Atrial septal defect, ventricular septal defect (VSD), and atrioventricular septal defect (AVSD) are among the most common congenital heart lesions, with most children surviving to adulthood. However, the clinical course of these patients is largely unknown, particularly pertaining to inpatient care. The purpose of this study was to assess hospitalizations for septal defects in adults with congenital heart disease (CHD) and risk factors associated with significant morbidity and mortality. The 2007 Nationwide Inpatient Sample was used to assess national prevalence of hospitalizations in adults with CHD with septal defects. Co-morbidities and risk factors for mortality were also determined. There were 84,308 adult CHD admissions in the United States in 2007. Fifty-four percent of adult CHD admissions had diagnoses of septal defects, with 48% having atrial septal defect, 7% having VSD, and 0.4% having AVSD. Overall in-hospital mortality was 2.1%. Common co-morbidities included arrhythmias (31%), heart failure (20%), and diabetes mellitus (18%). On multivariable analysis, independent risk factors for mortality included presence of VSD (odds ratio 3.1, 95% confidence interval [CI] 1.5 to 6.5), trisomy 21 (odds ratio 2.9, 95% CI 1.1 to 7.5), and pulmonary hypertension (odds ratio 1.5, 95% CI 1.0 to 2.4). In conclusion, this study of hospitalizations in adults with septal defects found that admissions are common and associated with significant co-morbidities. Overall mortality is low but is increased in patients with VSD. Cardiac and noncardiac co-morbidities are commonly encountered. Many noncardiac conditions, including trisomy 21 and the youngest and oldest groups, are associated with an increased risk of death.
In the pediatric population, cardiac septal defects are a common group of congenital heart defects including atrial septal defect (ASD), ventricular septal defect (VSD), and atrioventricular septal defect (AVSD). As reported by Marelli et al in 2007, prevalences of septal defects in the entire adult population in Quebec in 2000 were 0.88 per 1,000 for ASD, 0.78 per 1,000 for VSD, and unspecified defects of septal closure in 0.03 per 1,000 adults. Data regarding admissions in adults with congenital heart disease (CHD) with septal defects are limited. The purpose of this study was to identify nationwide rates of hospitalization for adults with septal defects and factors associated with morbidity and mortality in this cohort.
Methods
To assess the national prevalence of hospitalizations in adults with CHD with septal defects, a database representative of all nationwide hospital admissions was used to estimate adult CHD hospitalizations. Risk factors for mortality were evaluated including presence of arrhythmias, older age, renal impairment, sepsis, hepatic impairment, stroke, and nonoperative intubation (insertion of an artificial airway outside the confines of an operating suite).
Data were obtained using discharge data from the 2007 Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. The NIS is the largest all-payer inpatient care database in the United States, containing data from approximately 8 million hospital stays each year. The 2007 NIS contains all discharge data from 1,044 hospitals located in 40 states approximating a 20% stratified sample of United States community hospitals. The sampling frame for the 2007 NIS is a sample of hospitals that includes approximately 90% of all hospital discharges in the United States. This estimates data for >39 million hospitalizations. The NIS includes data for patients covered by Medicare, Medicaid, private insurance, and the uninsured. The large NIS sample enables analyses of rare conditions such as congenital anomalies, uncommon treatments such as organ transplantation, and special patient populations. The NIS can be weighted to produce national estimates.
Demographic information included age in years and gender. Septal defects, other cardiac diagnoses, noncardiac diagnoses, and procedures were defined by the International Classification of Disease, Ninth Revision codes listed in Table 1 . Primary outcomes were annual number of admissions for all adult CHD diagnoses and septal defects. The secondary outcome of interest was death during hospitalization.
