Closure of secundum atrial septal defects in the adult and elderly patients

Transcription

1 European Journal of Cardio-Thoracic Surgery 43 (2013) doi: /ejcts/ezs405 Advance Access publication 14 August 2012 ORIGINAL ARTICLE a b c d Closure of secundum atrial septal defects in the adult and elderly patients Camilla Nyboe a,b, *, Morten Fenger-Grøn b,c, Jens Erik Nielsen-Kudsk d and Vibeke Hjortdal a Department of Cardiothoracic Surgery, Aarhus University Hospital, Aarhus, Denmark Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark Research Unit for General Practice, Aarhus University, Aarhus, Denmark Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark * Corresponding author. Department of Cardiothoracic Surgery, Aarhus University Hospital, Brendstrupgaardsvej 100, 8200 Aarhus N, Denmark. Tel: ; camilla@nyboe.nu (C. Nyboe). Received 28 March 2012; received in revised form 7 June 2012; accepted 11 June 2012 Abstract OBJECTIVES: Treatment of atrial septal defect (ASD) in adults is still controversial, and with older age the likelihood of treatment is decreased. The aim of this study was to investigate the effect of ASD closure in adults and especially in the elderly in our institution in a retrospective review. METHODS: Adult patients (n = 220) underwent surgical or catheter closure for an isolated ASD at Aarhus University Hospital from 1990 to Eleven were lost to follow-up and 13 had cardiac comorbidity, and thus 196 were eligible for analysis in the study. Hospital records were reviewed and symptoms and echocardiographic findings registered preoperatively and at 3-month follow-up. Patients were divided into Group I (n = 117): between 18 and 50 years old and Group II (n = 79): older than 50 years. Symptoms and echocardiographic findings before and 3 months after closure were compared within and between the two groups. RESULTS: One patient (0.5%) died during follow-up. Complications occurred in 16% in Group I and 22% in Group II. There was an absolute risk reduction of 62 and 52%, respectively in right ventricle (RV) dilation after operation. Atrial fibrillation was noticed preoperatively in 6% of the young and 47% of the elderly, with an absolute risk reduction after treatment of 20% in Group II (P < ). Subjective symptoms occurred in 75% in Group I and 99% in Group II with a postoperative reduction to 43 and 67%, respectively. In Group I, 70% felt an improvement of symptoms while this was true for 89% in Group II. CONCLUSIONS: Symptoms and RV dilation are more pronounced in the elderly (>50 years), but reversibility is the same as in the young (<50 years) patients. The elderly benefit substantially from ASD closure. Based on these data, ASD closure is recommendable even after the fifth decade. Keywords: Atrial septal defect Grown-up congenital heart disease Catheterization Surgery INTRODUCTION Atrial septal defect (ASD) is one of the most common congenital heart diseases in adults [1]. Patients may live through to their 6th or 7th decade before symptoms appear [2]. At that time, increased perfusion of the lungs may lead to dyspnoea, and dilation of the right atrium increases the risk of atrial arrhythmias [3]. Correction of the defect within the first few decades of life is beneficial and normalizes risk of associated morbidity later in life [4, 5]. However, there is still no consensus on the optimal treatment strategy in the elderly with ASD. Against correction in the elderly is an increased risk of complications and higher mortality due to comorbidity [1, 4, 6, 7]. The natural history of the disease was investigated in the 1960s and Presented at the 46th Annual Meeting of the Association for European Paediatrics and Congenital Cardiology, Istanbul, Turkey, May s, but also in a more recent study in the 1990s, and optimal medical treatment was thought to match surgical repair [1, 5]. Furthermore, several studies have shown that ASD closure has no effect on the development of atrial arrhythmias and no effect on mortality in the smaller and less severe defects [4, 8 11]. The outcome after operation is in all matters inferior for the elderly compared with those operated on earlier in life. Thus, some advise that correction should not be performed routinely in the elderly patients [1, 7, 8, 12, 13]. In favour of correction are other and more contemporary studies showing the substantial effect of closure in the elderly on mortality and subjective symptoms such as dyspnoea [6, 14 16] _ENREF_6. The aim of this retrospective review was to investigate symptoms, presence of atrial fibrillation and right ventricle (RV) dilation in adults and elderly patients treated for ASD in the modern era. The Author Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

