Determinants of elevated pulmonary artery pressure in adults with atrial septal defect: a transesophageal echocardiography study
A Bakalli, A Berisha, B Mustafa, X Krasniqi, V Mahmutaj, N RexhaAbstract
Introduction
Atrial septal defect (ASD) is a common congenital cardiac anomaly in adults, often remaining asymptomatic until midlife. If undiagnosed, ASDs can lead to right heart dilation, arrhythmias, pulmonary hypertension, and heart failure. Accurate assessment of defect type, size, and hemodynamic significance is essential for guiding management. Transesophageal echocardiography (TEE) provides high-resolution imaging, enabling precise evaluation of anatomical and functional parameters, which is critical for selecting optimal interventional or surgical strategies.
Methods
We retrospectively analyzed 46 patients with ASD selected from a database of 550 TEE studies at our Cardiology Clinic. Patients were stratified by pulmonary artery systolic pressure (PASP) into two groups: PASP >45 mmHg and PASP ≤45 mmHg. Demographic characteristics, defect morphology, and hemodynamic parameters were compared between groups.
Results
Secundum-type ASD predominated (87%), followed by primum (8.7%) and sinus venosus (4.3%). The cohort was 65.2% female, with a mean age of 45.7 ± 15.9 years. The mean defect diameter was 21.7 ± 9.7 mm, mean PASP was 45.2 ± 17.8 mmHg, and mean Qp:Qs ratio was 3.03 ± 1.8, indicating a significant left-to-right shunt. Right ventricular and atrial dimensions averaged 43.1 ± 9.8 mm and 47.3 ± 6.4 mm, respectively. Patients with PASP >45 mmHg were older and had higher Qp:Qs ratios and larger right heart dimensions (p < 0.05 for all, as shown in table 1). Multiple linear regression (table 2) including age, Qp:Qs ratio, and right heart dimensions significantly predicted PASP (F = 9.805, p < 0.001, R² = 0.543, adjusted R² = 0.478), with right ventricular diameter as the sole independent predictor (B = 0.699, p = 0.027).
Conclusion
In this adult ASD cohort, secundum-type defects predominated, and significant left-to-right shunting was associated with right heart dilation and elevated pulmonary artery pressures. Patients with PASP >45 mmHg were older and demonstrated larger Qp:Qs ratios, as well as increased right ventricular and atrial dimensions. Multiple linear regression identified right ventricular diameter as the sole independent predictor of PASP, highlighting the critical role of right ventricular remodeling in the development of pulmonary hypertension. These findings underscore the importance of detailed TEE assessment for risk stratification and management planning in adult patients with ASD.Table 1For image description, please refer to the figure legend and surrounding text.Table 2For image description, please refer to the figure legend and surrounding text.