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Xue YH, Huang IC, Tuan SH, Cheng CC, Cheng H, Lu YS, Chou CC, Chang YL, Lin KL. Cardiopulmonary functional capacity in Taiwanese children with atrial septal defects. J Chin Med Assoc 2024; 87:653-658. [PMID: 38666778 DOI: 10.1097/jcma.0000000000001102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND Most existing studies measure atrial septal defect (ASD) outcomes based on morbidity rates such as atrial arrhythmias and heart failure rather than the functional assessment of physical capacity postprocedure. Few studies have evaluated cardiopulmonary function in ASD children. This study represents the largest sample population in the current research, encompassing a total of 122 Taiwanese children with ASD who had undergone treatment, to evaluate cardiopulmonary functional capacity through the implementation of cardiopulmonary exercise testing (CPET), and to investigate whether variations in treatment may impact their cardiopulmonary function. METHODS This is a retrospective cohort study with the data collected from January 2010 to December 2021. All patients and controls (age-, sex-, and body mass index-matched) underwent CPET and pulmonary function testing. RESULTS In total, 122 ASD patients (surgically closed ASDs 27, transcatheter-closed ASDs 48, and follow-up unrepaired ASD 47) and 244 healthy controls were recruited. The ASD group exhibited lower peak metabolic equivalent (MET), peak oxygen consumption (VO 2 , p < 0.001), and peak minute ventilation ( p = 0.028) along with MET and VO 2 at the anaerobic threshold (AT) ( p = 0.012) compared to the control group. No statistically significant differences were observed in the pulmonary function test. Among surgically closed, transcatheter closed and unrepaired ASD subgroups, no significant variances were seen in CPET and pulmonary function tests. CONCLUSION Taiwanese ASD children exhibited diminished exercise capacity and cardiopulmonary performance compared to their healthy counterparts. Differences among specific ASD treatments in cardiopulmonary tests were non-significant.
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Affiliation(s)
- Yu-Hao Xue
- Department of Physical Medicine and Rehabilitation, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, ROC
| | - I-Ching Huang
- Department of Physical Medicine and Rehabilitation, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, ROC
| | - Sheng-Hui Tuan
- Department of Physical Medicine and Rehabilitation, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, ROC
- Institute of Allied Health Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan, ROC
- Department of Rehabilitation Medicine, Cishan Hospital, Ministry of Health and Welfare, Kaohsiung, Taiwan, ROC
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC
| | - Cheng-Chang Cheng
- Department of Physical Medicine and Rehabilitation, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, ROC
| | - Hsuan Cheng
- Department of General Medicine, Kaohsiung Medical University Chung-Ho Memorial Hospital, Kaohsiung, Taiwan, ROC
| | - Yen-Sen Lu
- Department of Physical Medicine and Rehabilitation, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, ROC
| | - Chia-Chun Chou
- Department of Physical Medicine and Rehabilitation, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, ROC
| | - Yung-Liang Chang
- Department of Physical Medicine and Rehabilitation, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, ROC
| | - Ko-Long Lin
- Department of Physical Medicine and Rehabilitation, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, ROC
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC
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Van Praagh R. Interatrial Communications. CONGENIT HEART DIS 2022. [DOI: 10.1016/b978-1-56053-368-9.00009-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Zwijnenburg RD, Baggen VJ, Witsenburg M, Boersma E, Roos-Hesselink JW, van den Bosch AE. Risk Factors for Pulmonary Hypertension in Adults After Atrial Septal Defect Closure. Am J Cardiol 2019; 123:1336-1342. [PMID: 30709596 DOI: 10.1016/j.amjcard.2019.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 01/08/2019] [Accepted: 01/11/2019] [Indexed: 10/27/2022]
Abstract
Atrial septal defect (ASD) closure is performed to prevent pulmonary hypertension (PH), which is associated with poor outcome. This study investigated the prevalence of PH in adults before and after ASD closure and explored associations between patient characteristics and PH after ASD closure. Consecutive adult patients who underwent surgical or percutaneous ASD closure in the Erasmus MC, the Netherlands, were included (2000 to 2014). Echocardiograms before and after ASD closure were retrospectively assessed. Patients were categorized into 3 groups (no PH, possible PH, and PH) based on tricuspid regurgitation velocity (<2.9, 2.9 to 3.4, and ≥3.4 m/s) or mean pulmonary arterial pressure (<20, 20 to 24, and ≥25 mm Hg). Cox regression was performed to identify associations between patient characteristics and PH after ASD closure. Of the 244 eligible patients who underwent ASD closure, 198 (81%) had echocardiograms both before and median 15 (interquartile range 12 to 35) months after ASD closure (median age at closure 45 [interquartile range 30 to 57] years, 75% woman). The prevalence of PH was 13.1% (n = 26) before ASD closure and 5.0% (n = 10) after closure. New York Heart Association III to IV (hazard ratio [HR] 11.07, 95% confidence interval [CI] 3.12 to 39.29, p <0.001), pulmonary disease (HR 10.43, 95% CI 2.12 to 51.21, p = 0.004), cardiac medication use (HR 3.96, 95% CI 1.02 to 15.34, p = 0.047), right ventricular fractional area change (HR 0.87, 95% CI 0.81 to 0.93, p <0.001), and tricuspid annular plane systolic excursion (HR 0.75, 95% CI 0.59 to 0.95, p = 0.018) were significantly associated with PH. In conclusion, adult patients with low pulmonary pressures before ASD closure are not at risk of PH after closure. Nevertheless, PH remained prevalent in approximately 5% of patients. Especially those patients with high New York Heart Association functional class, presence of pulmonary disease, cardiac medication use and impaired RV function at baseline are at risk.
