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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