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Published on: February 8, 2022
The role for cardiopulmonary exercise testing in patients with atrial septal defects: a review
Anthony J Barron1, Roland Wensel, Darrel P Francis
1International Centre for Circulatory Health, Imperial College London and Imperial College NHS Trust, UK. anthonybarron@hotmail.co.uk
Insights
Secundum atrial septal defects (ASD) are common congenital heart issues. Cardiopulmonary exercise testing (CPET) may help identify patients who benefit from ASD closure, improving outcomes.
Area of Science:
- Cardiology
- Congenital Heart Disease
- Diagnostic Tools
Background:
- Secundum atrial septal defects (ASD) are common congenital heart abnormalities.
- Untreated ASD can lead to significant morbidity and mortality, including heart failure and pulmonary hypertension.
- Historically, surgical closure was limited to large defects due to procedure-related morbidity.
Purpose of the Study:
- To review the current evidence for using cardiopulmonary exercise testing (CPET) in guiding atrial septal defect (ASD) closure decisions.
- To explore objective measures of exercise capacity as an alternative to subjective symptoms or signs of shunt/heart failure.
- To evaluate the role of CPET in identifying patients who would benefit from ASD closure.
Main Methods:
- Review of existing literature on atrial septal defect closure and cardiopulmonary exercise testing.
- Analysis of studies comparing outcomes of surgical versus percutaneous ASD closure.
- Examination of the utility of CPET in assessing exercise capacity in patients with ASD.
Main Results:
- Percutaneous ASD closure has become first-line, increasing utilization despite significant morbidity.
- Traditional criteria for ASD closure (symptoms, shunt size, RV failure) may not identify all patients who could benefit.
- CPET offers an objective measure of exercise capacity that may aid in selecting appropriate candidates for ASD closure.
Conclusions:
- The increased utilization of ASD closure, particularly percutaneous methods, necessitates refined patient selection criteria.
- Cardiopulmonary exercise testing (CPET) shows promise as an objective tool to identify patients with ASD who may benefit from closure.
- Further research is warranted to establish definitive guidelines for CPET in ASD management.
Abstract:
Secundum atrial septal defects (ASD) are the commonest congenital cardiac abnormality. They are often identified incidentally, or in conjunction with an acquired cardiac abnormality. Untreated they may lead to significant morbidity and mortality, with consequences including right ventricular overload and right heart failure, pulmonary arterial hypertension, shunt reversal and cyanosis, and arrhythmias. Deciding whether to close an ASD can consume as much clinical time as finding them or indeed closing them. In the past when surgical closure was the only option, the morbidity of the procedure, including the need for sternotomy or thoracotomy, limited its use to large defects considered likely to result in shunt reversal or heart failure. Smaller defects were often managed conservatively. However within the past 2 decades percutaneous closure has come to the fore and is now considered first line when morphology allows. With lower morbidity, this has "lowered the bar" in terms of who is considered for closure, although the absolute mortality risk of either procedure is low. However, even though mortality is low, morbidity is still significant after percutaneous closure. Despite this, the utilisation of ASD closure has dramatically increased in the last decade with a sudden rise from 2001, owing largely to growth in percutaneous closures. Instead of looking for symptoms, which are subjective, or evidence of large shunt/RV failure, an objective measure of exercise capacity might help identify other patients who would benefit from closure. This review will look at the current evidence of cardiopulmonary exercise testing (CPET) in ASD closure.
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