Abstract
Background
Mitral regurgitation (MR) associated with atrial septal defect (ASD) has been observed to improve following ASD closure; however, aggravation of preexisting MR can occur postprocedure, with the underlying mechanisms of these adverse outcomes remaining poorly understood.
Method
This retrospective study evaluated 95 patients who underwent surgical secundum ASD closure, all of whom received preoperative and postoperative transthoracic echocardiography (TTE). Patient characteristics from preoperative TTE, as well as sex and age, were analyzed to identify predictors of MR. Follow-up TTE was conducted at 1 month, 3 months, 6 months, 1 year, and 2 years postprocedure, with all patients successfully completing the 2-year follow-up.
Results
The univariate logistic regression analysis indicated that age, gender, LA, RA-VD, RA-HD, RV, ASD diameter, AS diameter, PAP, and peak tricuspid regurgitation velocity may serve as predictors of MR worsening. Subsequent multiple logistic regression analysis revealed that LA size was an independent predictor of MR worsening and acted as a protective factor. Our research indicates a marked reduction in the right cardiac system after ASD closure, with significant remodeling of the LA within the first 6 months. The relative size of the LV increased notably within 2 years. The postoperative changes in LA differed between the worsening MR group and the nonworsening MR group.
Conclusion
In conclusion, “prophylactic” mitral annuloplasty during ASD surgery may prove advantageous for patients with an enlarged LA, and the presence of additional risk factors associated with mitral annuloplasty heightens the recommendation for concurrent intervention.
Keywords: predictor, mitral regurgitation, atrial septal defect closure, cardiac geometric change
Introduction
ASD closure is indicated for right ventricular volume overload with left-to-right flow to prevent arrhythmias and right heart failure in later decades. Over time, the presence of an atrial shunt contributes to right chamber enlargement and an age-dependent decline in left ventricular (LV) compliance, leading to both right ventricular (RV) and LV dysfunction. Notably, mitral regurgitation (MR) associated with ASD has been observed to improve following ASD closure; however, aggravation of preexisting MR can occur postprocedure, with the underlying mechanisms of these adverse outcomes remaining poorly understood. 1 2 We therefore hypothesized that alterations in cardiac geometry may play an important part in the mechanism of MR. 3 4 This study aims to identify preoperative predictors of worsening MR and to elucidate the subsequent changes in cardiac geometry following surgical closure of secundum ASD in adult patients.
Patients and Methods
The study protocol received approval from the Hospital Institutional Ethics Committee. Due to the retrospective nature of patient enrollment, written informed consent was waived.
Study Population
This retrospective study investigated 532 consecutive adults (age ≥ 18 years) who underwent surgical secundum ASD closure from 2017 to 2021 at our hospital. To evaluate the impact of secundum ASD closure on MR, the study excluded patients who underwent any concomitant procedures at secundum ASD closure, such as mitral valve operation ( n = 84), tricuspid valve operation ( n = 323), aortic valve operation ( n = 6), and other congenital heart disease repairs ( n = 24). Ultimately, 95 patients (28.42% male; mean age,37 years) were enrolled, and all of whom presented with sinus rhythm. The 95 patients underwent preoperative transthoracic echocardiography and postoperative follow-up TTE. Surgical methods for ASD closure included direct closure or patch closure, with autologous pericardial patch utilized in some cases to minimize tautness or septal shift following closure.
