Benefit of ASD closure in different age

groups

Wahid Syed, Majeed Dar, Hakeem

Zubair Ashraf, Ghulam Nabi Lone,
Shyam Singh, Farooq Ganie & Mudasir
Sidiq
Indian Journal of Thoracic and
Cardiovascular Surgery

ISSN 0970-9134

Indian J Thorac Cardiovasc Surg

DOI 10.1007/s12055-017-0527-9

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 Author's personal copy
Indian J Thorac Cardiovasc Surg
DOI 10.1007/s12055-017-0527-9
ORIGINAL ARTICLE
Benefit of ASD closure in different age groups
Wahid Syed 1 & Majeed Dar 1 & Hakeem Zubair Ashraf 1 & Ghulam Nabi Lone 1 &
Shyam Singh 1 & Farooq Ganie 1 & Mudasir Sidiq 1
Received: 17 October 2016 / Revised: 17 March 2017 / Accepted: 22 March 2017
# Indian Association of Cardiovascular-Thoracic Surgeons 2017
Abstract
Introduction Untreated atrial septal defect (ASD) leads to
various complications. These complications can be mod-
ified to a variable extent after closure of the defect, de-
pending upon the age at the time of closure. While some
patients get the total benefit of ASD closure, others are
better left alone than undergo closure.
Purpose We aimed to evaluate how the closure of ASD
modifies the cardiopulmonary status during long follow
up in different age groups.
Material and methods Our study included 224 patients
operated in last 20 years. They were divided into three
age groups, viz. less than 20 years, 20 to 40 years, and
more than 40 years. The clinical and investigative data
about each patient’s preoperative cardiopulmonary status
was compared with postoperative status using appropriate
statistical method.
Results Prevalence of arrhythmia and pulmonary artery
hypertension (PAH) was predominant in advanced age
group. Each of these showed favorable improvement af-
ter surgical closure; however, the effect was more pro-
nounced in younger age groups. Persistence or new onset
arrhythmia was seen in older patients; the trend however
was not significant. There was a significant positive cor-
relation between arrhythmia and PAH grade. Right ven-
tricular remodeling in follow up was significant in pa-
* Wahid Syed
dr.wahidsyed@gmail.com
1
Department of CVTS, Sher-i-Kashmir Institute of Medical Sciences,
Room F-20, SR Hostel, Block C, SKIMS, Srinagar, JK 190011, India
tients more than 20 years of age. The New York Heart
Association (NYHA) functional class also showed a sig-
nificant improvement to better class in all age groups.
Conclusion We conclude that definite morbidity in older
patients is a strong argument favoring surgical closure
early in life. In the older age group, hemodynamic ben-
efits are much less pronounced and should be taken into
account before surgical treatment is advised.
Keywords ASD . Arrhythmia . PAH
Introduction
Patients with an atrial septal defect (ASD) develop symptoms
predominantly due to right ventricular dysfunction, pulmo-
nary hypertension, and arrhythmia. Patient with isolated
ASD may remain asymptomatic for two to three decades. In
fact, many patients remain unaware of their decreased exercise
capacity and only once ASD is closed, they realize their symp-
tom improvement [1]. Pulmonary artery hypertension (PAH)
is one of the most serious long-term side effects of ASD.
Those at risk for developing pulmonary hypertension benefit
most from ASD closure, but once pulmonary hypertension is
present, surgical risk increases [2]. Atrial arrhythmia in these
patients is the result of chronic right atrial dilation, and with
advancing age, chances of improvement in arrhythmias are
little after ASD closure. In continuum to these validated facts
about ASD, we conducted a study on a large group of 224
patients of ASD belonging to different age groups to further
analyze the effects of ASD on cardiopulmonary systems pre-
and post-closure.
 Author's personal copy
Aims and objectives
The purpose of our study was to evaluate the preoperative
cardiopulmonary status in patients with ASD in terms of atrial
arrhythmias (fibrillation and/or flutter), pulmonary arterial hy-
pertension and its grade, and right heart failure and symptom
