Abstract
Objectives
This study aimed to assess current temporal trends in utilization of ICE versus TEE guided closure of interatrial communications, and to compare periprocedural complications and resource utilization between the two imaging modalities.
Background
While transesophageal echocardiography (TEE) has historically been used to guide percutaneous structural heart interventions, intracardiac echocardiography (ICE) is being increasingly utilized to guide many of these procedures such as closure of interatrial communications.
Methods
Using the Nationwide Inpatient Sample, all patients aged >18 years, who underwent ASD or PFO closure with either ICE or TEE guidance between 2003 and 2014 were included. Comparative analysis of outcomes and resource utilization was performed using a propensity score-matching model.
Results
ICE guidance for interatrial communication closure increased from 9.7% in 2003 to 50.6% in 2014. In the matched model, the primary endpoint of major adverse cardiovascular events occurred less frequently in the ICE group versus the TEE group (11.1% vs 14.3%, respectively, P = 0.008), mainly driven by less vascular complications in the ICE group (0.5% vs 1.3%, P = 0.045). Length of stay was shorter in the ICE group (3 ± 4 vs 4 ± 4 days, P < 0.0001). Cost was similar in the two groups 18 454 ± 17 035$ in the TEE group vs 18 278 ± 15 780$ in the ICE group (P = 0.75).
Conclusions
Intracardiac echocardiogram utilization to guide closure of interatrial communications has plateaued after a rapid rise throughout the 2000s. When utilized to guide interatrial communication closure procedure, ICE is as safe as TEE and does not increase cost or prolonged hospitalizations.
Keywords: atrial sep-tal defect, intracardiac echocardiography, patent foramen ovale, transcatheter closure, transesophageal echocardiography
1 INTRODUCTION
Percutaneous closure of Interatrial communication (IAC) was first introduced by King et al in 1976 to treat a 17-year-old girl with secundum atrial septal defect (ASD). This technique became widely adopted and further expanded to closure of Patent Forman Ovale (PFO) in the late 1980s.1 Although these procedures have been occasionally done with fluoroscopy-guidance, transesophageal echocardiography (TEE) has historically been the modality of choice for intraoperative guidance. In 1991, ultrasound cardioscopy, later termed intracardiac echocardiography (ICE), was introduced to guide ASD closure.2,3 Since then, both modalities have been used successfully to guide IAC closure and other structural heart interventional procedures.4,5 These two modalities (TEE and ICE) are very different in terms of availability, ease of use, imaging quality, and cost. Single center studies have suggested the safety and possibly the superiority of ICE over TEE in guiding ASD and PFO closure cases.6–17 However, no large-scale comparative studies between the two modalities have been performed.
Our study aims to utilize a large nationwide database to:
Assess the temporal trends in utilization of ICE versus TEE to guide percutaneous IAC closure in the United States.
Compare periprocedural complications in patients undergoing IAC closure with ICE versus TEE.
Compare resource utilization (cost and hospital length of stay) between ICE and TEE in percutaneous IAC closure.
2 MATERIALS AND METHODS
2.1 Study data
The Nationwide Inpatient Sample (NIS) was used to derive patient relevant information between January 2003 and December 2014. The NIS is the largest publicly available all-payer administrative claims-based database and contains information about patient discharges from approximately 1000 non-federal hospitals in 45 states. It contains clinical and resource utilization information on 5–8 million discharges annually, with safeguards to protect the privacy of individual patients, physicians, and hospitals. These data are stratified to represent approximately 20% of US inpatient hospitalizations across different hospital and geographic regions (random sample). National estimates of the entire US hospitalized population were calculated using the Agency for Healthcare Research and Quality sampling and weighting method.
2.2 Study population
We analyzed the NIS dataset between 2003 and 2014 using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes. Patients >18 years of age with diagnosis ASD/PFO (diagnosis code 745.5), who underwent percutaneous closure (procedure code 35.52) were included. Codes 372.8 and 88.72 were used to identify ICE and TEE procedures, respectively. We excluded all patients who had both ICE and TEE during same admission (Fig. 1).
FIGURE 1.
Flow diagram of patients’ selection from National Inpatient Sample (NIS) database
2.3 Trends and outcomes of ICE and TEE
The trends of intracardiac and TEE utilization in patients, who underwent percutaneous ASD/PFO closure during the 12-year study period were assessed. Patients’ baseline demographic, comorbidity, and hospital characteristics were described. In-hospital morbidity and mortality outcomes of ICE and TEE were assessed.