Echocardiographic Evaluation
Images were digitally stored and analyzed offline at the end of each study. Echocardiographic measurements were obtained as the average of three consecutive cardiac cycles. Comprehensive echocardiography assessments were conducted by experienced sonographers using commercially available ultrasound systems. The dimensions of left atrial (LA) and RV were measured in subcostal view, long-axis views, and apical four-chamber views by M-mode echocardiography in accordance with the current guidelines of the American Society of Echocardiography/European Association of Echocardiography. LV was measured in the subcostal view and long-axis views. RA and atrial septum (AS) were measured in apical four-chamber views. In this plane, we calculated RA-HD/VD, where HD is the horizontal diameter of the RA and VD the vertical diameter of the RA. The maximum ASD diameter was measured in both the subcostal short- and long-axis views. The pulsed-wave Doppler-derived transtricuspid velocity was obtained using apical four-chamber views. The early diastolic (E) and atrial (A) wave velocities were measured by means of pulsed-wave Doppler recording. For assessment of cardiac geometry, we categorized these parameters into left chamber parameters (LA, LV), right chamber parameters (RA-HD, RA-VD, RV), and parameters reflecting the relationships between chambers (RA-HD/VD, LA/LV, LV/RV). MR was quantified in the parasternal long-axis view or the apical long-axis view by measuring the width of the vena contracta. Color flow Doppler settings were maintained consistently throughout the study. The severity of MR was graded as slight (<0.9 mm), mild (1.0–2.9 mm), moderate (3.0–6.9 mm), or severe (≥7.0 mm). Worsening MR was defined as an increase in the severity of MR by a grade of 1 or more following the procedure. Follow-up TTE was conducted at 1 month, 3 months, 6 months, 1 year, and 2 years postprocedure, with all 95 patients completing the 2-year follow-up.
Predictors of MR
The preoperative TTE characteristics, along with sex and age of the patients, were assessed to identify predictors of MR.
Statistical Analysis
All data were analyzed using SPSS version 24.0 statistical software. For the evaluation of predictors of MR, metric data were expressed as x̄ ± S or M [P25, P75], while categorical data were expressed as n (%). The risk factors for worsening MR following ASD closure were examined using binary logistic regression. The ROC curve was employed to assess the model's fit, with a significance level set at p < 0.05. For following up cardiac geogmetric Changes, the comparison of the differences in variables before and after closure was conducted using the Wilcoxon rank sum test. Comparisons of variables at various follow-up time points postclosure were conducted using the repeated measures Friedman test, with p < 0.05 indicating statistical significance.
Results
Predictors of MR
This study involved a total of 95 participants, categorized based on the presence of worsening MR following surgical ASD closure. Within the worsening MR group, there were 11 males (64.71%) and 6 females (35.29%), with an average age of 52 years. In contrast, the nonworsening MR group comprised 16 males (20.51%) and 62 females (79.49%), with an average age of 34.5 years (see Table 1 ). A univariate logistic regression analysis was performed, using worsening MR as the dependent variable and baseline patient characteristics as independent variables. The analysis indicated that age, gender, LA, RA-VD, RA-HD, RV, ASD diameter, AS diameter, PAP, and peak tricuspid regurgitation velocity may serve as predictors of MR worsening ( p < 0.05; see Table 2 ). Subsequent multiple logistic regression analysis revealed that LA size was an independent predictor of MR worsening and acted as a protective factor ( p < 0.05; see Table 2 ). The ROC curve analysis results demonstrated an area under the curve of 0.925, with a 95% confidence interval of 0.857 to 0.992 and a standard error of 0.034 ( p < 0.05), indicating statistical significance. The proximity of the ROC curve area to one suggests excellent model fit, as illustrated in Fig. 1 .
Table 1. Characteristics of study participants ( n [%]/M[P 25 ,P 75 ]/x̄ ± S) .
