Post-pericardiotomy syndrome in pediatric patients following surgical closure of secundum atrial septal defects: incidence and risk factors

Predictors of post-pericardiotomy syndrome after native valve-sparing aortic valve surgery

BACKGROUND

We aimed to determine the rate and impact of post-pericardiotomy syndrome after native valve-sparing aortic valve surgery and the perioperative factors associated with its occurrence.

METHODS

All consecutive patients who underwent native valve-sparing aortic valve surgery (i.e., repair ± ascending aorta replacement, valve-sparing root replacement, Ross procedure ± ascending aorta replacement) at our institution between January 2021 and August 2023 served as our study population. Post-pericardiotomy syndrome was diagnosed if patients showed at least two of the following diagnostic criteria: evidence of (I) new/worsening pericardial effusion, or (II) new/worsening pleural effusions, (III) pleuritic chest pain, (IV) fever or (V) elevated inflammatory markers without alternative causes. A logistic regression model was calculated.

RESULTS

During the study period, 91 patients underwent native valve-sparing aortic valve surgery. A total of 21 patients (23%) developed post-pericardiotomy syndrome early after surgery (PPS group). The remaining 70 patients (77%) showed no signs of post-pericardiotomy syndrome (non-PPS group). Multivariate logistic regression revealed blood type O (OR: 3.15, 95% CI: 1.06-9.41, p = 0.040), valve-sparing root replacement (OR: 3.12, 95% CI: 1.01-9.59, p = 0.048) and peak C-reactive protein >15 mg/dl within 48 hours postoperatively (OR: 4.27, 95% CI: 1.05-17.29, p = 0.042) as independent risk factors. 73% (8/11) of patients displaying all three risk factors, 60% (9/15) of patients with blood type O and valve-sparing root replacement, 52% (11/21) of patients with blood type O and early postoperative peak C-reactive protein >15 mg/dl and 45% (13/29) of patients with early postoperative peak C-reactive protein >15 mg/dl and valve-sparing root replacement developed post-pericardiotomy syndrome.

CONCLUSION

In summary, blood type O, valve-sparing root replacement and peak C-reactive protein >15 mg/dl within 48 hours postoperatively are significantly associated with post-pericardiotomy syndrome after native valve-sparing aortic valve surgery. Particularly, the presence of all three risk factors is linked to a particularly high risk of post-pericardiotomy syndrome.

Early Post-operative ECG Changes as a Predictor of Post-pericardiotomy Syndrome Following Atrial Septal Defect Repair

To identify risk factors associated with post-pericardiotomy syndrome (PPS) in patients undergoing surgical repair of atrial septal defects (ASD). A single-center retrospective study. Tertiary academic hospital. Included were patients of all ages who underwent surgical ASD repair, while exclusion criteria included the absence of post-operative electrocardiogram (ECG), lack of follow-up post-discharge and factors hindering ECG interpretation. Demographic and clinical data, including ECG changes indicative of pericardial inflammation, were collected. The primary outcome measure was the development of PPS, determined based on the standardized European Society of Cardiology (ESC) criteria. Among 190 patients who underwent surgical ASD repair, 154 (81%) met the inclusion criteria. Of these, 25 (16%)in total developed PPS, of which 60% were ≥ 18 years of age and 56% female. Significant associations relating both early ECG changes and pre-discharge pericardial effusion with subsequent occurrence of PPS were found in both univariate and multivariate analyses. The study establishes correlations of both early post-operative ECG changes indicative of inflammation and pre-discharge pericardial effusion with subsequent occurrence of PPS in patients undergoing surgical ASD repair. Both utilizing the standardized ESC definition of PPS and incorporating a physician-validated ECG evaluation strengthened the methodologic approach in establishing these relationships. The results also highlight the importance of considering age as a potential risk factor for PPS. Further research is needed to validate these findings and explore additional risk factors predicting early identification and management of patients at high risk for PPS following surgical ASD repairs.

Posterior pericardial window: a simple and reproducible technique in order to prevent pericardial tamponade in paediatric cardiac surgery

OBJECTIVE

Pericardial tamponade, which increases postoperative mortality and morbidity, is still not uncommon after paediatric cardiac surgery. We considered that posterior pericardiotomy may be a useful and safe technique in order to reduce the incidence of early and late pericardial tamponade. Herein, we present our experience with creation of posterior pericardial window following congenital cardiac surgical procedures.

