Atrial septal defect complications
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Priyamvada Singh, M.B.B.S. [2]; Cafer Zorkun, M.D., Ph.D. [3] Ayokunle Olubaniyi, M.B,B.S [4]Assistant Editor(s)-In-Chief: Kristin Feeney, B.S. [5]
Overview
Atrial septal defect is associated with complications such as migraine headache with aura, atrial fibrillation, pulmonary hypertension, heart failure, and stroke.
Complications
Atrial Septal Defect and Migraine Headache with Aura (MHA)
A relationship between migraine with aura and right-to-left shunt or patent foramen ovale has been documented in many studies.[1] Patent foramen ovale is more common in patients with migraine headache with aura than in the general population. The prevalence of PFO in migraineurs varies between 40 - 60% as compared to 17 - 30% of people in the general population.[2] In a study, the prevalence of PFO in migraineurs with aura was found to be 47% as compared to 17% among the control subjects. The presence of a large shunt may also increase the odds of having MHA by more than 7-folds.[3] A recent meta-analysis suggests a 3-fold increase in the risk of patients with PFO developing MHA.[4] In a similar manner, migraine with aura is more prevalent in the presence of PFO.
Although the exact causal relationship remains unclear, several pathogenetic mechanisms have been explained, namely:
- Co-inheritance - An autosomal dominant inheritance of atrial shunts was linked to the inheritance of MHA.[5]
- Increased neuronal excitability - Right-to-left shunting of blood exposes neurons to microemboli or vasoactive peptides such as serotonin, which triggers migraine attacks by lowering the neuronal excitability threshold.
- Reduced plasma atrial natriuretic peptide - Atrial natriuretic peptide, which is released by atrial myocytes in response to atrial stretch, is known to play roles in natriuresis, inhibition of platelet aggregation[6] and lowering of vasoreactivity of vascular smooth muscles to vasoconstrictor substances (i.e., it helps in vasodilation). As a result of increased blood volume observed in atrial shunts, patients with ASD have elevated levels of ANP, which subsequently normalizes following closure in majority of patients.[7] As a direct result of this, migraine auras may be facilitated due to the lack of vasodilatory and antiplatelet activities in vulnerable patients.
PFO Closure
Although there is no direct evidence to link migraines and atrial septal defects, some researchers noted that closure of patent foramen ovale resulted in complete resolution or marked reduction in severity and frequency of migraine episodes.[8][9][10][11] A meta-analysis study involving 1,306 patients who underwent PFO closure reported 46% of cases with complete resolution of migraine symptoms and a significant improvement of migraine in 83% of cases.[12] Conversely, there were also reported cases of an increased frequency and severity of migraine attacks with prolonged aura symptoms following closure,[13][14] especially with the closure of secundum ASD.
The MIST (Migraine Intervention with STARFlex Technology) trial which is the only completed randomized trial for PFO closure for migraine headaches was highly critiqued for its failure in reaching its primary and secondary endpoints.[15] The ongoing PREMIUM and the terminated PRIMA randomized controlled trials promises to investigate the role of PFO closure in migraine patients and address the methodological flaws of the MIST trial.[16]
Currently, no conclusion can be drawn from all these studies, but available evidence suggests that PFO is not a risk factor for migraine headaches with aura.
Atrial Septal Defect and Stroke
Even without surgery, as many as 5-10% of all atrial septal defect patients experience thromboembolic events such as stroke and transient ischemic attack. Paradoxical emboli in atrial septal defect patients is not correlated with shunt size and can occur in all ASD patients. Early closure of ASD lowers the risk of developing atrial fibrillation.
Atrial Septal Defect and Atrial Fibrillation
50-60% of atrial septal defect patients over the age of 40 will develop atrial fibrillation. Late-onset atrial fibrillation is associated with bothmorbidity and mortality. Anticoagulation may lower the mortality risk. Closing an ASD at this point does not prevent occurrence of atrial fibrillation in these patients. But early closure of ASD lowers the risk of developing atrial fibrillation.
Atrial Septal Defect and Pulmonary Hypertension
15-20% of atrial septal defect patients develop pulmonary hypertension. Although rare in children and adolescents, pulmonary arterial hypertension is observed in approximately 50% of patients over the age of 40. The development of Eisenmenger's syndrome can result in reversal of the original left-to-right shunt which may switch to become a right-to-left shunt. Right-to-left shunting can in turn lead to deoxygenation (hypoxemia and cyanosis).
Atrial Septal Defect and Right Heart Failure
Atrial septal defect is associated with left-to-right shunting which in turn may be associated with right ventricular volume overload. Patients may experience right heart failure as a result of right ventricular volume overload.
References
- ↑ Anzola, GP.; Magoni, M.; Guindani, M.; Rozzini, L.; Dalla Volta, G. (1999). "Potential source of cerebral embolism in migraine with aura: a transcranial Doppler study". Neurology. 52 (8): 1622–5. PMID 10331688. Unknown parameter
|month=ignored (help) - ↑ Del Sette, M.; Angeli, S.; Leandri, M.; Ferriero, G.; Bruzzone, GL.; Finocchi, C.; Gandolfo, C. "Migraine with aura and right-to-left shunt on transcranial Doppler: a case-control study". Cerebrovasc Dis. 8 (6): 327–30. PMID 9774749.
