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ASD Closure in Older Adults
Abstract & Commentary
By Andrew J. Boyle, MD, PhD
Source: Humenberger M, et al. Beneﬁt of atrial septal defect closure in adults: Impact of age. Eur Heart J. 2011;32:553-560.
Atrial septal defects (asd) are the most frequent congenital heart defects. Closure of the defect (either surgically or percutaneously) is a Class 1 recommendation in the ACC/AHA guidelines for management of adults with congenital heart disease when there is right heart dilation. However, there are little data on the safety and effectiveness of percutaneous device closure of ASDs in older adults. Humenberger and colleagues present data on adult patients undergoing percutaneous device closure of secundum ASDs using the Amplatzer septal occluder (ASO) device. They excluded 20% of their patients from device closure because they had defects with a stretched balloon diameter > 36 mm or difficult defect morphology, and referred them for surgical closure instead. They also excluded patients with severe increases in pulmonary vascular resistance and high left atrial pressures that rose during balloon occlusion of the defect. Device closure was attempted in a large cohort of 237 patients and was successful in all but one. They divided the patients into three age ranges: < 40 years (n = 78), 40-60 years (n = 84), and > 60 years (n = 74), and followed them clinically and with serial echocardiography. All procedures were carried out under general anesthesia, with transesophageal (TEE) guidance. Aspirin was commenced pre-procedure and continued for 6 months.
Although the size of the ASD did not differ between age groups, increasing age was significantly associated with more symptoms, higher pulmonary artery (PA) systolic pressure, larger right ventricles, and higher prevalence of both tricuspid regurgitation and atrial fibrillation. Procedural success was achieved in 99.6%, and no major procedural complications occurred. At 3-month follow-up, 3% of patients had a small residual shunt and none had large residual shunts. Thrombus on the left atrial disc was detected in one patient with hematological malignancy 5 years after implantation, and this resulted in multiple peripheral emboli. There were 15 cases of new atrial fibrillation (6.3%); all were either medically or electrically converted to sinus rhythm. After ASD closure, RV size decreased from 41 ± 7, 43 ± 7, and 45 ± 6 mm to 32 ± 5, 34 ± 5, and 37 ± 5 mm for patients < 40 years, 40-60 years, and > 60 years, respectively (p < 0.0001). PAP decreased from 31 ± 7, 37 ± 10, and 53 ± 17 mmHg to 26 ± 5, 30 ± 6, and 43 ± 14 mmHg (p < 0.0001), respectively. In those older than age 60 years, the RV size and PA pressure were higher initially, and they remained higher after ASD closure. Residual pulmonary hypertension (PA systolic pressure > 40 mmHg) after ASD closure was noted in 0%, 6%, and 51% of patients < 40 years, 40-60 years, and > 60 years, respectively. Symptoms improved in all age groups, but the younger patients achieved asymptomatic status more frequently (97%, 89%, and 69% in patients < 40 years, 40-60 years, and > 60 years, respectively). The authors conclude that at any age, ASD closure is followed by symptomatic improvement and regression of PA pressure and RV size. However, the best outcome is achieved in patients with less functional impairment and less elevated PA pressure. They recommend ASD closure irrespective of symptoms early after diagnosis even in adults of advanced age.
This study adds to the growing body of evidence that percutaneous device closure of ASDs in older adults is safe and has salutary effects on symptoms, PA pressure, and RV size. Procedural success was high (99.6%) and no major procedural complications occurred. Importantly, thrombosis on the device was rare. Furthermore, it confirms that the incidence of new onset atrial fibrillation remains low (6% overall), but it should be noted that the incidence was higher in the older patients than the younger patients. This should help allay some of the fears of atrial arrhythmia in older patients receiving these devices.
It should be noted that this is an observational study, not a randomized trial, and does not compare percutaneous device closure with either medical or surgical management of ASDs. It confirms previous studies, and extends that safety and efficacy data in a larger cohort of older adults. All patients received the Amplatzer ASO device, which has an excellent safety record. These results may not be applicable to all ASD-closure devices (some of which have higher rates of thrombosis and/or inferior rates of defect closure). Furthermore, the authors excluded patients with irreversible elevations in pulmonary vascular resistance, and those in whom elevated left atrial pressure rose during test-occlusion of the defect. These patients would be at higher risk of peri-procedural complications. Their results should not be extrapolated to these higher-risk patients. The better results seen in the younger patients who had less elevation of PA pressure and less RV dilation suggest that closure of the defect earlier rather than later may lead to even better outcomes. One could speculate that we need not even wait for right heart dilation, and should just close ASDs as soon as they are discovered, but this treatment strategy remains to be tested in prospective randomized trials.
Financial Disclosure: Clinical Cardiology Alert's Editor, Michael H. Crawford, MD, is a speaker for Astra-Zenica, and peer reviewer, Ethan Weiss, MD, reports no financial relationship relevant to this field of study. Managing Editor, Neill Kimball, and Executive Editor, Leslie Coplin, report no financial relationships relevant to this field of study.