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Zwijnenburg RD, Baggen VJM, Geenen LW, Voigt KR, Roos-Hesselink JW, van den Bosch AE. The prevalence of pulmonary arterial hypertension before and after atrial septal defect closure at adult age: A systematic review. Am Heart J 2018; 201:63-71. [PMID: 29910057 DOI: 10.1016/j.ahj.2018.03.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 03/19/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND The development or persistence of pulmonary arterial hypertension (PAH) after atrial septal defect (ASD) closure at adult age is associated with a poor prognosis. The objective of this review was to investigate the prevalence of PAH before and after ASD closure and to identify factors that are associated with PAH. METHODS EMBASE and MEDLINE databases were searched for publications until March 2017. All studies reporting the prevalence of PAH or data on pulmonary artery pressures both before and after surgical or percutaneous ASD closure in an adult population (≥16 years of age) were included. Papers were methodologically checked and data was visualized in tables, bar charts and plots. RESULTS A total of 30 papers were included. The prevalence of PAH ranged from 29% to 73% before ASD closure and from 5% to 50% after closure; being highest in older studies, small study cohorts, and studies with high rates of loss to follow-up. The pooled systolic pulmonary artery pressure (PAP) was 43±13 before ASD closure and 32±10 after closure. The overall mean PAP was 34±10 before closure and 28±8 after closure. Studies with a higher mean PAP before closure and a higher mean age of the study cohort reported greater PAP reductions. CONCLUSIONS The prevalence of PAH and mean pulmonary pressures decreased in all studies, regardless of the mean age or pulmonary pressures of the cohort. The reported prevalence of PAH after ASD closure is substantial, although widely varying (5%-50%), which is likely affected by selection of the study cohort.
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Affiliation(s)
| | - Vivan J M Baggen
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Laurie W Geenen
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Kelly R Voigt
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
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Inai K. Can pulmonary vasodilator therapy expand the operative indications for congenital heart disease? Int Heart J 2015; 56 Suppl:S12-6. [PMID: 25787792 DOI: 10.1536/ihj.14-396] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The operability of congenital heart disease with left to right shunt depends on the severity of the pulmonary vascular disease induced by the increased pulmonary blood flow. Although some recommendations exist regarding operative indications according to pathological, hemodynamic, and epidemiological factors, the evidence underlying these recommendations is not conclusive. Recently, oral pulmonary vasodilator therapy has been reported to improve outcomes in patients with idiopathic pulmonary arterial hypertension, and this therapy also appears to be effective in patients with congenital heart disease and pulmonary arterial hypertension, including those with postoperative pulmonary hypertension and Eisenmenger syndrome. It is expected that the availability of novel pulmonary vasodilator therapy will expand the operative indications in patients with congenital heart disease with left to right shunt, but there is currently insufficient evidence to definitively determine this. A multicenter double-blind study should be conducted to further examine this issue.
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Affiliation(s)
- Kei Inai
- Department of Pediatric Cardiology, Heart Institute, Tokyo Women's Medical University
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Taggart NW, Connolly HM, Hagler DJ. Acute Heart Failure after Percutaneous Pulmonary Valve (Melody Valve) Implantation. CONGENIT HEART DIS 2011; 8:E61-3. [DOI: 10.1111/j.1747-0803.2011.00570.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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ZAIDI ALIN, CHEATHAM JOHNP, RAMAN SUBHAV, COOK STEPHENC. Multislice Computed Tomographic Findings in Symptomatic Patients After Amplatzer Septal Occluder Device Implantation. J Interv Cardiol 2009; 22:92-7. [DOI: 10.1111/j.1540-8183.2008.00418.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Erkut B, Becit N, Unlu Y, Ceviz M, Kocogullari CU, Ates A, Karapolat BS, Kaygin MA, Kocak H. The effect of surgical treatment for secundum atrial septal defect in patients more than 30 years old. Heart Surg Forum 2007; 10:E376-80. [PMID: 17855202 DOI: 10.1532/hsf98.20071059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND We prospectively examined whether surgical treatment of secundum atrial septal defects in patients 30 years old improves their early- and mid-term clinical outcomes. Our clinical experience is reviewed to assess the importance of surgical management in elderly patients with atrial septal defect. METHODS We analyzed 41 patients older than 30 years of age who underwent surgical correction of a secundum atrial septal defect. To evaluate the effects of surgical treatment, we compared functional capacity, diuretic administration, rhythm status, and echocardiographic parameters of all patients before and after the operation. RESULTS The median follow-up period was 4.2 years (range, 6 months-7 years). There were no operative deaths. Functional class in most of the patients improved after operation. Two patients reverted to normal sinus rhythm after the operation. There was only one new atrial fibrilation among patients in the postoperative term. Right atrial and right ventricular dimensions and pulmonary artery pressures were significantly decreased, and ejection fractions were significantly increased after the operation. The need for diuretic treatment was decreased after surgical repair. No residual intracardiac shunts were identified during follow-up. There were no cerebrovascular thromboembolic accidents in the early postoperative period. CONCLUSION Surgical closure of atrial septal defects in patients over 30 years old can improve their clinical status and prevent right ventricular dilatation and insufficiency. The operation must be performed as soon as possible, even if the symptoms or the hemodynamic impact seem to be minimal.