2 C. Nyboe et al. / European Journal of Cardio-Thoracic Surgery 753 MATERIALS AND METHODS The study population consisted of all 220 patients aged 18 years corrected for a secundum ASD between 1990 and 2008 at Aarhus University Hospital either by surgery or the transcatheter technique. Thirteen patients were excluded due to cardiac comorbidity. Valve surgery was performed on six, coronary surgery on three and other cardiac surgery on four patients. Eleven patients were lost to follow-up and 196 patients were therefore eligible for analysis. The follow-up period was at least 3 months. The patients were divided into two groups. Group I included patients who had their ASD closed between age 18 and 49 years and Group II included patients who had their defect closed after 50 years of age (Table 1). All patients were diagnosed with a transthoracic cross-sectional and transoesophageal echocardiography prior to closure. RV was considered dilated when RV LV in a transthoracic apical 4-chamber view and the criteria for pulmonary arterial hypertension (PAH) was a tricuspid regurgitation gradient 40 mmhg. All patients were discussed at a joint cardiology and surgical conference. The ASD was closed by the catheter technique if possible and otherwise the patient underwent surgery. Two independent investigators reviewed all hospital records. A third investigator was consulted in case of divergence in findings. Pre and postoperative echocardiography and subjective symptoms were registered. Atrial fibrillation (AF) was registered from a 12-lead electrocardiogram or description of such in the hospital record and divided into either chronic AF or paroxysmal AF. All patients >40 years had coronary arteriography performed and were excluded if intervention was required. Transthoracic echocardiography was performed and symptoms registered again 3 months after closure. Patients who had not undergone the scheduled echocardiography at the time of registration (n =8) were contacted and echocardiography was performed. The mean time before control for the patients with late follow-up was 3.6 years ( ). Patients with arrhythmias were followed-up until 1 year postoperatively. Statistical analysis Confidence limits for differences between group means were calculated from a normal approximation, and P-values consequently assessed using unpaired t-tests. Chi-squared tests were used for comparison of proportions. Absolute risk reduction with corresponding confidence limits and P-values were calculated in a generalized linear model (using the binomial family and identity link) performing robust variance estimation to account for the cluster-effect of repeated measures on each study subject. Confidence limits for proportions were assessed by Jeffrey s method. All calculations were carried out using statistical software Stata 12.0 (Stata Corp. LP, TX, USA), and the considered significance level was 5%. This study was approved by The Danish Data Protection Agency ( j.nr ) and the National Board of Health ( j.nr /193/KWH). RESULTS One patient (age 19 years), who had congenital rheumatic disease and a severely dilated RV prior to surgery, suffered severe persistent arrhythmias and died. The patient was operated on and developed cardiac incompensation and sinus bradycardia after discharge. During a pacemaker implantation the patient died from electro-mechanic dissociation. The mean age was 44.2 ± 17.7 years (range 18 81) at the time of closure. In Group I (n = 117), the mean age was 32 ± 10.5 years and in Group II (n = 79), it was 62 ± 8.0 years. Group I had a mean hospital stay of 4.4 ± 3 days and Group II, 3.9 ± 2.7 days. There was no statistically significant difference between mean hospital stay in the two age groups [confidence interval (CI): 0.4; 1.3, P = 0.27], but patients who had transcatheter closure had a shorter hospital stay than those who had surgery performed [2.1 vs 6.9 days (CI: 4.3; 5.2), P < ]. Complications occurred equally often in the two groups (19 patients in Group I and 17 in Group II), P = 0.35 (Table 2). When groups were separated according to transcatheter closure or surgery, there was a statistically significant difference between those two groups (P = ). We did not see post-incisional supraventricular arrhythmias in any of the patients. Except for the one death, the complications were temporary and caused no permanent damage. All new post-procedure arrhythmias were treated and converted to sinus rhythm before the patients were discharged. New arrhythmias seen after discharge were not considered to be a complication. Three patients were surgically treated after failed transcatheter closure. Cryoablation was not performed routinely on patients with AF until year 2000 when the treatment was introduced in our Table 2: Complications after closure in the two age groups and in groups divided by method of closure Complications Group I years Group II >50 years Transcatheter closure Surgery CONGENITAL Table 1: Number of patients in the different groups Number in each group Transcatheter treatment Surgery Total Age years (Group I) Age >50 years (Group II) Total Pneumonia New arrhythmias Pneumothorax Haematoma Minor bleeding Pericardial effusion Minor infections Light chest pain Cardiac ischaemia Emergency surgery Total 19 (16.2%) 17 (21.5%) 11 (9.9%) 25 (29.4%) P = 0.35 P <

3 754 C. Nyboe et al. / European Journal of Cardio-Thoracic Surgery institution. From that time on, patients with AF undergoing surgery were offered cryoablation. It was performed in 17 (8.6%) patients, 11 in Group I and 6 in Group II. Four of those had AF prior to surgery and 13 participated in a prophylaxis project and did not have AF prior to surgery [17]. None of the 17 had AF afterwards. Radiofrequency ablation (RFA) was not performed during surgery in any of the patients. In Group I, 84% had RV dilation and three out of four patients had symptoms prior to closure (Table 3). More than half experienced dyspnoea and some had mild symptoms such as dizziness and fatigue. Only few had been diagnosed with AF even though 25% registered palpitations. After closure, the incidence of dyspnoea was significantly decreased and the right ventricular dimensions diminished. As expected, symptoms were more common in Group II than in Group I. Prior to closure, all but one person in this older group had symptoms. In particular, AF (47%) and dyspnoea (77%) were seen much more frequently in this group (6 and 54%, respectively). As seen in Fig. 1, many patients were relieved of their AF after closure. This was particularly seen for those with paroxysmal AF. In the elderly patients, there was a reduction in AF after closure of 43%. One year after treatment, three of the six patients with newly diagnosed AF were in sinus rhythm. AF increased with higher age as expected (Table 4). We found that the reduction in AF was seen in all elderly patients, and even in the patients above 70 years, one in four were relieved of their AF. RFA and direct current (DC) cardioversion was tried in five patients with chronic AF with no effect. Of the patients with remaining chronic AF after closure, six did not have any reduction in RV and six had PAH before closure, suggesting a more severe Table 3: Number of patients with symptoms before and after closure disease. At a later follow-up, we found that three patients in Group I and four in Group II had obtained sinus rhythm. Right ventricular dilation decreased in both groups after treatment and almost 78% in Group II experienced a reduction in RV dilation within 3 months after closure. Almost no patients were asymptomatic in this group before closure, while one-third became asymptomatic after closure. The difference in absolute risk reduction between the two groups was statistically significant for AF, PAH and symptom improvement with a larger improvement in Group II. Surgery vs catheter treatment The patients in the surgery group were significantly younger than the catheter-treated patients (39 vs 48 years, P < ) and more had a dilated RV (99 vs 92%, P = 0.046). Right ventricular dilation decreased more in the transcatheter group and there were more complications in the surgery group (Table 5). DISCUSSION The elderly patients in this study did benefit significantly from closure, with reduction of their symptoms. Some were relieved from AF and PAH. Like several other studies, we found a significant decrease in dyspnoea and subjective improvement in symptoms in both age groups after closure of the defect. Others found that the effect of closure diminishes with older age [18, 19]. Veldtman et al. [18] finds that the remodelling in the RV after closure is present in the elderly but not to the same degree as for the younger patients. In this study, we found that age does Symptoms before and after ASD closure related to age Group I (18 49 years), n = 117 Group II (>50 years), n = 79 Group I vs Group II Pre/post (n) ARR (CI) (%) P-value Pre/post (n) ARR (CI) (%) P-value ARR-dif (CI), (%) P-value AF 7/7 0 ( 5; 5) /21 20 ( 31; 10) < ( 32; 9) < Chronic AF 4/3 20/16 PAH 9/0 8 ( 13; 3) /1 18 ( 26; 9) < ( 20; 0) Dyspnoea 65/17 41 ( 51; 31) < /22 49 ( 61; 38) < ( 23; 7) Palpitations 31/21 9 ( 18; 1) /17 8 ( 20; 5) ( 14; 16) Dizziness 5/0 4 ( 8; 1) /0 6 ( 12; 1) ( 9; 5) Chest pain 8/1 6 ( 11; 1) /0 11 ( 18; 4) ( 14; 3) Syncope 7/0 6 ( 10; 2) /1 4 ( 9; 2) ( 5; 9) Fatigue 16/0 13 ( 20; 7) < /2 11 ( 19; 4) ( 8; 12) Cerebral insults 8/0 7 ( 11; 2) /1 10 ( 18; 3) ( 12; 6) RV dilation 109/37 62 ( 70; 53) < /36 52 ( 63; 41) < ( 5; 24) Other 19/16 3 ( 10; 5) /6 13 ( 24; 1) ( 24; 4) Asymptomatic 29/66 32 (21; 42) < /27 33 (22; 44) < ( 14; 17) Improvement (%) 82 (70) 70 (89) 19 (8; 29) RV decrease (%) 96 (82) 62 (79) 4 ( 15; 8) Residual ASD (%) 6 (5) 4 (5) 0 ( 6; 6) Hospital stay (SD) 4.4 ± ± Defect size (cm) 2.2 ± ± Corresponding absolute risk reductions (ARR) in percents, P-values and confidence intervals (CI), within the age group and between Groups I and II. AF: atrial fibrillation with number of chronic AF below. The remaining is paroxysmal. PAH: pulmonary arterial hypertension; RV dilation: right ventricular dilation; RV decrease: number of patients with reduction in RV; Improvement: number of patients with improvement of symptoms.

4 C. Nyboe et al. / European Journal of Cardio-Thoracic Surgery 755 Figure 1: Total number of patients with AF before and after closure. Table 4: The percentage of patients with AF before and after closure in the elderly patients in different age groups Atrial fibrillation in the elderly patients Age Number Before closure (%) After closure (%) Total Risk reduction (%) not influence the effect of closure and the elderly benefit equally from closure compared with the younger patients regarding RV remodelling also. One major argument against transcatheter or surgical treatment of an ASD in the elderly is the reported increased number of complications and mortality [4, 6, 20]. Murphy et al. found in a long-term (27 years) follow-up study in 123 patients, that the oldest patients had a survival of only 67% compared with a matched control group after surgery. Many of the deaths in this group occur in the immediate postoperative period. These patients were treated five or six decades ago and new modalities for peri and postoperative care and treatment have been developed since then. In this study, we found only one death, which occurred in the young group. Complications were few in both the young and elderly patients and did not occur more often in the elderly. We believe that today s continuously increasing knowledge on how to handle surgery, transcatheter techniques and postoperative care results in fewer complications and shorter hospital stays, from both of which elderly patients benefit. Right ventricular dilation reduction has been found to decrease overall after closure [18]. Ghosh et al. [19] also found a size reduction in RV in the elderly, but not as pronounced as in the young. They measured the RV reduction in actual size, while this study only reports whether a reduction was seen. We found no difference in the reduction of RV size between age groups and that substantial RV reduction is possible even in the elderly patients. One of the most