| Variables | Patients with worsening MR ( n = 17) | Patients without worsening MR ( n = 78) |
|---|---|---|
| Age, y | 52.0 (44.0, 57.0) | 34.5 (25.0, 48.0) |
| Sex, n (%) | ||
| Male | 11 (64.71) | 16 (20.51) |
| Female | 6 (35.29) | 62 (79.49) |
| LA, mm | 44.2 (5.1) | 34.4 (4.59) |
| RA-VD, mm | 54.0 (52.0, 63.0) | 44.0 (41.0, 49.0) |
| RA-HD, mm | 67.0 (65.0, 71.0) | 54.0 (50.0, 58.0) |
| RA-HD/VD | 0.8 (0.7, 0.9) | 0.8 (0.8, 0.9) |
| LV, mm | 39.0 (36.0, 45.0) | 39.0 (35.0, 41.0) |
| RV, mm | 42.7 (6.1) | 38.3 (5.4) |
| LV/RV | 1.0 (0.9, 1.1) | 1.0 (0.9, 1.2) |
| ASD diameter, mm | 36.7 (7.9) | 27.8 (6.6) |
| AS diameter, mm | 65.0 (54.0, 69.0) | 50.0 (46.0, 55.0) |
| PG, mmHg | 3.0 (2.0, 4.0) | 4.0 (3.0, 5.0) |
| PAP, mmHg | 62.6 (15.1) | 54.7 (13.0) |
| E/A | 1.2 (0.7, 1.3) | 1.3 (0.8, 1.6) |
| Peak TR velocity, cm/s | 355.2 (49.3) | 325.7 (48.2) |
Table 2. Univariate logistic regression analysis and multivariable logistic regression analysis of risk factors for postoperative MR aggravation.
| Variables | Univariate logistic regression analysis | Multivariable logistic regression analysis | ||||
|---|---|---|---|---|---|---|
| P | OR | 95% Cl | P | OR | 95% Cl | |
| Age | 0.008 | 0.941 | 0.900–0.984 | 0.917 | 0.996 | 0.920–1.078 |
| Sex | ||||||
| Male | reference | |||||
| Female | 0.001 | 7.104 | 2.280–22.132 | 0.106 | 4.295 | 0.734–25.135 |
| LA | <0.001 | 0.718 | 0.618–0.835 | 0.032 | 0.783 | 0.626–0.979 |
| RA-VD | 0.001 | 0.889 | 0.829–0.953 | 0.851 | 1.016 | 0.864–1.193 |
| RA-HD | 0.001 | 0.876 | 0.813–0.945 | 0.851 | 1.026 | 0.876–1.202 |
| RV | 0.007 | 0.874 | 0.792–0.964 | 0.287 | 0.902 | 0.747–1.090 |
| LV/RV | 0.060 | 15.586 | 0.892–272.277 | 0.581 | 0.955 | 0.811–1.124 |
| ASD diameter | <0.001 | 0.835 | 0.758–0.919 | 0.581 | 0.955 | 0.811–1.124 |
| AS diameter | <0.001 | 0.861 | 0.800–0.926 | 0.415 | 0.943 | 0.820–1.085 |
| PG | 0.031 | 1.561 | 1.041–2.341 | 0.778 | 1.088 | 0.643–1.838 |
| PAP | 0.037 | 0.958 | 0.921–0.997 | 0.680 | 1.033 | 0.885–1.205 |
| E/A | 0.233 | 1.936 | 0.654–5.732 | – | – | – |
| Peak TR velocity | 0.030 | 0.987 | 0.976–0.999 | 0.659 | 0.991 | 0.950–1.033 |
Fig. 1.
Predictive efficacy of risk factors affecting postoperative MR aggravation.
Follow-Up Cardiac Geometric Changes
This study comprised 95 individuals with an average age of 37 years, including 27 males (28.42%) and 68 females (71.58%). The average measurements prior to ASD closure were as follows: RA-VD 45 mm, RA-HD 55 mm, and RA-HD/VD ratio 0.83; LA size averaged 35 mm, LV size 38 mm, and LA/LV ratio 0.92; RV size averaged 39 mm, with an LV/RV ratio of 1.
Postoperative follow-up data indicated an overall decreasing trend in cardiac geometric parameters, except for LV size and LV/RV ratio (see Table 3 ). Specifically, LA size demonstrated a statistically significant reduction within 6 months postoperatively ( p < 0.05). Although LA continued to decrease at one and 2 years postsurgery, these differences were not statistically significant. Overall, LA levels exhibited an initial decline followed by a gradual recovery, with significant differences observed across different postoperative time points ( p < 0.05). During follow-up, RA-VD, RA-HD, RA-HD/VD, LA/LV, and RV all showed a significant decrease compared with preoperative levels ( p < 0.05). With the exception of RA-HD, all variables demonstrated significant differences between the various postoperative time points ( p < 0.05). In contrast, LV and LV/RV ratios increased during follow-up, with significant differences noted at each stage compared with preoperative measurements ( p < 0.05). There were also significant differences between various postoperative time points ( p < 0.05).