METHODS

This retrospective study evaluated 229 patients who underwent paediatric cardiac surgical procedures between June 2021 and January 2023. A posterior pericardial window was created in all of the patients. In neonates and infants, pericardial window was performed at a size of 2x2 cm, whereas a 3x3 cm connection was established in elder children and young adults. A curved chest tube was placed and positioned at the posterolateral pericardiophrenic sinus. An additional straight anterior mediastinal chest tube was also inserted in every patient. Transthoracic echocardiographic evaluations were performed daily to assess postoperative pericardial effusion.

RESULTS

A total of 229 (135 male, 94 female) patients were operated. Mean age and body weight were 24.2 ± 26.7 months and 10.2 ± 6.7 kg, respectively. Eight (3.5%) of the patients were neonates where 109 (47.6%) were infants and 112 (48.9%) were in childhood. Fifty-two (22.7%) re-do operations were performed. Six (2.6%) patients underwent postoperative surgical re-exploration due to surgical site bleeding. Any early or late pericardial tamponade was not encountered in the study group.

CONCLUSIONS

Posterior pericardial window is an effective and safe technique in order to prevent both the early and late pericardial tamponade after congenital cardiac surgery.

The effects of milking and suction drain management methods in paediatric patients after cardiac surgery

AIM

The aim of this study is to determine the effects of milking and suction methods on maintaining drain patency following cardiac surgery in paediatric patients.

METHODS

This was a randomized controlled trial. The patients were assigned to three groups (suction method, milking method, and control group) between July 2018 and December 2019.

RESULTS

The most frequent medical diagnoses were tetralogy of Fallot (34.4%, n = 31) and ventricular septal defect (14.4%, n = 13). Heart rate may increase unless a method was chosen to maintain drain patency (F: 4.450, p = 0.003); suction (F: 0.528 p = 0.781) and milking (F: 2.281 p = 0.070) methods did not significantly increase the heart rate. The use of a manipulation method for maintaining drain patency maintained stability of the blood pressure values and did not affect haemodynamic stability, oxygen saturation, and body temperature. There was no statistically significant difference within and among the groups (p > 0.05) in relation to the volume of bleeding between admission until the sixth hour, although there was greater bleeding with the milking method (2.67 ± 15.30 ml) and less bleeding (-5.00 ± 23.30) with the suction method.

CONCLUSION

The milking and suction methods used to maintain drain patency can be employed and will assist with maintaining the stability of the patient within the first critical 6 h. Further studies need to be conducted in order to clarify that the recommendations can be generalized to all children with congenital heart disease.

Paediatrician's guide to post-operative care for biventricular CHD: a review

IMPORTANCE

Paediatricians play an integral role in the lifelong care of children with CHD, many of whom will undergo cardiac surgery. There is a paucity of literature for the paediatrician regarding the post-operative care of such patients.

OBSERVATIONS

The aim of this manuscript is to summarise essential principles and pertinent lesion-specific context for the care of patients who have undergone surgery or intervention resulting in a biventricular circulation.

CONCLUSIONS AND RELEVANCE

Familiarity with common issues following cardiac surgery or intervention, as well as key details regarding specific lesions and surgeries, will aid the paediatrician in providing optimal care for these patients.

Pericardial effusion after congenital heart surgery

Objective

Pericardial effusion after cardiac surgery remains an important cause of morbidity and mortality. We describe the risk factors of pericardial effusion after congenital heart surgery through analyzing data from a nationwide, multi-institutional registry.

Methods

The Japan Congenital Cardiovascular Surgery Database, which reflects routine clinical care in Japan, was used for this retrospective cohort study. Multivariable regression analysis was done after univariable comparison of patients with pericardial effusion and no pericardial effusion.

Results

The study enrolled 64,777 patients registered with the Japan Congenital Cardiovascular Surgery Database between 2008 and 2016; 909 of these had postoperative pericardial effusion (1.4%) and were analyzed along with 63,868 patients without pericardial effusion. Univariable analysis found no difference between the groups in terms of gender, early delivery, or preoperative mechanical ventilatory support. In the pericardial effusion group, cardiopulmonary bypass use was lower (58.4% vs 62.1%), whereas the cardiopulmonary bypass time (176.9 vs 139.9 minutes) and aortic crossclamp time (75.1 vs 62.2 minutes) were longer, and 30-day mortality was higher (4.1% vs 2.2%). Multivariable analysis identified trisomy 21 (odds ratio, 1.54), 22q.11 deletion (odds ratio, 2.17), first-time cardiac surgery (odds ratio, 2.01), and blood transfusion (odds ratio, 1.43) as independent risk factors of postoperative pericardial effusion. In contrast, neonates, infants, ventricular septal defect, atrial septal defect, tetralogy of Fallot repair, and arterial switch operation were correlated with a low risk of pericardial effusion development.

