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Year : 2018  |  Volume : 7  |  Issue : 2  |  Page : 92-97

Echocardiographic right ventricular deformation indices before and after atrial septal defect closure: A scomparison between device and surgical closure

1 Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
2 Echocardiography Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran

Date of Web Publication22-May-2018

Correspondence Address:
Dr. Maryam Shojaeifard
Echocardiography Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Vali-e-Asr St., Niayesh highway, Tehran
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/rcm.rcm_5_18

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Background: Secundum atrial septal defects (ASD2) are one of the most common congenital disorders in children which includes about 10%–20% of congenital heart defects. In recent years, closure of secundum ASD percutaneously has been proposed to reduce mortality, morbidity, and become the standard method in both pediatric and young adults. The aim of this study was to determine the right ventricular (RV) function by strain and strain rate echocardiography parameters in children who underwent surgically versus percutaneous ASD2 device closure. Methods: In this cohort study, all children underwent ASD2 treatment from May 2014 to April 2016 were enrolled in this study. Echocardiography was performed 24 h after transcatheter closure and 3 days after surgical closure. MyLab 60 echo machine (Esoate, Florance, Italy) equipped with a multi-frequency 5 MHz transducer was used, and all echocardiographic data were collected by same pediatric cardiologist. All demographic characteristics and echocardiography indices were compared using SPSS version 18 between two groups. Results: Thirty-six patients (63.2%) were treated by the transcatheter closure and 21 (36.8%) underwent surgery. Longitudinal RV strain (S), longitudinal RV strain rate (S'), and early diastolic longitudinal RV strain rate (E') were improved significantly in device patients in comparison with surgical patients (P < 0.001). There were no significant differences between RV longitudinal dimension and Mid RV size change after procedures in two groups (P > 0.05). However, tricuspid valve annular diameter was significantly decreased in patients who underwent ASD percutaneous device closure in comparison with a surgical group (P = 0.004). Conclusion: The results of this study showed that percutaneous ASD2 device closure will results in better RV function in comparison to surgical closure

Keywords: Atrial septal defect, deformation, percutaneous transcatheter device closure, right ventricle, surgical closure

How to cite this article:
Moradian M, Daneshamooz H, Shojaeifard M, Ghadrdoost B, Langeroudi HM, Khorgami MR. Echocardiographic right ventricular deformation indices before and after atrial septal defect closure: A scomparison between device and surgical closure. Res Cardiovasc Med 2018;7:92-7

How to cite this URL:
Moradian M, Daneshamooz H, Shojaeifard M, Ghadrdoost B, Langeroudi HM, Khorgami MR. Echocardiographic right ventricular deformation indices before and after atrial septal defect closure: A scomparison between device and surgical closure. Res Cardiovasc Med [serial online] 2018 [cited 2022 Jun 27];7:92-7. Available from: https://www.rcvmonline.com/text.asp?2018/7/2/92/232977

  Introduction Top

Secundum atrial septal defect (ASD2) is one of the most common congenital disorders in children and included about 10%–20% of congenital heart defects.[1] In this disease, atrial septal defect allows pulmonary venous blood return to the right atrium (RA) through the defect.[2] Size of the defect, amount of the shunt, and associated anomalies will lead to a wide spectrum of symptoms from asymptomatic cases to right side volume overload, pulmonary hypertension, and atrial arrhythmia.[3] The disease may remain unknown until adulthood due to the lack of significant symptoms in the first decade of life.[1]

It is obvious that timely treatment is recommended in these patients. Making the decision to repair the ASD depends on clinical and echocardiography findings such as the size, location, amount of shunt flow, and the presence or absence of pulmonary hypertension.[4] ASD2 surgical closure was first described 5 decades ago and was considered the standard method of treatment for years. Although ASD2 surgical closure is a safe method with low mortality, this method needs thoracotomy or sternotomy and cardiopulmonary bypass (CPB) and may lead to open cardiac surgery complications as well as chest scar. In recent years, transcatheter or device closure has been proposed to reduce mortality and morbidity in these patients. These newly introduced methods decrease hospital stay, costs, and psychological stress of patients and their family.[5]

Some rare complications have been reported in ASD2 device closure; include residual shunt, catheter breaking, and embolization, device thrombosis, the involvement of nearby valves, aortic or atrium wall erosions and artifacts in magnetic resonance imaging (MRI).[6] Defect-shape and size and patient age are important factors to select the method for ASD2 closure.[7],[8]

To best of our knowledge, there are not enough reports using echocardiographic strain and strain-rate imaging to compare myocardial function in children who underwent ASD2 device closure versus surgical closure.

