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A comparison of surgical and medical therapy for atrial septal defect in adults
S Konstantinides1, A Geibel, M Olschewski
1Abteilung Innere Medizin III-Kardiologie, Universitätsklinik Freiburg, Germany.
Insights
Surgical closure of atrial septal defects in adults over 40 improves survival and prevents heart failure progression. While it reduces overall mortality, close monitoring for atrial arrhythmias is still recommended post-surgery.
Area of Science:
- Cardiology
- Cardiac Surgery
- Clinical Outcomes Research
Background:
- Atrial septal defect (ASD) closure is common for patients >40 years.
- Prognosis for unrepaired ASDs in this age group is unclear.
- Outcomes of surgical vs. medical treatment after age 40 lack controlled comparison.
Purpose of the Study:
- To compare the long-term outcomes of surgical repair versus medical management for isolated atrial septal defects in patients diagnosed after age 40.
Main Methods:
- Retrospective study of 179 consecutive patients with isolated ASDs diagnosed >40 years.
- Comparison between 84 surgically treated patients and 95 medically treated patients.
- Mean follow-up of 8.9 years.
Main Results:
- Surgical closure significantly reduced all-cause mortality (RR 0.31).
- Adjusted 10-year survival: 95% for surgical vs. 84% for medical treatment.
- Surgical treatment prevented functional deterioration (NYHA class, RR 0.21).
- No significant difference in new atrial arrhythmias or cerebrovascular insults.
Conclusions:
- Surgical repair of ASD in patients >40 increases long-term survival and limits heart failure progression.
- Medical therapy is less effective in improving survival and function.
- Post-surgical monitoring for atrial arrhythmias is crucial to mitigate thromboembolic risk.
Background:
The surgical closure of an atrial septal defect is frequently recommended for patients over 40 years of age. However, the prognosis for such patients with unrepaired defects is largely unknown, and the outcome for patients operated on after the fourth decade of life has not yet been compared with that for medically treated patients in a controlled follow-up study.
Methods:
In a retrospective study, we examined the clinical course of 179 consecutive patients with isolated atrial septal defects diagnosed after the age of 40. The 84 patients (47 percent) who underwent surgical repair were compared with the 95 patients (53 percent) who were treated medically. The mean (+/-SD) follow-up period was 8.9 +/- 5.2 years (range, 1 to 26).
Results:
Multivariate analysis revealed that surgical closure of the defect significantly reduced mortality from all causes (relative risk, 0.31; 95 percent confidence interval, 0.11 to 0.85). The adjusted 10-year survival rate of surgically treated patients was 95 percent, as compared with 84 percent for the medically treated patients. In addition, surgical treatment prevented functional deterioration, as measured by the New York Heart Association class (relative risk, 0.21; 95 percent confidence interval, 0.08 to 0.55). However, the incidence of new atrial arrhythmias or of cerebrovascular insults in the two groups was not significantly different.
Conclusions:
The surgical repair of an atrial septal defect in patients over 40 years of age, as compared with medical therapy, increases long-term survival and limits the deterioration of function due to heart failure. However, surgically treated patients should be followed closely for the onset of atrial arrhythmias so as to reduce the risk of thromboembolic complications.