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Affiliation(s)
- Bilgehan Erkut
- Department of Cardiovascular Surgery, Medical Faculty of Ataturk University, Erzurum, Turkey.
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9
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Weber M, Dill T, Deetjen A, Neumann T, Ekinci O, Hansel J, Elsaesser A, Mitrovic V, Hamm C. Left ventricular adaptation after atrial septal defect closure assessed by increased concentrations of N-terminal pro-brain natriuretic peptide and cardiac magnetic resonance imaging in adult patients. Heart 2005; 92:671-5. [PMID: 16216861 PMCID: PMC1860932 DOI: 10.1136/hrt.2005.065607] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To determine in an observational study whether N-terminal pro-brain natriuretic peptide (NT-proBNP) is raised in patients with an atrial septal defect (ASD) and whether concentrations change after interventional closure. METHODS 12 patients (6 men, mean (SD) age 44.4 (18.6) years) with a moderate sized ASD type II (23.3 (4.5) mm, pulmonary to systemic flow ratio 2.1 (0.68)) were investigated. In all patients a magnetic resonance imaging (MRI) study was performed and NT-proBNP was assessed at baseline and early (9 (13) days) and late (138 (64) days) after intervention. RESULTS Concentrations of NT-proBNP were found to be within the normal range at baseline (median 87 pg/ml, interquartile range 65-181 pg/ml) but increased early after the interventional closure (315 pg/ml, 133-384 pg/ml, p = 0.005 versus baseline). The increase of NT-proBNP was associated with an increase in left ventricular dimensions as assessed by MRI (left ventricular end diastolic volume 104 (27) ml to 118 (27) ml, p = 0.003). Late after ASD closure NT-proBNP returned to baseline concentrations (102 pg/ml, 82-188 pg/ml, p = 0.004 versus early follow up). CONCLUSION These findings suggest the presence of transitory haemodynamic stress during adaptation of the left ventricle after ASD closure, which may contribute to the understanding of the pathological mechanism of acute heart failure and delayed improvement of exercise capacity after ASD closure.
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Affiliation(s)
- M Weber
- Department of Cardiology, Kerckhoff Heart Centre, Bad Nauheim, Germany.
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Attie F, Rosas M, Granados N, Zabal C, Buendía A, Calderón J. Surgical treatment for secundum atrial septal defects in patients >40 years old. A randomized clinical trial. J Am Coll Cardiol 2001; 38:2035-42. [PMID: 11738312 DOI: 10.1016/s0735-1097(01)01635-7] [Citation(s) in RCA: 162] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
We prospectively examined whether surgical treatment of secundum atrial septal defects (ASDs) in patients > or =40 years old improves their long-term clinical outcome. Surgical treatment of secundum ASDs in adults > 40 years old is a subject of controversy because of the perception of good long-term clinical outcomes in patients with unrepaired ASDs and the lack of data from randomized trials. We recruited 521 patients > 40 years old with secundum ASDs referred for treatment; 48 were excluded. Patients were randomly assigned to surgical closure (n = 232) or medical treatment (n = 241). The primary and secondary end points were a composite of major cardiovascular events (death, pulmonary embolism, major arrhythmic event, embolic cerebrovascular event, recurrent pulmonary infection, functional class deterioration or heart failure) and overall mortality, respectively. We assessed possible prognostic markers. The analysis was performed on an intention-to-treat basis. The median follow-up period was 7.3 years (range 2 to 13). The risk of having the primary end point was significantly higher in the medical group, which had a univariate hazards ratio of 1.99 (95% confidence interval [CI] 1.23 to 3.22) and a multivariate hazards ratio of 1.85 (95% CI 1.08 to 3.17). Although the survival analysis did not reveal differences in overall mortality between the surgical and medical treatments (hazards ratio 1.71, 95% CI 0.76 to 3.86), the multivariate analysis, adjusted by age at entry, mean pulmonary artery pressure and cardiac index, demonstrated significant differences between the study groups (hazards ratio 4.09, 95% CI 1.41 to 11.89). Surgical closure was superior to medical treatment in improving both the composite of major cardiovascular events and overall mortality in patients > 40 years old with secundum ASDs. This superiority was related to the mean pulmonary artery pressure, age at diagnosis and cardiac index. Because of the higher risk of morbidity and mortality, we believe that anatomic closure should always be attempted as the initial treatment for ASDs in adults > 40 years old with pulmonary artery systolic pressure < 70 mm Hg and a pulmonary/systemic output ratio > or =1.7. The operation must be performed as soon as possible, even if the symptoms or the hemodynamic impact seems to be minimal.
