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Ann Thorac Surg 1996;62:1096-1099
© 1996 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Surgical Treatment of Isolated Secundum Atrial Septal Defect in Patients More Than 50 Years Old

Department of Cardiovascular Surgery, Akita University School of Medicine, Akita, Japan

Accepted for publication April 25, 1996.

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Background. Arrhythmia-related thromboembolic accidents continue to occur in patients even after closure of secundum atrial septal defect. Older age is usually not a contraindication to the repair of an atrial septal defect. To assess the importance of the type of management in elderly patients with atrial septal defect our clinical experience is reviewed.

Methods. Between 1974 and 1994, 49 patients 50 years of age or older (average, 57.4 years) underwent surgical closure of secundum atrial septal defect. All patients have been followed up for 2 to 21 years (mean, 9.7 years).

Results. There were no operative deaths. Functional classes in most of the patients were improved after operation. There were two cerebrovascular thromboembolic accidents with one permanent neurologic dysfunction, hemiparesis, and one septal dehiscence in the early postoperative period. One patient (2%) died of renal failure 6 years after operation, late arrhythmias developed in 3 patients (6%), 3 patients had a late stroke (6%), and 1 patient was not available for follow-up.

Conclusions. Long-term operative results are satisfactory and beneficial to the quality of life in elderly patients. Because there is no safe and effective nonsurgical alternative to surgical closure, atrial septal defect repair in elderly patients without severe pulmonary vascular disease should not be delayed once the diagnosis had been made.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Surgical closure of isolated secondary type atrial septal defect (ASD) has become a safe procedure, with minimal risk of mortality or serious morbidity [1] in younger patients. Operative indication and curability are still controversial concerning the elderly patients with ASD [2]. The objectives of surgical closure of an ASD are the reversal of hemodynamic abnormalities and the prevention of complications, including heart failure and irreversible pulmonary vascular obstructive changes [3], leading to improvement of symptoms. The majority of the elderly patients already have symptoms of congestive heart failure [4], and the frequency of atrial fibrillation or tricuspid regurgitation (TR) increases with age. As a consequence of these complications, postoperative New York Heart Association (NYHA) functional class remains in II or more in many patients [5]. We present the results of early and late postoperative follow-up of 2 to 21 years after the closure of an ASD in elderly patients, giving special attention to the long-term results of cardiac rhythm at operation, pulmonary artery pressure, and prophylactic care for postoperative thromboembolism.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Forty-nine patients more than 50 years of age (range, 50 to 73 years, with an average age of 57.4 years) with ASD underwent direct suture closure or Dacron patch (USCI Sauvage Filamentous, Billerica, MA) closure during the period between October 1974 and February 1994 at Akita University Hospital. In addition to the primary ASD closure, 13 patients underwent either DeVega (n = 5) or Kay (n = 8) tricuspid annuloplasty (TAP) for TR. Patients having a partial anomalous pulmonary venous connection, or a partial form of persistent atrioventricular canal were excluded from this study. Patients with pulmonary hypertension (PH) were included in this study. Pulmonary hypertension was defined in three categories: severe PH = pulmonary systemic blood pressure ratio (Pp/Ps) more than 0.75, n = 1 (2%); moderate PH = 0.5 < Pp/Ps < 0.75, n = 4 (8%); mild PH = 0.25 < Pp/Ps < 0.5, n = 29 (59%); normal pulmonary artery pressure is Pp/Ps less than 0.25, n = 15 (31%). There were 29 women and 20 men with an age range at operation of 50 to 73 years (mean, 57.4 years). Electrocardiogram, chest roentgenogram, echocardiographic findings, NYHA functional class evaluation were obtained 1 week before operation. Preoperative NYHA functional classes were 7 patients (15%) in class I, 25 (51%) in class II, 14 (29%) in class III, and 3 (6%) in class IV. All patients were operated on through median sternotomy under cardiac arrest and complete extracorporeal circulation. Direct suture closure (26 patients) or Dacron patch closure (23 patients) of the ASD were performed. To prevent thromboembolic complications, in last 16 patients (since May 1989) anticoagulation therapy was started immediately after the removal of thoracic drainage tubes. Concomitant disorders were Gilbert syndrome in 1 patient, idiopathic thrombocytopenic purpura in 1 patient, and moderate to severe TR in 20 patients. After intraoperative examination 13 of 20 patients with TR were considered to undergo TAP simultaneously with ASD repair. Early postoperative evaluation was done 1 month after operation. Later all patients, except 1 (lost to follow-up) were followed up for 2 to 21 years (mean, 9.6 years) by questionnaire or telephone interview with the patient or the referring physician or both.

