Management of atrial septal defect in middle age

Transcatheter closure of atrial septal defect in the elderly: a systematic review and meta-analysis

OBJECTIVE

Despite the establishment of transcatheter closure as the treatment of choice in adults with secundum atrial septal defects (ASDs), the effectiveness of this approach in the elderly is disputed. This systematic review and meta-analysis aims to explore the impact of transcatheter ASD closure in patients ≥60 years old.

METHODS

We systematically searched four major electronic databases (PubMed, CENTRAL (Cochrane Central Register of Controlled Trials), Scopus and Web of Science), ClinicalTrials.gov, article references and grey literature. Primary outcomes were the right ventricular end-diastolic diameter (RVEDD) and the New York Heart Association functional class change, whereas secondary outcomes included systolic pulmonary arterial pressure (sPAP), left ventricular end-diastolic diameter (LVEDD), brain natriuretic peptide (BNP), tricuspid valve regurgitation (TR) change, as well as the rate of atrial arrhythmias and all-cause mortality.

RESULTS

In total, 18 single-arm cohorts comprising 1184 patients were included. RVEDD was reduced after ASD closure (standardised mean difference (SMD) -0.9, 95% CI -1.2 to -0.7). Elderly patients had 9.5 times higher odds of being asymptomatic after ASD closure (95% CI 5.06 to 17.79). Furthermore, ASD closure improved sPAP (mean difference (MD) -10.8, 95% CI -14.6 to -7), LVEDD (SMD 0.8, 95% CI 0.7 to 1.0), TR severity (OR 0.39, 95% CI 0.25 to 0.60) and BNP (MD -68.3, 95% CI -114.4 to -22.1). There was a neutral effect of ASD closure on atrial arrhythmias.

CONCLUSIONS

Transcatheter ASD closure is beneficial for the elderly population since it improves functional capacity, biventricular dimensions, pulmonary pressures, TR severity and BNP. However, the incidence of atrial arrhythmias did not change significantly after the intervention.

PROSPERO REGISTRATION NUMBER

CRD42022378574.

Transcatheter closure of atrial septal defects in adults > or =40 years of age: immediate and follow-up results

BACKGROUND

Controversy still exists regarding closure of atrial septal defects (ASDs) in patients >40 years of age who are largely asymptomatic or do not have large shunts (LS). If left unrepaired, the majority of patients will experience symptoms and will have a shorter life span compared to patients who undergo repair. This study presents the outcomes of closure of ASDs in adults >40 years using the Amplatzer septal occluder.

METHODS

A total of 113 patients (79F/34M) with a mean age of 57.9 years (SD 11.9) who had indications for closure (right ventricular [RV] enlargement by echocardiograpy, clinically symptomatic) underwent an attempt of transcatheter closure. The mean size of ASD as measured by transesophageal echocardiography (TEE) (30 patients) or intracardiac echocardiography (83 patients) was 17.2 mm (SD 7.3) with mean Qp:Qs of 2.2:1 (SD 1.1). Follow-up at 24 hours, 6 month, and yearly thereafter included physical examination, TEE, and/or transthoracic echocardiography; furthermore, chart review (n = 112) as well as telephone interviews (n = 56) were conducted to determine clinical symptomatic status.

RESULTS

The procedure was successful in 112 patients and 1 patient failed due to the presence of a large defect (44 mm). One hundred four patients had a single device implanted, 7 had two, and 1 had three. Following the procedure, 96 patients had immediate complete closure (CC), 3 had trivial shunt (TS), 11 had small shunt (SS), and 2 had moderate shunt (MS). At 24 hours postprocedure, 100 patients had CC, 7 had TS, 3 had SS, 1 had MS, and 1 had LS. Four patients had complications: one had device migration within 24 hours, two had atrial arrhythmias (supraventricular tachycardia, atrial tachycardia), and one had large hematoma. At 6 months postprocedure, 100 patients had CC, 6 had TS, 5 had SS, and 1 had MS. At 6-month follow-up, the right ventricle end-diastolic dimension decreased from 35.3 mm (SD 7.6) preprocedure to 23.8 mm (SD 6.6) (P < 0.001) and the majority of patients reported improvement in their symptoms.

CONCLUSIONS

ASD closure is safe and effective in patients over 40 years of age with minimal complications. The procedure resulted in a decrease in the RV size that was accompanied by improvement in clinical symptoms. Our findings suggest that device closure of ASDs in adult patients >40 years of age should be the first option of management.