Conclusions

The incidence of postoperative pericardial effusion in congenital cardiac surgery was 1.4%. Trisomy 21, 22q.11 deletion, first-time cardiac surgery, and blood transfusion were identified as the principal factors predicting the need for pericardial effusion drainage.

Incidence and predictors of pericardial effusion following surgical closure of atrial septal defect in children: A single center experience

OBJECTIVES

To evaluate the incidence of pericardial effusion (PE) after surgical atrial septal defect (ASD) closure and to investigate the presence of predictive risk factors for its development.

METHODS

We collected data from 203 patients followed at Bambino Gesù Children's Hospital of Rome who underwent cardiac surgery for ASD repair between January 2015 and September 2019.

RESULTS

A total of 200/203 patients with different types of ASD were included. Patients were divided into two groups: Group 1) 38 (19%) who developed PE and Group 2) 162 (81%) without PE. No differences were noted between the two groups with regard to gender or age at the surgery. Fever in the 48 h after surgery was significantly more frequent in group 1 than in group 2 (23.7 vs. 2.5%; p < 0.0001). ECG at discharge showed significant ST-segment elevation in children who developed PE, 24.3 vs. 2.0% in those who did not (p < 0.0001). Group 1 patients were divided into two subgroups on the basis of the severity of PE, namely, 31 (81.6%) with mild and 7 (18.4%) with moderate/severe PE. Patients with moderate/severe PE had a significantly higher BMI value (median 19.1 Kg/m²) (range 15.9-23.4, p = 0.004).

CONCLUSION

The presence of fever and ST-segment elevation after surgery predicts subsequent development of PE suggesting a closer follow-up for these categories of patients. A higher BMI appears to be associated with a higher risk of moderate/severe PE.

Current pharmacotherapy management of children and adults with pericarditis: Prospectus for improved outcomes

Pericarditis is the most common inflammatory pericardial disease in both children and adults. Since the 2015 European Society of Cardiology Guidelines for the diagnosis and management of pericardial disease were published, there have been significant updates to management. Pharmacotherapy has been historically reserved for idiopathic pericarditis (IP). However, there has been increasing use of pharmacotherapies, such as anti-inflammatory therapies, colchicine, and immunotherapies for other causes of pericarditis, such as post-cardiac injury syndromes (PCIS). Nevertheless, the quality of data varies depending on PCIS or idiopathic etiologies, as well as the adult and pediatric population. High-dose anti-inflammatory therapies should be used to manage symptoms associated with either etiology of pericarditis in both adults and children, but do not ameliorate the inflammatory disease process. Choice of anti-inflammatory should be guided by drug-drug/disease interactions, cost, tolerability, patient age, and should be tapered accordingly over several weeks to months. Colchicine should be added as adjuvant therapy to anti-inflammatory therapies in adults and children with IP, as it has been shown to lower the risk of recurrence, reduce pericarditis symptoms, and improve morbidity. Colchicine is also reasonable to add to adults and children with pericarditis secondary to PCIS. Systemic glucocorticoids increase risk of recurrence in adults and children with IP and are reserved for second-line treatment in acute and recurrent IP; they are generally avoided in PCIS. Immunotherapies are regarded as third-line for recurrent IP in adults and children. Limited evidence exists to support their use in patients with pericarditis from PCIS. Pharmacovigilance strategies, such as C-reactive protein and adverse drug event monitoring, are also important toward balancing efficacy and safety of the various strategies used to manage pericarditis in adults and children.