- ↑ Schwerzmann, M.; Nedeltchev, K.; Lagger, F.; Mattle, HP.; Windecker, S.; Meier, B.; Seiler, C. (2005). "Prevalence and size of directly detected patent foramen ovale in migraine with aura". Neurology. 65 (9): 1415–8. doi:10.1212/01.wnl.0000179800.73706.20. PMID 16148260. Unknown parameter
|month=ignored (help) - ↑ Schwedt, TJ.; Demaerschalk, BM.; Dodick, DW. (2008). "Patent foramen ovale and migraine: a quantitative systematic review". Cephalalgia. 28 (5): 531–40. doi:10.1111/j.1468-2982.2008.01554.x. PMID 18355348. Unknown parameter
|month=ignored (help) - ↑ Schwerzmann, M.; Nedeltchev, K.; Meier, B. (2007). "Patent foramen ovale closure: a new therapy for migraine". Catheter Cardiovasc Interv. 69 (2): 277–84. doi:10.1002/ccd.20966. PMID 17253601. Unknown parameter
|month=ignored (help) - ↑ Ulker, S.; Akgür, S.; Evinç, A.; Soykan, N.; Koşay, S. (1995). "Platelet aggregation and atrial natriuretic peptide". Gen Pharmacol. 26 (6): 1409–12. PMID 7590139. Unknown parameter
|month=ignored (help) - ↑ Erbay, AR.; Yilmaz, MB.; Balci, M.; Sabah, I. (2004). "Atrial natriuretic peptide levels in adult patients before and after surgery for correction of atrial septal defects: relationship with atrial arrhythmias". Clin Sci (Lond). 107 (3): 297–302. doi:10.1042/CS20040141. PMID 15142035. Unknown parameter
|month=ignored (help) - ↑ Azarbal B, Tobis J, Suh W, Chan V, Dao C, Gaster R (2005). "Association of interatrial shunts and migraine headaches: impact of transcatheter closure". J Am Coll Cardiol. 45 (4): 489–92. PMID 15708691.
- ↑ Adams H (2004). "Patent foramen ovale: paradoxical embolism and paradoxical data". Mayo Clin Proc. 79 (1): 15–20. PMID 14708944.
- ↑ Giardini, A.; Donti, A.; Formigari, R.; Salomone, L.; Palareti, G.; Guidetti, D.; Picchio, FM. (2006). "Long-term efficacy of transcatheter patent foramen ovale closure on migraine headache with aura and recurrent stroke". Catheter Cardiovasc Interv. 67 (4): 625–9. doi:10.1002/ccd.20699. PMID 16548006. Unknown parameter
|month=ignored (help) - ↑ Reisman, M.; Christofferson, RD.; Jesurum, J.; Olsen, JV.; Spencer, MP.; Krabill, KA.; Diehl, L.; Aurora, S.; Gray, WA. (2005). "Migraine headache relief after transcatheter closure of patent foramen ovale". J Am Coll Cardiol. 45 (4): 493–5. doi:10.1016/j.jacc.2004.10.055. PMID 15708692. Unknown parameter
|month=ignored (help) - ↑ Butera, G.; Biondi-Zoccai, G.; Sangiorgi, G.; Abella, R.; Giamberti, A.; Bussadori, C.; Sheiban, I.; Saliba, Z.; Santoro, T. (2011). "Percutaneous versus surgical closure of secundum atrial septal defects: a systematic review and meta-analysis of currently available clinical evidence". EuroIntervention. 7 (3): 377–85. doi:10.4244/EIJV7I3A63. PMID 21729841. Unknown parameter
|month=ignored (help) - ↑ Riederer, F.; Kaya, M.; Christina, P.; Harald, G.; Peter, W. "Migraine with aura related to closure of atrial septal defects". Headache. 45 (7): 953–6. doi:10.1111/j.1526-4610.2005.05166_2.x. PMID 15985118.
- ↑ Yankovsky, AE.; Kuritzky, A. (2003). "Transformation into daily migraine with aura following transcutaneous atrial septal defect closure". Headache. 43 (5): 496–8. PMID 12752756. Unknown parameter
|month=ignored (help) - ↑ Dowson, A.; Mullen, MJ.; Peatfield, R.; Muir, K.; Khan, AA.; Wells, C.; Lipscombe, SL.; Rees, T.; De Giovanni, JV. (2008). "Migraine Intervention With STARFlex Technology (MIST) trial: a prospective, multicenter, double-blind, sham-controlled trial to evaluate the effectiveness of patent foramen ovale closure with STARFlex septal repair implant to resolve refractory migraine headache". Circulation. 117 (11): 1397–404. doi:10.1161/CIRCULATIONAHA.107.727271. PMID 18316488. Unknown parameter
|month=ignored (help) - ↑ Tepper, SJ.; Cleves, C.; Taylor, FR. (2009). "Patent foramen ovale and migraine: association, causation, and implications of clinical trials". Curr Pain Headache Rep. 13 (3): 221–6. PMID 19457283. Unknown parameter
|month=ignored (help)