Table 3. Cardiac geometry changes in echocardiographic parameters of postoperative patients at follow-up.
| Variable | Baseline | Follow-up in 1 mo | Follow-up 3 mo | Follow-up 6 mo | Follow-up 1 y | Follow-up 2 y |
|---|---|---|---|---|---|---|
| LA | 35.0 (32.0, 39.0) | 33.0 (29.0, 35.0) a | 33.0 (30.0, 36.0) a | 34.0 (31.0, 37.0) a | 34.0 (32.0, 38.0) | 34.05 (31.0, 38.0) b |
| RA-VD | 45.0 (42.0, 52.0) | 35.0 (33.0, 38.0) a | 33.0 (30.036.0) a | 34.0 (31.0, 36.0) a | 32.0 (30.0, 36.0) a | 34.5 (30.0, 37.0) a b |
| RA-HD | 55.0 (50.0, 61.0) | 44.0 (41.0, 50.0) a | 42.0 (38.0, 46.0) a | 42.0 (38.0, 44.0) a | 42.0 (38.0, 44.0) a | 42.0 (39.0, 46.0) a |
| RA-HD/VD | 0.83 (0.78, 0.90) | 0.79 (0.73, 0.85) a | 0.78 (0.72, 0.83) a | 0.81 (0.75, 0.86) | 0.81 (0.74, 0.85) a | 0.81 (0.76, 0.83) a b |
| LV | 38.0 (35.0, 41.0) | 42.0 (39.0, 45.0) a | 42.0 (40.0, 45.0) a | 44.0 (42.0, 47.0) a | 45.0 (42.0, 47.0) a | 45.5 (43.0, 48.0) a |
| LA/LV | 0.92 (0.82, 1.05) | 0.78 (0.69, 0.85) a | 0.76 (0.71, 0.83) a | 0.76 (0.71, 0.82) a | 0.77 (0.71, 0.84) a | 0.76 (0.69, 0.84) a b |
| RV | 39.0 (35.0, 43.0) | 27.0 (25.0, 29.0) a | 26.0 (23.0, 27.0) a | 25.0 (22.0, 27.0) a | 24.0 (22.0, 26.0) a | 24.0 (21.0, 27.0) a b |
| LV/RV | 1.00 (0.85, 1.14) | 1.56 (1.42, 1.72) a | 1.71 (1.57, 1.91) a | 1.84 (1.65, 2.00) a | 1.89 (1.67, 2.05) a | 1.98 (1.74, 2.15) a b |
Indicates comparisons of echocardiographic parameters at different follow-up times with presurgical Baseline ( p < 0.05).
Indicates comparisons of echocardiographic parameters at different follow-up times ( p < 0.05).
The data were stratified based on the presence of worsening postoperative MR following ASD closure (see Table 4 ). The analysis revealed that postoperative MR influences changes in cardiac indicators at different stages. In the group with worsening MR, LA exhibited a significant increase 1 year postsurgery ( p < 0.05), while in the group without worsening MR, LA showed an overall decreasing trend, with significant differences at 1 month, 3 months, and 1 year compared with preoperative levels ( p < 0.05). Other indicators remained consistent with the changes observed before stratification.
