Special Considerations in Atrial Septal Defect Closure for elderly

Ho Chi Minh City Jan 2012 Geetha Kandavello

Institute Jantung Negara Malaysia

ASD in the elderly

Does closure of the defect benefit all patients?

• Survival

• Functional class

• Atrial arrhythmias and risk for thromboembolism

• Pulmonary hypertension

Method of closure

• Transcatheter or surgical closure

• ? Fenestrated ASD closure

Is there a need for concomitant treatment?

• Antiarrhythmic intervention

• Valve repair

Risk of complications

• Impaired left ventricular compliance

• Co morbidities

ASD in the elderly

Patient 1: 57 yrs old male

Diagnosis: secundum ASD

Co morbidities: DM, HPT, dyslipidemia, COAD, obese (BMI 31)

NYHA functional class lll

Pink, resting Sao2 95%

Lungs: basal crepts

Murmur: ESM Upper L sternal edge

ECG: atrial fibrillation , rate 70 resting

CXR: cardiomegaly, plethora

ECHO: RA, RA dilated and PA

large secundum ASD 29mm

severe TR , PG 48mmhg

mild MR, LA 4.9mm

LVEF : 65%

Grade 2 LV diastolic dysfunction

Depressed RV function

Cardiac cath:

Ao : 131/90/103 PA: 71/19/48

LVedp :20mmhg , RV edp 18 mmhg

LA mean 18mmhg , RA mean 18

Ao sat 90%, PA :79%, LA :88%

Qp:Qs 2.0 , PVR : 2.96 wood unit , TPG : 28

What would be the treatment options 1. Medical therapy 2. Surgical closure and tricuspid annuloplasty 3. Surgical closure and tricuspid annuloplasty +MAZE 4. Transcatheter closure of ASD 5. Fenestrated ASD closure

Survival outcomes

A comparison of surgical and medical therapy for ASD in adults

• Retrospective non-randomised

– 179 patients over 40 years old

– All had Qp/Qs more than 1.5

– 163 (91%) secundum defects.

– Surgery ( n= 84) and medical treatment (n=95)

– Mean age at surgery: 56.9 yrs,

– Follow-up evaluation mean: 8.9 years (1-26) Konstantinides: N Engl J Med 1995

Konstantinides, N Engl J Med 1995

Surgical group Surgical group (n=84)

Medical group (n=95)

Event

Early Late

Death 0 3 21

TIA/Stroke 3 9 6

New onset atrial fibrillation/flutter

6 13 16

pacemaker 2 9 2

Total no. of events 11 34 45

Total no. (%) of patients with > 1 event

9(11) 25(30) 37(39)

Cardiovascular events during follow up

Konstantinides, N Engl J Med 1995

Prospective randomised study Isolated secundum and sinus venosus ASD Age >40 Systolic PAP < 70 Qp:Qs >1.7 Primary and secondary end point

Attie et al JACC 2001

Event-free probability for primary end point by type of treatment and age of entry

Surgical closure improved the composite of major cardiovascular events and survival

The total number of heart failures, strokes and embolic events did not differ significantly age at diagnosis, mPAP >35 mm Hg and medical treatment were the main risk markers.

Functional capacity

New York Heart Association Functional Class in different age groups before and after surgical closure of atrial septal defect

18-40 years 40-60 years >60 years Classification (n = 101) (n = 83) (n = 27) Before surgery NYHA class I 47 (46%) 17 (21%) 0 (0%) NYHA class II 53 (52%) 35 (42%) 9 (33%) NYHA class III 2 (2%) 25 (30%) 15 (56%) NYHA class IV 0 (0%) 6 (7%) 3 (11%) After surgery NYHA class 1 90 (89%) 42 (51%) 0 (0%) NYHA class II 11 (11%) 32 (39%) 22 (85%) NYHA class III 0 (0%) 8 (20%) 4 (15%) NYHA class IV 0 (0%) 0 (0%) 0 (0%) Mortality 0 1 1

Berger F. Ann Thorax Surg 1999

ASD closure: functional capacity

– 37 adults with ASD (mean 49 yrs[19-76])

– Exercise MVO2 prior to catheter closure and 6 months later

Brochu et al Circulation 2002

ASD closure: functional capacity

– 37 adults with ASD (mean 49 yrs[19-76])

– Exercise MVO2 prior to catheter closure and 6 months later

Brochu et al Circulation 2002

significant improvement in exercise capacity occur rapidly after percutaneous ASD closure in adults considered asymptomatic or mildly symptomatic.