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Affiliation(s)
- F Attie
- Departments of Adult Congenital Heart Disease and Pediatric Cardiology, National Institute of Cardiology of Mexico Ignacio Chávez, Mexico City, Mexico.
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Jemielity M, Dyszkiewicz W, Paluszkiewicz L, Perek B, Buczkowski P, Ponizyński A. Do patients over 40 years of age benefit from surgical closure of atrial septal defects? Heart 2001; 85:300-3. [PMID: 11179271 PMCID: PMC1729662 DOI: 10.1136/heart.85.3.300] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To determine the value of surgical closure of atrial septal defects in patients over 40 years of age. METHODS Retrospective analysis of 76 patients (63 women, 13 men), age range 40-62 years (mean (SD) 45.8 (5.1) years), who underwent surgical repair of atrial septal defect. Pre- and postoperative clinical status (New York Heart Association (NYHA) functional class) was assessed, and ECG, x ray, and echocardiographic investigations performed. Follow up was between 1 and 17 years. RESULTS One operative and one late death occurred during the study period. Before operation, 47 patients (61.8%) were in NYHA functional classes III and IV. After operation, 61 patients (82.4%) were in classes I and II. Four patients had atrial fibrillation before surgery versus nine after surgery. Before operation, 52 patients had intensified pulmonary vascularity compared with only seven after operation. Echocardiographic examination showed a significant reduction in right ventricular dimension (4.10 (0.91) v 2.95 (0.36) cm, p < 0.001). No residual intracardiac shunts were identified on echocardiographic follow up. CONCLUSIONS Surgical closure of atrial septal defects in patients over 40 years old can improve their clinical status and prevent right ventricular dilatation and insufficiency.
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Affiliation(s)
- M Jemielity
- Department of Cardiac Surgery, Institute of Cardiology, Karol Marcinkowski University of Medical Sciences, Poznań, Poland.
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SIEVERT HORST. Interventional Versus Surgical Closure of Atrial and Ventricular Septal Defects: Advantages and Limitations of the Catheter-Based Approach. J Interv Cardiol 2000. [DOI: 10.1111/j.1540-8183.2000.tb00332.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Abstract
The 1990s have seen considerable growth in our knowledge of outcomes in patients with atrial septal defect (ASD), improved techniques for imaging and diagnosing ASD, and advances in the treatment of ASD. Exciting new surgical procedures, such as minimally invasive surgery, the Cox-Maze procedure for patients with atrial fibrillation, and lung transplantation for patients with severe pulmonary artery hypertension, are now available. In my opinion, echocardiography is the procedure of choice for the diagnosis and characterization of ASD. Children and adults with ASD should undergo surgical repair unless there are contraindications. Surgical repair "early" in life prolongs survival and may prevent atrial fibrillation. Surgical repair in "older" adults prolongs survival and alleviates symptoms but will not abolish sustained or paroxysmal atrial fibrillation. Patients with ASD and atrial fibrillation (sustained or paroxysmal) should undergo surgical repair of ASD and a Cox-Maze procedure.
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Affiliation(s)
- WE Hopkins
- University of Vermont College of Medicine, Cardiology Unit, McClure 1, 111 Colchester Avenue, Burlington, VT 05401, USA
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Kobayashi Y, Nakanishi N, Kosakai Y. Pre- and postoperative exercise capacity associated with hemodynamics in adult patients with atrial septal defect: a retrospective study. Eur J Cardiothorac Surg 1997; 11:1062-6. [PMID: 9237588 DOI: 10.1016/s1010-7940(96)01131-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE This study evaluated the pre- and postoperative exercise capacity in adult patients with atrial septal defect (ASD) associated with hemodynamic variables. METHODS Adults (70) with ASD underwent symptom-limited exercise tests. Peak O2 uptake (Peak VO2) and % peak VO2, that is the percentage of predicted value, were measured. These patients were divided into three groups according to pulmonary-to-systemic flow ratio (Qp/Qs) and systolic pulmonary arterial pressure (PAs); Group A: Qp/Qs < or = 3, PAs < or = 50 mm Hg, Group B: Qp/Qs > 3, any PAs, Group C: Qp/Qs < or = 3, PAs > 50 mm Hg. Exercise test was repeated in 22 patients after surgical closure of ASD (mean 4.6 +/- 2.0 months). RESULTS Peak VO2 was significantly lower in group B (P < 0.01) and group C (P < 0.01) than in group A (19.3 +/- 5.7, 17.6 +/- 3.6, 27.6 +/- 6.3 ml/min/kg, respectively). In patients except those in group C, there were a weak negative correlation between PAs and % peak VO2 (r = 0.61) and a significant negative correlation between Qp/Qs and % peak VO2 (r = 0.86). Postoperative peak VO2 increased significantly in group A (27.2 +/- 5.1-31.1 +/- 5.1 ml/min/kg, P < 0.05) and group B (16.7 +/- 3.3-21.5 +/- 2.1 ml/min/kg, P < 0.01). However, there was no significant difference between pre- and postoperative peak VO2 in group C (16.8 +/- 1.3-17.8 +/- 2.8 ml/min/kg, NS). CONCLUSIONS In ASD patients except those with small or moderate left-to-right shunt and high pulmonary arterial pressure, there was a significant negative correlation between Qp/Qs and peak VO2 corrected by age and gender. Patients with large left-to-right shunt and/or high pulmonary arterial pressure had reduced exercise capacity. However, exercise capacity in patients with large left-to-right shunt increased after closure of ASD regardless of whether they had high pulmonary arterial pressure.
