Procedural outcomes: the evidence is growing.
Interestingly, in this issue of the Journal, Garg et al. showed
that no significant differences in clinical and procedural outcomes were
observed comparing septal vs. device puncture, apart from total
procedural time that was significantly longer with TSP via the closure
device vs. the native septum (p = 0.004), mostly due to longer time
needed to perform TSP. This suggests a similar maneuverability of the
catheters in left atrium with both approaches. Recurrence of AF was not
significantly different in the two groups and was comparable to AF
ablation outcomes in patients without ASD closure device. As expected,
long-term freedom from AF was higher in paroxysmal and persistent AF,
while long-standing persistent AF patients were more unlikely to
maintain sinus rhythm during follow-up. Considering the high
success-rate in the early stages of AF, timing of catheter ablation is
crucial and a “wait-and-see ” strategy with a prolonged drug
treatment12 is probably not worth it for ASD patients.
Of note, despite different follow-up strategies no residual interatrial
shunt was reported in the three cohorts. In a medium-term follow-up (3
to 6 months after the procedure), Santangeli et
al .6 relied on contrast transthoracic
echocardiography (TTE), with and without Valsalva maneuvers, Li et
al. 7 utilized TEE. Sang et
al. 8 relied only on non-contrast enhanced TTE, hence
we cannot exclude that in this cohort the presence of a residual
interatrial shunt might have been missed in some cases. Post-procedural
shunts at ICE and contrast TTE were noted in a non-negligible number of
patients in the first cohort6; therefore timing and
the best strategy for evaluating residual shunts are of great
importance. Follow-up in cases with direct puncture of the ASD closure
device is even more challenging, because of the so-called “shadow
effect ” that might hamper a correct “anatomical” detection of the
residual shunt. In our opinion, use of bubble-contrast TTE, enhanced
with novel 3D imaging techniques, may be the best follow-up strategy in
these patients, minimizing the risks of an incorrect detection of
residual shunt, as well as avoiding discomfort of TEE (Figure
1) .
To sum up, despite limited data and a relatively small sample size, this
meta-analysis highlights the feasibility and safety of catheter ablation
in patients with ASD closure devices. In our opinion, these procedures
should be centralized at high-volume centers; use of ICE should be
encouraged, and a thorough follow-up with contrast-enhanced
echocardiography should be performed. Garg et al. should be
applauded for their work, useful to shed some light on this challenging
population, establishing that AF ablation in patients with percutaneous
atrial septal closure devices is safe and effective, but in the right
hands.