Late Results of Atrial Septal Defect Donald J.
Magilligan, Jr, MD; Conrad
R.
Repair in Adults
Lam, MD; Joseph W. Lewis, Jr, MD; Julio C. Davila,
\s=b\ Repair of secundum atrial septal defects in 75 patients older than age 40 years was associated with a good long-term result, from five to 21 years postoperatively, in 89% of patients who were class I and II preoperatively and in 86% of those in normal sinus rhythm preoperatively. Functional class III or IV, atrial fibrillation, a higher pulmonary artery mean pressure and higher pulmonary vascular resistance affected the prognosis adversely. Repair of atrial septal defect in adults did not reverse existing atrial fibrillation and did not protect against the onset of new atrial fibrillation.
(Arch Surg 113:1245-1247, 1978) Atrial septal defect is the commonest form of congenital heart disease found in adults.1 Numerous reports attest to the fact that successful closure with low mortality can be accomplished in the older patient.-*3 It has been shown that with secundum atrial septal defects there is a rapid increase in the incidence of severe disability and death in patients older than the age of 40 years4*5 and, therefore, it has been recommended that all patients should have their defects closed even if they are asympto¬ matic." However, because some patients may survive to the eighth and ninth decades,7 and because some patients will not be helped by surgery, others have recommended a more selective approach to closure of secundum atrial septal defects in adults." To better assess which patients will be helped by surgery, we undertook this review of the longterm results of closure of atrial septal defect in adults. MATERIAL AND METHODS All patients 40 years of age or older who survived closure of an ostium secundum atrial septal defect were reviewed. The first operation took place in 1954, and only patients who underwent surgery from that date to 1973 were included so that there was at least a five-year follow-up. Current patient status was evaluated by personal history and physical examination, review of medical records, patient questionnaire, or telephone interview or letters to family or private physician. Follow-up was complete in all
patients.
Preoperative Clinical
Features
Seventy-five patients were available for review. There were 55 females and 20 males. Ages ranged from 40 to 61 years, and averaged 47 years. Preoperative functional classification (New York Heart Association) was as follows: class IV, two patients; class III, 17 patients; and classes I and II, 56 patients. Sixty Accepted for publication July 28, 1978. From the Division of Thoracic and Cardiac Surgery (Drs Magilligan, Lam, and Lewis), Henry Ford Hospital, Detroit, and the A. Ward Ford Memorial Institute (Dr Davila), Wausau Hospital North, Wausau, Wis. Presented at the 26th scientific meeting of the International Cardiovascular Society, Los Angeles, June 23, 1978. Reprint requests to Division of Thoracic and Cardiac Surgery, Henry Ford Hospital, Detroit, MI 48202 (Dr Magilligan).
MD
patients
were in normal sinus rhythm and 15 were in atrial fibrillation. Of the 15 patients in atrial fibrillation, nine were classes III and IV and six were class II (Table 1). Cardiac catheterization was performed in all patients. The mean pulmonary artery pressure ranged from 8 to 51 mm Hg and averaged 21.7 mm Hg. The mean pulmonary artery pressure was elevated (25 mm Hg or greater) in 21 patients, and of these, nine were classes III and IV and 12 were class II. The mean pulmonary artery pressure was considerably higher in patients with more severe symptoms (class III and IV) than in those with less severe symptoms (class I and II) (Table 1). The ratio of pulmonary to systemic flow (Q„/Q5) ranged from 1.0:1 to 7.8:1 and averaged 2.99:1. In some patients, data was incomplete and, therefore, pulmonary vascular resistance (PVR) was calculated in 62 patients. The PVR ranged from 30.5 to 672 dynes/s/cm- '· and averaged 88.7 dynes/s/cm". In those patients with severe symp¬ toms (class III and IV), the PVR was substantially elevated compared with the PVR in less symptomatic patients (class I and
II) (Table 1).