discussed subjects regarding closing an ASD in the elderly is the impact on AF. Several studies find no or only very little effect on the development of AF when treated late in life [1, 4, 6, 10, 11, 21]. One study investigated the use of DC cardioversion before closure and found that this can improve the conversion rate [22]. Only four patients received this treatment though, and further investigation concerning this approach would be beneficial. We have performed RFA and DC conversion on five patients with chronic AF after closure with no effect. Giamberti et al. investigated 15 patients with an average age of 54 years. They had either chronic or paroxysmal AF and were treated with irrigated RFA during surgical closure of their defect. Two years after surgery, 13 were still in sinus rhythm [23]. We have since year 2000 performed Cryoablation on our patients undergoing surgery and four out of four patients have converted to sinus rhythm. Another study found a reduction in AF after closure of the defect with a reduction in AF from 16 to 7 patients (56%). The patients had a median age of 26 years (mean 35.2 ± 13.6) and the age is not quite comparable with the Group II of our study [13]. We found that after 3 months, there was a decrease in AF in the elderly patients of 20%. One year after closure, the decrease was 25%. With the routine use of either cryo- or RFA methods, the effect on AF could be even bigger than what we have seen in this study. In a study of AF in patients above 60 years, Berger et al. [21] found a reduction in AF after closure in both the patients above 60 years and between 40 and 60 years. The effect was not as large for the oldest of the patients as for those younger than 60 years. In our study, we find an equally large effect in patients from 50 to 80 years of age. We therefore believe that closure of an ASD is beneficial in reducing AF even in elderly patients with a history of several years of arrhythmias. As seen in other studies, many patients still have AF though, and an individual approach with follow-up and anticoagulation therapy is often needed. CONGENITAL

5 756 C. Nyboe et al. / European Journal of Cardio-Thoracic Surgery Table 5: Number of patients with symptoms before and after closure organized by method of closure Symptoms before and after ASD closure related to method of closure Transcatheter (n = 111) Surgery (n = 85) Transcatheter vs surgery Pre/post (n) ARR (CI) (%) P-value Pre/post (n) ARR (CI) (%) P-value ARR-diff (CI) (%) P-value AF 28/21 6 ( 13; 5) /7 11 ( 19; 3) ( 15; 6) PAH 10/1 8 ( 13; 3) /0 17 ( 24; 9) < ( 18; 1) Dyspnoea 72/20 47 ( 57; 37) < /19 41 ( 52; 30) < ( 9; 21) Palpitations 34/26 7 ( 18; 4) /12 9 ( 19; 0) ( 16; 12) Dizziness 3/0 3 ( 6; 5) /0 8 ( 14; 2) ( 12; 1) Chest pain 11/1 9 ( 15; 3) /0 7 ( 13; 2) ( 6; 10) Syncope 5/1 4 ( 8; 1) /0 7 ( 13; 2) ( 10; 4) Fatigue 15/2 12 ( 18; 5) < /0 14 ( 22; 7) < ( 12; 8) Cerebral insults 14/0 13 ( 19; 6) < /1 2 ( 7; 2) (3; 18) RV dilation 103/29 67 ( 76; 58) < /44 46 ( 57; 35) < (7; 35) Other 19/15 4 ( 13; 6) /7 11 ( 19; 2) ( 20; 6) Asymptomatic 14/45 28 (18; 38) < /48 38 (25; 50) < ( 6; 25) Improvement (%) 91 (82) 61 (72) 10 ( 22; 2) RV decrease (%) 86 (78) 72 (85) 7 ( 4; 18) Residual ASD (%) 5 (5) 5 (6) 1 ( 5; 8) Hospital stay (SD) 2.1 ± ± 2.5 < Defect size (cm) 1.7 ± ± 1.0 < Corresponding absolute risk reductions (ARR) in percents, P-values and confidence intervals (CI) within and in between groups. AF: atrial fibrillation; PAH: pulmonary arterial hypertension; RV dilation: right ventricular dilation; RV decrease: number of patients with reduction in RV; Improvement: number of patients with improvement of symptoms. The younger patients investigated in this study were found to have fewer symptoms than the elderly. However, already at an early age we found RV dilation and a large number of patients with palpitations and dyspnoea. This advocates that treatment at an early age is still preferable when possible. The patients offered treatment in this study had either symptoms or a dilated RV. Patients in both age groups with smaller defects, with no symptoms or objective measurements, are not treated as a standard. The treatment of those defects should be investigated