Table 4. Cardiac geometry changes in echocardiographic parameters of postoperative patients at follow-up by patients with/without worsening MR.
| Variable | Baseline | Follow-up 1 mo | Follow-up 3 mo | Follow-up 6 mo | Follow-up 1 y | Follow-up 2 y |
|---|---|---|---|---|---|---|
| Patients with worsening MR | ||||||
| LA | 43.0 (40.0, 46.0) | 39.0 (36.0, 44.0) | 41.0 (39.0, 44.0) | 42.0 (39.0, 44.0) | 44.0 (42.0, 46.0) a | 47.0 (42.0, 46.0) |
| RA-VD | 53.0 (49.0, 61.0) | 40.0 (35.0, 43.0) a | 39.0 (34.0, 41.0) a | 37.0 (34.0, 42.0) a | 39.0 (37.0, 43.0) a | 44.0 (37.0, 45.5) a |
| RA-HD | 65.0 (60.0, 71.0) | 52.0 (44.0, 55.0) a | 51.0 (44.0, 56.0) a | 50.0 (40.0, 56.0) a | 52.0 (46.0, 53.0) a | 51.0 (42.5, 53.5) a |
| RA-HD/VD | 0.85 (0.76, 0.91) | 0.76 (0.73, 0.79) a | 0.78 (0.73, 0.84) a | 0.78 (0.68, 0.82) a | 0.78 (0.75, 0.81) | 0.82 (0.75, 0.88) |
| LV | 38.0 (36.0, 39.0) | 44.0 (40.0, 47.0) a | 45.0 (42.0, 47.0) a | 48.0 (45.0, 50.0) | 48.0 (46.0, 49.0) a | 47.0 (45.0, 50.0) a |
| LA/LV | 1.15 (1.03, 1.23) | 0.87 (0.81, 0.98) | 0.89 (0.82, 0.95) | 0.84 (0.81, 0.98) | 0.90 (0.85, 1.02) | 0.98 (0.87, 1.12) |
| RV | 41.0 (39.0, 45.0) | 29.0 (27.0, 30.0) a | 27.0 (26.0, 28.0) a | 26.0 (25.0, 27.0) a | 26.0 (24.0, 27.0) a | 27.0 (26.5, 28.0) a b |
| LV/RV | 0.91 (0.76, 1.08) | 1.62 (1.42, 1.72) a | 1.70 (1.57, 1.86) a | 1.85 (1.70, 1.96) a | 1.85 (1.70, 1.92) a | 1.71 (1.62, 1.81) a b |
| Patients without worsening MR | ||||||
| LA | 34.0 (31.0, 37.0) | 31.0 (29.0, 34.0) a | 32.0 (29.0, 34.0) a | 34.0 (30.0, 35.0) | 33.5 (31.0, 36.0) a | 34.0 (30.0, 35.0) b |
| RA-VD | 44.0 (41.0, 49.0) | 35.0 (32.0, 38.0) a | 32.0 (29.0, 35.0) a | 33.0 (31.0, 35.0) a | 32.0 (29.0, 35.0) a | 33.0 (30.0, 36.0) a b |
| RA-HD | 54.0 (50.0, 58.0) | 43.0 (40.0, 48.0) a | 41.0 (38.0, 45.0) a | 41.0 (38.0, 44.0) a | 41.0 (38.0, 43.0) a | 42.0 (38.0, 45.0) a |
| RA-HD/VD | 0.83 (0.78, 0.90) | 0.79 (0.73, 0.85) a | 0.79 (0.72, 0.83) a | 0.82 (0.75, 0.86) | 0.81 (0.72, 0.86) a | 0.80 (0.76, 0.83) a b |
| LV | 39.0 (35.0, 41.0) | 41.0 (39.0, 44.0) a | 42.0 (40.0, 45.0) a | 43.0 (41.0, 46.0) a | 44.5 (42.0, 47.0) a | 45.0 (43.0, 48.0) a b |
| LA/LV | 0.88 (0.80, 0.97) | 0.76 (0.68, 0.84) a | 0.75 (0.70, 0.80) a | 0.74 (0.70, 0.80) a | 0.76 (0.70, 0.81) a | 0.73 (0.68, 0.80) a |
| RV | 38.0 (35.0, 42.0) | 27.0 (25.0, 29.0) a | 25.0 (22.0, 27.0) a | 24.5 (22.0, 27.0) a | 24.0 (22.0, 26.0) a | 22.0 (20.0, 25.0) a b |
| LV/RV | 1.03 (0.88, 1.16) | 1.55 (1.43, 1.71) a | 1.72 (1.58, 1.95) a | 1.84 (1.62, 2.10) a | 1.90 (1.67, 2.05) a | 2.02 (1.82, 2.18) a b |
Indicates comparisons of echocardiographic parameters at different follow-up times with presurgical Baseline ( p < 0.05).