| Septal defect codes | |
| Ostium primum atrial septal defect | 745.61 |
| Ostium secundum atrial septal defect | 745.5 |
| Ventricular septal defect | 745.4 |
| Endocardial cushion defect, unspecified type | 745.6 |
| Other endocardial cushion defect | 745.69 |
| Unspecified defect of septal closure | 745.9 |
| Noncongenital heart defect codes | |
| Heart failure | 398.91, 402, 404, 428 |
| Acute renal failure | 584 |
| Chronic renal failure | 585 |
| Cyanosis | 782.5 |
| Respiratory infections | 464, 466, 480, 481, 482, 483, 484, 485, 486, 487, 488, 513, 997.31 |
| Respiratory failure | 518 |
| Bacterial endocarditis | 421 |
| Coronary artery disease | 410, 411, 413, 414 |
| Acute myocardial infarction | 410 |
| Diabetes mellitus | 249, 250, 648.8 |
| Arrhythmias | 426, 427, 785.0 |
| Hepatic impairment | 570, 571, 572, 573 |
| Ischemic or hemorrhagic stroke | 430, 431, 432, 433, 434, 437, 438, 997 |
| Pulmonary hypertension | 416 |
| Sepsis | 995, 038, 545, 771, 790.7 |
| Procedures | |
| Cardiac catheterization | 00.66, 35.0, 35.5, 35.9, 36.0, 37.2, 88.5 |
| Electrophysiologic Study | 37.26 |
| Pacemaker or internal cardiac defibrillator implantation | 37.8, 37.9, 00.5 |
| Percutaneous coronary intervention | 00.66, 36.01, 36.02, 36.05, 36.06, 36.07 |
| Cardiac surgery | 35, 37, 38, 39 |
All analyses were conducted with SPSS 18.0 (SPSS, Inc., Chicago, Illinois) to account for the complex stratified survey design and clustering by hospital. Sample weights were used to produce annual national estimates according to the Healthcare Cost and Utilization Project “weight to discharge” parameter. Statistical analysis was as follows. For univariable analysis, a contingency table analysis was performed with results being expressed as odds ratios with 95% confidence intervals (CIs). All co-morbidities found to have a p value <0.1 were included in multivariable analysis. Multivariable analysis with logistic regression was performed to determine independent risk factors for mortality. Results were determined to be statistically significant with a p value <0.05.
Results
There were 84,308 adult CHD admissions in the NIS database in 2007 (95% CI 71,284 to 97,332). This constituted 0.3% of all adult admissions in the United States for 2007. Of the total number of adult CHD admissions, 54% had diagnoses of septal defects (45,797, 95% CI 38,139 to 53,456). ASDs accounted for 48% of adult CHD admissions, VSDs accounted for 7% of adult CHD admissions, and AVSDs accounted for 0.4% of all adult CHD admissions ( Table 2 ). Some co-morbidities were seen in this cohort, the most common being arrhythmias in 31%. Co-morbidities are presented in Table 3 . In addition, many procedures were performed as presented in Table 4 .
| Characteristic | Overall |
|---|---|
| Women | 25,356 (55%) |
| Length of stay (days) | 5.9 (5.6–6.1) |
| Age 18–30 years | 4,070 (9%) |
| Age 31–50 years | 11,927 (26%) |
| Age >50 years | 29,801 (65%) |
| Cardiac diagnoses ⁎ | |
| Atrial septal defect | 40,362 (33,489–47,234) |
| Age | 59.4 (58.6–60.2) |
| Ventricular septal defect | 5,592 (4,702–6,482) |
| Age | 46.9 (45.4–48.4) |
| Atrioventricular septal defect | 310 (207–413) |
| Age | 40.2 (36.4–44.0) |
| Unspecified defect of septal closure | 194 (120–267) |
| Age | 60.5 (54.4–66.5) |
| Total septal defects | 45,797 (38,139–53,456) |
| Age | 58.0 (57.2–58.8) |
| Arrhythmias ⁎ | 31% (14,147) |
| Atrial arrhythmias | 78% (10,960) |
| Ventricular arrhythmias | 9% (1,241) |
| Unspecified arrhythmias | 26% (3,627) |
| Heart failure | 20% (9,004) |
| Diabetes mellitus | 18% (8,267) |
| Stroke | 18% (8,228) |
| Pulmonary hypertension | 13% (5,948) |
| Pneumonia | 6% (2,830) |
| Acute renal failure | 6% (2,542) |
| Sepsis | 4% (1,653) |
| Respiratory failure | 5% (2,198) |
| Acute myocardial infarction | 4% (1,581) |
| Trisomy 21 | 2% (774) |
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