Abstract
Background
Atrial septal defects (ASD) often go unrecognized until very late in life. The impact of ASD closure on life expectancy in elderly patients remains unclear. This study compares the survival of patients≥65-years who underwent ASD closure with their average life expectancy (ALE).
Methods
Single-centre retrospective study including all patients ≥65-years who underwent ostium secundum (OS) ASD closure (surgical/percutaneous) between 1998-2020. Baseline characteristics and the predicted peri-procedural ALE (as determined per pre-defined national ALE tables) for every given patient were assessed.
Results
706 patients underwent OS ASD closure, 37 (5%) had ≥65 years–mean age 69±5 years, 62% presented with heart failure. Mean ASD size=21±9mm, 22% patients had severe tricuspid regurgitation, mean systolic pulmonary artery pressure (SPAP)=50±11mmHg. Five patients were treated surgically. At a mean follow-up of 9±5 years, mortality rate was 46%, occurring 8.8±5.3 years after the procedure. 25 (68%) outlived their predicted ALE. Overall, the mean age of death did not differ from the predicted ALE (79±6 vs. 84±1 years, p=0.304), however there was a 10-year absolute difference between patients who died prematurely vs. those who surpassed ALE (77±4 vs. 87±3 years, p<0.001). Patients who failed to reach ALE had higher SPAP (58±10 vs. 46±8mmHg, p=0.001) and a higher incidence of severe tricuspid regurgitation (42 vs. 12%, p=0.040).
Conclusion
Survival after late ASD closure was comparable to the expected ALE, though one-third of the patients died prematurely. Higher SPAP and severe tricuspid regurgitation were associated with premature death. ASD closure in elderly requires a thorough evaluation to ensure maximum benefit.
Graphical abstract
Introduction
Atrial septal defect (ASD) is the second most common congenital cardiac anomaly in adults, accounting for about 8–10% of all congenital heart defects, and may pass unrecognized until the 6th or 7th decade of life The most prevalent type of atrial defect is the ostium secundum ASD (OS ASD). In elderly ASDs commonly present with atrial fibrillation and heart failure OS ASD patients also carry an increased risk of pulmonary arterial hypertension (PAH) and paradoxical systemic embolism.
Long-term exposure to chronic volume overload due to left-right shunt leads to right chambers dilation and an increase in pulmonary artery pressure, with ASD closure being recommended, irrespective of symptoms, if haemodynamically significant (i.e., pulmonary/systemic flow [Qp:Qs] ratio >1.5 or right chambers dilation) or in the presence of paradoxical embolism. , Early-life surgical or percutaneous repair results in excellent long-term outcomes, whereas results appear less favourable when intervention is delayed until adulthood
Some reports showed that OS ASD in the elderly is associated with symptomatic relief, reduced risk of PAH and remodelling of the right heart chambers in the short term, , however, the effect on survival remains uncertain.
We aimed to assess survival after OS ASD closure (surgical or percutaneous) and to compare it to the individual average life expectancy (ALE) at the time of closure, in a cohort of patients older than 65 years.
Methods
Study design and population
This is a retrospective study including all consecutive patients older than 65 years who underwent surgical or percutaneous OS ASD closure, at a single tertiary centre between January 1998 and December 2020.
Only symptomatic patients or hemodynamically significant isolated OS ASD (defined by the presence of right heart dilatation and/or Qp:Qs ratio > 1.5 OS ASD) were included in the analysis. Percutaneous closure was performed in patients with an ASD smaller than 40 mm in diameter and adequate rims (>5 mm in length, except for the anterior superior rim). Surgery was performed in patients unsuitable for percutaneous closure, with multi-fenestrated ASD and/or with insufficient rims, or with intended tricuspid valve surgical intervention Patients with other types of ASD and concomitant congenital defects were excluded from the analysis.
Patients were further divided into two groups: 1) those who reached the ALE after closure, and 2) those who did not reach the ALE (i.e., died before their expected ALE at the time of OS ASD closure); with the purpose of finding predictors of premature death.
Data collection and average life expectancy determination
Baseline characteristics (demographic, clinical, imaging, and procedural-related) were retrospectively collected in the institutional information systems. The predicted ALE (according to the national ALE table [ine.pt]) at the time of the ASD closure was determined to each individual patient.
Echocardiographic study
All patients underwent a comprehensive transthoracic echocardiogram and transesophageal echocardiogram (TEE) by experienced cardiologists before ASD closure, using various commercially available ultrasound systems, with a 2D or 3D probe, in accordance with guidelines at the time. , The ASD size refers to the maximum diameter measured using either a baseline TEE study (2D images) or an intraprocedural TEE/intracardiac echocardiography study. Tricuspid regurgitation was quantified qualitatively according to colour Doppler acquisitions as mild, moderate and severe. Echocardiographic data were collected retrospectively after analysing available reports.