Evaluation of right ventricular (RV) function by echocardiography is challenging because its geometry is complex and also it is located more anterior in the chest. However, RV function assessment is very important in ASD2 patients because of chronic volume overload.[9],[10],[11],[12],[13],[14]

Tissue Doppler imaging (TDI) as well as strain and strain rate speckle tracking analysis are novel echocardiographic techniques that can detect both left ventricular (LV) and RV dysfunction earlier than other echocardiographic parameters in pediatric age group patients and even during fetal life.[15] The objective of this study was to evaluate RV function in ASD2 patients before and after ASD2 closure and compare the strain and strain rate of RV in two groups who underwent surgical closure versus percutaneous device closure.

  Methods Top


In this cohort study, 57 pediatric patients younger than 15 years with isolated ASD2 who were admitted to Rajaie Cardiovascular Medical and Research Center between May 2014 and April 2016 were enrolled. This study was approved by our local ethical committee according to the Helsinki Declaration of the World Medical Association (2000). The diagnosis of ASD was confirmed by transthoracic echocardiography. Indication for ASD closure in pediatric patients is almost the same as adults although growth retardation and frequent respiratory infections also play important role in making the decision. All of the selected patients in our study, pulmonary blood flow to systemic blood flow (QP/QS) ratio was more than 1.5/1 and RA and RV were dilated.

Patient selection for device closure was based on interatrial septal length and defect rims. If the left side disc was larger than the interatrial septal length and the defect rims were insufficient patient was referred for surgical closure. Patients who met the inclusion criteria for both groups, the option of either surgery or device closure were explained to their parents, who then decided between surgery and percutaneous closure. Exclusion criteria were the presence of any other type of congenital heart disease that has to be repaired by surgery.

Before interventions, demographic characteristics of children (age and sex), and anthropometric indices (height and weight) were recorded in a checklist.


We used a MyLab 60 echo machine (Esoate, Florence, Italy) equipped with a multi-frequency 5 MHz transducer. All echocardiographic examinations were performed by a same pediatric cardiologist before and after surgery or device closure. For RV we evaluated average global longitudinal deformation indices in RV free wall without considering the septum. The harmonic imaging of apical four chamber view with focusing on RV and 45–65 frames per se cond were obtained meanwhile good electrocardiographic signals were recorded and stored to be analyzed offline. Then, for each patient, a clip with a best endocardial border of RV was selected and processed by X strain software. The end systolic frame with sharpest borders was selected, and RV endocardial surface was traced manually. Like other RV deformational studies and since RV wall is thin only endocardial border was traced [Figure 1].
Figure 1: RV endocardial border tracing in four chamber view

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The strain and strain rate graphics of longitudinal deformation indices of RV were obtained automatically by a velocity vector imaging method, and different parameters were calculated. Global longitudinal strain and strain rate values of right ventricle were also obtained. Three separate waves of RV global longitudinal strain and strain rates including S wave for strain, S' wave which represents systolic function and E' and A' waves representing early and late diastolic function, respectively, for strain rate were evaluated [Figure 2] and [Figure 3].
Figure 2: Global longitudinal strain of RV free wall

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Figure 3: Global longitudinal strain rate of RV free wall

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Device implantation

The amplatzer septal occluder was used for ASD closure. All procedures were done under general anesthesia with endotracheal intubation. The right femoral vein was accessed, and right heart catheterization was performed for hemodynamic evaluation and to ensure that pulmonary vascular resistance is normal. A sizing balloon catheter was used to measure the stretched balloon diameter. The device chosen for closure was 0–2 mm larger than the stretched balloon diameter in the case of the adequate rims and if the superior/anterior rim was deficient, a device 4 mm larger than the stretched balloon diameter was chosen. Under fluoroscopic and transesophageal echocardiography guidance, device was deployed while guide wire was in left upper pulmonary vein.[16]


All surgical procedures were performed using CPB. The RA was opened through median sternotomy The ASD was closed either by direct suture or using a pericardial patch depending on its size and anatomical type.

Statistical analysis

The statistical analyses were performed using SPSS software version 15.0 for Windows (SPSS Inc., Chicago, IL, USA). Quantitative data were expressed as mean ± standard deviation and qualitative data as number (%). To evaluate the data distribution, the one-sample Kolmogorov–Smirnov test was used. Qualitative data were compared using Chi-square or Fisher's exact test. Mann–Whitney U or Student's t-test was used to compare quantitative variables. Paired t-test or Wilcoxon was used to compare changes before and after the procedures. Mann–Whitney U was used to compare ordinal variable in two groups. A value of P < 0.05 was considered as statistically significant.

  Results Top

Fifty-seven patients were enrolled in the study, 21 ones (36.8%) were undergone surgical closure, and for 36 children (63.2%) device closure was performed. Mean age of all patients was 5 ± 2.7 years. Their mean height and weight were 108.6 ± 20.1 cm and 17.5 ± 7.8 kg, respectively. Mean ASD size was 1.2 ± 0.5 cm.