Statistical Analysis
Clinical data were collected retrospectively. All data were presented as mean ± standard deviations of the mean. Values were compared by means of Student's paired or unpaired t test. A p value less than 0.05 was accepted as statistically significant.

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Early Follow-up
All 49 patients survived the operation. To evaluate the advantage of surgical treatment on clinical improvement of ASD closure, we compared cardiac catheterization data, cardiothoracic ratio value (ratio of the transverse diameter of the heart to the internal diameter of the chest at the level of the highest point on the right hemidiaphragm), NYHA functional class, and electrocardiogram of all patients before and after operation. Postoperative NYHA class showed improvement in most of the patients; 31 (63%) in class I, 16 (33%) in class II, and 2 (4%) in class III. The most of the postoperative classes II and III patients (13 of 18 patients) were in atrial fibrillation (AF). Four of 25 patients in class II and 1 of 14 in class III showed no improvement after operation. Except these 5 patients and 7 in class I before operation, 37 of 49 patients (76%) showed substantial improvement of NYHA functional class after operation (Figs 1 and 2). Most of them were in sinus rhythm before operation.

View larger version (52K): [in this window] [in a new window]   Fig 1. . Early and late postoperative New York Heart Association functional class changes after atrial septal defect repair in elderly patients.

View larger version (29K): [in this window] [in a new window]   Fig 2. . Early and late postoperative electrocardiographic changes. (AF = patients with atrial fibrillation; SR = patients with normal sinus rhythm.)

Preoperative echocardiography revealed moderate or severe TR in 20 patients. The TR was undetectable or trivial in 24 patients. On the basis of water competent test of the tricuspid valve of these 20 patients (with moderate or severe TR) during cardiac arrest, TAP (DeVega or Kay) was performed only in 13 patients. Patients with TAP with DeVega's or Kay's method did equally well during the follow-up period. The TR was considered trivial or overestimated in the remaining 7 patients and TAP was not done in these patients. The TAP with ASD repair resulted substantial improvement of cardiothoracic ratio value in patients with preoperative AF (Fig 3).

View larger version (20K): [in this window] [in a new window]   Fig 3. . Changes in cardiothoracic ratio (CTR) value in different groups of patients (TAP(-)-SR = patients without tricuspid annuloplasty [TAP] and with sinus rhythm [SR]; TAP(-)-AF = patients without TAP and with atrial fibrillation [AF]; TAP(+)-SR = patients with TAP and SR; TAP(+)-AF = patients with TAP and AF). Notice that despite remarkable improvement, the cardiothoracic ratio value still remains higher in patients with preoperative atrial fibrillation.

One patient with a primarily closed ASD underwent reoperation for septal dehiscence diagnosed by echocardiography in the early postoperative period. The reason of dehiscence was thought to be the friability of the septum as well as overdistention of the heart at the time of weaning from cardiopulmonary bypass. No more septal dehiscence was diagnosed in our series of patients in the late postoperative period.

Late Follow-up
Forty-eight patients were followed up for 2 to 21 years (mean, 9.6 years) and 1 patient was not available for follow-up (Table 1). One patient with AF without anticoagulant therapy operated on before May 1989 died of renal failure complicated with disseminated intravascular coagulopathy and respiratory failure 6 years after operation at another hospital. Thromboembolism of the renal artery had not been ruled out in this patient. Thirty-two patients are in NYHA functional class I, 14 in class II, and 1 in class III (Fig 1). Two patients had a transient ischemic attack.

Three patients with bradycardia and AF necessitated pacemaker implantation. These 3 patients had preoperative TR, and underwent TAP as well. Late arrhythmias developed in 3 patients, with conversion to AF from sinus rhythm, and 4 patients had resolution of their preoperative arrhythmias.

Mitral valve regurgitation was detected in 2 patients during late follow-up period. Mitral regurgitation, caused by prolapse of anterior leaflet was detected in 1 patient, 2 years after operation and mitral valve replacement was performed 11 years after the initial operation. One patient is waiting for mitral valve replacement.