class; and to further analyze the postoperative outcome of
surgical closure of ASD on long-term follow up on these
parameter.
Material and methods
This was a retrospective and prospective study, conducted
in the department of Cardiovascular and Thoracic
Surgery. All the patients with ASD secundum who had
undergone surgical closure since 1990 were included in
the study. Patients’ preoperative data was retrieved from
record section as well as on out-patient follow up. Each
patient’s age and sex, detailed history and clinical exam-
ination, and type and size of ASD were noted, and assess-
ment of functional status to assign the patient to a partic-
ular NYHA functional class was done. Arrhythmias were
evaluated preoperatively and postoperatively with electro-
cardiography (ECG), or ambulatory 24-h Holter monitor-
ing wherever required, at 1 week, 6 months, and 1 and
5 years. Pulmonary artery pressures on preoperative echo-
cardiographic or cardiac catheterization were compared
with postoperative values of pulmonary pressures at
2 weeks, 6 months, and 5 years. The echocardiographic
measurement of pulmonary pressures were corrected to
actual readings, by addition of 10 mmHg difference be-
tween invasive and echo reading. Pulmonary hypertension
(systolic) was graded as grade 1 (mild, 30–49 mmHg);
grade 2 (moderate, 50–70 mmHg); grade 3 (severe, 70–
110 mmHg); and grade 4 (systemic, >110 mmHg).
Preoperative NYHA class was compared with postopera-
tive status at 1 week and 6 months. The pre- and postop-
erative results were subjected to statistical analysis using
Student t test, chi-square, or Fisher’s exact, as appropriate,
for the entire cohort and stratified by age at procedure,
considering a p value of <0.05 as significant.
Table 1 Age wise arrhythmia
distribution, pre op and post op Age group n Pre op arrhythmias
<20 years 62 2 1
20–40 years 90 13
>40 years 72 46
Indian J Thorac Cardiovasc Surg
Exclusion criteria
All patients with other hemodynamically severe congenital
heart diseases, e.g., pulmonary valve stenosis, infundibular
stenosis, and common atrium, ASD primum (partial AV ca-
nal), and patients with documented lung diseases such as
COPD, asthma, or lung parenchymal diseases were excluded.
Observations
Total number of patients enrolled for the study was 286, in-
cluding those from the medical records of past 20 years.
However, 62 patients could not be traced, thus were excluded
from the study. Out of the remaining 224 study cases, 94
(42%) were males and 130 (58%) were females. Out of 224
cases, 92 underwent primary closure and remaining 132
underwent patch closure of ASD. All the cases were per-
formed on arrested heart. Patients were divided into three
groups based on age: group I included 62 cases of less than
20 years of age, group II included 90 cases between 20 and
40 years of age, and group III included 72 cases of more than
40 years of age; henceforth referred to as G-I, G-II, and G-III
respectively.
Arrhythmias (atrial fibrillation, flutter)
Preoperatively, arrhythmias were present in 2 (3.2%) cases in
G-I, 13 (14.44%) cases in G-II, and 46 (63.88%) cases in G-III
which was statistically significant as compared to age-
matched controls (Table 1). Postoperatively, from G-I, none
had arrhythmia at 5 years. In G-II, 7 out of 13 persisted with
arrhythmias, while as in G-III, 32 (69.56%) out of 46 persisted
with arrhythmias at 5 years. The mean age of this group of
patients who persisted with arrhythmias was greater than those
who converted to sinus rhythm. Six cases of new onset ar-
rhythmias were seen in >40 years age group (Fig. 1).
Pulmonary artery hypertension
Preoperatively, in G-I, grade 1 pulmonary artery hypertension
(PAH) was present in 4 (6.4%) out of 62 patients. In G-II,
grade 1 PAH was present in 19, grade 2 in 13, and grade 3
in 6 cases (total 42.22% out of 90 patients). In G-III, grade 1
Post op arrhythmias
1 week 6 months 1 year 5 years
0 0 0
10 7 7 7
39 37 32 32
 Author's personal copy
Indian J Thorac Cardiovasc Surg

