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Original research
Fluid challenge and balloon occlusion testing in patients with atrial septal defects
  1. Michele D’Alto1,
  2. Andrew Constantine2,3,
  3. Massimo Chessa4,
  4. Giuseppe Santoro5,
  5. Gianpiero Gaio6,
  6. Mario Giordano6,
  7. Emanuele Romeo1,
  8. Paola Argiento1,
  9. Julie Wacker4,
  10. Angelo Fabio D’Aiello4,
  11. Berardo Sarubbi7,
  12. Maria Giovanna Russo6,
  13. Robert Naeije8,
  14. Paolo Golino1,
  15. Konstantinos Dimopoulos2,3
  1. 1 Department of Cardiology, University 'L Vanvitelli' - Monaldi Hospital, Naples, Italy
  2. 2 Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
  3. 3 National Heart and Lung Institute, Imperial College London, London, UK
  4. 4 Pediatric Cardiology Department and GUCH Unit, IRCCS Policlinico San Donato, San Donato Milanese, Italy
  5. 5 Heart Hospital “G. Pasquinucci”, National Research Council – Tuscany Foundation “G. Monasterio”, Massa, Italy
  6. 6 Paediatric Cardiology, University 'L Vanvitelli' - Monaldi Hospital, Naples, Italy
  7. 7 Adult Congenital Heart Disease Unit, Monaldi Hospital, Naples, Italy
  8. 8 Department of Pathophysiology, Free University of Brussels Campus de la Plaine, Brussels, Belgium
  1. Correspondence to Dr Michele D’Alto, Ospedale Monaldi, piazzale Ettore Ruggieri, 1, 180131 Naples, Italy; mic.dalto{at}


Introduction Careful, stepwise assessment is required in all patients with atrial septal defect (ASD) to exclude pulmonary vascular or left ventricular (LV) disease. Fluid challenge and balloon occlusion may unmask LV disease and post-capillary pulmonary hypertension, but their role in the evaluation of patients with ‘operable’ ASDs is not well established.

Methods We conducted a prospective study in three Italian specialist centres between 2018 and 2020. Patients selected for percutaneous ASD closure underwent assessment at baseline and after fluid challenge, balloon occlusion and both.

Results Fifty patients (46 (38.2, 57.8) years, 72% female) were included. All had a shunt fraction >1.5, pulmonary vascular resistance (PVR) <5 Wood Units (WU) and pulmonary arterial wedge pressure (PAWP) <15 mm Hg. Individuals with a PVR ≥2 WU at baseline (higher PVR group) were older, more symptomatic, with a higher baseline systemic vascular resistance (SVR) than the lower PVR group (all p<0.0001). Individuals with a higher PVR experienced smaller increases in pulmonary blood flow following fluid challenge (0.3 (0.1, 0.5) vs 2.0 (1.5, 2.8) L/min, p<0.0001). Balloon occlusion led to a more marked fall in SVR (p<0.0001) and a larger increase in systemic blood flow (p=0.024) in the higher PVR group. No difference was observed in PAWP following fluid challenge and/or balloon occlusion between groups; four (8%) patients reached a PAWP ≥18 mm Hg following the addition of fluid challenge to balloon occlusion testing.

Conclusions In adults with ASD without overt LV disease, even small rises in PVR may have significant implications on cardiovascular haemodynamics. Fluid challenge may provide additional information to balloon occlusion in this setting.

  • congenital heart disease
  • atrial septal defect
  • pulmonary arterial hypertension
  • cardiac catheterisation

Data availability statement

No data are available.

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  • Correction notice This article has been corrected since it was first published online. Author 'Fabio D'Aiello' has been corrected to 'Angelo Fabio D'Aiello' and the 4th affiliation has been corrected to include 'IRCCS'. Additionally, the figure 2 legend has been corrected so that the light blue colour indicates the lower PVR (<2 WU) group and the dark blue colour denotes the higher PVR (≥2 WU) group.

  • Contributors MD planned the study, and MD and ER performed data collection. KD, AC and MD analysed the data and prepared the draft manuscript, which was then critically reviewed and revised by all authors. MD is responsible for the overall content of the article as a guarantor.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.