Demographic and clinical data

The comparisons of demographic and clinical data between surgery and device closure groups are shown in [Table 1]. There were no significant differences between the two groups regarding demographic and clinical data. There was no significant electrocardiographic difference including rhythm (P = 0.136) and axis (P = 0.109) between catheter and surgery groups.
Table 1: Comparison of demographic, clinical data and atrial septal defects indexes between groups

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Echocardiographic data

Echocardiographic indices before and after the procedure in two groups (Surgical closure and device closure) are shown in [Table 2]. RV longitudinal dimension, mid RV size, and tricuspid valve annulus diameter were significantly decreased in both groups after intervention (P < 0.05). Longitudinal RV strain (S) was significantly decreased after surgery (worsen) and increased (improved) after device closure (P < 0.05). Longitudinal RV strain rate (S') was increased (improved) after ASD device closure (P < 0.05) but was not significantly changed after surgery (P = 0.38). Early diastolic longitudinal RV strain rate (E') was significantly increased (improved) after device closure, but there were no significant changes after surgery.
Table 2: Comparison the echocardiographic indices before versus after procedure

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Echocardiographic indices in surgical versus device closure are shown in [Table 3]. RV longitudinal strain (S) and strain rate (S'), and early diastolic longitudinal RV strain rate (E') were improved significantly in device patients in comparison with surgical patients (P < 0.001). There were no significant differences between RV longitudinal dimension and mid RV size in two groups (P > 0.05). Tricuspid valve annular diameter change was more significant in patients who underwent ASD percutaneous device closure in comparison with surgical group (P = 0.004).
Table 3: Comparison the echocardiographic indices in surgical versus device closure

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  Discussion Top

Assessment of RV function is an ever challenging issue in congenital heart diseases. Traditional echocardiographic evaluation of RV function includes two-dimensional (2D), M Mode, and Doppler (conventional Doppler and tissue Doppler) modalities. 2D echo relies on semi-quantitative measurements of fractional area change and visual evaluation of RV wall motion and right heart chambers size. Doppler study is useful to predict RV systolic pressure, pulmonary artery mean and diastolic pressure, dp/dt (rate or pressure change over time), Myocardial Performance Index (MPI). M mode technique can quantify TAPSE (tricuspid annular plane systolic excursion). Relatively, newer technique TDI is also used to assess both systolic and diastolic annular motion of tricuspid valve and isovolumic acceleration of RV.[17]

RV's complex anatomy and thin wall as well as its anterior location are the most important limiting factors in the echocardiographic evaluation. However, 2D strain and strain rate analyses are novel techniques that focus on specific speckle (natural acoustic markers) motion patterns and track them frame by frame during a cardiac cycle, and in this way, strain and strain rate can evaluate wall deformation. Deformation analyses can differentiate between active and passive myocardial tissue movement.[18],[19]

Longitudinal RV free wall strain and strain rate imaging can provide a reliable RV longitudinal quantification because RV contraction is more based on longitudinal shortening. RV function is a very important prognostic factor in ASD patients because this chamber has to tolerate chronic volume overload. We decided to compare these values in ASD patients before and after its closure between two groups who undergone surgery versus device closure. To the best of our knowledge, there are no confirmed normal reference values of RV speckle tracking in the pediatric field.[17]

In a study by Eyskens et al. in 2006 they evaluated longitudinal peak systolic velocities, peak systolic strain rate, and end-systolic strain of midsegment of RV free wall and septum in 21 pediatric patients before and after ASD device closure and compared with a control group. In their study, RV deformation indices in patient group were not different from the control group and did not change after ASD device closure and concluded that strain and strain rate are load independent while myocardial velocities are load dependent because these velocities obviously decreased after ASD device closure in comparison with control group. They even believe that the device within the atrial septum may affect interventricular septum deformation and decrease septal function.[2] Furthermore, in another study by Kowalik et al., there was no difference in RV deformation indices between ASD patients and control group in adults.[3] On Ding et al. study, it was showed that after transcatheter closure of ASD not only RV volume overload was relieved but also RV function was improved. They used MPI by tissue Doppler modality to evaluate RV function.[14]

In our study, we compared global longitudinal strain and strain rate of RV free wall of ASD patients in two groups who underwent surgically versus percutaneous device closure before and after procedures. Fifty-seven ASD 2 patients were enrolled in the study. Their mean age and weight were 5 years and 17.5 kg, respectively: deformation indices in two groups of surgical ASD closure and device closure had no meaningful different based on the age and sex of the patients. ASD closure reduced cardiac chambers size in both groups. However, tricuspid annular size reduction was more significant in percutaneous ASD closure group. The study shows that echocardiographic RV function indices improved after percutaneous ASD2 closure but deformational indices of RV reduced after surgical closure.