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Affiliation(s)
- Y Kobayashi
- Department of Internal Medicine, National Cardiovascular Center, Suita, Osaka, Japan
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Helber U, Baumann R, Seboldt H, Reinhard U, Hoffmeister HM. Atrial septal defect in adults: cardiopulmonary exercise capacity before and 4 months and 10 years after defect closure. J Am Coll Cardiol 1997; 29:1345-50. [PMID: 9137234 DOI: 10.1016/s0735-1097(97)00058-2] [Citation(s) in RCA: 71] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES The purpose of the study was to evaluate the cardiopulmonary exercise capacity and ventilatory function in adults with atrial septal defect (ASD) preoperatively and 4 months and 10 years postoperatively. BACKGROUND Only few data are available on cardiopulmonary exercise tolerance after ASD closure, but detailed knowledge might be helpful for indication for defect closure in certain patients. METHODS The study was performed in adult patients (mean [+/-SD] age at operation 39.9 +/- 11.5 years; left-right shunt 9.6 +/- 5.6 liters/min; pulmonary/systemic flow ratio 2.8 +/- 1.2; mean pulmonary artery pressure 18.2 +/- 6.2 mm Hg). Cardiopulmonary exercise testing was performed with a bicycle ergometer. We determined peak oxygen uptake, anaerobic threshold, performance at anaerobic threshold and maximal performance in relation to these variables in a normal group. Ventilatory function at rest was expressed by vital capacity, maximal voluntary ventilation and forced expiratory volume in 1 s. RESULTS Preoperatively, ventilatory function at rest was only moderately reduced to approximately 75% to 85%. Four months postoperatively we found no significant improvement, but 10 years postoperatively ventilatory function at rest was normalized. Preoperative cardiopulmonary exercise capacity was markedly reduced to 50% to 60%; early postoperatively it was only slightly higher, but late postoperatively exercise capacity significantly improved and was completely normalized. CONCLUSIONS Although preoperative cardiopulmonary capacity in adult patients with nonrestrictive ASD was significantly decreased, some improvement was seen at 4 months postoperatively, with complete restitution to normal at 10 years after shunt closure.
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Affiliation(s)
- U Helber
- Medizinische Klinik, Abteilung III, Eberhard-Karls-Universität, Tübingen, Germany
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Abstract
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.
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Affiliation(s)
- M A Gatzoulis
- Royal Brompton Hospital, National Heart & Lung Institute, London, United Kingdom
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18
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Affiliation(s)
- C Ward
- Regional Cardiac Centre, Wynthenshawe Hospital, Manchester
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19
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Kano Y, Abe T, Tanaka M, Takeuchi E. Electrophysiological abnormalities before and after surgery for atrial septal defect. J Electrocardiol 1993; 26:225-9. [PMID: 8409816 DOI: 10.1016/0022-0736(93)90041-b] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The authors evaluated the electrophysiological parameters, atrial-His interval, His-ventricular interval, Wenckebach cycle length, corrected sinus node recovery time (CSNRT), and sinoatrial conduction time (SACT) before and after operation in 28 children with atrial septal defect (ASD). Before operation, electrophysiological abnormalities were detected in 20 (79%) of the 28 patients. Preoperative comparison of the mean value in each parameter between the two age groups showed higher values in all parameters in the older group. In 17 patients who underwent operation, atrial-His interval, Wenckebach cycle length, CSNRT, and atrial effective refractory period (AERP) significantly decreased after operation; preoperatively abnormal Wenckebach cycle length, CSNRT, and AERP values were normalized in many of them. Thus, electrophysiological abnormalities were already present before operation in the ASD children and were severer in the older children, but were improved to some degree following operation.
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Affiliation(s)
- Y Kano
- Department of Thoracic Surgery, Nagoya University School of Medicine, Japan
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Horvath KA, Burke RP, Collins JJ, Cohn LH. Surgical treatment of adult atrial septal defect: early and long-term results. J Am Coll Cardiol 1992; 20:1156-9. [PMID: 1401616 DOI: 10.1016/0735-1097(92)90372-t] [Citation(s) in RCA: 156] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVES The purpose of this study is to determine the early and late results of the surgical repair of atrial septal defect in adults. BACKGROUND Progressively limiting, untreated atrial septal defect can lead to the early death of middle-aged adults. Recently it has been suggested that the closure of atrial septal defects might be accomplished with interventional cardiac techniques. Although the long-term results of the transcatheter closure are as yet unknown, the outcome of surgical therapy has been shown to be beneficial for almost 40 years. METHODS Between 1971 and 1991, 166 consecutive patients underwent surgical repair of a secundum or sinus venosus atrial septal defect, or both, at the Brigham and Women's Hospital, Boston. There were 120 women and 46 men in this group; the mean age was 44 years and 58 (35%) of the patients were > or = 50 years old. The average pulmonary to systemic flow ratio was 3.0, and 57 patients had a peak systolic pulmonary artery pressure > 30 mm Hg. RESULTS There were two operative deaths (early mortality rate 1.2%), and 13% of the patients had a perioperative complication. One hundred fifty-three of the 164 survivors were followed up for a mean of 90 months (range 2 to 247). There were eight late deaths (late mortality rate 4.9%) and a late morbidity rate of 12.4% (in most cases due to arrhythmias). The 5- and 10-year survival rates are 98% and 94%, respectively, and the probability of event-free survival (with no morbidity or mortality) at 5 years is 97% and at 10 years is 92%. CONCLUSIONS The results indicate that the surgical correction of atrial septal defect in adults is safe and efficacious as confirmed by 20 years of follow-up.