2.4 Comparative outcomes analysis
We compared the outcomes of ICE and TEE utilization to guide percutaneous ASD/PFO closure. To account for potential confounders and reduce the effect of selection bias, a propensity score-matching model was developed using logistic regression to derive two matched groups for comparative outcomes analysis. After excluding patients, who underwent open/surgical ASD/PFO and concomitant TEE and ICE (during the same admission), patients who underwent “isolated” ICE or TEE were entered into a nearest neighbor 1:1 variable ration, parallel, balanced propensity-matching model using a caliper of 0.01.18,19 Propensity scores were derived from 41 hospital, clinical, and demographic covariates including the Elixhauser comorbidity index (eTable S1). The primary endpoint was a composite end point of major adverse cardiovascular events (MACCE = one of the following: procedure related death, in-hospital death, vascular complications, pacemaker implantation, cerebral vascular accidents, acute kidney injury, blood transfusion, cardiac tamponade, new onset atrial fibrillation). Procedure related death was defined as death occurring on the same day of the procedure. Secondary end points were cost and hospital length of stay.
2.5 Statistical analysis
Descriptive statistics are presented as frequencies with percentages for categorical variables and as means with standard deviations for continuous variables. Baseline characteristics were compared using a Pearson chi-squared test and Fisher’s exact test for categorical variables and an independent-samples t-test for continuous variables. We performed multiple imputations to impute missing values for race (missing in 23% of observations) using the fully conditional specification (FCS) method (an iterative Markov Chain Monte Carlo algorithm) in SPSS 24. A Cochran-Armitage test was used to evaluate trends in ICE versus TTE in patients, who underwent percutaneous closure of ASD/PFO. To estimate the cost of hospitalization, the NIS data were merged with cost-to-charge ratios available from the Healthcare Cost and Utilization Project. We estimated the cost of each inpatient stay by multiplying the total hospital charge with cost-to-charge ratios. Univariate logistic regression was performed to estimate odds ratios with 95% confidence intervals to determine predictors of vascular complications. Matched categorical variables were presented as frequencies with percentages and compared using McNemar’s test. Matched continuous variables were presented as means with standard deviations and compared using a paired-samples t test. A type I error rate of <0.5 was considered statistically significant. All statistical analyses were performed using SPSS version 24 (IBM corporation, Armonk, NY) and R, version 3.3.1.20
3 RESULTS
3.1 Temporal trends and baseline characteristics
A total of 4213 patients, who underwent closure of ASD or PFO between 2003 and 2014 were included. (National estimates [NE] = 20 779). ICE utilization increased from 9.7% in 2003 to 50.6% in 2014 (Fig. 2). Patient mean age was 53 ± 16 and 54 ± 16 years in the TEE and ICE groups, respectively. Chronic pulmonary disease, atrial fibrillation/flutter, coagulopathy, and coronary artery disease were more frequent in patients, who underwent TEE to guide IAC closure than those who underwent ICE, while peripheral vascular disease was more frequent in the ICE group. Baseline patient-level characteristics are shown in Table 1. ICE guidance was used more frequently than TEE guidance at teaching hospitals (80.6% vs 72.4%, P < 0.001).
FIGURE 2.
Temporal trends of intracardiac versus transesophageal echocardiography to guide transcatheter closure of ASD/PFO in the United States between 2003 and 2014. TEE, Transesophageal echocardiography; ICE, Intracardiac echocardiography
TABLE 1.