Other operations for gastric ulcer, breast cancer, and colon cancer were performed in 3 patients during the late follow-up period.

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
The controversy concerning the management of elderly patients with ASD is becoming largely resolved, and at present older age is not a contradiction to repair of an ASD [2, 6–11]. As there was only one late death related to a noncardiac event among our 49 elderly patients, our overall late results compared favorably with others [4, 6, 8]. Almost all elderly patients with ASD in our series had symptoms of congestive heart failure at the time of operation. A few asymptomatic elderly patients were operated on as well as the symptomatic patients. Because the frequency of AF becomes higher with age [2, 4, 8, 10, 11], from our study it is clear that a patient with ASD should be operated on although he or she is still asymptomatic.

Although the precise mechanism is unknown, as the electrophysiologic studies were not performed, in our series 20 of 24 patients (83%) with AF had AF after operation, only 4 patients (17%) during the early follow-up period and 4 more patients (19%) during late follow-up period returned to sinus rhythm (Fig 2). Postoperative abolition of AF could be due to the relief of atrial distention, reducing the tendency for atrial ectopy and thus reducing the initiating mechanism of arrhythmias. Development of AF in patients after ASD closure could conceivably be related to the formation of ectopic focus at the region of surgical repair or scar. Because postoperative improvement of functional class was achieved in all patients after operation, especially with sinus rhythm, ASD closure should be performed before the occurrence of AF.

The associated incidence of TR increases with age. In this study, moderate or severe TR was detected in 28% of the more than 50-year-old and in 50% of the more than 60-year-old patients. Echocardiographic examination of the tricuspid valve sometimes has a tendency of overestimation. If preoperative study shows moderate or severe TR, intraoperative transesophageal echocardiography or water competent test is advisable to get the information about the indication of TAP. Reduction of the cardiothoracic ratio value and improvement of functional class in patients with AF showed the effectiveness of ASD closure with concomitant TAP.

Pulmonary hypertension is the serious complication that influences the prognosis of ASD. In general, severe PH is uncommon in ASD. But it develops between 20 and 40 years of age and may be rapidly progressive, leading to shunt reversal, disability, and death [12]. The incidence of PH in elderly patients has been reported as relatively low [13, 14], and in our patients, severe PH was rare; however, AF with or without TR was the main cause of heart failure and disability. It is difficult to predict in which patient with ASD pulmonary vascular disease will develop. Fiore and colleagues [8] reported that the operative outcome in their series of ASD patients older than 50 years was not influenced by the presence of PH in the absence of greatly increased vascular resistance. In our view, one should be cautious in deciding to operate on patients with PH, irrespective of their age.

Postoperative brain embolism is an important complication after repair of ASD, and a cause of prolonged hospitalization and long-term disability. This incidence is related to the age of the patient at the time of operation and the presence of AF [15]. After the evidence of postoperative brain embolism in elderly patients, we started the administration of warfarin and ticlopidine immediately after the removal of chest drains. Considering the postoperative thromboembolism, we prefer direct suture closure of ASD, if possible. In our practice, patch is generally used to close a large and apparently round-shaped defect. Regarding the patch, we do not have a specific choice as to whether the material is Dacron or autologous pericardium. Although Fiore and co-workers [8] do not recommend anticoagulation therapy after closure of ASD, in our opinion, anticoagulation therapy should be started immediately after the operation in all elderly patients, regardless of whether a patch has been used or primary surgical closure has been performed. It is appropriate that anticoagulation therapy should be continued prophylactically at least for several months after operation. If the patient has AF it should be continued indefinitely, as advised by others [3, 16].

In conclusion, to prevent the development of arrhythmia and congestive heart failure, closure of the secundum ASD in elderly patients should not be delayed after diagnosis. It is safe to continue an anticoagulation regimen in patients with sustained AF even after operation. Long-term operative results are satisfactory and beneficial to the quality of life in elderly patients. Because there is no safe and effective nonsurgical alternative to surgical closure, ASD repair in elderly patients without severe pulmonary vascular disease should not be delayed once the diagnosis has been made.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Address reprint requests to Dr Shibata, Department of Cardiovascular Surgery, Akita University School of Medicine, Akita 010, Japan.

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 

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