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Affiliation(s)
- K A Horvath
- Department of Surgery, Harvard Medical School, Boston, Massachusetts
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Abstract
Congenital heart defects arise in approximately 1% of all live births, independent of ethnic and geographical considerations. With the development of new surgical procedures and current technologies a large number of these heart lesions can be surgically corrected in infancy. In the majority of cases patients evaluated some 10 to 20 years after surgery are asymptomatic and can lead a normal life. Despite their satisfactory clinical outcome patients may, nevertheless, show an abnormal pattern of physiological responses when submitted to dynamic exercise. This paper reviews the scientific literature concerning the exercise capabilities and the cardiorespiratory adjustments to exercise in patients surgically corrected for 4 of the most common congenital heart lesions: isolated atrial septal defect, isolated ventricular septal defects, pulmonary stenosis and tetralogy of Fallot. The maximal exercise tolerance of postoperative congenital heart defect patients may usually be related to: (a) the age of the patients at the time of surgery; (b) the severity of the lesions remaining after surgery; and (c) the age of the patients at the time of investigation. Although normal maximal exercise capabilities may be found in a good number of patients operated for either of the 4 lesions considered, this does not imply normal exercise haemodynamics. A general observation made in these 4 groups of patients is that of a subnormal exercise cardiac output which may or may not be fully compensated by an increase in peripheral oxygen extraction. The limitation in exercising cardiac output may, in turn, be attributed to either a subnormal stroke volume or a limitation in the chronotropic response to exercise or a combination of both factors. Residual pulmonary stenosis, increased pulmonary vascular resistance, increased myocardial stiffness are all factors that may contribute to the cardiac output limitation. A thorough explanation of underlying causes for the abnormal haemodynamic response to exercise, however, still remains to be provided.
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Affiliation(s)
- H Perrault
- Department of Physical Education, McGill University, Montreal, Quebec, Canada
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Yamaki S, Horiuchi T, Miura M, Haneda K, Ishizawa E, Suzuki Y. Secundum atrial septal defect with severe pulmonary hypertension. Open lung biopsy diagnosis of operative indication. Chest 1987; 91:33-8. [PMID: 3792083 DOI: 10.1378/chest.91.1.33] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
In 14 of 15 patients ranging in age from 1 to 62 years (mean of 34) with secundum atrial septal defect (ASD) and pulmonary hypertension over 60 mm Hg peak pressure, operative indication was determined by morphometric diagnosis of open biopsy of lung specimens. In one patient, open lung biopsy was also performed during corrective surgery. Pulmonary arterial changes in the 15 patients were grouped into four classifications as follow: (1) plexogenic pulmonary arteriopathy (six patients); (2) thromboembolism in small pulmonary arteries (three patients); (3) "musculoelastosis," intimal proliferation of longitudinal smooth muscle bundles and elastic fibers (three patients); and (4) combinations of (1), (2) or (1), (3) (three patients). We conclude concerning the operative indication that group 2 patients are operable in all cases and group 1 patients with Yamaki's index of pulmonary vascular disease of 2.2 or less; group 3 patients with the absence of complete occlusion of the small pulmonary arterial lumen are operable, and patients with clear evidence of severe plexogenic pulmonary arteriopathy in group 4 are not operable. Comparative analysis of pulmonary pathology and hemodynamic performance revealed that open lung biopsy should be performed to determine operative candidacy in cases with a pulmonary vascular resistance greater than 8 unit X m2, which is considered to represent the borderline of operability.
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Bagger JP, Thomsen PE, Bjerregaard P, Gøtzsche H, Rasmussen K. Intracardiac electrography in patients before and after surgical repair of secundum atrial septal defect. J Electrocardiol 1984; 17:347-52. [PMID: 6502051 DOI: 10.1016/s0022-0736(84)80071-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Nine patients (mean age 32 years, range 9-58) with a secundum atrial septal defect (ASD) were investigated by intracardiac electrography before and, on an average, 14 months after circumclusion of the defect. Postoperatively, four patients developed atrial fibrillation or flutter requiring treatment. After the repair, sinus node recovery time and the H-V interval increased significantly. The P-A interval, the A-H interval, sinoatrial conduction time, and the effective refractory period of the atrium (ERPA) remained unchanged. In the patients who developed atrial tachyarrhythmias, the mean preoperative ERPA was significantly longer than in the remaining patients; in patients with ERPA less than 220 ms, no atrial arrhythmias occurred. Our findings suggest that circumclusion of a secundum ASD has a sustained deleterious effect on sinus node function and His-Purkinje conduction. Preoperative determination of ERPA might be of value for the prediction of postoperative atrial arrhythmias in patients submitted to ASD repair.