Characteristics of patients undergoing ASD/PFO closure between 2003–2014
| Characteristic | All patients (n = 4213) | TEEa guidance (n = 2237) | ICEb guidance (n = 1976) | P value |
|---|---|---|---|---|
| Age-mean (SD), y | 53 (16) | 53 (16) | 54 (16) | 0.008 |
| Male-no (%) | 2424 (57.5) | 1299 (58.1) | 1125 (56.9) | 0.457 |
| Teaching hospital-no (%) | 3233 (76.7) | 1803 (80.6) | 1430 (72.4) | <0.0001 |
| Race-no. (%) | 0.007 | |||
| Caucasian | 3286 (78) | 1710 (76.4) | 1576 (79.8) | |
| African American | 305 (7.2) | 175 (7.8) | 130 (6.6) | |
| Hispanic | 373 (8.9) | 226 (10.1) | 147 (7.4) | |
| Non-elective admission status | 1479 (35.1) | 889 (39.7) | 590 (29.9) | <0.0001 |
| Medical Comorbidity-no (%) | ||||
| Hypertension | 1763 (41.8) | 910 (40.7) | 853 (43.2) | 0.102 |
| Diabetes | 531 (12.6) | 275 (12.3) | 256 (13) | 0.518 |
| Prior sternotomy | 111 (2.6) | 51 (2.3) | 60 (3) | 0.126 |
| Pulmonary disease | 440 (10.4) | 261 (11.7) | 179 (9.1) | 0.006 |
| Chronic renal failure | 120 (2.8) | 63 (2.8) | 57 (2.9) | 0.894 |
| Atrial fibrillation/flutter | 412 (9.8) | 242 (10.8) | 170 (8.6) | 0.016 |
| Deep venous thrombosis | 25 (0.6) | 17 (0.8) | 8 (0.4) | 0.134 |
| Anemia | 217 (5.2) | 127 (5.7) | 90 (4.6) | 0.1 |
| Coagulopathy | 101 (2.4) | 71 (3.2) | 30 (1.5) | <0.0001 |
| Conduction abnormalities | 64 (1.5) | 41 (1.8) | 23 (1.2) | 0.077 |
| Peripheral Vascular disease | 171 (4.1) | 72 (3.2) | 99 (5) | 0.003 |
| Coronary Artery disease | 462 (11) | 269 (12) | 193 (9.8) | 0.019 |
| Metastatic Ccancer | 9 (0.2) | 5 (0.2) | 4 (0.2) | 0.882 |
| Congestive heart failure | 28 (0.7) | 17 (0.8) | 11 (0.6) | 0.418 |
| Concomitant procedures-no (%) | ||||
| Right heart catheterization | 781 (18.5) | 423 (18.9) | 358 (18.1) | 0.509 |
| Left heart catheterization | 200 (4.7) | 115 (5.1) | 85 (4.3) | 0.201 |
| Percutaneous coronary intervention | 25 (0.6) | 15 (0.7) | 10 (0.5) | 0.488 |
| Primary payer-no (%) | 0.694 | |||
| Medicare/medicaid | 1530 (36.3) | 806 (36) | 724 (36.6) | |
| Private | 2444 (58) | 1298 (58) | 1146 (58) | |
| Self-pay/no charge/other | 239 (5.7) | 133 (5.9) | 106 (5.4) | |
| Median household income | 0.05 | |||
| 0–25th percentile | 837 (20.4) | 443 (20.4) | 394 (20.4) | |
| 26–50th percentile | 989 (24.1) | 486 (22.4) | 503 (26) | |
| 51–75th percentile | 1058 (25.8) | 579 (26.7) | 479 (24.8) | |
| 76–100th percentile | 1220 (29.7) | 661 (30.5) | 559 (28.9) | |
| Hospital region | 0.051 | |||
| Northeast | 911 (21.6) | 503 (22.5) | 408 (20.6) | |
| Midwest | 1177 (27.9) | 600 (26.8) | 577 (29.2) | |
| South | 1221 (29) | 629 (28.1) | 592 (30) | |
| West | 904 (21.5) | 505 (22.6) | 399 (20.2) |
Transesophageal echocardiography.
Intracardiac echocardiography.
3.2 Outcomes of TEE and ICE utilization to guide IAC closure
In the unmatched groups, the primary endpoint of MACCE occurred in 18% and 9.9% of IAC closures utilizing TEE and ICE guidance, respectively (P < 0.0001) (Table 2). Compared with patients who underwent ICE, those who underwent TEE had higher incidence of vascular complications, acute kidney injury, permanent pacemaker implantation, clinical stroke, and blood transfusion. TEE patients had longer length of stay and higher overall hospitalization cost (Table 2).
TABLE 2.