Atrial natriuretic peptide levels in adult patients before and after surgery for correction of atrial septal defects: relationship with atrial arrhythmias

In the present study, we have examined whether increased N-ANP (N-terminal pro-ANP) levels before and after surgery in patients with ASD (atrial septal defect) along with echocardiographic findings provide a better insight into the pathophysiology and increased morbidity and mortality following corrective surgery. Eighteen adult ASD patients (>20 years of age; six male and 12 female) with shunts (Qp/Qs≥2, where Qp/Qs is the pulmonary blood flow/systemic blood flow) had complete echocardiographic, clinical and laboratory parameters evaluated before and 6 months after surgery. Eight age- and sex-matched individuals (three male and five female) were enrolled as a control group. Blood samples for N-ANP analysis were obtained in both groups. N-ANP levels in the peripheral blood sample from ASD patients before surgery were significantly higher than those in the control group. In patients with ASD, mean N-ANP levels obtained from the pulmonary artery were significantly higher than that obtained from the peripheral vein. RA (right atrial) area, adjusted for body surface area, and RA long-axis and short-axis measurements were significantly higher in the patient group than the control group. N-ANP was correlated significantly with these parameters. Following corrective surgery, N-ANP values and RA area, RA long-axis and short-axis normalization decreased significantly and were accompanied by a decrease in systolic mean pulmonary artery pressure. N-ANP levels were normalized following septal closure in most patients, except in those with atrial fibrillation attacks following corrective surgery. In conclusion, we have shown correlations among variables indicating changes in the architecture of the right atrium along with temporal changes in ANP providing insights into the pathophysiology of post-operative atrial arrhythmias.

Surgical closure of atrial septal defects in adults: effect of age at operation on outcome

OBJECTIVE

To determine whether age has an effect on the long term outcome after surgical closure of atrial septal defects in patients aged 35 years and over.

METHODS

Retrospective analysis of 89 patients (64 women) operated on between 1989 and 1999. Patients were divided into two age groups: group I (aged 35-50 years, n = 51) and group II (> 50 years, n = 38). Follow up was between 1-11 years.

RESULTS

One operative death and two late deaths occurred in the study period (both in group II). Preoperatively, 29 (57%) patients were in New York Heart Association functional class III-IV in group I compared with 22 (58%) patients in group II (NS). After operation, 44 (86.2%) patients in group I were found to be in class I-II compared with 25 (71.5%, p < 0.05) in group II. Group I patients had a lower incidence of preoperative atrial fibrillation than those in group II (12 (23.5%) v 17 (43.6%), p < 0.05) and only four (7.8%) patients in group I were in atrial fibrillation requiring long term warfarin after surgery compared with 12 (34%, p < 0.05) in group II. Furthermore, echocardiography showed a greater reduction in right ventricular dimension in group I patients (mean (SD) 4.26 (0.82) v 2.71 (0.41) cm, p < 0.001) than in group II patients (4.36 (0.43) v 3.87 (0.29) cm, p = 0.21). No residual intracardiac shunts were identified during follow up.

CONCLUSIONS

Surgical closure of atrial septal defects in adult patients can improve clinical status and prevent right ventricular dilatation. The greatest benefit is seen in younger patients.

Transvenous closure of moderate and large secundum atrial septal defects in adults using the Amplatzer septal occluder

The aim was to determine the feasibility of using the Amplatzer septal occluder for closure of moderate and large secundum atrial septal defects in adults. Fifty patients aged 16-76 years (mean +/- SD, 40 +/- 15.5), underwent successful device implantation. Flow ratios of 1.4-8.5 (mean +/- SD, 2.6 +/- 1.6) were calculated. The defects were: centrally placed (n = 31), antero-superior with partial or total deficiency of aortic rim (n = 19), multiple (n = 3) and with aneurysmal septum (n = 23). They measured 4-25 mm (median 14) on echocardiography and balloon sized 7-31 mm (median 19.5). Devices of 7-34 mm (median 20) were implanted. Patient follow up for 1 month (50/50 patients), 3 months (40/50) and 12 months (13/50), achieved respective rates of 90%, 92% and 98% of complete occlusion. In one patient a transient atrioventricular block (2:1) developed, and one had a transient STT elevation. One female had an episode of 30 min loss of vision over the lateral aspect of the left eye 3 months after implantation. In conclusion, transvenous occlusion of secundum atrial septal defects with the Amplatzer septal occluder in adults is safe, and can be performed without significant complications. Large defects, defects with a very deficient or absent aortic rim, defects with an aneurysmal septum as well as some multiple defects can be closed with an almost 100% early complete occlusion rate. This makes the procedure an alternative to surgery for selected adult patients.

Should atrial septal defects in adults be closed?

BACKGROUND

By assessing current surgical outcome and symptomatic relief, this study attempts to answer whether atrial septal defects in adults should be closed.