Fig. 1 Arrhythmias, pre op and

post op Arrhythmias: Preop vs Postop
50
45
40
35
Pre op
30
post op 1 wk
25
post op 1 yr
20
post op 5 yrs
15
new onset post op
10
5
6
0
<20 yrs 20 40 yrs >40 yrs

PAH was present in 2, grade 2 in 32, and grade 3 in 19 cases
(total 73.61% out of 72 patients). Post-operatively, none had
PAH in G-I at 5 years. In G-II, significant decrease in PAH
was observed as 19 out of 38 had no PAH at 5 years, and none
was in grade 3 PAH. In G-III, 49 (92.45%) out of 53 persisted
with PAH at 5 years. However, there was decrease in the PAH
grade postoperatively, which was statistically insignificant
(Table 2). Observations regarding how the patients in partic-
ular PAH grade behaved in postoperative period revealed that
out of 25 patients with grade 1 PAH, 12 persisted with grade 1
PAH, 1 case worsened to grade 2, while as 12 cases had
normal pulmonary pressures at 5 years postoperatively. Out
of 45 patients with grade 2 PAH, 27 persisted with grade 2
PAH, 3 cases improved to grade 1, while 15 cases had normal
pulmonary pressures at 5 years postoperatively. Out of 25
patients with grade 3 PAH, 10 persisted with grade 3 PAH, 2
cases improved to grade 1, and 13 cases improved to grade 2.
No case had normal pulmonary pressures at 5 years postoper-
atively. Out of 95 with PAH in different grades, 27 had normal
pulmonary pressures at 5 years. Statistically, sample propor-
tion was 0.28, with 95% confidence interval (0.196–0.385),
and p value <0.001, which was statistically significant.
Correlation between PAH and arrhythmias
Positive correlation was seen between PAH and arrhythmia
preoperatively (Fig. 2). Out of 25 patients with grade 1
PAH, only 4 (16%) had arrhythmias. Out of 45 patients with
grade 2 PAH, 34 cases (75.55%) had arrhythmias, and out of
25 patients with grade 3 PAH, 23 (92%) had arrhythmias. The
correlation was found to be significant.
Right ventricular dimensions
Right ventricular dimensions showed a statistically significant
decrease in postoperative period at 5 years in patients of more
than 20 year age (G-II and G-III), while as the change was
insignificant in <20 years age (Table 3).
Right ventricular failure with NYHA functional class
In G-I, 6 patients out of 62 were in failure, mostly in functional
class I; of which only 1 was in failure at 5 months postoper-
atively who improved from class II to I. In G-II, out of 90
patients, 68 were in failure, including 9 in class I, 21 in class II,
38 in class III–IV. Of these, 58 were in failure at 6 months
postoperatively. However, functional class had improved sig-
nificantly: 84.21% cases improved from class III–IV to better
class. In G-III, out of 72 patients, 66 were in failure, including
5 in class I, 23 in class II, and 38 in class III. At 6 months post
op, 62 were in failure. But there was significant improvement
in functional class. Then, 71% cases improved from class III–
IV to better functional class (Table 4). Observations regarding
how the patients in particular NYHA functional class behaved

Table 2 Age-wise PAH grade

distribution, pre op and post op Age n Pre op pulmonary pressure Post op at 5 years

Grade 1 Grade 2 Grade 3 Grade 1 Grade 2 Grade 3

<20 years 62 4 0 0 0 0 0
20–40 years 90 19 13 6 14 5 0
>40 years 72 2 32 19 3 36 10
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Indian J Thorac Cardiovasc Surg