In hospital outcomes of patients undergoing ASD/PFO closure with intracardiac versus transesophageal echo guidance
| All patients (n = 4213) | TEE guidance (n = 2237) | ICE guidance (n = 1976) | P value | |
|---|---|---|---|---|
| Clinical outcome-no (%) | ||||
| All adverse events | 598 (14) | 403 (18) | 195 (9.9) | <0.0001 |
| In-hospital death | 27 (0.6) | 17 (0.8) | 10 (0.5) | 0.303 |
| Procedural death | 3 (0.1) | 1 (0.04) | 2 (0.1) | 0.163 |
| Vascular complications | 39 (0.9) | 30 (1.3) | 9 (0.5) | 0.003 |
| Vascular complications requiring surgery | 22 (0.5) | 12 (0.5) | 10 (0.5) | 0.891 |
| AKI | 81 (1.9) | 53 (2.4) | 28 (1.4) | 0.025 |
| AKI requiring dialysis | 7 (0.2) | 6 (0.3) | 1 (0.1) | 0.084 |
| Permanent pacemaker implantation | 27 (0.6) | 21 (0.9) | 6 (0.3) | 0.01 |
| Transient Ischemic attack | 180 (4.3) | 99 (4.4) | 81 (4.1) | 0.601 |
| Clinical stroke | 180 (4.3) | 117 (5.2) | 63 (3.2) | 0.01 |
| Blood transfusion | 108 (2.6) | 70 (3.1) | 38 (1.9) | 0.013 |
| Cardiac tamponade | 12 (0.3) | 8 (0.4) | 4 (0.2) | 0.346 |
| Atrial fibrillation/flutter (new onset) | 7 (2) | 5 (2.4) | 2 (1.4) | 0.488 |
| Length of stay-mean (SD), d | 3 (5) | 3 (5) | 2 (4) | <0.0001 |
| Cost of hospitalization (SD), $ | 19121 (18337) | 20386 (20781) | 17676 (14942) | <0.0001 |
| Hospital charges-mean (SD), $ | 57944 (65824) | 61843 (77342) | 53531 (49309) | <0.0001 |
| Discharged status | 0.006 | |||
| Discharged SNF/NH/IC | 215 (5.1) | 136 (6.1) | 79 (4) | |
| Discharged home | 3969 (94.2) | 2082 (93.1) | 1887 (95.5) |
3.3 Comparative outcomes in a propensity-matched cohort
Propensity score matching of patients utilizing TEE and ICE yielded a total of 3318 patients (1659 patients in each group, Fig. 1). Baseline characteristics were well matched between the two groups as detailed in Table 3. After propensity matching, the primary endpoint of MACCE in patients utilizing ICE remained lower than patients utilizing TEE (11.1% vs 14.3%, respectively, P = 0.008) (Fig. 3), driven mainly by the lower incidence of vascular complications (0.5% vs 1.3%, P = 0.045) (Fig. 4). Cost of hospitalization was not different between the two groups after propensity matching. However, length of stay remained significantly shorter in the group utilizing ICE compared to the TEE group (3 ± 4 vs 4 ± 4 days, P < 0.0001) (Table 4). In a subgroup analysis, the reduction of MACCE with IAC closure using ICE guidance vs TEE guidance was more pronounced at non-teaching hospitals, non-urgent admissions, and in the absence of significant comorbidities (e-Fig. S1).
TABLE 3.
Characteristics of propensity matched patients undergoing ASD/PFO closure between 2003–2014
| Characteristic | All patients (n = 3318) | TEE guidance (n = 1659) | ICE guidance (n = 1659) | P value |
|---|---|---|---|---|
| Age-mean (SD), y | 53 (16) | 53 (16) | 53 (16) | 0.608 |
| Male-no (%) | 1897 (57.2) | 949 (57.2) | 948 (57.1) | 0.99 |
| Teaching hospital-no (%) | 2603 (78.5) | 1290 (77.8) | 1313 (79.1) | 0.266 |
| Race-no. (%) | 0.424 | |||
| Caucasian | 2620 (79) | 1312 (79.1) | 1308 (78.8) | |
| African American | 241 (7.3) | 120 (7.2) | 121 (7.3) | |
| Hispanic | 276 (8.3) | 138 (8.3) | 138 (8.3) | |
| Non-elective admission status | 1117 (33.7) | 563 (33.9) | 554 (33.4) | 0.731 |
| Medical comorbidity-no (%) | ||||
| Hypertension | 1399 (42.2) | 700 (42.2) | 699 (42.1) | 0.99 |