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Ruschhaupt DG, Khoury L, Thilenius OG, Replogle RL, Arcilla RA. Electrophysiologic abnormalities of children with ostium secundum atrial septal defect. Am J Cardiol 1984; 53:1643-7. [PMID: 6731310 DOI: 10.1016/0002-9149(84)90594-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Sinus node (SN) and atrioventricular node (AVN) function were evaluated in 49 patients with secundum type atrial septal defect (ASD). Automaticity and conduction system function were assessed by intracardiac recording of the AH and HV intervals at rest, corrected SN recovery time, sinoatrial conduction time, AVN refractory period and the ability of the AVN to conduct rapidly paced atrial beats to the ventricles. Electrophysiologic abnormalities were found in 41% of the 34 patients who were studied before surgery. However, no preoperative abnormalities were present in children younger than 2.5 years. If only children older than 2.5 years were analyzed, the incidence of conduction abnormalities was similar for the patients studied before operation (62%) and those studied after operation (71%). The size and ejection fractions of the right and left ventricles, the magnitude of shunt flow and the size of the ASD did not differ between the patients with and those without electrophysiologic abnormalities. AVN dysfunction was present in 40% of the patients who were studied after surgical repair. While this frequency was more than twice the preoperative incidence of AVN dysfunction, it was not statistically significant. The data suggest that patient age is the major factor that influences the presence of conduction system dysfunction in patients with ASD.
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Abstract
The diagnosis of atrial septal defect was established in monozygotic twin females at age 63. Each patient mimicked a different acquired heart disease. One twin had congestive heart failure and atrial fibrillation and was diagnosed as having rheumatic mitral insufficiency. The other twin had atypical chest pain and systemic hypertension and was thought to have arteriosclerotic heart disease. In each case the correct diagnosis was made at cardiac catheterization. Although the same basic congenital heart lesion was present in both patients, the symptoms and findings differed. Symptomatic improvement was achieved by different therapeutic modalities. One patient had open heart surgery, while the other twin improved with medical therapy.
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Brandenburg RO, Holmes DR, Brandenburg RO, McGoon DC. Clinical follow-up study of paroxysmal supraventricular tachyarrhythmias after operative repair of a secundum type atrial septal defect in adults. Am J Cardiol 1983; 51:273-6. [PMID: 6823836 DOI: 10.1016/s0002-9149(83)80048-4] [Citation(s) in RCA: 54] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Adults with isolated secundum atrial septal defect (ASD) may present with paroxysmal atrial tachyarrhythmias. The clinical course of these rhythmic disturbances after correction of the ASD is unknown. Of 188 patients aged 44 years old or older with isolated ASD, 27 (14%) (mean age 52.7 years, range 44 to 71) had documented paroxysmal atrial tachyarrhythmias preoperatively: 16 had paroxysmal atrial fibrillation, 2 had atrial flutter, and 9 had supraventricular tachycardia. Among these 3 groups, there were no differences in age, sex, New York Heart Association class, duration of preoperative symptoms, mean right atrial and pulmonary arterial pressures, shunt size, atrial size, or follow-up period. After operative repair, follow-up data were available in all patients for a mean of 12 years (range 1.5 to 25). Of the 16 patients with preoperative paroxysmal atrial fibrillation, 14 (88%) continued to have increasingly frequent paroxysmal atrial fibrillation, culminating in sustained atrial fibrillation. In 1 of the 2 patients with paroxysmal atrial flutter, sustained atrial fibrillation developed. Of the 9 patients with preoperative paroxysmal supraventricular tachycardia, 5 had no further episodes of this arrhythmia postoperatively.
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Kolibash AJ, Magorien RD, Robinson JL, Leier CV. Hemodynamic effects of vasodilator therapy in severe left heart failure combined with large atrial septal defects. Am J Med 1982; 73:439-4. [PMID: 7124771 DOI: 10.1016/0002-9343(82)90750-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Two patients presented with severe left heart failure and large secundum atrial septal defects without severe pulmonary hypertension. The acute hemodynamic effects of two commonly used vasodilator agents, isosorbide dinitrate and hydralazine, are described. Although isosorbide dinitrate improved systemic forward cardiac output, it also increased left-to-right intracardiac shunting in both patients. On the other hand, hydralazine dramatically improved systemic toward output and concomitantly diminished left-to-right shunt flow in each patient (43 and 21 percent). The complexities of combined severe left ventricular failure and a large atrial septal defect with left-to-right shunting, and the importance of extensive hemodynamic monitoring at the time of pharmacologic intervention, are discussed.
