Risk factors for prolonged intensive care treatment following atrial septal defect closure in adults

doi:10.1016/j.ijcard.2007.02.022

International Journal of Cardiology

Volume 125, Issue 1, 28 March 2008, Pages 57-61

https://doi.org/10.1016/j.ijcard.2007.02.022 Get rights and content

Abstract

Background

Today, percutaneous or surgical closure of atrial septal defects (ASD) in adults are considered effective and safe treatments. However, some cases of severe left ventricular dysfunction after ASD closure were observed. This study aims at identifying predictors for prolonged intensive care unit stay, and postoperative inotropic support after ASD closure.

Methods

Records of 281 adult patients who had undergone surgical closure of a secundum ASD between 1974 and 2000 at an age over 30 years (mean 43.8, maximum 76 years) were reviewed retrospectively. The endpoints were defined as prolonged intensive care unit stay (> 2 days), and postoperative inotropic support (Dopamine, Dobutamine or Adrenalin).

Results

Thirty-day mortality rate was 0.7% (2 patients). Prolonged intensive care unit stay was observed in 70 patients (25%). Postoperative inotropic support was necessary in 84 patients (30%). Independent risk factors for prolonged intensive care unit stay in multivariate analysis were preoperative atrial fibrillation (p = 0.011), and larger ASD (p = 0.026). Older age at operation (p < 0.001) and longer time on extracorporeal circulation (p < 0.001) emerged as independent risk factor for postoperative use of inotropic support in multivariate analysis.

Conclusions

Surgical ASD closure in adults is usually safe. However, a distinct subgroup of patients is at risk for prolonged intensive care treatment. Timely closure of the ASD must be advised since older age emerged as a predictor for postoperative use of inotropic support. Since atrial fibrillation is a strong independent risk factor for prolonged intensive care unit stay the preservation of sinus rhythm must be aimed at.

Introduction

Since the first successful operation of an atrial septal defect (ASD) in 1952 [1], surgical closure became the treatment of choice for patients with this “simple congenital heart defect”. In recent time, transcatheter closure emerged as a reasonable alternative to surgery in selected cases [2]. In childhood, ASD closure shows excellent results with an extremely low rate of perioperative complications [3]. However, in adult patients, some cases of severe left ventricular dysfunction after surgical [4], [5], or transcatheter ASD closure were observed [6], [7]. The reduced left ventricular compliance [8] as a consequence of the chronic volume unloading due to the left-to-right shunt [9], and the inability of the left ventricle to cope with the increased blood flow after ASD closure, was presumed to be the mechanism for the development of left ventricular failure. In the majority of adult patients, however, surgical [10], [11], [12], or interventional [13] ASD closure are considered effective and safe treatments. Hence, it is important to identify those patients who are at higher risk for an increased morbidity, during hospital stay after ASD closure. Therefore, the aim of the present retrospective study was to assess demographic, anatomic, and hemodynamic predictors for prolonged intensive care unit stay, and postoperative inotropic support in a large cohort of 281 patients who had undergone surgical ASD closure beyond 30 years of age.

Section snippets

Patients and methods

The study group comprised all patients who had undergone surgical closure of a secundum ASD or patent foramen ovale at the age over 30 years between April 1974 and October 2000. Patients who were operated thereafter were excluded because in most of them cardiac catheterization prior to surgery was performed in general anesthesia, combined with transesophageal echocardiography, with the intention to perform a transcatheter ASD closure. The hemodynamic data evaluated on cardiac catheterization of

Preoperative data

Two hundred and eighty-one patients fulfilled the inclusion criteria (Table 1). Symptoms including exertional dyspnea, syncope, or palpitations were present in 106 patients (38%). Thirty-seven patients (13%) presented in NYHA functional class III, 118 patients (42%) presented in NYHA functional class II, and the remaining patients presented in class I. Nineteen patients (7%) were treated with diuretics, preoperatively. Two hundred and sixty-eight patients underwent cardiac catheterization prior

Discussion

It is widely accepted that severe left ventricular dysfunction can occur after surgical or transcatheter ASD closure. Immediate abnormal left heart function after surgical closure of ASD has first been described as early as in 1971 by Davis et al. [4]. The authors reported on 7 patients, who exhibited an increase in the pulmonary artery wedge pressure or left ventricular end-diastolic pressure or both. In 1978, Beyer et al. [5] reported on 16 patients with low output syndrome following surgical

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Cited by (13)