| Diabetes | 415 (12.5) | 208 (12.5) | 207 (12.5) | 0.99 |
| Prior sternotomy | 83 (2.5) | 42 (2.5) | 41 (2.5) | 0.99 |
| Chronic pulmonary disease | 327 (9.9) | 165 (9.9) | 162 (9.8) | 0.904 |
| Chronic renal failure | 91 (2.7) | 47 (2.8) | 44 (2.7) | 0.83 |
| Atrial fibrillation/flutter | 293 (8.8) | 151 (9.1) | 142 (8.6) | 0.622 |
| Deep venous thrombosis | 14 (0.4) | 7 (0.4) | 7 (0.4) | 0.99 |
| Anemia | 152 (4.6) | 76 (4.6) | 76 (4.6) | 0.99 |
| Coagulopathy | 54 (1.6) | 30 (1.8) | 24 (1.4) | 0.488 |
| Conduction abnormalities | 38 (1.1) | 16 (1) | 22 (1.3) | 0.417 |
| Peripheral vascular disease | 119 (3.6) | 59 (3.6) | 60 (3.6) | 0.99 |
| Coronary artery disease | 345 (10.4) | 176 (10.6) | 169 (10.2) | 0.728 |
| Metastatic cancer | 6 (0.2) | 3 (0.2) | 3 (0.2) | 0.99 |
| Congestive heart failure | 21 (0.6) | 12 (0.7) | 9 (0.5) | 0.664 |
| Concomitant procedures-no (%) | ||||
| Right heart catheterization | 634 (19.1) | 316 (19) | 318 (19.2) | 0.965 |
| Left heart catheterization | 163 (4.9) | 84 (5.1) | 79 (4.8) | 0.746 |
| Percutaneous coronary intervention | 19 (0.6) | 9 (0.5) | 10 (0.6) | 0.99 |
FIGURE 3.
All adverse event of intracardiac versus transesophageal echocardiography to guide transcatheter closure of ASD/PFO in a propensity-matched cohort. TEE, Transesophageal echocardiography; ICE, Intracardiac echocardiography
FIGURE 4.
In-hospital complications following intracardiac versus transesophageal echocardiography to guide transcatheter closure of ASD/PFO in a propensity-matched cohort
TABLE 4.
In hospital outcomes of propensity matched patients undergoing ASD/PFO closure with intracardiac versus transesophageal echo guidance
| All patients (n = 3318) | TEE guidance (n = 1659) | ICE Guidance (n = 1659) | P value | |
|---|---|---|---|---|
| Clinical outcome-no (%) | ||||
| All adverse event | 422 (12.7) | 237 (14.3) | 185 (11.1) | 0.008 |
| In-hospital death | 19 (0.6) | 10 (0.6) | 9 (0.5) | 0.99 |
| Procedural death | 3 (0.1) | 1 (0.1) | 2 (0.1) | 0.99 |
| Vascular complications | 30 (0.9) | 21 (1.3) | 9 (0.5) | 0.045 |
| Vascular complications requiring surgery | 19 (0.6) | 9 (0.5) | 10 (0.6) | 0.99 |
| AKI | 55 (1.7) | 32 (1.9) | 23 (1.4) | 0.272 |
| AKI requiring dialysis | 4 (0.1) | 3 (0.2) | 1 (0.1) | 0.625 |
| Permanent pacemaker implantation | 17 (0.5) | 12 (0.7) | 5 (0.3) | 0.143 |
| Transient Ischemic attack | 142 (4.3) | 73 (4.4) | 69 (4.2) | 0.798 |
| Clinical stroke | 127 (3.8) | 69 (4.2) | 58 (3.5) | 0.363 |
| Blood transfusion | 79 (2.4) | 45 (2.7) | 34 (2) | 0.229 |
| Cardiac tamponade | 7 (0.2) | 3 (0.2) | 4 (0.2) | 0.99 |
| Atrial fibrillation/flutter (new onset) | 3 (0.1) | 2 (0.1) | 1 (0.1) | 0.99 |
| Length of stay-mean (SD), d | 3 (4) | 3 (4) | 2 (4) | <0.0001 |
| Cost of hospitalization (SD), $ | 18366 (16417) | 18454 (17035) | 18278 (15780) | 0.75 |
| Hospital charges-mean (SD), $ | 56128 (63294) | 57683 (73391) | 54573 (51222) | 0.139 |
| Discharged status | 0.393 | |||
| Discharged SNF/NH/IC | 156 (4.7) | 86 (5.2) | 70 (4.2) | |
| Discharged home | 3142 (94.7) | 1562 (94.2) | 1580 (95.2) |
4 DISCUSSION
The major findings of our study are: (1) The utilization of ICE for IAC closure increased significantly during the study period. Currently about half of IAC closures are done with ICE guidance; (2) ICE closure of IAC was associated with less complications, shorter length of stay, and similar cost compared with TEE guided closure.