ASD closure: functional capacity

J Am Coll Cardiol 2004;43:1886–91

•Prospective •Consecutive 32 patients •Cardiopulmonary exercise testing and transthoracic echo day before and 6 months post ASD occlusion •mean age at closure 42.6+ 16.7 •84% NYHA functionl class 1

:

Giardini et a : J Am Coll Cardiol 2004;43:1886–91

Giardini et a : J Am Coll Cardiol 2004;43:1886–9

Conclusion:

• transcatheter ASD closure leads to a significant increase in peak VO2 within six months

• the mechanism responsible for peak VO2 improvement

after ASD closure :

increase of LV output due to increased volume loading of the LV & improved ventricular interaction

ASD closure: functional capacity

Atrial arrhythmias

• Incidence of atrial arrhythmias before and after surgery in adults

• the effect of surgical closure to pre-existing atrial arrhythmias

Berger F: Ann Thorac Surg 1999;68:75-8

211 adults patients with ASD Age: more than 18 years

Mean 39 +13

Pre-op

Post op

Follow up

Clinical assessment ECG and Holter Cardiac cath

185 2° ASD 26 Sinus venous

Patch 158 Direct suture 53

Daily ECG Holter before d/c

Holter at 6 months

Bayer F. Ann Thorax Surg 1999

Incidence of preoperative and postoperative atrial flutter/fibrillation in different age groups before and after surgical closure of atrial septal defect

Bayer F. Ann Thorax Surg 1999

18-40 years 40-60 years >60 years Category (n = 101) (n = 83) (n = 27) Before surgery SVES 1 (1%) 2 (2%) 2 (8%) Atrial flutter 1 (1%) 12 (15%) 5 (19%) Atrial fibrillation 0 (0%) 12 (15%) 16 (61%) Immediately after surgery Atrial flutter 17 (17%) 23 (28%) 10 (39%) Atrial fibrillation 2 (2%) 14 (17%) 15 (58%) Late after surgery Atrial flutter 0 (0%) 7 (9%) 3 (11%) Atrial fibrillation 0 (0%) 8 (10%) 13 (48%)

Atrial arrhythmia after surgical ASD closure

Evaluate the incidence and predictors of preoperative and post operative atrial arrhythmias

• 213 adult patients, 1986 – 1997

• Symptomatic and significant left to right shunt.

• Mean age at closure 41+14 yrs

• Mean duration of follow up 3.8 +2.5 yrs

» Gatzoulis M: N Eng J Med 1999;340:839-46

Preoperative atrial flutter or fibrillation

Patients with Patients without atrial flutter arrhythmia or fibrillation P Variable (n = 40) (n = 173) value Age at repair 59 + 11 37 + 13 <0.001

Left-to-right shunt 2.4 + 0.7 2.4 + 0.7 0.78 (Qp:Qs ratio)

Pulmonary arterial 25.0 + 9.7 19.7 + 8.2 <0.001 pressure (mmHg)

Pul arterial wedge 12.0 + 4.7 9.6 + 4.2 0.08 pressure (mmHg)

NYHA class (%) <0.001 I 10.0 35.8 II 37.5 39.9 III 50.0 24.3 IV 2.5 0

Gatzoulis, N Engl J Med 1999

Kaplan-Meier estimates of late postoperative atrial flutter or fibrillation

100 90 80 70 60 50 40 30 20 10 0

0 1 2 3 4 5

Age <40 years at time of surgery (n = 110)

Age >40 years at time of surgery (n = 103)