Postpericardiotomy syndrome after cardiac surgery

Postpericardiotomy syndrome (PPS) is a well-known complication after cardiac surgery. The syndrome results in prolonged hospital stay, readmissions, and invasive interventions. Previous studies have reported inconsistent results concerning the incidence and risk factors for PPS due to the differences in the applied diagnostic criteria, study designs, patient populations, and procedure types. In recent prospective studies the reported incidences have been between 21 and 29% in adult cardiac surgery patients. However, it has been stated that most of the included diagnoses in the aforementioned studies would be clinically irrelevant. This challenges the specificity and usability of the currently recommended diagnostic criteria for PPS. Moreover, recent evidence suggests that PPS requiring invasive intervention such as the evacuation of pleural and/or pericardial effusion is associated with increased mortality. In the present review, we summarise the existing literature concerning the incidence, clinical features, diagnostic criteria, risk factors, management, and prognosis of PPS. We also propose novel approaches regarding to the definition and diagnosis of PPS. Key messages: Current diagnostic criteria of PPS should be reconsidered, and the analyses should be divided into subgroups according to the severity of the syndrome to achieve more clinically applicable and meaningful results in the future studies. In contrast with the previous presumption, severe PPS - defined as PPS requiring invasive interventions - was recently found to be associated with higher all-cause mortality during the first two years after cardiac surgery. The association with an increased mortality supports the use of relatively aggressive prophylactic methods to prevent PPS. The risk factors clearly increasing the occurrence of PPS are younger age, pleural incision, and valve and ascending aortic procedures when compared to CABG.

Does Early Drain Removal Affect Postoperative Pericardial Effusion after Congenital Cardiac Surgery?

Background

Patients undergoing cardiac surgery require postoperative chest drainage. However, the drain is difficult to keep in place in children with congenital heart disease. Since 2015, at Kyungpook National University Hospital, the chest tube is removed on postoperative day 1 in patients who have undergone simple congenital cardiac surgery (i.e., closure of an atrial or ventricular septal defect). In this study, we evaluated the relationship between the duration of drain placement and the likelihood of pericardial effusion after congenital cardiac surgery.

Methods

The medical records of patients who underwent closure of an atrial or ventricular septal defect at our hospital between January 2014 and December 2016 were reviewed. In total, 162 patients who received follow-up echocardiography and had information available on postoperative pericardial effusion after the repair procedure were enrolled.

Results

Echocardiography was performed at a median of 5 days (range, 4 to 6 days) postoperatively before discharge from the hospital. Pericardial effusion occurred in 21 patients (13.0%), of whom only 3 (1.9%) had moderate or greater pericardial effusion, regardless of the drain duration. All patients improved during outpatient follow-up without invasive management. No patient had severe complications because of pericardial effusion. The duration of drain placement did not affect the incidence of postoperative pericardial effusion (p=0.069). Operative survival was 100%.

Conclusion

Based on our study, we recommend removing the drain as soon as its role is complete, generally on postoperative day 1, because early removal does not increase the incidence of pericardial effusion in patients undergoing simple congenital cardiac surgery.

Early Surgical Closure of Atrial Septal Defect Improves Clinical Status of Symptomatic Young Children with Underlying Pulmonary Abnormalities

Elective closure of atrial septal defect (ASD) is usually recommended during preschool ages. However, ASD may contribute to deteriorating health in the presence of significant comorbidity and, thus, may need earlier closure. There is a lack of clarity regarding the indications for and outcomes after ASD closure in infancy and early childhood. We investigated the benefits and safety of surgical ASD closure in symptomatic patients under 2 years of age. Retrospective chart review was conducted in patients who underwent surgical ASD closure within the first 2 years of life. Of 31 symptomatic ASD patients, 22 had persistent respiratory symptoms, 24 failure to thrive, and 9 pulmonary hypertension. Overall, 26 patients (84.0%) showed clinical improvement after ASD closure, including improved respiratory status (17/22; 77.3%), resumption of normal growth (15/24; 62.5%), and resolution of pulmonary hypertension (7/7; 100%, 2 patients unable to assess postoperatively). Two medically complicated patients died a few months after surgery unrelated to surgical complications. Four out of 8 ventilator-dependent patients were weaned from mechanical ventilation within 1 month after ASD closure. Closure of ASD did not improve those patients with highly advanced lung disease and/or medically complex conditions including underlying genetic abnormalities. Surgical complications were uncommon. Postoperative hospital stay was 4 to 298 days (median 8 days). The majority of our patients demonstrated significant clinical improvement after ASD closure. Early ASD closure is safe and beneficial for symptomatic infants and young children with associated underlying pulmonary abnormalities, especially bronchopulmonary dysplasia.

Pericarditis - Clinical presentation and characteristics of a pediatric population

INTRODUCTION

Pericarditis is an inflammation of the pericardium. It may be infectious or secondary to a systemic disease. The aim of this study was to analyze the clinical findings, course, treatment and follow-up of children diagnosed with pericarditis at our center.

METHODS

We performed a retrospective analysis of all children admitted to our pediatric cardiology unit with pericarditis between 2003 and 2015. Patient characteristics were summarized using frequencies and percentages for categorical variables and medians with percentiles for continuous variables.

