Ann Thorac Surg 2004;77:2149-2150
© 2004 The Society of Thoracic Surgeons
Invited commentary
Volkmar Falk, MD, PhD,
Thomas Walther, MD, PhD
Department of Cardiac Surgery Heartcenter Leipzig Strümpellstrasse 39 Leipzig 04289, Germany
e-mail: falv{at}medizin.uni-leipzig.de
e-mail: walt{at}medizin.uni-leipzig.de
Transcatheter closure of atrial septal defects (ASD) has emerged as a reliable technique that is increasingly applied for closure of ostium secundum atrial septal defects and patent foramen ovale (PFO). It is widely regarded as the primary therapy for simple ASD morphologies and small defects. Device closure of an ASD yields good results, saves the patient from open heart surgery and is therefore most attractive to the patient.
It is important to remember that the shift from an established surgical therapy to interventional treatment occurred without randomized trials comparing the efficacy of both therapies. Based on the questionable logic that a less traumatic approach justifies an inferior functional result transcatheter closure of ASDs was readily accepted. While obvious benefits such as no need for an incision or anesthesia, a shorter hospitalization and avoidance of cardiopulmonary bypass favour a transcatheter over a surgical approach, the functional results are not completely satisfying. In a recent study, a primary procedural success rate of only 90.6% was reported [1]. In another series, 8% of the patients requried surgery for residual shunts due to malposition or dislocation of the device or severe vascular complications [2]. In this light the authors once more define the gold standard for the treatment of atrial septal defects—surgery [3]. With a tailored approach avoiding large incisions and the exclusive use of autologous pericardial patch repairs the authors demonstrate a 100% freedom from residual shunts. Most patients can be extubated in the OR and discharged within less than a week with a guaranteed functional result and no need for additional anticoagulant therapy or prophylaxis against endocarditis. The long-term results are excellent while evidence from long-term follow-up of patients with device closure of ASDs rarely exceeds a few years. Furthermore the surgical results are independent of the underlying morphology whereas sinus venosus defects, ostium primum defects and large defects with a deficient anterior rim are usually excluded from interventional treatment.
While the fast development of interventional technology has established device closure as the primary therapy of simple ASDs the surgical evolution continues. Interventional cardiologists have to be made aware of and compare their results to the current standard of surgical therapy that is provided in this paper by Hopkins: a 100% success rate independent of age, lesion size and morphology with minimal complications and short term hospitalization.
References
- Staniloae CS, El-Khally Z, Ibrahim R, Dore A, De Guise P, Mercier LA. Percutaneous closure of secundum atrial septal defect in adults a single center experience with the amplatzer septal occluder. J Invasive Cardiol 2003;15:393–7
- Berdat P.A., Chatterjee T., Pfammatter J.P., Windecker S., Meier B., Carrel T. Surgical management of complications after transcatheter closure of an atrial septal defect or patent foramen ovale. Thorac Cardiovasc Surg 2000;120:1034-1039.
- Hopkins R.A., Bert A.A., Buchholz B., Guarino K., Meyers M. Surgical patch closure of atrial septal defects. Ann Thorac Surg 2004;77:2144-2150.[Abstract/Free Full Text]
