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Ann Thorac Surg 1996;61:657-659
© 1996 The Society of Thoracic Surgeons

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Original Article: Cardiovascular

Should Atrial Septal Defects in Adults Be Closed?

Royal Brompton Hospital, National Heart & Lung Institute, London, United Kingdom

Accepted for publication October 12, 1995.

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
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 postoperatively.

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.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Atrial septal defect is the third most common form of congenital heart disease in adults [1]. Presentation beyond childhood, although sometimes resulting from the development of symptoms, more often occurs unexpectedly during routine medical screening. It is certainly not easy to advise a patient without obvious symptoms to undergo an operation, especially when the defect has been present from birth. It has been argued that conservative treatment may well be best for such patients [2], as these defects can be compatible with a normal life span [3], and surgical closure inevitably carries a risk of death or morbidity [4], risks that increase with older age [5]. In addition, the risk of arrhythmias, a late sequelae of atrial septal defects, may be unchanged by late surgical repair [6]. This debate has been based by and large on natural history data and surgical results from a previous era [7]. The purpose of this study was to report the current surgical outcome for atrial septal defects in adult patients, assess the impact of closure on symptoms, and search for possible predictors of clinical outcome.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
The study group comprised all adult patients (age > 21 years) who underwent surgical repair of an isolated atrial septal defect by the same surgeon between June 1988 and June 1994. This period was selected both to reflect current surgical techniques and to allow a minimal length of follow-up of 6 months. Patients with atrioventricular septal defects were excluded from the study, whereas patients requiring additional repair of partial anomalous pulmonary venous drainage were included.

Hospital records were evaluated for preoperative and postoperative clinical, electrocardiographic, radiologic, and hemodynamic details. Postoperative cardiac catheterization data were not available, as there were no clinical indications for repeat invasive studies in these patients. Serial QRS duration measurements on surface electrocardiograms were made, and corresponding cardiothoracic ratios on posteroanterior chest radiographs were determined with a view to detecting any mechanoelectric interactions in this group of patients [8]. Electrocardiograms and chest radiographs obtained prior to operation, during the immediate postoperative period (within 1 week after operation), and at the first (within 3 to 6 months from operation) and last outpatient follow-up visits were analyzed by two investigators who had no knowledge of relevant clinical data. Surgical data were obtained from the surgical notes.

The current follow-up status of the patients was determined largely by written questionnaire. Particular emphasis was placed on exercise performance, arrhythmias, and other cardiovascular events (thromboembolism, stroke or transient ischemic attack, infective endocarditis). Patients were asked to grade (worse, no change, better, much better) any changes in exertional dyspnea and overall exercise performance compared with their preoperative condition.

Data are presented as the mean ± the standard deviation unless indicated otherwise. The Student t test was used to identify significant differences between preoperative and postoperative variables. Logistic regression analysis of variables to compare patients with and without symptomatic improvement after operation was also performed.

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Thirty-nine adult patients (15 men, 24 women) underwent surgical closure of an atrial septal defect because of symptoms (33 patients) or a significant left-to-right atrial shunt (6 patients) during the study period. Age ranged from 21 to 65 years (median age, 26 years; mean age, 35.2 ± 13.6 years).

Preoperative Data
Thirty-seven patients had a secundum atrial septal defect and 2, a superior sinus venosus type of defect. The diagnosis was established with echocardiography in 35 patients (transesophageal echocardiography in 9) and at cardiac catheterization in 4. Fifteen additional patients underwent cardiac catheterization mainly with a view to assessing pulmonary vascular resistance and excluding coexisting coronary artery disease.

Thirteen patients had moderate to severe elevation of pulmonary artery pressure (mean pressure range, 20 to 45 mm Hg; mean pressure, 26.9 ± 8.3 mm Hg), but none had a reversed atrial shunt. No patient had ischemic heart disease. In 2 patients, drainage of an upper right pulmonary vein into the superior caval vein necessitated a modified patch closure. On color Doppler echocardiography, 6 patients had mild to moderate tricuspid regurgitation and 1 patient, mild mitral regurgitation. Thirty-three patients had been symptomatic before operation (23 with exertional dyspnea, 16 with palpitations, 1 with syncope, 2 with paradoxical embolus, 1 with bacterial endocarditis). The 6 asymptomatic patients were referred for operation on the basis of a significant atrial shunt (pulmonary systemic flow ratio of greater than 1.5:1) with echocardiographic evidence of right heart volume loading.