Indicates comparisons of echocardiographic parameters at different follow-up times ( p < 0.05).
In the group with worsening MR, no statistically significant differences were noted for LA, RA-VD, RA-HD, RA-HD/VD, LV, and LA/LV across different postoperative time points ( p > 0.05). Conversely, the group without worsening MR showed significant differences at various time points after ASD closure ( p < 0.05), with changes in other indicators aligning with those prior to stratification.
Patients were categorized according to the degree of postoperative worsening MR into a mild group (Group A) and a moderate to severe group (Group B), as illustrated in Fig. 2 . The results indicated that the trends in variable changes related to cardiac chamber structure were similar between the two groups; however, the recovery of variables in Group B occurred later than in Group A. While the trends in left ventricular measurements were comparable across both groups, LA worsening was more pronounced in Group B. The trends for right ventricular variables were largely consistent between the two groups.
Fig. 2.
Changes in echocardiographic parameters of postoperative at follow-up in the mild group (group A ) and moderate to severe group (group B ).
Discussion
While transcatheter closure has emerged as the preferred treatment for secundum ASD, surgical closure retains a significant role, particularly in patients with concomitant significant valvular disease or challenging anatomical locations. Postoperatively, some patients experience improvement in MR, whereas others exhibit exacerbation. Limited studies have addressed the risk factors associated with MR following ASD closure and evaluated the chronological changes in MR after the procedure. We hypothesize that ASD closure redistributes pressure between the left and right cardiac systems, thereby altering the overall cardiac structure. Consequently, this study aimed to clarify the preoperative predictive factors for MR after ASD closure and to elucidate the changes in cardiac geometry postoperatively to optimize therapeutic approaches.
This is the rare study to investigate the risk factors for MR following surgical ASD closure while comprehensively observing changes in cardiac geometry. The study included 95 patients with ASD and slight MR who underwent isolated surgical closure, excluding those with concomitant procedures. Our findings revealed that worsening MR occurred in 18 patients (18.95%) after ASD closure. The univariate logistic regression analysis indicated that age, gender, LA, RA-VD, RA-HD, RV, ASD diameter, AS diameter, PAP, and peak tricuspid regurgitation velocity are potential predictors of MR worsening ( p < 0.05). Notably, ASD diameter, age, gender, and peak tricuspid regurgitation velocity were established as risk factors, with the remaining factors identified for the first time in this context. 3 5 Multiple logistic regression analysis indicated that LA size was an independent predictor of MR worsening and acted as a protective factor ( p < 0.05). The ROC curve analysis confirmed the robustness of the regression model.
