ASD In Elderly-

Surgery Or Leave It

Alone?

Dr. Rahul Arora

1st Year PDT

Department Of Cardiology

Case 1

A child of 10 years age with shunt Qp/Qs

=2:1with features of right volume overload.

what to do?

Case 2

A female of 40 years age with shunt Qp/Qs

=2:1with volume overload but without any

other complication. what to do?

Case 3

A male of 70 years age with shunt Qp/Qs

=2:1with atrial arhythmia. what to do?

HIGHLIGHTS

Types of ASD?

How elderly differ from young in

pathophysiology ?

Clinical features difference

Effects of comorbidities & pathophysiology on

treatment ?

What type of asd is device closurable ?

What type require surgery ?

What type to be considered to be leave it

alone?

Introduction

Secundum-type atrial septal defect (ASD) is

the most commonly encountered congenital

heart lesion in the elderly patient. 1

There are three types of ASDs with three

different anatomical features: ostium

secundum, ostium primum and sinus venosus

ASDs.

Early surgical repair results in excellent long

term outcome in young but less favourable

results were seen, when intervention was

carried out in adults. 2

Physiologic Consequences

Shunt Flow Size of defect

Relative compliance of ventricles

Relative resistance of pulmonary/systemic circulation

LR shunting results in diastolic overload of RVand increased pulmonary blood flow

RV dilatation/failure and rarely severe pulm HTN(Eisenmenger’s) may ensue over time ~5%

With age, deterioration chiefly due to 3

decrease LV compliance, increased LR shunt

increase in atrial arrhythmias

pulm HTN develops, RV volume + pressure OL

Elderly patients have high filling pressures d/t

LV diastolic dysfunction

HTN

IHD

Renal disease

ASD provides a protective effect by acting as a

pop up valve in this hemodynamic setting.

Clinical Symptoms

Often asymptomatic until 3-4th decade for moderate-large ASD, may present later in life for initially smallerASD

Fatigue

DOE

Atrial arrhythmias

Paradoxical Embolus

Recurrent Pulmonary infections

Humenberger et al reported that elderly(>60 years)patients had higher prevelance of symptoms, atrialfibrillation, tricuspid regurgitation, comorbidities andalso had higher PA pressures as compared to youngpatients. 4

Treatment

Medical : diuretics, ACEI, Aldactone

Repair

Consider when sxs, Qp:Qs>1.5

Surgical

Mortality 1-3% in most series

PVR > 6-8 Woods Units - Contraindication

Interventional

Only for secundum defects

94-96% success (Amplatzer)

Asd closure vs medical

management

Adult patients with unrepaired ASDs are atincreased risk of cardiovascular events.

Rosas et al followed 200 unoperated adultpatients for 1.6 to 22 years and observed 37events(18.5%) of which 5 were due to suddendeath, 7 had heart failure, 13 had severepulmonary infections, 5 had embolic eventsand 4 had strokes.

Age at presentation, pulmonary HTN andarterial O2 saturation were predictors of pooroutcome.

Asd closure in elderly: harm or

benefit?

Harjula et al reported operative mortality of 6%and major postoperative complications in 24 % ofpatients older than 60.

However there was symptomatic improvementand significant reduction in mean PA pressure inall surviving patients.

Another study compared 3 different patient agegroups (<40 years;78 patients, 40 to 60 years;84patients and > 60 years;74 patients)undergoingtranscatheter asd closure and showed animprovement in symptoms in all groups withreduction of PA pressure and RV size withoutincrease in mortality.

Surgery vs medical

A prospective randomized trial compared surgical andmedical therapy in 473 patients (> 40 years)followedfor median duration of 7.3 years. There was trendtowards higher sudden death, congestive heart failureand overall mortality in medical arm.

In another retrospective study( mean age 54+/-years),the surgical closure of the defect significantly reducedmortality from all causes.(RR 0.31).

The adjusted 10 year survival rate of surgically treatedpatients was 95% as compared to 84% for medicallytreated patients.

Importantly, incidence of new atrial arrythmia or ofcerebrovascular insults in the two groups was notsignificantly different.

Hanninen et al followed 67 patients( 19% surgical closure and 81% device closure) with mean age of 68 years( range 60-86 years) for 3.3 years.

Asd closure was associated with

quality of life comparable to age matched healthy controls,

↓RVEDd,

↑LVEDd and

improvement in biventricular function and NYHA class

but no change in prevelance of atrial arrhythmias

Nyboe et al showed that symptoms, atrial

arrhytmias and RV dilatation were more

pronounced in the elderly(> 50 years), but

reversibilty is the same as in the young (<50

years)

They also found 20 % absolute risk reduction

of atrial fibrillation in patients > 50 years age.

Wilson et al also reported resolution of AF in

half of the patients post device closure.

AHF After ASD closure

↑ed risk due to abrupt elevation of lv preloadespecially in elderly with LV dysfunction and ↑edLVED pressure.

Temporary ballon occlusion : screeening tool topredict any adverse hemodynamic changes thatwould preclude closure of the ASD.

Fenestrated closure: preserves the offloadingproperties of the ASD, prevent secondarypulmonary hypertension and possible pulmonaryedema.

Surgery vs device closure

Surgery has higher mortality and complication rates in elderly as compared to young.

The study by jategaonkar et al assessed 96 patients older than 60 years who underwent transcatheter ASD closure and demonstrated limited but significant (mean 1 to 2 ml/kg per min increase in peak oxygen consumption, improvement in exercise capacity, post closure reduction in RV enlargement as measured by transthoracic echocardiography, and reduction in functional class.

Hanninen et al reported major complication rates

were 23% and 7% in the surgical and device

closure group, respectively. The beneficial effects

were similar in both groups with no procedural

related deaths.

Rosas et al showed significantly higher primary

event rate( 25 % vs 13% ) drivent by moderate

bleeding, mild respiratory infection and

arrhythmias in surgical group as compared to

device closure. The event rate was higher in older

patients and those with systolic PA presssure > 50

mm Hg, but there was no mortality

Conclusion

Elderly patients with ASDs almost always havesignificant associated comorbidities.

ASD closure is associated with significant improvementin symptoms and is associated positive cardiacremodeling even in elderly patients.

Defect closure in patients with raised LV end diastolicpressure may precipitate acute CHF in few patients.

Test ballon occlusion may reliably predict thehemodynamic consequences of ASD closure.

Periprocedural anticongestive therapy and fenestratedASD closure should be considered in these patients.

ASD closure decreases morbidity by improvement infunctional class and reduced respiratory infections andmay prevent paradoxical embolism, but with nosignificant mortality benefit.

Final Verdict…………….

Given the success rate of percutaneous

closure devices and lower complication rate as

compared to surgery, device closure may be

preferable in the elderly.

references

1. Lindsey JB, Hillis LD. Clinical update: atrialseptal defects in adults.Lancet. 2007;369:1244-46.

2. Murphy JG, Gersh BJ, McGoon MD, et al. Long term outcome after surgical repair of isolated atrial septal defect. Follow up at 27 to 32 years.N Engl J Med.1990;323:1645-50.

3. Perloff, NEJM 1995.

4. Humenberger M, Rosenhek R, Gabriel H, et al.benefit of atrial septal defect closure in adults: impact of age. Eur Heart J2011;32:553-60.

THANK

YOU