Electrocardiographic and radiologic data are shown in Table 1. The incidence of preoperative atrial arrhythmias was 41%. Six of 7 patients older than 50 years had documented atrial fibrillation or flutter. Five of these patients had mild to moderate tricuspid regurgitation. We did not distinguish between paroxysmal and sustained arrhythmias.

Follow-up
All patients were alive and well at follow-up (range, 6 months to 6 years; mean time, 3.3 ± 2.2 years). Maximum QRS duration decreased significantly (p < 0.001) in the immediate postoperative period (within 1 week after operation), thus reflecting acute volume unloading of the right ventricle after atrial septal defect closure, and remained unchanged thereafter (see Table 1). In conjunction with this, the cardiothoracic ratio, which initially increased (presumably because of the effect of cardiopulmonary bypass), was also significantly lower (p < 0.001) 3 to 6 months after operation. None of the patients had a residual atrial shunt as judged by echocardiography.

Thirty-seven of the 39 patients replied to the written questionnaire; the remaining 2 were assessed at a recent outpatient clinic visit. Symptomatic improvement was recorded for 27 (81.8%) of the 33 symptomatic patients. The grades for exertional dyspnea were as follows: worse—0 patients; no change—2 patients; better—14 patients; and much better—7 patients. Three (50%) of the 6 previously asymptomatic patients reported improved functional capacity after operation. Regarding arrhythmias, 7 of the 16 patients with atrial arrhythmias prior to repair were still in atrial fibrillation or flutter at follow-up. In 4 of these 7 patients, tricuspid regurgitation persisted unchanged after surgical intervention. Nine patients (56.3%) converted to sinus rhythm with no further documented arrhythmias at a mean follow-up of 2.5 ± 2.4 years. The 23 patients in sinus rhythm before operation remained in sinus rhythm with no new arrhythmias at a mean follow-up of 2.85 ± 1.94 years.

Analysis of variables for comparison of patients with and without symptomatic improvement after operation failed to reveal any significant predictors or determinants of clinical outcome. No patient had late cardiovascular events such as thromboembolism, stroke, or transient ischemic attacks after repair.

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
It has been debated whether surgical intervention should be performed in adults with atrial septal defect [9]. Most would agree that in the young adult with symptoms and normal or nearly normal pulmonary vascular resistance, surgical closure is recommended for the same prophylactic reasons that apply to children. Potential complications during pregnancy may be an additional indication in young women. Currently controversy centers around the management of older patients who have a variable degree of elevated pulmonary artery pressure or younger patients with atrial septal defects who are asymptomatic at the time of diagnosis. This controversy has remained unresolved because it is based on natural history data and on comparison of patients treated medically versus those undergoing various surgical techniques from a previous era.

Although occasionally a patient with atrial septal defect may remain asymptomatic into older age [10], in our study as in other studies [11, 12], most patients become symptomatic much earlier. Most of our patients, the oldest of whom was 65 years, were seen by us for the first time when symptoms, usually shortness of breath, palpitations, or both, developed. It is also of interest that in half of the patients thought to be asymptomatic prior to operation, functional capacity clearly improved postoperatively. It may be that a number of patients with an atrial septal defect who have not had operation consider themselves asymptomatic simply because of long-term adaptation of their life-style to a subtle disability. The diagnosis was established with cross-sectional echocardiography, although early in the series, diagnostic cardiac catheterization was performed in a few patients. In the current era of transesophageal echocardiography, cardiac catheterization is reserved for patients older than 40 years to exclude coexisting ischemic heart disease or for patients with clinical evidence of pulmonary hypertension, the degree of which may be difficult to assess even with Doppler echocardiography.