further, especially concerning development and treatment of AF. Study limitations The follow-up period in this study is only 3 months, and some of the symptoms seen are rare in nature, i.e. cerebrovascular events and syncope. Not many patients experience those symptoms in the follow-up period, and perhaps a longer follow-up might have resulted in more events in some of these categories. The retrospective design carries with it some limitations in what information is available and how many patients can be included in the study. The patients in the two groups differ somewhat, with the younger patients tending to have surgery and the transcatheter treatment performed more frequently in the elderly. When transcatheter closure was introduced, the tendency to close defects in older patients may have increased. The transcatheter technique results in a shorter hospital stay and fewer complications. This result seems to agree with other studies [12, 24]. This can partially explain the fact that the elderly patients have complications and hospital stays that match that of the young. The patients eligible for transcatheter treatment are those with small, symmetrical and singular defects while patients with larger, multiple or asymmetrical defects normally undergo surgery. This can influence the result on complications especially arrhythmias, which are seen more frequently in the surgery group. The reason younger patients tend to have surgery more often than the elderly could be because larger defects are more likely to cause symptoms earlier in life and hence the patients are referred to surgery before they reach old age. However, we did not find any significant difference between sizes of the defect between the two age groups. CONCLUSIONS This study investigates both the outcome and differences in up-to-date surgery and transcatheter techniques used for closure of an ASD as well as the impact of age on the outcome after closure. We find that the outcome is equally good for both young and elderly patients in almost all parameters. They have similar reduction in right ventricular size, decrease in dyspnoea and most other symptoms. Many elderly patients are relieved from AF. The effect is not diminished with increasing age and most elderly experience subjective improvement of symptoms. The elderly have no increased hospitalization, complications or mortality compared with the young. Elderly patients should therefore not be withheld from closure of a significant ASD. Funding This project was funded by Aarhus University and Region Midt. This work was supported by Aarhus University (Jr.nr / 2-66) and Region Midt ( Jr.nr ). Conflict of interest: none declared.

6 REFERENCES [1] Shah D, Azhar M, Oakley CM, Cleland JG, Nihoyannopoulos P. Natural history of secundum atrial septal defect in adults after medical or surgical treatment: a historical prospective study. Br Heart J 1994;71:224 7; discussion 228. [2] Seldon WA, Rubinstein C, Fraser AA. The incidence of atrial septal defect in adults. Br Heart J 1962;24: [3] Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA et al. ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2008;52:e [4] Murphy JG, Gersh BJ, McGoon MD, Mair DD, Porter CJ, Ilstrup DM 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: [5] Campbell M. Natural history of atrial septal defect. Br Heart J 1970;32: [6] Konstantinides S, Geibel A, Olschewski M, Gornandt L, Roskamm H, Spillner G et al. A comparison of surgical and medical therapy for atrial septal defect in adults. N Engl J Med 1995;333: [7] Ward C. Secundum atrial septal defect: routine surgical treatment is not of proven benefit. Br Heart J 1994;71: [8] Attie F, Rosas M, Granados N, Zabal C, Buendia A, Calderon J. Surgical treatment for secundum atrial septal defects in patients >40 years old. A randomized clinical trial. J Am Coll Cardiol 2001;38: [9] Webb G, Gatzoulis MA. Atrial septal defects in the adult: recent progress and overview. Circulation 2006;114: [10] Magilligan DJ Jr, Lam CR, Lewis JW Jr, Davila JC. Late results of atrial septal defect repair in adults. Arch Surg 1978;113: [11] Silversides CK, Siu SC, McLaughlin PR, Haberer KL, Webb GD, Benson L et al. Symptomatic atrial arrhythmias and transcatheter