After a progressive significant upward trend between 2003 and 2009, the utilization of ICE for IAC closure plateaued since 2010 at about 50% of all IAC closures. This could be explained by the concerns about additional cost, relative lack of physician training, and/or fear of higher rates of complications (vascular complications, tamponade, etc.). Our study confirmed that in a contemporary nationwide cohort of patients, ICE guidance for IAC closure is at least as safe as TEE guided IAC closure is associated with significantly shorter length of stay, and does not increase the overall cost. Certain procedural complications that can be possibly attributed to navigating the ICE probe into and in the right atrium (tamponade and new onset atrial arrhythmia) were similar in the two groups. Vascular complications were surprisingly higher in the TEE guidance group. Possible plausible explanation include the frequent use of arterial lines in the TEE group for hemodynamic monitoring during general anesthesia, access site bleeding during or immediately after reversal of anesthesia after initial hemostasis, and other unmeasured confounders. Although further studies are needed to further investigate this finding, this study does, however, provide reassurance that the use of ICE does not increase the rate vascular complications.
Concerns about higher cost with ICE utilization have been addressed in two prior studies.5,21 Our findings confirmed that at a national level and in various settings, the use of ICE to guide IAC closure did not increase the global cost of hospitalization. The cost of TEE, general anesthesia, and the reduced length of stay likely offset the additional cost of the ICE catheter. Although our study is unable to perform a comparative assessment of the efficacy and accuracy of ICE versus TEE guidance, several cohort studies have shown that ICE guidance for IAC closure is associated with equivalent short-term efficacy rates and decreased procedure times compared to TEE guidance.13,15–17
The field of structural heart disease interventions is rapidly expanding. The number and variety of novel structural heart interventional procedures have substantially increased in the last decade (e-Fig. S2). Many of these procedures were initially introduced for high-risk patients, who were deemed intolerant of traditional surgery. Therefore, there is a growing interest in the utilization of ICE to guide these procedures to mitigate the need for general anesthesia in these high-risk patients.6–12 The potential applications of ICE are likely to further expand with the ongoing modifications and improvement in ICE technology.22 IAC closure is a comparatively simple intervention and is therefore an ideal procedure for burgeoning ICE users, especially given its demonstrated safety, and cost-effectiveness.23
5 LIMITATIONS
(1) The NIS is derived from hospital claims data without access to individual medical records and is therefore subject to the short-comings of administrative datasets. Inconsistencies related to diagnosis coding are however, addressed with several HCUP quality control measures to minimize these possibilities; (2) ICD-9-CM codes do not distinguish between ASD and PFO closure, which may have influenced our results. Perhaps TEE was chosen more for complex ASDs with deficient rims or for multi-fenestrated defects. Also, compared with patients with PFOs, those with ASD more frequently have pulmonary hypertension and right ventricular dysfunction, which may have affected the outcomes; (3) clinical data such as the indication for the procedure, hemodynamics, procedural length, fluoroscopy time, and clinical efficacy are not captured in this administrative database. However, our goal was to perform a comparative analysis between TEE and ICE guidance in IAC closure with regards to complication rates and resource utilization. We believe these data are fairly accurate in the NIS and; (4) with any observational data there is potential for confounders biasing our results, though we believe that our vigorous propensity matching helped to mitigate this possibility in many cases.
Strengths of our results include the large sample size, which suggests broad generalizability, and use of standardized definitions established by the Agency for Healthcare Research and Quality.
6 CONCLUSIONS
Intracardiac echo utilization to guide IAC closure has plateaued after a rapid rise throughout the 2000s. Compared with TEE guidance, ICE guidance of IAC closure does not increase total costs or rates of adverse events, and may reduce hospital length of stay. Confirmation of these findings requires further studies that are able to clearly separate ASD and PFO closure procedures.
Supplementary Material
Acknowledgments
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Footnotes
SUPPORTING INFORMATION
Additional Supporting Information may be found online in the supporting information tab for this article.
DISCLOSURE
All authors listed meet the authorship criteria according to the latest guidelines of the International Committee of Medical Journal Editors, and all authors are in agreement with the manuscript.
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