The 0% mortality and the low morbidity in our series are particularly encouraging. Only 1 older patient with severe pulmonary hypertension required prolonged hospitalization. The patient with pulmonary embolism was not anticoagulated at the time. Since then, it has been our policy to anticoagulate for 3 months all patients requiring a patch repair, and probably as a result of that, we have not encountered further cases of systemic or pulmonary embolism.

The majority of symptomatic patients improved after surgical intervention. Ideally, formal exercise tests should be performed before and after operation, but the patient's personal assessment of exercise capacity indicates relative changes. Fifty-six percent of the patients with atrial arrhythmias converted to and maintained sinus rhythm without further arrhythmic events. There was a trend toward persistence of atrial tachyarrhythmias after operation in older patients as well as in patients with tricuspid regurgitation. Right atrial enlargement in the latter may remain after surgical intervention and explain the development or persistence of atrial arrhythmias. Whether early surgical closure of an atrial septal defect in patients with tricuspid regurgitation improves outcome in terms of arrhythmias remains speculative, however. None of the previously asymptomatic patients experienced symptoms during follow-up.

There were significant changes in the QRS duration on the electrocardiogram and in the cardiothoracic ratio from the chest radiograph, which were in keeping with the hemodynamic changes after surgical closure. Acute unloading of the right ventricle led to shortening of the QRS duration, whereas a similar effect on the cardiothoracic ratio was somewhat delayed, presumably because of the initial effects of cardiopulmonary bypass.

We were unable to identify predictors of clinical outcome, perhaps because of the relatively small number of patients in and the retrospective nature of our study. Nevertheless, we have shown that surgical intervention for atrial septal defects in adults can be performed with no mortality and low morbidity. Outcome was independent of pulmonary artery pressure in the presence of a left-to-right atrial shunt. In conclusion, today, operation for isolated atrial septal defect in the adult patient has a low risk and a high chance of symptomatic improvement. Long-term data are necessarily lacking, but we believe our data justify the conclusion that surgical treatment is currently the management of choice.

	Acknowledgments

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
We thank Professor Philip A. Poole-Wilson, Dr Anthony F. Rickards, Dr Kim M. Fox, and Dr Paul J. Oldershaw for allowing us to study their patients. We also thank Dr Jan A. Till for her helpful comments regarding the manuscript.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Address reprint requests to Dr Gatzoulis, Royal Brompton Hospital, National Heart & Lung Institute, Sydney St, London SW3 6NP, UK.

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 

1. Dickinson DF, Arnold R, Wilkinson JL. Congenital heart disease among 160,480 liveborn children in Liverpool 1960 to 1969: implications of surgical treatment. Br Heart J 1981;46:55–62.[Abstract/Free Full Text]
2. Shah D, Azhar M, Oakley CM, Cleland JGF, Nihoyannopoulos P. Natural history of secundum atrial septal defect in adults after medical or surgical treatment: a historical prospective study. Br Heart J 1994;71:224–8.[Abstract/Free Full Text]
3. Perloff JK. Ostium secundum atrial septal defect—survival for 87 and 94 years. Am J Cardiol 1984;53:388–9.[Medline]
4. Dave KS, Pakrashi BC, Wooler GH, Ionescu MI. Atrial septal defects in adults: clinical and hemodynamic results of surgery. Am J Cardiol 1973;31:7–13.[Medline]
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6. Murphy JG, Gersh BJ, McGoon MD, et al. Long-term outcome after surgical repair of isolated atrial septal defect. N Engl J Med 1990;323:1645–50.[Abstract]
7. Cambell M, Neil C, Suzman S. The prognosis of atrial septal defect. Br Med J 1957;1:1375–83.[Free Full Text]
8. Gatzoulis MA, Till J, Somerville J, Redington AN. Mechanoelectrical interaction in tetralogy of Fallot: QRS prolongation relates to right ventricular size and predicts malignant ventricular arrhythmias and sudden death. Circulation 1995;92:231–7.[Abstract/Free Full Text]
9. Ward C. Secundum atrial septal defect: routine surgical treatment is not of proven benefit. Br Heart J 1994;71:219–23.[Free Full Text]
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