Fig. 2 PAH and arrhythmia

correlation Correlation : PAH and Arrhythmia

Grade3

PAH grade
Grade2
Arrhythmic
Non Arrhythmic

Grade1

0% 20% 40% 60% 80% 100%

Arrhthmia Incidence

in postoperative period revealed that out of 19 patients in class I, increased incidence of atrial arrhythmia with age and its per-
3 persisted in the same class, while as 16 cases had no symp- sistence post surgery in advanced age. In contrast, the inci-
toms of failure at 6 months postoperatively. Out of 45 patients dence of arrhythmia was less among patients who underwent
in class II, 2 remained in the same class, 40 improved to class I, ASD closure during childhood, even after long-term follow-
while 3 cases had no symptoms of failure at 6 months postop- up [7]. In one study, they concluded that those who were
eratively. Out of 76 patients in class III–IV, 17 persisted in the arrhythmic were older (mean [±SD] age, 59 ± 11 vs.
same class, 26 cases improved to class II, and 33 cases im- 37 ± 13 years) and had significantly higher mean pulmonary
proved to class I. No case improved to normal functional level arterial pressures (MPAP) [5].
at 6 months postoperatively. The improvement to the better It has also been documented that the more advanced the age
functional class was statistically significant in each group. at the time of ASD closure, the more is the risk of persistence
of atrial arrhythmia postoperatively. The propensity to arrhyth-
mia in this population may be due to arrhythmogenic foci in
the region of the pulmonary veins and vena caval junctions [8].
Discussion In our study, there was a significant positive correlation with
the PAH grade also (Fig. 2). As the grade of PAH increased in
There are many studies published over decades where in the our study population, the prevalence of postoperative atrial
effects of ASD closure on the cardiopulmonary systems has tachyarrhythmia also increased, from 16% prevalence in grade
been evaluated. Most of the studies show results in accordance 1 PAH to 92% in grade 3. Gatzoulis et al. [5] also demonstrated
with that of ours. Data from the literature demonstrates that the this correlation; the patients with arrhythmias had significantly
incidence of preoperative atrial arrhythmia increases with age
[3]. Some authors have observed that while as flutter has ten-
dency to revert to normal rhythm, atrial fibrillation is present Table 4 Right ventricular failure (NYHA class) distribution, pre op and
in older age group with lesser tendency to revert to sinus post op
rhythm [4]. There are two major studies addressing the ques-
Pre op Post op 1 week Post op 6 months
tion of outcome of ASD closure on arrhythmia in adults [5, 6].
Together, they analyze 424 patients. Both studies, which were Age: <20 years, n = 62
conducted independently, showed remarkably similar results. Class I 5 1 1
The mean age of patients with atrial arrhythmia was 59 ± 11 Class II 1 0 0
and 57 ± 10 years in each study group. Both reports found an Class III–IV 0 0 0
Age: 20–40 years, n = 90
Table 3 Right ventricular dimensions, mean (SD); pre op and post op Class I 9 36 44
Class II 21 11 8
Age Preop (cm) Post op 5 years (cm) p value
Class III–IV 38 X 6
<20 years 3.87 (0.63) 3.26 (0.68) NS Age: >40 years, n = 72
20–40 years 4.10 (0.91) 2.95 (0.68) <0.05 Class I 5 22 31
>40 years 4.38 (0.47) 3.01 (0.42) <0.05 Class II 23 20 20
Class III–IV 38 X 11
NS not significant
 Author's personal copy
Indian J Thorac Cardiovasc Surg
higher MPAP (25.0 ± 9.7) compared to those in normal rhythm
(19.7 ± 8.2 mmHg).
Pulmonary hypertension associated with an isolated ASD
is rare in childhood, although 35 to 50% of patients with
unrepaired ASD have elevated pulmonary resistance by age
40. A study by Peter M.E. et al. [9] showed that median age
was 15 years higher in patients with PAH than to those without
(51 vs. 36 years; p 0.001). Further analysis showed that there
was an increase in probability of PAH with a factor of 1.041
for each extra year of age. Our results showed the trend of
increase in prevalence and severity in grade of PAH as the age
at surgery for ASD increased (Table 2). ASD closure decrease
the severity of PAH or even normalizes in young patients, but
in older patients, there is little improvement in PAH, due to the
histological transformation in pulmonary vascular bed [10].
Our study showed a significant improvement in functional
class after ASD closure in patients with RV failure (Table 4).
Nearly all the literature available on the effect of ASD closure
on RV failure substantiates our results. A Japanese study [11]
on 49 patients who were followed up for a mean of 9.7 years
observed that 37 of 49 patients (76%) showed improvement to
better functional class after operation. M. Jamielity et al. [12]
too observed similar results. However, a review study by
Shelby Kutty et al. [13] reported that out of 300 patients with
isolated secundum ASD, the NYHA class was unchanged in
227 patients, while others improved or worsened.
Summary and conclusion
In summary, arrhythmias are more prevalent in patients with
advanced age at the time of surgery. ASD closure leads to
decrease in prevalence of arrhythmias, which is more pro-
nounced in patients less than 40 years of age. Risk of persis-
tence of arrhythmias increases beyond 40 years of age. PAH
increases in prevalence and severity as the age of ASD pa-
tients increases. ASD closure causes decrease in PAH grade in
patients of less than 40 years of age. In more than 40 years of
age, the PAH does not improve significantly. There is a pos-
itive correlation between PAH and arrhythmias. The more
severe the grade of PAH, the more are the chances of persis-
tence of arrhythmias. Postoperatively, there was a significant
improvement in functional class in all age groups. We con-
clude that all patients of ASD should be offered the treatment
early in life, as the morbidity in older patients (over 40 years of
age) is a strong argument favoring surgical closure early in
life.
Compliance with ethical standards
Declaration by the corresponding author I certify that I have no
commercial or non-commercial associations that might pose a conflict
of interest in connection with the submitted article. It is further certified
that none among the co-authors of the submitted article has any conflict of
interest.
Research involving human participants and/or animals All proce-
dures performed in this study involved only human participants and were
in accordance with the ethical standards of the institutional research com-
mittee and with the 1964 Helsinki Declaration and its later amendments
or comparable ethical standards.
Informed consent Informed consent was obtained from all individual
participants included in the study.
Conflict of interest The authors declare that they have no conflict of
interest.
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