Procedure related variables
Percutaneous closure
All patients that underwent percutaneous ASD closure had echocardiogram guidance with TEE or intracardiac echocardiography. Baseline hemodynamic assessments were conducted for each patient, before closure. Ballon sizing with a 24 mm or 34 mm balloon (AGA medical Corp., Golden Valley, MN, USA) was performed using the “stop-flow” technique without overstretching. The device size was similar to or up to 2 mm above the stretched diameter. Various types of ASD occluders were employed. A gentle “Minnesota wiggle” procedure was performed before device deployment to assure its stability. After the procedure, patients received dual antiplatelet therapy (usually aspirin 100 mg OD and clopidogrel 75mg OD) for one month followed by at least an additional 5 months of single antiplatelet therapy (usually aspirin), if not on anticoagulation therapy. If the patient was on anticoagulation, aspirin or clopidogrel was used for 1 to 6 months, according to patient’s bleeding risk and physician’s discretion.
Surgical closure
Surgical techniques included ASD closure using an autologous pericardial patch, with concomitant tricuspid valve repair if there was significant tricuspid regurgitation with a dilated tricuspid ring. Anticoagulation was maintained when clinically indicated (e.g., atrial arrhythmias).
Follow-up
Available clinical and imaging information was retrospectively collected, as well as potential complications and residual shunt. Residual shunt was classified according to the colour jet width as trace <1 mm, small >1 mm and <2 mm, moderate >2 mm and <4 mm, and large if >4 mm The occurrence of complications such as significant bleeding (defined as haemoglobin fall greater than 2g/dL), femoral artery pseudoaneurysm, erosion, device embolization or residual shunt were collected from medical records.
Statistical analysis
Categorical variables were reported as numbers and percentages, and continuous variables as mean ± standard deviations (normal distribution), or as median and interquartile range for variables with skewed distributions. Normal distribution was checked using Shapiro-Wilk test or skewness and kurtosis, as appropriate. Clinical characteristics of the subgroups of interest were compared using the χ2-test and Fisher’s exact test (when applicable) for dichotomous variables; and the student’s t-test or Mann-Whitney U test (when applicable) for continuous variables. Categorical variables were compared by two-tailed χ-square. A two-sided p-value <0.05 was considered statistically significant. The statistical analysis was performed with IBM SPSS Statistics 26.0 (IBM Corp, Armonk, NY, USA).
Results
Baseline patient´s characteristics
During the study period, 706 consecutive patients underwent isolated OS ASD closure (177 surgically and 529 percutaneously) at our centre. A total of 37 (5.2%) patients had ≥ 65 years ( Fig. 1 ), 28 (76%) were females and the mean age at the time of ASD closure was 69±5 years ( Table 1 ). There was no difference regarding age of closure between groups, nor average ALE ( Table 1 ). Most patients (n=27, 73%) presented with NYHA functional class ≥ II and 19 (51%) had atrial fibrillation. The mean ASD size, as measured by TEE, was 21±9mm, the mean SPAP was 50±11mmHg, 21 (57%) patients had moderate or severe tricuspid regurgitation, and 2 (5%) had right ventricle (RV) systolic dysfunction (tricuspid annular plane systolic excursion [TAPSE] < 17mm) ( Table 2 ).
| Overall population | Group 1: Patients who reached predicted ALE | Group 2: Patients who didn´t reach predicted ALE | p-value | ||
|---|---|---|---|---|---|
| Number of patients, n (%) | 37 (100.0) | 25 (67.6) | 12 (32.4) | ||
| Age of closure, years (mean±SD) | 69.3±4.5 | 69.8±4.6 | 68.3±4.1 | 0.356 | |
| Death, n (%) | 17 (45.9) | 5 (20.0) | 12 (100.0) | 0.001 | |
| Age of death, years (mean±SD) | 79.4±5.8 | 86.5±2.6 | 76.8±4.2 | 0.001 | |
| Predicted ALE, years (mean±SD) | 15.3±3.6 | 14.5±3.6 | 16.1±3.6 | 0.204 | |
| Time from closure to death, years (mean±SD) | 9.4±4.8 | 11.4±3.8 (n=5) | 7.6±5.4 | 0.138 | |
| Percutaneous closure, n (%) | 32 (86.5) | 20 (80.0) | 12 (100.0) | 0.096 | |
| Male sex, n (%) | 9 (24.0) | 8 (32.0) | 1 (8.3) | 0.116 | |
| Hypertension, n (%) | 20 (54.0) | 14 (56.0) | 6 (50.0) | 0.732 | |
| Diabetes mellitus, n (%) | 5 (13.5) | 5 (20.0) | 0 (0.0) | N/A | |
| Current smoker, n (%) | 5 (13.5) | 5 (20.0) | 0 (0.0) | N/A | |
| AF/AFL, n (%) | 19 (51.3) | 11 (44.0) | 8 (66.6) | 0.408 | |
| Chronic disease*, n (%) | 3 (8.1) | 2 (8.0) | 1 (8.3) | 0.218 | |
| Clinical Presentation | |||||
| Ischemic stroke, n (%) | 5 (13.5) | 4 (16.0) | 1 (8.3) | 0.523 | |
| Pulmonary thromboembolism, n (%) | 1 (2.7) | 0 (0.0) | 1 (8.3) | 0.143 | |
| Heart Failure, n (%) | 27 (72.9) | 16 (64.0) | 11 (91.7) | 0.066 | |
| NYHA Class, n (%) | I | 10 (27.0) | 9 (36.0) | 1 (8.3) | 0.178 |
| II | 21 (56.7) | 13 (52.0) | 8 (66.6) | ||
| III | (16.2) | 3 (12.0) | 3 (25.0) | ||
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