closure of atrial septal defects in adult patients. Heart 2004;90: European Journal of Cardio-Thoracic Surgery 43 (2013) doi: /ejcts/ezs470 Advance Access publication 22 August 2012 [12] Patel A, Lopez K, Banerjee A, Joseph A, Cao QL, Hijazi ZM. Transcatheter closure of atrial septal defects in adults >or =40 years of age: immediate and follow-up results. J Interv Cardiol 2007;20:82 8. [13] Gatzoulis MA, Redington AN, Somerville J, Shore DF. Should atrial septal defects in adults be closed? Ann Thorac Surg 1996;61: [14] Yalonetsky S, Lorber A. Percutaneous closure of a secundum atrial septal defect in elderly patients. J Invasive Cardiol 2007;19: [15] John Sutton MG, Tajik AJ, McGoon DC. Atrial septal defect in patients ages 60 years or older: operative results and long-term postoperative follow-up. Circulation 1981;64: [16] Yalonetsky S, Lorber A. Comparative changes of pulmonary artery pressure values and tricuspid valve regurgitation following transcatheter atrial septal defect closure in adults and the elderly. Congenit Heart Dis 2009;4: [17] Lukac P, Hjortdal VE, Pedersen AK, Mortensen PT, Jensen HK, Hansen PS. Prevention of atrial flutter with cryoablation may be proarrhythmogenic. Ann Thorac Surg 2007;83: [18] Veldtman GR, Razack V, Siu S, El-Hajj H, Walker F, Webb GD et al. Right ventricular form and function after percutaneous atrial septal defect device closure. J Am Coll Cardiol 2001;37: [19] Ghosh S, Chatterjee S, Black E, Firmin RK. Surgical closure of atrial septal defects in adults: effect of age at operation on outcome. Heart 2002;88: [20] Nasrallah AT, Hall RJ, Garcia E, Leachman RD, Cooley DA. Surgical repair of atrial septal defect in patients over 60 years of age. Long-term results. Circulation 1976;53: [21] Berger F, Vogel M, Kramer A, Alexi-Meskishvili V, Weng Y, Lange PE et al. Incidence of atrial flutter/fibrillation in adults with atrial septal defect before and after surgery. Ann Thorac Surg 1999;68:75 8. [22] Giardini A, Donti A, Specchia S, Formigari R, Oppido G, Picchio FM. Long-term impact of transcatheter atrial septal defect closure in adults on cardiac function and exercise capacity. Int J Cardiol 2008;124: [23] Giamberti A, Chessa M, Foresti S, Abella R, Butera G, de Vincentiis C et al. Combined atrial septal defect surgical closure and irrigated radiofrequency ablation in adult patients. Ann Thorac Surg 2006;82: [24] Du ZD, Hijazi ZM, Kleinman CS, Silverman NH, Larntz K. Comparison between transcatheter and surgical closure of secundum atrial septal defect in children and adults: results of a multicenter nonrandomized trial. J Am Coll Cardiol 2002;39: EDITORIAL COMMENT Atrial septal defect closure in the adult remains controversial Tjark Ebels* Division of Paediatric and Congenital Cardiothoracic Surgery, Centre for Congenital Heart Diseases, University Medical Centre Groningen, Groningen, Netherlands * Corresponding author. Division of Paediatric and Congenital Cardiothoracic Surgery, Centre for Congenital Heart Diseases, University Medical Centre Groningen, PO Box 30001, Groningen 9700RB, Netherlands. Tel: ; fax: ; t.ebels@umcg.nl (T. Ebels). Keywords: Atrial septal defect C. Nyboe et al. / European Journal of Cardio-Thoracic Surgery 757 CONGENITAL Treatment of atrial septal defect in the adult is still controversial.. is the opening sentence of the paper by Nyboe et al. [1] in this issue of the journal. Whether this paper has been able to enlighten us from the darkness of controversiality, is the question at stake. As with most surgical procedures, there has been no prospectively randomized trial into the merits of closing atrial septal defect (ASD), and the Nyboe paper is no exception in this aspect. The consequence being that we have no other option than to make inferences from cohort studies. In this paper, a cohort of 220 patients is described having had their ASD s closed in a single institution over an 18-year period. The selection criteria for ASD closure are, however, not specified, and scrutiny of Table 3 detailing pre- and postoperative symptoms brings us no further. Whether or not these patients came to medical attention through some sort of screening or through symptoms or a combination thereof is entirely unclear. The