METHODS

Thirty-nine adult patients aged 35.2 +/- 13.6 years underwent operation for an atrial septal defect between June 1988 and June 1994. Indications for closure were symptoms (33 patients) or a significant left-to-right atrial shunt (6 patients). Data were obtained from hospital records, and the latest status of the patients was determined by a written questionnaire.

RESULTS

There were no deaths. Pulmonary embolism in 1 patient was the only complication observed. The QRS duration on the surface electrocardiogram decreased immediately (p < 0.001), and the cardiothoracic ratio on chest radiographs was significantly lower 3 to 6 months after operation (p < 0.001), both findings reflecting improved hemodynamics. No residual shunts were seen on follow-up (mean follow-up, 3.3 +/- 2.2 years). Twenty-seven (81.8%) of the 33 symptomatic patients improved clinically in terms of exercise performance, atrial arrhythmias, or both. Three (50%) of the 6 previously asymptomatic patients reported improved functional capacity post-operatively.

CONCLUSIONS

Today, operation for atrial septal defects in adults can be performed with no mortality and low morbidity and results in symptomatic improvement in the majority of patients. Clinical improvement was seen even in patients who considered themselves asymptomatic preoperatively. We advocate closure of atrial septal defects in adult patients with symptoms or significant atrial shunts.

A comparison of surgical and medical therapy for atrial septal defect in adults

BACKGROUND

The surgical closure of an atrial septal defect is frequently recommended for patients over 40 years of age. However, the prognosis for such patients with unrepaired defects is largely unknown, and the outcome for patients operated on after the fourth decade of life has not yet been compared with that for medically treated patients in a controlled follow-up study.

METHODS

In a retrospective study, we examined the clinical course of 179 consecutive patients with isolated atrial septal defects diagnosed after the age of 40. The 84 patients (47 percent) who underwent surgical repair were compared with the 95 patients (53 percent) who were treated medically. The mean (+/-SD) follow-up period was 8.9 +/- 5.2 years (range, 1 to 26).

RESULTS

Multivariate analysis revealed that surgical closure of the defect significantly reduced mortality from all causes (relative risk, 0.31; 95 percent confidence interval, 0.11 to 0.85). The adjusted 10-year survival rate of surgically treated patients was 95 percent, as compared with 84 percent for the medically treated patients. In addition, surgical treatment prevented functional deterioration, as measured by the New York Heart Association class (relative risk, 0.21; 95 percent confidence interval, 0.08 to 0.55). However, the incidence of new atrial arrhythmias or of cerebrovascular insults in the two groups was not significantly different.

CONCLUSIONS

The surgical repair of an atrial septal defect in patients over 40 years of age, as compared with medical therapy, increases long-term survival and limits the deterioration of function due to heart failure. However, surgically treated patients should be followed closely for the onset of atrial arrhythmias so as to reduce the risk of thromboembolic complications.

Long-term outcome after surgical repair of isolated atrial septal defect. Follow-up at 27 to 32 years

BACKGROUND

Atrial septal defects have been surgically correctable for more than 30 years. The long-term survival rates among patients treated in the early era of cardiac surgery are poorly documented, but such data are of critical importance to the future medical care, employability, and insurability of these patients.

METHODS

To determine the natural history of surgically corrected atrial septal defects, we studied all 123 patients who underwent repair of an isolated defect (ostium secundum or sinus venosus) at the Mayo Clinic between 1956 and 1960, 27 to 32 years after the procedure. The follow-up status of all patients was determined by written questionnaires and telephone interviews. Hospital records and death certificates were obtained if interim hospitalization or death had occurred.

RESULTS

The overall 30-year actuarial survival rate among survivors of the perioperative period was 74 percent, as compared with 85 percent among controls matched for age and sex. The perioperative mortality was 3.3 percent (four deaths). Actuarial 27-year survival rates among patients in the younger two quartiles according to age at operation (less than or equal to 11 years and 12 to 24 years) were no different from rates among controls--97 percent and 93 percent, respectively. In the two older quartiles (25 to 41 years and greater than 41 years), 27-year survival rates were significantly less (P less than 0.001)--84 percent and 40 percent, respectively--than in controls (91 and 59 percent). Independent predictors of long-term survival according to multivariate analysis were age at operation (P less than 0.0001) and systolic pressure in the main pulmonary artery before operation (P less than 0.0027). When repair was performed in older patients, late cardiac failure, stroke, and atrial fibrillation were significantly more frequent.

CONCLUSIONS

Among patients with surgically repaired atrial septal defects, those operated on before the age of 25 have an excellent prognosis, but older patients require careful, regular supervision.

The adult atrial septal defect: results of surgical repair

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