Atrial septal defect (ASD) is a common congenital cardiac lesion that results in chronic right ventricular (RV) volume overload, leading to progressive RV dilatation, functional impairment, tricuspid annular enlargement, and the development of functional tricuspid regurgitation (TR). The magnitude and chronicity of left-to-right shunting drive structural and geometric remodeling of the right heart chambers and the tricuspid valve (TV) apparatus. , Percutaneous transcatheter closure is the established treatment for secundum ASD and is associated with reversal of these maladaptive changes; however, the degree of recovery and the predictors of RV functional improvement remain incompletely defined. Three-dimensional echocardiography (3DE) enables accurate volumetric and geometric assessment of the RV and TV apparatus and may provide additional insight into remodeling patterns and their determinants.
We conducted a prospective cohort study including 30 consecutive patients with secundum ASD who underwent successful percutaneous device closure. All patients underwent comprehensive echocardiographic assessment using 3DE at baseline and at 3-month follow-up. Measured parameters included RV systolic pressure (RVSP), tricuspid annular plane systolic excursion (TAPSE), TR severity, 3D RV end-diastolic volume index (EDVi), end-systolic volume index (ESVi), ejection fraction (EF), TV tenting volume, TV tenting height, and 3D TV annulus diameter. RV reverse remodeling was defined as an increase in 3D RV EF ≥5% at follow-up. This definition was selected to reflect clinically meaningful improvement in RV systolic performance beyond measurement variability.
At 3 months following ASD closure, there was significant improvement in RV hemodynamics, volumes, and systolic function. RVSP decreased from 44.2 ± 5.4 to 25.6 ± 3.8 mm Hg (p < 0.001), reflecting effective unloading of the pulmonary circulation and right ventricle. 3D RV EDVi decreased from 71.3 ± 13.6 to 62.9 ± 11.9 mL/m² (p < 0.001), and ESVi decreased from 35.7 ± 8.3 to 29.2 ± 5.9 mL/m² (p < 0.001), indicating significant reverse remodeling of RV chamber size. In parallel, 3D RV EF increased from 49.4 ± 8.5% to 56.1 ± 6.9% (p = 0.004), demonstrating recovery of systolic function following relief of chronic volume overload. TAPSE showed a modest but statistically significant reduction (20.8 ± 5.3 to 18.4 ± 4.0 mm; p = 0.016), which likely reflects normalization of previously augmented longitudinal motion in the setting of volume loading rather than true functional decline, as supported by the simultaneous improvement in 3D RV EF.
All patients demonstrated marked improvement in TR severity, with a transition from moderate-to-severe TR at baseline to mild TR at follow-up. This was accompanied by significant reductions in TV apparatus parameters, including tenting volume (1.23 ± 0.64 to 0.93 ± 0.47 mL; p < 0.001), tenting height (0.82 ± 0.25 to 0.64 ± 0.20 cm; p < 0.001), and 3D TV annulus diameter (6.37 ± 2.15 to 6.15 ± 2.01 cm; p < 0.001). These findings reflect reverse remodeling of the tricuspid valve complex and subvalvular apparatus, suggesting that functional TR in ASD is largely driven by geometric distortion secondary to RV dilatation and is reversible following elimination of volume overload.
RV reverse remodeling, defined by improvement in 3D RV EF ≥5%, occurred in 63.3% of patients. Patients without significant improvement in RV EF had higher baseline EF values and a greater prevalence of severe TR, suggesting a ceiling effect for EF recovery in patients with preserved baseline function and more advanced structural remodeling in those with severe TR. These findings imply that both baseline functional status and severity of valvular involvement influence the capacity for early reverse remodeling.
Among all evaluated baseline parameters, TV tenting height emerged as the most accurate predictor of RV reverse remodeling. A cutoff value of ≤0.7 cm demonstrated 70.3% accuracy and 90.9% specificity, outperforming RV volumetric indices and annular dimensions. This observation highlights the importance of subvalvular geometry in determining RV remodeling potential. Tenting height reflects the degree of leaflet tethering caused by papillary muscle displacement and RV geometric distortion, and thus serves as a direct marker of structural remodeling severity. Patients with less pronounced tethering appear to have a more favorable substrate for reverse remodeling after ASD closure.
These findings underscore that relief of RV volume overload results in early and measurable reverse remodeling detectable by 3DE, affecting both ventricular performance and tricuspid valve geometry. , The strong association between TV tenting height and RV functional recovery suggests that subvalvular remodeling is a key determinant of reversibility. Incorporation of TV apparatus assessment into routine preprocedural evaluation may enhance risk stratification and improve prediction of outcomes following ASD closure. These findings are consistent with and extend the work of Martín-García et al. (2020), who demonstrated progressive reductions in TV annular diameter and tenting parameters over 6 to 12 months postclosure.
Three-dimensional echocardiography offers a comprehensive and reproducible assessment of RV volumes, function, and tricuspid valve geometry and may provide incremental value over conventional 2-dimensional techniques in this setting. The ability to simultaneously evaluate chamber remodeling and valve apparatus geometry represents a significant advantage, particularly in conditions such as ASD, where structural changes are closely interrelated.
This study has several limitations, including its relatively small sample size, single-center design, and short-term follow-up. The 3-month follow-up period captures early remodeling but may not fully reflect the extent of long-term structural recovery. Additionally, cardiac magnetic resonance imaging was not used as a reference standard for RV volumetric assessment. Larger studies with longer follow-up are needed to validate these findings and further define the clinical utility of 3D-derived parameters.
In conclusion, percutaneous ASD closure results in significant early RV reverse remodeling and improvement in tricuspid valve geometry as assessed by 3DE. Baseline TV tenting height ≤0.7 cm is the most accurate predictor of RV reverse remodeling and may serve as a practical and clinically useful marker for identifying patients most likely to benefit from intervention and favorable recovery.
All patients demonstrated significant improvement in right ventricular (RV) hemodynamics, function, and tricuspid valve (TV) geometry following ASD closure. TAPSE decreased modestly (p = 0.016), consistent with normalization of supranormal RV longitudinal motion. Tricuspid regurgitation improved markedly, with all patients transitioning from moderate-to-severe to mild (p < 0.001), accompanied by reductions in TV tenting volume, tenting height, and annular diameter (all p < 0.001). RV reverse remodeling occurred in 63.3% of patients and was less frequent in those with higher baseline RV EF (p = 0.015) and severe TR (p = 0.004) as shown in Table 1 .
Table 1
Key echocardiographic changes before and after ASD closure
| Parameter | Preclosure Mean ± SD | Postclosure Mean ± SD | Mean Δ ± SD | t | p-value |
|---|---|---|---|---|---|
| RVSP (mmHg) | 44.2 ± 5.4 | 25.6 ± 3.8 | 18.5 ± 7.0 | 14.44 | <0.001 |
| TAPSE (mm) | 20.8 ± 5.3 | 18.4 ± 4.0 | 2.43 ± 5.22 | 2.55 | 0.016 |
| 3D RV EF (%) | 49.4 ± 8.5 | 56.1 ± 6.9 | −6.71 ± 11.9 | −3.10 | 0.004 |
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