Percutaneous Closure of a Secundum Atrial Septal Defect in
Elderly Patients

Patients and Methods
We retrospectively reviewed all patients > 60 years of age who underwent percutaneous ASD closure under our supervision since 1998. All patients underwent baseline clinical and echocardiographic evaluation including intra-atrial shunt calculation. Transcatheter ASD closure was performed using the Amplatzer septal occluder (AGA Medical Corp., Golden Valley, Minnesota). Balloon sizing of the defect served to guide the selection of the appropriate device diameter.
Periprocedural complications were analyzed. The patients who were suspected for hemodynamic compromise following ASD closure underwent transient 15-minute ASD balloon occlusion with repeated measurements of pulmonary wedge pressure, left ventricular end-diastolic pressure, systemic arterial pressure and cardiac output. The indications for this test were: impaired ventricular diastolic function, moderately or severely elevated pulmonary pressure and modest left ventricular size. In addition, these patients were pretreated with diuretics and afterload reduction therapy to prevent hemodynamic instability following ASD closure.
Postprocedural follow up included clinical and echocardiographic evaluation at 10 days, 1 month, 6 months and 12 months following catheterization, with subsequent annual examination. Twenty-four hour ambulatory ECG recordings were performed for patients with palpitations. Special attention was paid to exercise capacity, changes in pulmonary artery pressure and right ventricular volume.

Results

Since 1998, 196 patients underwent percutaneous ASD closure at our center. Ninety of them were adult (≥ 18 years of age), and 23 patients were ≥ 60 years. Demographic and clinical characteristics of the elderly patients are described in Table 1. All but 1 patient had a native ASD. One patient had residual ASD following surgical closure. The mean nonstretched ASD diameter was 17.8 ± 5 mm. The mean balloon- stretched ASD diameter was 22.4 ± 6.3 mm. All patients underwent percutaneous ASD closure using the Amplatzer septal occluder (mean 25 ± 7 mm).
In 8 patients, transient 15-minute ASD balloon occlusion was performed according to the above-mentioned indications (see Patients and Methods). In all of these patients, transient balloon occlusion was well tolerated clinically in terms of pulmonary wedge pressure, cardiac output and systemic arterial pressure values.
Coronary angiography was also performed in 19 patients (83%). In 18 of them, normal coronary arteries or nonsignificant CAD was found. One patient underwent a combined procedure including transcatheter ASD closure and right coronary artery stenting.⁴
The procedure was uneventful in 19 cases (83%). Two patients, who underwent coronary angiography during the same procedure, developed femoral artery pseudoaneurysm. Both were treated conservatively. In one case, a small spontaneously resolved pericardial effusion was observed postcatheterization. One patient developed an allergic reaction to the contrast media. The mean post-discharge follow up was 29 ± 22 months.
During the follow-up period, all patients remained alive without serious cardiovascular complications. One patient was diagnosed with three-vessel CAD and thus underwent coronary artery bypass surgery 2 years after ASD closure. In this patient, coronary evaluation was not performed before the ASD closure. Two patients, who had no history of arrhythmia, developed atrial fibrillation. One of them developed the arrhythmia on the third day following the procedure and was successfully treated with propafenone without further recurrence of the arrhythmia. The second patient developed rapid atrial fibrillation, accompanied by transient right hemyparesis 5 days following the procedure. Brain computer tomography revealed no focal ischemic pathology, and transesophageal echocardiography (TEE) showed appropriate position of the septal occluder, without thrombus attached to the device or in the left atrial appendage. The patient was converted to sinus rhythm with amiodarone, but several days later she developed rapid atrial flutter, which was treated by electric cardioversion. Further follow up of this patient was uneventful.

Following the procedure, 15 patients (65%) reported improvement in their exercise capacity. The mean New York Heart Association (NYHA) score decreased from 2.43 ± 0.8 before the procedure, to 1.7 ± 0.5 after the procedure. The changes in NYHA score are summarized in Figure 1.
In 9 patients (39%), partial reduction of the right ventricular size was observed, whereas in 7 patients (30%), the right ventricle had reached the normal size.
The mean systolic pulmonary artery pressure dropped from 51.5 ± 14 to 34 ± 9 mmHg for 1 year following the ASD closure. The changes in pulmonary artery pressure are summarized in Figure 2. Therefore, the data indicate that transcatheter ASD was effective and safe.

