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Ann Thorac Surg 1999;68:75-78
© 1999 The Society of Thoracic Surgeons

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Original Articles

Incidence of atrial flutter/fibrillation in adults with atrial septal defect before and after surgery

^a Department of Congenital Heart Disease, Deutsches Herzzentrum Berlin, Berlin, Germany
^b Department of Cardiac Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany

Address reprint requests to Dr Vogel, Deutsches Herzzentrum, Augustenburger Platz 1, 13353 Berlin, Germany
e-mail: mvogel{at}dhzb.de

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. There is controversy about the benefit of surgical repair for atrial septal defect in adults, especially its effect on the incidence of supraventricular dysrhythmias, atrial flutter and fibrillation. We studied their incidence before and after operation.

Methods. We examined surface and 24-hour Holter electrocardiograms before, early (between 3 and 7 days), and late (more than 6 months) after operation, performed at age 42.2 years (range, 18.5 to 74.9 years), in 211 adults with atrial septal defect. Patients were arbitrarily divided into three groups: age 18 to 40 years (n = 101), age 40 to 60 years (n = 83), and age more than 60 years (n = 27). All consecutive patients operated on between January 1988 and December 1996 and having a pulmonary to systemic flow ratio of 1.5:1 or greater were included in this study.

Results. The age of patients without arrhythmias before or after atrial septal defect closure (39 ± 13 years) was significantly lower than that of patients with flutter (54 ± 12 years) or fibrillation (59 ± 8 years). The incidence of atrial flutter was influenced by surgical repair as atrial flutter converted to sinus rhythm late after operation in 10 of 18 patients. However, there was no change in the incidence of atrial fibrillation before (n = 28) and after (n = 21) operation.

Conclusions. Our data show that surgical correction of atrial septal defect leads to regression of the incidence of atrial flutter but not fibrillation. Thus, surgical repair of atrial septal defect to abolish supraventricular tachyarrhythmias in adults is warranted, but in patients with fibrillation, it may have to be combined with a Maze operation in the future.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Atrial septal defect is one of the most common congenital heart diseases in adults [1]. Presentation in adulthood occurs because of symptoms like dyspnea at rest or exercise or tachyarrhythmias, or it may occur unexpectedly during medical screening. Recently, there has been some debate in the literature about the benefit of closure of atrial septal defects in adulthood [2, 3]. Arguments for closure include prevention of pulmonary vascular disease, improvement of quality of life, and avoidance of arrhythmias [2, 4, 5]. It is unclear whether adult patients with atrial septal defect presenting with tachyarrhythmias benefit from surgical closure of atrial septal defect with regard to their rhythm disturbance [6, 7]. The purpose of this study was to examine the incidence of supraventricular tachyarrhythmias in adult patients with atrial septal defect before and after surgical treatment and the effect of surgery on the arrhythmias.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Between January 1988 and December 1996, 211 consecutive patients older than 18 years of age underwent surgical closure of an atrial septal defect at the Deutsches Herzzentrum, Berlin. Every consecutive adult patient with a preoperative pulmonary to systemic flow (Qp/Qs) ratio of 1.5:1 or more was included in this study on the basis that he or she had situs solitus, concordant atrioventricular and ventriculoarterial connections, and an atrial septal defect (n = 185) in the fossa ovalis (so-called secundum atrial septal defect) or a sinus venosus defect (n = 26), which was surgically closed by either a patch (n = 158) or direct suture (n = 53). Patients with a partial atrioventricular septal defect (so-called primum atrial septal defect) were excluded from this study, as well as any patient requiring reconstruction of an atrioventricular valve or any additional surgical procedures except for coronary artery bypass graft surgery, which was performed in 6 adult patients aged 60.7 years (range, 48 to 73 years) at the time of the closure of the atrial septal defect.