Years after surgery Gatzoulis, N Engl J Med 1999

Predictors of late atrial flutter or fibrillation

Variable Risk ratio P value (95% CI)

Multivariate analysis

Age at repair (per year) 1.1 (1.0 - 1.1) 0.001 Preoperative atrial flutter or fibrillation 9.9 (2.7 - 37.7) <0.001 Postoperative atrial flutter or fibrillation or junctional rhythm 3.9 (1.3 - 12.6) 0.02 NYHA class >III 1.0 (0.4 - 2.3) 0.09 Mean pulmonary artery pressure, >20 mmHg 1.2 (0.1 - 10.6) 0.64 Hypertension 1.6 (0.7 - 3.8) 0.43 Heart failure 2.1 (0.8 - 5.8) 0.13 Duration of bypass during surgery, >35min 2.0 (0.3 - 12.1) 0.54

Gatzoulis, N Engl J Med 1999

ASD : atrial arrhythmias

• Atrial arrhythmias increased with age

• preoperative atrial flutter or paroxysmal supraventricular tachycardia can evolve into sustained postoperative AF

• surgical correction of ASD in adults did not decrease the occurrence of AF.

• factors predisposing to the late postoperative Age more than 40 years old at the time of surgery higher preoperative pulmonary artery pressure preoperative atrial flutter or fibrillation postoperative atrial flutter or fibrillation or junctional rhythm • Even after a successful defect closure, patients are

exposed to the risks of stroke owing to arrhythmia-related thromboembolism and to the risks associated with chronic drug therapy (antiarrhythmic agents or warfarin

ASD : atrial arrhythmias

Atrial arrhythmias after ASD closure

• Does Cox Maze procedure modify the outcome ASD closure in selected group of patients?

MAZE for AF with ASD

Kobayashi et al Circulation 1998

• 26 pts with ASD and AF

• No deaths

• Reoperation for bleeding

• 22/23 pts R/L Maze SR

• AF recurred in all 3 R

Maze

Patient profiles for the maze and control groups

Maze Group Control Group Characteristic (n = 26) (n = 45) P Age at operation, y 58.2 + 9.1 54.7 + 8.9 NS

Sex, M//F 16/15 16/29 NS

Cardiothoracic ratio, % 64 + 7 58 + 0.0008

Qp/Qs 3.6 + 1.5 3.4 + 1.3 NS

Mean PA pressure, mmHg 24 + 7 19 + 7 0.0013

Presence of TR, n (%) 14 (54%) 13 (29%) 0.046

Presence of MR, n (%) 5 (19%) 2 (4%) NS

Cardiac measurement by echocardiography, mm LAD 47 + 9 36 + 6 <0.0001 LVEDD 37 + 7 37 + 5 NS LVESD 25 + 7 25 + 5 NS

Kobayashi, Circulation 1998; 98:II-399-II-402

Results of surgery in the maze and control groups

Kobayashi, Circulation 1998; 98:II-399-II-402

Maze Group Control Group Characteristic (n = 26) (n = 45) P ACC time, min 108 + 44 28 + 13 <0.0001

CPB time, min 168 + 62 57 + 20 <0.0001

Chest tube drainage, mL 850 + 480 430 + 250 <0.0001

Blood transfusion, mL 540 + 780 40 + 240 <0.0001

Need for transfusion, n (%) 10 (38%) 1 (2%) <0.0001

Death, n (%) Hospital 0 (0%) 0 (0%) NS Late 0 (0%) 0 (0%) NS

Complication, n (%) Chest reopening for bleeding 3 (12%) 0 (0%) 0.046 Stroke 1 (4%) 0 (0%) NS Aortic dissection 0 (0%) 1 (2%) NS

Late complication, n (%) Paroxysmal AF 0 (0%) 8 18%) 0.023 Stroke 0 (0%) 1 (2%) NS Congestive heart failure 0 (0%) 1 (2%) NS Thromboembolism 0 (0%) 0 (0%) NS