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Clark EB, Kugler JD. Preoperative secundum atrial septal defect with coexisting sinus node and atrioventricular node dysfunction. Circulation 1982; 65:976-80. [PMID: 7074763 DOI: 10.1161/01.cir.65.5.976] [Citation(s) in RCA: 36] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Sinus node dysfunction in patients after repair of the secundum atrial septal defect has been ascribed to surgical damage. We studied 15 consecutive patients with secundum atrial septal defect before operative intervention. Noninvasive testing included 34-hour electrocardiographic monitoring and a standard 13-lead ECG. Intracardiac electrophysiologic techniques included corrected sinus node recovery time, sinoatrial conduction time, His bundle recording to measure AH and HV intervals, the atrial pacing rate at which atrioventricular node Wenckebach occurred, and atrioventricular nodal refractory period. The ECG revealed an ectopic atrial rhythm in two patients. Intracardiac electrophysiology showed an abnormal corrected sinus node recovery time (range -40 to 800 msec) in 10 patients. Five patients had evidence of atrioventricular nodal dysfunction with prolonged AH interval or abnormal atrial pacing rate at which atrioventricular Wenckebach occurred. These data indicate that sinus node dysfunction or atrioventricular node dysfunction were present before surgical intervention.
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Lomholt P. Circumclusion of atrial septal defect in elderly patients. SCANDINAVIAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 1980; 14:159-63. [PMID: 7433934 DOI: 10.3109/14017438009100991] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The results of surgical closure of atrial septal defect of secundum type (ASD) in 28 patients over 40 years of age with a closed method, circumclusion ad modum Søndergaard, are presented. One death occurred in the postoperative period caused by cerebral embolism in a patient with increased pressure in the pulmonary artery and atrial fibrillation. The most frequent postoperative complications were transient atrial arrhythmias and the post-pericardiotomy syndrome. The pressures in the pulmonary artery decreased in all patients, who had increased pressures pre-operatively. In two patients with pulmonary vascular resistance of 6 mmHg/l/min before operation the resistance was significantly reduced postoperatively. Residual shunts of less than 30% of the systemic flow were present in 4 cases. The ASD recurred years after the operation in two patients. At follow-up examinations on an average 44 months after operation, 75% had improved. In 20 cases the heart was reduced in size. In the remaining 6 the heart size was unchanged or larger, in spite of eliminated shunts in 5 of the 6 patients. Of 8 patients with atrial fibrillation before operation, two gained stable sinus rhythm postoperatively. It is concluded that circumclusion is also an effective method in the elderly patient with ASD and that such patients should undergo surgical repair of the defect.
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Forfang K, Simonsen S, Andersen A, Efskind L. Atrial septal defect of secundum type in the middle-aged. Clinical results of surgery and correlations between symptoms and hemodynamics. Am Heart J 1977; 94:44-54. [PMID: 868742 DOI: 10.1016/s0002-8703(77)80342-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Nasrallah AT, Hall RJ, Garcia E, Leachman RD, Cooley DA. Surgical repair of atrial septal defect in patients over 60 years of age. Long-term results. Circulation 1976; 53:329-31. [PMID: 1245039 DOI: 10.1161/01.cir.53.2.329] [Citation(s) in RCA: 39] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
In order to evaluate results of surgical repair of secundum atrial septal defect (ASD) in patients 60 years of age or older, a review was made of 16 patients who had undergone such operation between January 1964 and December 1974. Before operation eight patients were in functional classification III (New York Heart Association), seven were in class II, and one was in class I. Twelve patients had a left-to-right shunt greater than 3:1. Pulmonary artery systolic pressure was greater than 40 mm Hg in 12 patients and greater than 60 mm Hg in five. Four patients had documented paradoxical emboli and were being treated with Coumadin. Before operation all patients but one were receiving digoxin. Repair was accomplished by direct suture in two patients and Dacron patch graft in 14. No deaths occurred during the postoperative period. Postoperatively, ten patients were in class I, five in class II, and one remained in class III. The hospital stay ranged from eight to 20 days (average 11 days). Two patients died one year and another (at the age of 77) five years after surgery. The remaining 13 patients are alive and well three months to 11 years after surgery. We conclude that repair of secundum ASD in patients over the age of 60 is safe, has low morbidity, and produces considerable clinical improvement.
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Smith DC, Vieweg WV, Folkerth TL, Hagan AD. Idiopathic hypertrophic subaortic stenosis with ostium secundum atrial septal defect: successful surgical correction. Chest 1975; 68:246-8. [PMID: 1171000 DOI: 10.1378/chest.68.2.246] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
The first report of coincident IHSS and ostium secundum ASD is corroborated and successful septal myotomy and myectomy with patch closure of the ASD is described.
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Clark DS, Hirsch HD, Tamer DM, Gelband H. Electrocardiographic changes following surgical treatment of congenital cardiac malformations. Prog Cardiovasc Dis 1975; 17:451-65. [PMID: 124901 DOI: 10.1016/s0033-0620(75)80004-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Amplatz K, Formanek A, Knight L, Tadavarthy SM, Gypser G, Bardach G. Radiographic changes in the postoperative patient. Prog Cardiovasc Dis 1975; 17:403-38. [PMID: 1144775 DOI: 10.1016/s0033-0620(75)80002-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Hairston P, Parker EF, Arrants JE, Bradham RR, Lee WH. The adult atrial septal defect: results of surgical repair. Ann Surg 1974; 179:799-804. [PMID: 4823852 PMCID: PMC1356079 DOI: 10.1097/00000658-197405000-00036] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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