Preoperative and postoperative diagnostic investigations
Preoperative evaluation included standard 12-lead and at least one 24-hour Holter electrocardiogram. One hundred eighty-one of 211 patients underwent preoperative cardiac catheterization at our institution using standard fluid-filled catheters to assess pulmonary artery pressure and calculate shunt size. In all patients, a detailed history was taken. Postoperatively, all patients had temporary epicardial atrial and ventricular pacemaker wires put in, which were connected to an external pacemaker. These were removed on the third to seventh postoperative day. For the first three postoperative days, one standard 12-lead electrocardiogram was routinely performed each day and additionally during the days immediately after operation, if indicated. Before hospital discharge, at least one 24-hour Holter electrocardiogram was performed. All patients had at least another 24-hour Holter recording a minimum of 6 months after operation.

The preoperative Qp/Qs was 2.5 (range, 1.5 to 6.5). Mean pulmonary artery pressure was 19 ± 10 mm Hg (range 12 to 68 mm Hg); it was less than 20 mm Hg in 67%, between 20 and 30 mm Hg in 20%, and more than 30 mm Hg in 13%. One hundred sixty-seven patients (79%) were in New York Heart Association (NYHA) class 1 or 2, and 44 patients (21%) were in NYHA class 3 or 4 before surgical treatment (Table 1).

Statistical analysis
A McNemar test was performed to compare proportions of atrial flutter or fibrillation before, immediately after, and late after surgical closure of atrial septal defects and to compare NYHA functional class before and after surgical treatment of atrial septal defect. An unpaired Student’s t test was performed to compare the age of patients without atrial tachydysrhythmias with those with atrial flutter or fibrillation before operation. A simple regression analysis was calculated to perform a correlation between age and size of left-to-right shunt.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
There was a significant improvement (p = 0.001) in NYHA functional class after surgical closure of the atrial septal defect. There was 1% mortality with 2 deaths within 30 days of operation in patients aged 57 and 68 years. The 57-year-old patient with pulmonary hypertension (mean pulmonary artery pressure, 68 mm Hg) died of a pulmonary hypertensive crisis 8 hours after the operation. She was operated on because at the preceding cardiac catheterization she was found to respond to a combination of inhaled oxygen and intravenous prostacyclin with an increase in Qp/Qs from 1.8 to 2.5 and a fall in systolic pulmonary artery pressure from 125 to 75 mm Hg. One 65-year-old patient had coronary artery disease in addition to the atrial septal defect and a bypass graft on the right and left anterior descending coronary artery was performed. He died in low-output cardiac failure on the second day after the operation. There were two reoperations: one reoperation on the first postoperative day because of bleeding resulting in cardiac tamponade, and one on the 10th day in a patient with a significant residual shunt (Qp/Qs > 1.5:1) after operation, who was found to have an additional unroofed coronary sinus.

The mean age of the patients without any arrhythmias is 39 ± 13 years (range, 18 to 73 years), the mean age of those with atrial flutter before operation is significantly (p = 0.0001) higher at 54.1 ± 12 years (range, 21 to 75 years), and the mean age of those with atrial fibrillation is 59 ± 7.8 years (range, 44 to 71 years) (p = 0.0001 for comparison of preoperative sinus rhythm versus fibrillation). Thus, the incidence of flutter and fibrillation increases with age, but there is no difference (p = 0.09) between the age of patients presenting with flutter or fibrillation (Table 2).

There is a difference between patients with atrial flutter and those with atrial fibrillation (Table 2). In those with atrial flutter, the increase in the incidence of atrial flutter early after operation is significant (p = 0.01), as is the decrease at late follow-up compared with the incidence before operation (p = 0.04). Preoperative flutter could be converted to permanent sinus rhythm late after atrial septal defect repair in 10 of 18 patients. Treatment of atrial flutter in the immediate postoperative period included cardioversion (n = 16), antiarrhythmic drugs (Table 3), and overdrive pacing (n = 4). By contrast, in patients with atrial fibrillation, the difference between the incidence of fibrillation preoperatively and late postoperatively is not significant (p = 0.07). Two patients, one aged 48 years and one aged 61 years, required pacemaker implantation because of persistent bradycardiac junctional rhythm after electrical cardioversion of atrial fibrillation. One 50.5-year-old patient with sinus rhythm demonstrated a new atrial fibrillation after operation that persisted. All patients with persistent atrial flutter/fibrillation are receiving either warfarin or aspirin for anticoagulation therapy.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