Discussion
ASD is the most frequent congenital heart defect to be initially diagnosed in adult and even elderly patients.¹ Significant ASDs are associated with increased morbidity and mortality,⁵ but it is not clear if mechanical (surgical or percutaneous) closure of the ASD in adult patients will improve survival or decrease morbidity. Elderly ASD patients frequently suffer from reduced exercise capacity,⁶ arrhythmia,⁷ pulmonary hypertension, as well as concomitant cardiac and extracardiac pathology (ischemic heart disease, diabetes, lung disease, etc). Previous trials have produced controversial results about the effect of surgical ASD closure on mortality and morbidity. The study by Murphy et al reported on increased mortality in patients who underwent surgical ASD which was repaired after the age of 25 years and compared results with healthy controls.⁸ Another retrospective study, which examined morbidity and mortality simultaneously in surgically versus medically managed ASD patients > 40 years of age, showed a survival benefit in the surgical patients.⁹ On the other hand, a prospective, randomized trial by Attie et al showed no clear survival benefit with surgical ASD closure.¹⁰ Several trials have demonstrated improvement in exercise capacity in adult patients after percutaneous or surgical ASD closure,^11–13 even in asymptomatic or mildly symptomatic patients.¹⁴
Unlike previous trials involving ASD patients > 40 years of age, we focused on ASD management in elderly patients of ≥ 60 years of age. We were able to find only one trial supporting our argument; this trial described technical considerations and short-term outcomes of the transcatheter ASD closure in elderly patients.¹⁵ This population seems to be the most problematic because of the signs of hemodynamic compromise and concomitant pathology.
The majority of previous trials compared surgical and conservative ASD management. Percutaneous ASD closure is a significantly less invasive procedure with a lower risk of the complications associated with surgery (anesthesia, thoracotomy, heart-lung pump, etc.).
In our study group, the ASD closure itself was completely uneventful in the majority of patients. Only 1 patient developed a small, self-resolved pericardial effusion. Other periprocedural complications (femoral artery pseudoaneurysm and allergic reaction to the contrast media) were associated with concomitant arterial access and coronary angiography.
Two patients presented with atrial fibrillation several days following transcatheter ASD closure. Both were successfully treated. One of these patients developed a concomitant transient neurological deficit without brain computed tomographic abnormalities and without thrombus formation on the device by transesophageal echocardiography. The majority of patients reported improvement in exercise tolerance, and echocardiographic examination showed a reduction in right ventricular dimension and decreased pulmonary artery pressure.
Several studies have reported acute pulmonary edema due to abrupt elevation in the left ventricular preload following percutaneous ASD closure in elderly patients with impaired systolic or diastolic left ventricular function.^16–18 This complication was not observed in our study group. All presented patients had normal left ventricular systolic function. The patients who were suspected for hemodynamic compromise following ASD (impaired ventricular diastolic function, moderately or severely elevated pulmonary pressure, modest left ventricular size, etc.) underwent transient 15-minute ASD balloon occlusion with repeated measurements of pulmonary wedge pressure left ventricular end-diastolic pressure, systemic arterial pressure and cardiac output.
Study Limitations. The main limitation of our trial is the lack of a control group. It is still not clear whether elderly patients have survival benefit after percutaneous ASD closure. Another limitation is that our conclusion about improvement in exercise capacity was made on the basis of the patients’ subjective impression, and not on the basis of oxygen uptake or other functional measurements.¹⁹
Nevertheless, our study identifies that percutaneous ASD closure is an effective and safe procedure, even in elderly patients. We recommend closing ASDs, irrespective of age, in the absence of severe left ventricular diastolic dysfunction. Patients who present with clinical and hemodynamic instability during transient balloon occlusion of the defect should not be recommended for transcatheter ASD closure.

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