Previous studies have suggested an association between MR and mitral annular dilation, with perioperative atrial fibrillation leading to mitral annular dilation and retraction of the posterior mitral leaflet, both of which are related to MR exacerbation. 6 Since all patients in our study maintained sinus rhythm, we assert that LA enlargement can lead to posterior mitral leaflet retraction against the LV wall, compromising mitral leaflet coaptation and potentially worsening MR. 7 Certain studies suggest that the D-shaped restoration of septal configuration abnormalities exacerbates MR. 8 These investigations may elucidate the mechanisms behind MR aggravation from different perspectives. Taking these findings into consideration, we speculate that the mechanism of aggravation of MR is as follows: the heart, akin to other organs, undergoes a range of adaptive changes and gradually returns to a normal or near-normal state following the correction of abnormalities or malformations. However, should these changes exceed a certain threshold, they surpass the heart's capacity for remodeling. This phenomenon also accounts for the improvement and deterioration of MR post-ASD closure. Large ASD diameter, AS diameter, PAP, and peak tricuspid regurgitation velocity reflect decreased left ventricular compliance. Concurrently, the abnormal changes in LA, RA-VD, RA-HD, RV size, and ASD diameter-each reflective of cardiac structure-may result in an incomplete remodeling process following ASD closure. 9 The correlation between worsening MR and ASD diameter may arise from surgical alterations in the physiological morphology of the mitral annulus associated with larger ASD diameters. In this study, a “large” ASD is specifically defined as a diameter exceeding 36.7 mm, the mean value observed in our control cohort. While the influence of large ASD closure on cardiac geometry has been acknowledged in the literature, a consensus on its precise assessment remains elusive. Certain investigators prioritize alterations in end-diastolic volume. In contrast, we posit that the dimensions of the individual cardiac chambers—specifically the left and right sides—and the dynamic interplay between them constitute a more robust and clinically relevant reflection of real-world cardiac architecture. Furthermore, we hypothesize that not all geometric perturbations inevitably lead to adverse outcomes. However, once this compensatory threshold is surpassed—that is, when the geometric alteration exceeds the heart's self-adaptive capacity—deleterious consequences, such as the exacerbation of mitral MR, are likely to ensue. In elderly patients, reduced cardiac compliance may further contribute to worsening MR. While these factors are identified as risk factors for MR exacerbation, their mere presence does not necessarily dictate MR worsening. Nevertheless, among various risk factors, LA size is regarded as an independent risk factor. 10 Previous work by Ring et al confirmed that total LA emptying fraction, reservoir strain, and contractile strain are independent predictors of severe MR requiring surgical intervention. 11 This suggests that LA dimensions are a reliable indicator of the extent of pathological cardiac remodeling. In our study, three cases exhibited moderate or greater MR, with no reduction observed within 2 years of follow-up, presenting an average LA diameter of 44.67 mm. Therefore, the management of predictors is thought to be important to prevent MR. Clinically, our findings suggest that patients exhibiting these risk factors might benefit from “prophylactic” mitral annuloplasty during ASD closure, particularly when the LA diameter exceeds 44.67 mm. Moreover, the presence of multiple risk factors further reinforces this recommendation.
Our research indicates a marked reduction in several indicators of the right cardiac system after ASD closure, with significant remodeling of the LA within the first 6 months. The relative size of the LV in the left cardiac system increased notably within 2 years. The postoperative changes in LA differed between the worsening MR group and the nonworsening MR group, potentially reflecting the interaction between LA size and MR.
We categorized the degree of postoperative MR into Group A and Group B. The results indicated similar trends in the parameters across both groups, though the remodeling of variables in Group B occurred later than in Group A. The trends for left ventricular parameters were comparable between both groups, yet the LA size increased more significantly in Group B, while the trends for right ventricular parameters remained consistent across both groups.
Limitation
This study investigated the risk factors associated with MR following ASD closure; however, the sample size was limited, and the retrospective nature of the analysis necessitates validation through larger, prospective studies. While we hypothesize that MR is linked to mitral annular dilation, our retrospective design did not allow for the measurement of mitral annular diameter, coaptation of the mitral leaflets, and other pertinent parameters. Although further statistical analysis for subgroup comparisons was not feasible, we present the data as trend graphs to facilitate future research endeavors.
Conclusion
In conclusion, “prophylactic” mitral annuloplasty during ASD surgery may prove advantageous for patients with an enlarged LA, and the presence of additional risk factors associated with mitral annuloplasty heightens the recommendation for concurrent intervention.
Conflict of Interest The authors declare that they have no conflict of interest.
Contributors' Statement
C.L. contributed to data curation, formal analysis, investigation, methodology, project administration, software, supervision, and writing—original draft. Z.Z. contributed to formal analysis, investigation, methodology, project administration, validation, and writing—review and editing. J.X. contributed to conceptualization, formal analysis, methodology, project administration, resources, supervision, visualization, and writing—review and editing.
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