RESULTS

Fifty patients were analyzed (40 male, 10 female) with a median age of 14 years. The most common diagnosis was acute pericarditis (80%). Thirty-five patients (70%) presented with chest pain and 26% reported fever. Cardiomegaly was identified on chest X-ray in 11 patients (22%), 30 patients (60%) had an abnormal ECG and 44 patients (80%) had alterations on the transthoracic echocardiogram. In 17 cases (34%) there was myocardial involvement. Forty-eight percent of patients presented with infectious pericarditis and the pathologic agent was identified in half of them. Postpericardiotomy syndrome was diagnosed in five cases. The first-line therapy was aspirin in 50% of cases. Pericardiocentesis was performed in 12 patients. The median length of stay was nine days. There was symptom recurrence in seven children.

CONCLUSIONS

In this study, acute infectious pericarditis was the most common presentation and about one third of patients also had myocarditis. The symptom recurrence rate was not negligible and is probably related to the type of therapy employed.

Recurrent Pericarditis in Children and Adolescents

Recurrent pericarditis (RP) is a clinical syndrome characterized by recurrent attacks of acute pericardial inflammation. Prognosis quoad vitam is good, although morbidity might be significant, especially in children and adolescents. Multiple potential etiologies result in RP, in the vast majority of cases through autoimmune or autoinflammatory mechanisms. Idiopathic RP is one of the most frequent diagnoses, that requires the exclusion of all known etiologies. Therapeutic advances in the last decade have been significant with the recognition of the effectiveness of anti IL1 therapy, but a correct diagnostic and therapeutic algorithm is of key importance. Unfortunately, most of evidence comes from studies in adult patients. Here we review the etiopathogenesis, diagnosis and management of RP in pediatric patients.

Risk of Clinically Relevant Pericardial Effusion After Pediatric Cardiac Surgery

Pericardial effusion (PE) after pediatric cardiac surgery is common. Because of the lack of a uniform classification of the presence and severity of PE, we evaluated PE altering clinical management: clinically relevant PE. Risk factors for clinically relevant PE were studied. After cardiac surgery, children were followed until 1 month after surgery. Preoperative variables were studied in the complete cohort. Perioperative and postoperative variables were studied in a case-control manner. Patients with and without clinically relevant PE were matched on age, gender, and diagnosis severity in a 1:1 ratio. Multivariate analysis was conducted using important preoperative variables from the complete cohort combined with perioperative and postoperative variables from the case-control data. 1241 surgical episodes in 1031 patients were included. Clinically relevant PE developed in 136 episodes (11.0%). Multivariate correlation with the outcome was present for age, BSA (adjusted odds ratio: 1.6, 95% CI 0.9-2.8), right-sided heart defect (adjusted odds ratio: 1.3, 95% CI 0.9-1.9), history of previous operation (adjusted odds ratio: 0.5, 95% CI 0.3-0.7), cardiopulmonary bypass use (adjusted odds ratio: 2.1, 95% CI 0.9-4.5), duration of CPAP postoperatively, and an inotropic score (adjusted odds ratio: 1.01, 95% CI 0.998-1.03). In this large patient cohort, 11.0% of postoperative periods of pediatric cardiac surgery were complicated by PE requiring alteration of treatment. Secondly, we newly identified cardiopulmonary bypass use and right-sided heart defects as risk factors for clinically relevant PE and confirmed previously described risk factors: age, CPAP duration, BSA, and inotropic score and a previously described risk reductor: history of previous operation.

Does Prophylactic Ibuprofen After Surgical Atrial Septal Defect Repair Decrease the Rate of Post-Pericardiotomy Syndrome?

Post-pericardiotomy syndrome (PPS) is an inflammatory process involving the pleura, pericardium, or both and occurs after cardiothoracic surgery. Surgical atrial septal defect (ASD) closure is associated with higher incidence of PPS post-operatively as compared to other operations. Reported incidence of PPS varies from 1 to 40%. NSAIDs are often used to treat PPS and in our center, some practitioners have prescribed ibuprofen prophylactically. This study sought to investigate the impact of prophylactic treatment with ibuprofen on the development and severity of PPS following surgical ASD closure, with particular attention to secundum-type ASDs. We retrospectively reviewed clinical and operative data of all surgical ASD repairs in our center from 1/2007 to 7/2017. ASDs were grouped by subtype. PPS was considered positive if the primary cardiologist diagnosed and documented clinical signs of PPS on post-operative outpatient follow-up. Records were reviewed to confirm documented diagnosis of PPS. A total of 245 cases were reviewed with 207 having sufficient data. Median age was 2 years (range 4 months-27 years), female 57%. Overall incidence of PPS was 10%. There was no difference in incidence of PPS in those prescribed ibuprofen as compared to those who were not. This was true for both the entire cohort and the subgroup analysis (P = 1.0). Four patients overall required pericardiocentesis, none of whom received prophylactic ibuprofen. Prophylactic ibuprofen prescription following surgical ASD repair did not reduce the rate of PPS in our cohort.