Surgery Sixty-two patients underwent repair using cardiopulmonary bypass. Forty of these 62 patients had the defect closed by direct suture and 22 using a prosthetic patch. Early in the series, 13 patients underwent repair by closed atrioseptopexy using the two-pointed needle described by Lam,9 In four patients operated on by closed technique, a recurrent defect developed requiring reoperation from eight to 11 years after the original surgery. Three were operated on using cardio¬ pulmonary bypass and are well from 20 to 21 years after the first operation and 12,13, and 14 years after the second operation. One underwent reoperation using the atrial well technique and died in the postoperative period 10 years and 7 months after the initial surgery.
POSTOPERATIVE RESULTS
There have been 17 deaths from eight months to 17 years postoperatively. Actuarial survival at five years was 88%; ten years was 74%; 15 years was 64%; and 20 years was 53% (Fig 1). The cause of death was due to congestive heart failure in 11 patients, suspected myocardial infarction in two, cancer in two, hepatitis in one, and suicide in one. As stated previously, one of the 13 cardiac deaths was in a patient who required a second operation for residual defect. Eleven of the 13 patients dying from cardiac causes never showed improvement after surgery. Six of the 11
restudied: five showed no defect and the one with a residual defect died after a second operation. The two patients who showed initial improvement after surgery followed by deterioration, died six and seven years postop¬ eratively of suspected myocardial infarction. There are 58 patients alive from five to 21 years at a mean follow-up of 13 years postoperatively. Fourteen are class 1,42 are class II, and two are class III. This represents were
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Table 1 .—Preoperative Clinical and Laboratory Features of Patients in Class III and IV Compared With Patients in Class I and II
80--
Class I and II: No Class III and IV: Severe Symptoms
or
Less Severe
Present series
Symptoms
No. of patients_19_56 9-47 Atrial fibrillation, % 6-17
Pulmonary artery mean
Natural
history
pressure, mm
Hg_26.68
Pulmonary
±
2.43 SE*
20.89
±
0.847 SE
77.75
±
6.72
vascular
resistance, dynes/ 5
s/cm
165.02
±
41.09
SEf
8 9 10 11 12 13 14 15 16 17 18 19 20 21
SE
*»P< .01.
tP
Magilligan, Jr, MD; Conrad
R.
Repair in Adults
Lam, MD; Joseph W. Lewis, Jr, MD; Julio C. Davila,
\s=b\ Repair of secundum atrial septal defects in 75 patients older than age 40 years was associated with a good long-term result, from five to 21 years postoperatively, in 89% of patients who were class I and II preoperatively and in 86% of those in normal sinus rhythm preoperatively. Functional class III or IV, atrial fibrillation, a higher pulmonary artery mean pressure and higher pulmonary vascular resistance affected the prognosis adversely. Repair of atrial septal defect in adults did not reverse existing atrial fibrillation and did not protect against the onset of new atrial fibrillation.
(Arch Surg 113:1245-1247, 1978) Atrial septal defect is the commonest form of congenital heart disease found in adults.1 Numerous reports attest to the fact that successful closure with low mortality can be accomplished in the older patient.-*3 It has been shown that with secundum atrial septal defects there is a rapid increase in the incidence of severe disability and death in patients older than the age of 40 years4*5 and, therefore, it has been recommended that all patients should have their defects closed even if they are asympto¬ matic." However, because some patients may survive to the eighth and ninth decades,7 and because some patients will not be helped by surgery, others have recommended a more selective approach to closure of secundum atrial septal defects in adults." To better assess which patients will be helped by surgery, we undertook this review of the longterm results of closure of atrial septal defect in adults. MATERIAL AND METHODS All patients 40 years of age or older who survived closure of an ostium secundum atrial septal defect were reviewed. The first operation took place in 1954, and only patients who underwent surgery from that date to 1973 were included so that there was at least a five-year follow-up. Current patient status was evaluated by personal history and physical examination, review of medical records, patient questionnaire, or telephone interview or letters to family or private physician. Follow-up was complete in all
patients.
