dec 2020, 29 (158) 200099; DOI: 10.1183/16000617.0099-2020

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      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
      European Respiratory Review Dec 2020, 29 (158) 200099; DOI: 10.1183/16000617.0099-2020
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