Point-of-Care Ultrasound to Diagnose Postpericardiotomy Syndrome in a Child

We report a case of a patient presenting with abdominal pain after cardiac surgery who was noted on point-of-care ultrasound (POCUS) to have pericardial and pleural effusion, in addition to ascites. The most notable findings were pleural and pericardial effusions, which combined with symptomatology met criteria for postpericardiotomy syndrome. Point-of-care ultrasound expedited the diagnosis of a pericardial effusion with impending tamponade and transfer for pericardiocentesis and placement of pericardial drain.

Prevalence and Risk Factors for Pericardial Effusions Requiring Readmission After Pediatric Cardiac Surgery

Pericardial effusion (PE) may require readmission after cardiac surgery and has been associated with postoperative morbidity and mortality. We sought to identify the prevalence and risk factors for postoperative PE requiring readmission in children. A retrospective analysis of the Pediatric Health Information System database was performed between January 1, 2003, and September 30, 2014. All patients ≤18 years old who underwent cardiac surgery were identified by ICD-9 codes. Those readmitted within 1 year with an ICD-9 code for PE were identified. Logistic regression analysis was performed to determine risk factors for PE readmissions. Of the 142,633 surgical admissions, 1535 (1.1%) were readmitted with PE. In multivariable analysis, older age at the initial surgical admission [odds ratio (OR) 1.17, p < 0.001], trisomy 21 (OR 1.24, p = 0.015), geographic region (OR 1.33-1.48, p ≤ 0.001), and specific surgical procedures [heart transplant (OR 1.82, p < 0.001), systemic-pulmonary artery shunt (OR 2.23, p < 0.001), and atrial septal defect surgical repair (OR 1.34, p < 0.001)] were independent risk factors for readmission with PE. Of readmitted patients, 44.2% underwent an interventional PE procedure. Factors associated with interventions included shorter length of stay (LOS) for the initial surgical admission (OR 0.85, p = 0.008), longer LOS for the readmission (OR 1.37, p < 0.001), and atrial septal defect surgery (OR 1.40, p = 0.005). In this administrative database of children undergoing cardiac surgery, readmissions for PE occurred after 1.1% of cardiac surgery admissions. The risk factors identified for readmissions and interventions may allow for improved risk stratification, family counseling, and earlier recognition of PE for children undergoing cardiac surgery.

Cost comparison of transcatheter and operative closures of ostium secundum atrial septal defects

BACKGROUND

Clinical outcomes for transcatheter and operative closures of atrial septal defects (ASDs) are similar. Economic cost for each method has not been well described.

METHODS

A single-center retrospective cohort study of children and adults<30 years of age undergoing closure for single secundum ASD from January 1, 2007, to April 1, 2012, was performed to measure differences in inflation-adjusted cost of operative and transcatheter closures of ASD. A propensity score weight-adjusted multivariate regression model was used in an intention-to-treat analysis. Costs for reintervention and crossover admissions were included in primary analysis.

RESULTS

A total of 244 subjects were included in the study (64% transcatheter and 36% operative), of which 2% (n = 5) were ≥18 years. Crossover rate from transcatheter to operative group was 3%. Risk of reintervention (P = .66) and 30-day mortality (P = .37) were not significantly different. In a multivariate model, adjusted cost of operative closure was 2012 US $60,992 versus 2012 US $55,841 for transcatheter closure (P < .001). Components of total cost favoring transcatheter closure were length of stay, medications, and follow-up radiologic and laboratory testing, overcoming higher costs of procedure and echocardiography. Professional costs did not differ. The rate of 30-day readmission was greater in the operative cohort, further increasing the cost advantage of transcatheter closure. Sensitivity analyses demonstrated that costs of follow-up visits influenced relative cost but that device closure remained favorable over a broad range of crossover and reintervention rates.

CONCLUSION

For single secundum ASD, cost comparison analysis favors transcatheter closure over the short term. The cost of follow-up regimens influences the cost advantage of transcatheter closure.