The study showed immediate improvement rate in the transcatheter group was more than surgery group which can be attributed to adverse effects of CPB on myocardial function in the surgery group. Of course, proving this idea needs more precise evaluation, especially using laboratory tests.

One of the limitations of this study was that we only evaluate RV free wall myocardial function immediately after procedures and we are about to evaluate our patients for long term too. Furthermore, the hypotheses that CPB effect on myocardial function is the cause of reduced strain and strain rate of RV myocardial free wall needs more consideration because there are some studies that showed the presence of a device within interatrial septum will results on decreased inter ventricular sepal deformation indices.[2] We did not evaluate the interventricular septal deformation indices. Furthermore, the only available software was X strain which was designed for LV evaluation, and we had to use it for RV while making some changes.

  Conclusion Top

Strain and strain rate imaging is a relatively new and promising tool for evaluation of a myocardial function that is not routinely used in pediatric cardiology patients yet. This technique is sensitive to evaluate longitudinal myocardial shortening and detect any dysfunction sooner than conventional echocardiographic methods. This study showed that deformation indices of RV were improved after interventional ASD2 closure in pediatric age group. There are a few if any similar study in pediatric age group regarding RV deformation evaluation before and after ASD closure comparing the effects of two different types of treatment on myocardial function and it was the first in Iran. Based on our findings, ASD device closure in selected patients will result on better RV function immediately after the procedure in comparison to surgical closure.


We kindly appreciate pediatric echo laboratory nurses and personnel for their cooperation.

Financial support and sponsorship

Conducting of the study is all supported by the staff of Rajaie Cardiovascular Medical and Research Center.

Conflicts of interest

There are no conflicts of interest.

  References Top

Tashiro H, Suda K, Tananari Y, Itou S. Impact of transcatheter closure of atrial septal defects on cardiac function. J Med Ultrason (2001) 2012;39:147-53.  Back to cited text no. 1
Eyskens B, Ganame J, Claus P, Boshoff D, Gewillig M, Mertens L, et al. Ultrasonic strain rate and strain imaging of the right ventricle in children before and after percutaneous closure of an atrial septal defect. J Am Soc Echocardiogr 2006;19:994-1000.  Back to cited text no. 2
Kowalik E, Kowalski M, Hoffman P. Is right ventricular myocardial deformation affected by degree of interatrial shunt in adults? Eur J Echocardiogr 2011;12:400-5.  Back to cited text no. 3
Van de Bruaene A, Stroobants D, Benit E. Percutaneous closure of inter-atrial communications (atrial septal defect and patent foramen ovale): Single-centre experience and mid-term follow-up. Acta Cardiol 2015;70:133-40.  Back to cited text no. 4
Monfredi O, Luckie M, Mirjafari H, Willard T, Buckley H, Griffiths L, et al. Percutaneous device closure of atrial septal defect results in very early and sustained changes of right and left heart function. Int J Cardiol 2013;167:1578-84.  Back to cited text no. 5
Berger F, Vogel M, Alexi-Meskishvili V, Lange PE. Comparison of results and complications of surgical and amplatzer device closure of atrial septal defects. J Thorac Cardiovasc Surg 1999;118:674-8.  Back to cited text no. 6
Du ZD, Hijazi ZM, Kleinman CS, Silverman NH, Larntz K; Amplatzer Investigators, et al. Comparison between transcatheter and surgical closure of secundum atrial septal defect in children and adults: Results of a multicenter nonrandomized trial. J Am Coll Cardiol 2002;39:1836-44.  Back to cited text no. 7
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Samiei N, Bayat F, Moradi M, Parsaei M, Haghighi SZ, Mohebbi A, et al. Comparison of the response of the right ventricle with endovascular occlusion and surgical closure in adults with atrial septal defect one year after intervention. Clin Med Insights Cardiol 2010;4:143-7.  Back to cited text no. 9
Balcı KG, Balcı MM, Aksoy MM, Yılmaz S, Aytürk M, Doǧan M, et al. Remodeling process in right and left ventricle after percutaneous atrial septal defect closure in adult patients. Turk Kardiyol Dern Ars 2015;43:250-8.  Back to cited text no. 10
Guo JJ, Luo YK, Chen ZY, Cao H, Yan XP, Chen H, et al. Long-term outcomes of device closure of very large secundum atrial septal defects: A comparison of transcatheter vs. intraoperative approaches. Clin Cardiol 2012;35:626-31.  Back to cited text no. 11
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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3]

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