Surgical treatment for secundum atrial septal defects in patients >40 years old

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.

Improvement in Exercise Capacity in Asymptomatic and Mildly Symptomatic Adults After Atrial Septal Defect Percutaneous Closure

“…More recently, a randomized study to either medical treatment or surgical ASD closure for NYHA I or II patients Ͼ40 years old demonstrated that surgical closure decreased the occurrence of long-term major cardiovascular events, primarily because of a decrease in the incidence of recurrent pneumonia. 19 Our results confirm the limitations of clinical evaluation of functional class in a chronic disease. Rostagno et al 20 showed in his study of chronic heart failure patients that concordance between NYHA classification and levels of performance using cardiopulmonary exercise testing was Ͻ50%.…”

Evaluation of Exercise Capacity with Cardiopulmonary Exercise Testing and Type B Natriuretic Peptide Concentrations in Adult Patients with Patent Atrial Septal Defect

“…The ostium secundum type of atrial septal defect (ASD II) is the most common congenital heart defect diagnosed in adults and makes up 40% of acyanotic shunt heart disease in individuals over the age of 40 years [1,2,3]. Because of the mostly asymptomatic course of the disease, ASD sometimes goes unrecognized until the later decades of life [3,4,5].…”

“…Only 50% of the affected population survives until the age of 50 years and the annual mortality rate in persons older than 50 years reaches 6–7% [3, 4]. Over time the left-to-right atrial shunt increases and pulmonary pressure becomes higher, resulting in a right ventricular load increase [1, 6]. Debate on optimum ASD management in adulthood remains open.…”

“…Surgical risk increases with age; it is less than 1% when surgical repair is performed in children and 3% in adults after the age of 40 years [3, 4]. However, surgical closure of the defect performed even at an older age may decrease the risk of pulmonary hypertension [6] and prolong life [1, 3]. Patients with ASD II in the fourth and fifth decade of life usually find their exercise capacity satisfactory [5,7,8,9,10,11,12,13].…”

Is it worth closing the atrial septal defect in patients with insignificant shunt?

“…First of all, we can avoid complications of open heart surgery, which is absolutely crucial in the group of patient with insignificant shunt. Another benefit is avoidance of a surgical scar commonly called by psychologists a “scar of the human soul” and shorter hospitalization time [8, 9]. It allows even percutaneously, the closure of the ASD in the patients with insignificant shunt is controversial.…”