Closure of ASD in adults

Benefit of Atrial Septal Defect Closure in Adults: Impact of Age
Humenberger M, Rosenhek R, Gabriel, et al.
Eur Heart J 2010;Oct 12:[Epub ahead of print].

Comments (3)Study Question:
What is the effect of age on the clinical benefit of atrial septal defect (ASD) closure in adults?
Methods:
A cohort of 236 patients undergoing transcatheter ASD closure at a single center was studied. Patients were divided into three groups based on age.
Group A included patients younger than age 40 (n = 78),
Group B included patients ages 40-60 (n = 84), and
Group C included patients older than 60 years (n = 74).
Pulmonary pressures, right ventricular size, and symptoms were assessed before and after device closure.

Results:
The mean age for the entire cohort was 49 ± 18 years. There was no difference in defect size (median 22 mm; interquartile range, 19-26 mm) or shunt ratio (Qp:Qs 2.2; interquartile range, 1.7-2.9). Pulmonary pressure and right ventricular size were significantly related to age. Right ventricular size (by two-dimensional echocardiogram measures) decreased in all groups. Post-procedure, the systolic pulmonary artery pressure (PAP) decreased from 31 ± 7 to 26 ± 5 mm Hg in group A, 37 ± 10 to 30 ± 6 mm Hg in group B, and 53 ± 17 to 43 ± 14 mm Hg in group C (p < 0.0001). Absolute changes in right ventricular size and PAP did not differ between the groups. Symptoms were present in 13%, 49%, and 83% of patients prior to the procedure, and 3%, 11%, and 34% of patients after the procedure in groups A, B, and C, respectively. Functional status was related to PAP.
Conclusions:
At any age, ASD closure is followed by symptomatic improvement, and decrease in right ventricular size and PAP.

Perspective:
Closure of ASD in adults of advancing age has long been an area of controversy in congenital cardiology. Most studies comparing defect closure with conservative management were done in the era of surgical closure and did not convincingly demonstrate a survival benefit. Most studies, including this one, demonstrate significant improvement in symptoms after closure of ASD. The impact on atrial arrhythmias is less clear. The minimal mortality and overall low complication rate of device closure make it an attractive option for older adults who may have multiple comorbidities. This study supports closure of ASDs in older adults, particularly for symptomatic relief. As patients with long-standing ASD may not appreciate their level of symptomatology, all patients with significant ASD should be strongly considered for device closure.
Author(s):
Timothy B. Cotts, M.D., F.A.C.C.