Current concept of transcatheter closure of atrial septal defect in adults
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Citation Excerpt :
Extrapolation of studies on younger patients is not appropriate in the geriatric patients. First, elder patients with ASD acquire comorbid conditions include arrhythmia, hypertension, respiratory distress, kidney disease, etc. that always play a significant role in their heart conditions [4,9]. Second, elder ASD patients may have inherently superior resilience, milder disease, or balanced physiology in contrast to those not surviving to an advanced age.
After the introduction of catheter intervention for atrial septal defect (ASD) in the pediatric population, therapeutic advantages of this less invasive procedure were focused on adult through geriatric populations. The most valuable clinical benefits of this procedure are the significant improvement of symptoms and daily activities, which result from the closure of left to right shunt without thoracotomy and cardiopulmonary bypass surgery. These benefits contribute to increase the number of adult patients of this condition who have hesitated over surgical closure. In terms of technical point of view for catheter closure of ASD, the difficulties still exist in some morphological features of defect, or hemodynamic features in the adult population. Morphological features of difficult ASD closure are (1) large (≥30 mm) ASD, (2) wide rim deficiency, and (3) multiple defects. Hemodynamic features of difficult ASD are (1) severe pulmonary hypertension, (2) ventricular dysfunction, and (3) restrictive left ventricular compliance (diastolic dysfunction) after ASD closure. To complete the catheter ASD closure under these difficult conditions, various procedural techniques have been introduced. These are new imaging modalities such as real-time three-dimensional imaging, new technical modifications, and new concepts for hemodynamic evaluation. Especially, real-time three-dimensional transesophageal echocardiography can provide the high quality imaging for anatomical evaluation including maximum defect size, surrounding rim morphology, and the relationship between device and septal rim. In adult patients, optimal management for their comorbidities is an important issue, which includes cardiac function, atrial arrhythmias, respiratory function, and renal function. Management of atrial arrhythmias is a key issue for the long-term outcome in adult patients. Because the interventional procedures are not complication-free techniques, the establishment of a surgical back-up system is essential for the safe achievement of the procedure. Finally, the establishment of a team approach including pediatric and adult cardiologists, cardiac surgeons, and anesthesiologists is the most important factor for a good therapeutic outcome.
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Two-dimensional (2D) and color Doppler transthoracic echocardiography (TTE) can demonstrate the presence of ASDs, chamber dilatation, estimated pulmonary artery pressure, shunt ratio, and other coexisting heart disease with high sensitivity and specificity in real time. And the advent of tissue Doppler imaging could facilitate understanding of cardiac diastolic function in which impaired cardiac function before ASD closure may lead to development of congestive heart failure after ASD closure especially in elderly patients [14,15]. However, in terms of accurate assessment of ASD morphology including measurements of maximal diameter and surrounding rims, 2D TTE has sometimes limited ability to visualize ASDs in detail clearly, especially in adult patients, thus precise evaluation using TEE are necessary in most ASD patients (Fig. 3) [16,17].
Adult congenital heart disease is one of the most important clinical issues not only for pediatric cardiologists but also adult cardiologists. After the introduction of catheter intervention for atrial septal defect in the pediatric population, therapeutic advantages of this less invasive procedure now focused on even geriatric patients. The most valuable clinical benefit of this procedure is the significant improvement in symptoms and daily activities, which result from the closure of left to right shunt without thoracotomy or cardiopulmonary bypass surgery. Although currently available therapeutic options for device closure for congenital heart disease in Japan are limited to atrial septal defect, patent ductus arteriosus, or some vascular abnormalities such as coronary arteriovenous fistula, various new techniques or devices such as ventricular septal defect device, pulmonary valve implantation, are going to be introduced in the near future. To perform safely and achieve good procedure success, real time imaging plays an important role in interventional procedures. Real time three-dimensional transesophageal echocardiography can provide high quality imaging for anatomical evaluation including defect size, surrounding rim morphology, and the relationship between device and septal rim. In adult patients, optimal management of comorbidities is an important issue, including cardiac function, arrhythmias, pulmonary function, and renal function. In particular, atrial arrhythmias are key issues for long-term outcome. Because the interventional procedures are not complication-free techniques, the establishment of a surgical back-up system is essential for achieving a safe procedure. Finally, the establishment of a team approach including pediatric and adult cardiologists, cardiac surgeons, and anesthesiologists is the most important factor for a good therapeutic outcome. Their roles include pre-interventional hemodynamic evaluation, good imaging technique for anatomical evaluation, management of comorbidities, and surgical back up.
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Risk factors for prolonged intensive care treatment following atrial septal defect closure in adults

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Patients and methods

Preoperative data

Discussion

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Ann Thorac Surg

J Am Coll Cardiol

Am Heart J

Closure of atrial septal defects with the aid of hypothermia; experimental accomplishments and the report of one successful case

Surgery

Long-term outcome after surgical repair of isolated atrial septal defect. Follow-up at 27 to 32 years

N Engl J Med