Preoperative Clinical
Features
Seventy-five patients were available for review. There were 55 females and 20 males. Ages ranged from 40 to 61 years, and averaged 47 years. Preoperative functional classification (New York Heart Association) was as follows: class IV, two patients; class III, 17 patients; and classes I and II, 56 patients. Sixty Accepted for publication July 28, 1978. From the Division of Thoracic and Cardiac Surgery (Drs Magilligan, Lam, and Lewis), Henry Ford Hospital, Detroit, and the A. Ward Ford Memorial Institute (Dr Davila), Wausau Hospital North, Wausau, Wis. Presented at the 26th scientific meeting of the International Cardiovascular Society, Los Angeles, June 23, 1978. Reprint requests to Division of Thoracic and Cardiac Surgery, Henry Ford Hospital, Detroit, MI 48202 (Dr Magilligan).
MD
patients
were in normal sinus rhythm and 15 were in atrial fibrillation. Of the 15 patients in atrial fibrillation, nine were classes III and IV and six were class II (Table 1). Cardiac catheterization was performed in all patients. The mean pulmonary artery pressure ranged from 8 to 51 mm Hg and averaged 21.7 mm Hg. The mean pulmonary artery pressure was elevated (25 mm Hg or greater) in 21 patients, and of these, nine were classes III and IV and 12 were class II. The mean pulmonary artery pressure was considerably higher in patients with more severe symptoms (class III and IV) than in those with less severe symptoms (class I and II) (Table 1). The ratio of pulmonary to systemic flow (Q„/Q5) ranged from 1.0:1 to 7.8:1 and averaged 2.99:1. In some patients, data was incomplete and, therefore, pulmonary vascular resistance (PVR) was calculated in 62 patients. The PVR ranged from 30.5 to 672 dynes/s/cm- '· and averaged 88.7 dynes/s/cm". In those patients with severe symp¬ toms (class III and IV), the PVR was substantially elevated compared with the PVR in less symptomatic patients (class I and
II) (Table 1).
Surgery Sixty-two patients underwent repair using cardiopulmonary bypass. Forty of these 62 patients had the defect closed by direct suture and 22 using a prosthetic patch. Early in the series, 13 patients underwent repair by closed atrioseptopexy using the two-pointed needle described by Lam,9 In four patients operated on by closed technique, a recurrent defect developed requiring reoperation from eight to 11 years after the original surgery. Three were operated on using cardio¬ pulmonary bypass and are well from 20 to 21 years after the first operation and 12,13, and 14 years after the second operation. One underwent reoperation using the atrial well technique and died in the postoperative period 10 years and 7 months after the initial surgery.
POSTOPERATIVE RESULTS
There have been 17 deaths from eight months to 17 years postoperatively. Actuarial survival at five years was 88%; ten years was 74%; 15 years was 64%; and 20 years was 53% (Fig 1). The cause of death was due to congestive heart failure in 11 patients, suspected myocardial infarction in two, cancer in two, hepatitis in one, and suicide in one. As stated previously, one of the 13 cardiac deaths was in a patient who required a second operation for residual defect. Eleven of the 13 patients dying from cardiac causes never showed improvement after surgery. Six of the 11
restudied: five showed no defect and the one with a residual defect died after a second operation. The two patients who showed initial improvement after surgery followed by deterioration, died six and seven years postop¬ eratively of suspected myocardial infarction. There are 58 patients alive from five to 21 years at a mean follow-up of 13 years postoperatively. Fourteen are class 1,42 are class II, and two are class III. This represents were
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/29/2015
Table 1 .—Preoperative Clinical and Laboratory Features of Patients in Class III and IV Compared With Patients in Class I and II
80--
Class I and II: No Class III and IV: Severe Symptoms
or
Less Severe
Present series
Symptoms
No. of patients_19_56 9-47 Atrial fibrillation, % 6-17
Pulmonary artery mean
Natural
history
pressure, mm
Hg_26.68
Pulmonary
±
2.43 SE*
20.89
±
0.847 SE
77.75
±
6.72
vascular
resistance, dynes/ 5
s/cm
165.02
±
41.09
SEf
8 9 10 11 12 13 14 15 16 17 18 19 20 21
SE
*»P< .01.
tP