Effects of flutter/fibrillation
The importance of atrial flutter and more so fibrillation lies in its association with stroke, which occurred in 4 of our patients before and in 1 after atrial septal defect closure. In a long-term follow-up study of surgically treated atrial septal defects, 22% of late deaths were caused by stroke, and all of these occurred in patients with atrial flutter/fibrillation [8]. Stroke also was the main cause of mortality in patients who had undergone surgical closure of their atrial septal defect at age older than 60 years [9]. Thus, in elderly patients with atrial septal defect, atrial fibrillation, if it persists, is responsible for major morbidity and mortality in the long-term follow-up after surgical correction [10–12].

Atrial flutter
Atrial flutter may occur in patients with atrial septal defect because of atrial dilatation, increased atrial pressure [6], and conduction disturbances [13]. The incidence of atrial flutter may regress after the reason for atrial dilatation, ie, the shunt, is abolished [5, 13]. Although return to normal atrial size after closure of an atrial septal defect in late adulthood is rare [5, 9], in our study the incidence of atrial flutter was reduced by surgical closure of the defect, and some patients experienced regression of atrial flutter even when their defect was closed in the sixth or seventh decade of life. This, to our knowledge, has not previously been reported. Previous studies have examined a possible relationship between other clinical variables and the prevalence of paroxysmal or chronic supraventricular tachyarrhythmias [7, 11, 12]. Interestingly, no significant correlation between the magnitude of the preoperative shunt size, and thus presumably right atrial dimension, and occurrence of atrial flutter was found [11]. In this study, we also did not find a correlation between the incidence of atrial flutter with the size, but rather with the duration of the left-to-right shunt. Some studies have found a correlation between the clinical condition of the patient as expressed using the NYHA classification and rhythm disturbances, which seem to be more frequent in patients with a worse clinical condition, ie, higher NYHA class [9]. However, the presence of a rhythm disturbance also influences clinical well-being and may determine the NYHA functional class of the patient. In our patient series, paroxysmal supraventricular tachycardia was the presenting symptom in 19% of adults. Our data could not confirm the findings of one smaller study, in which a correlation between pulmonary artery pressure and the incidence of atrial flutter/fibrillation was reported [12].

Atrial fibrillation
Atrial fibrillation can be caused by multiple circus movements [6] and may be maintained because of the large number of circuits with little chance of spontaneous organization or termination. As chronic atrial fibrillation leads to changes in the atrial myocardium [14], it is not surprising that atrial fibrillation persisted after surgical treatment of the atrial septal defect. Recently, a right-sided Maze procedure has been advocated in combination with atrial septal defect closure as an effective treatment of atrial fibrillation [15, 16]. Considering the data presented on the risks and benefits of an associated Maze procedure, a controlled study of a right-sided Maze procedure in adults with an atrial septal defect and atrial fibrillation seems warranted.

Limitations of this study
Inasmuch as we have elected to close all atrial septal defects with a Qp/Qs greater than 1.5:1, we do not have a (randomized) control group of patients, who were managed only medically. Thus, with this study we cannot determine whether medical management alone would have been as effective in reducing the incidence of atrial flutter or more effective in reducing the incidence of fibrillation in adult patients with atrial septal defects. In most of our patients, the follow-up time is not long enough to determine the late effects on the incidence of tachyarrhythmias years after surgical closure.

Because return to normal rhythm decreases the risk of developing stroke and may also lead to an improved quality of life, we conclude from these data that adult patients benefit from surgical closure of atrial septal defects. Presence of atrial flutter constitutes no contraindication to operation because the incidence of atrial flutter may regress, whereas the optimal management of patients with associated atrial fibrillation remains to be determined.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

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