Effects of the maze procedure in the late follow up

Conventional maze Right sided maze Effect (n = 23) (n = 3) Cardiac rhythm by ECG, n (%) Sinus rhythm 22 (96%) 0 (0%) Junctional rhythm 1 (4%) 0 (0%) Sustained AF 0 (0%) 3 (100%) Pacemaker 0 (0%) 0 (0%) Presence of atrial A wave by pulsed Doppler, n (%) Trans-MV and TV flow 20 (87%) 0 (0%) Trans-TV flow only 2 (9%) 0 (0%) Total, n (%) 22 (96%) 0 (0%)

Kobayashi, Circulation 1998; 98:II-399-II-402

Standard MAZE procedure should

be considered for patients with

atrial fibrillation associated with ASD

Left ventricle compliance

• elderly and hypertensive

• hypertrophied, less compliant LV.

• Restrictive left ventricular dysfunction in elderly may be masked by the presence of an ASD.

• Deterioration of left ventricular diastolic function can occur with acute hemodynamic change following closure of ASD, leading to acute lung edema.

Left ventricular dysfunction

Pulmonary edema following transcatheter closure of atrial septal defect in a 53 yr old man Ann Pediatr Cardiol. 2010 Jan-Jun; 3(1): 90–91.

Pre closure 24 hours post closure

Effect of elimination of RV volume overload by transcatheter device closure avoiding the confounding factors of surgery

(Am J Cardiol 2004;93:1374–1377)

12 patients (mean age 44.4 +18.6 years)

12 patients (mean age 44.4 +18.6 years)

presence of transitory haemodynamic stress during adaptation of the left ventricle after ASD closure may contribute to the understanding of the pathological mechanism of acute heart failure and delayed improvement of exercise capacity after ASD closure.

Pulmonary hypertensiom

Pulmonary hypertension

• PHT increases progressively with advancing age

• Rate of progression is variable

• Multifactorial cause

• Uncommon , 5-10% pulmonary vascular disease

Column1 <40 (n=104) >40 (n=49) P value

Size 23.1 ± 5.44 24.7 ± 5.3 0.796

PHT 41.90% 37.20% 0.618

Eisenmenger 10.50% 12.24% 0.645

Mean PA Pr 44.4 ± 24.7 45.0 ± 25.2 0.974

PVR 6.74 ± 6.8 5.83 ± 6.9 0.994

Qp:Qs 2.98 ± 2.12 3.45 ± 3.40 0.450

PA:Ao 0.54 ± 0.27 0.81 ± 1.48 0.955

IJN 2008-2009

Pulmonary hypertension

Circulation 76, No. 5, 1037-1042, 1987.

Mayo clinic 1953-1978 702 pts secundum /sinus venosus ASD 6% has pulmonay vascular obstructive disease ( total pulmonary resistance > 7u/m2 ) Surgery 26 pts [mean age 47yrs (27-71)] medical 14pts [Mean age 44(19-75)] Follow up median 12 years

surgery

medical

Jo& Su5rez de Lezo et al, Am Heart J 2002;144:877-80

N =29 Mean age : 56+ 14 Atrial fibrillation : 41% Follow up

Percutaneous device occlusion of ASD in adult patients with pulmonary hypertension is safe and effective, even in severely symptomatic patients, and provides significant and prolonged relief.

FENESTRATED ASD CLOSURE

• 15 patients

• Mean age was 66 years (range 48–77).

• mPAP 35.3+ 8.3

• Mean PVR : 2.52 +1.47

• Mean Qp:Qs : 2.59+1.1

• Conclusion: fenestrated ASD occluders are an important therapeutic adjunct for interventional ASD occlusion, especially for elderly and high-risk patients.

Fenestrated Occluders for Treatment of ASD in Elderly Patients with Pulmonary Hypertension and/or Right Heart Failure BRUCH et al , J Interven Cardiol 2008;21:44–49

Fenestrated closure

• Pretreatment evaluation of LV diastolic dysfunstion

• Fenestrated closure protects against temporary high left-sided pressures

• Pre and post treatment with diuretics, afterload reduction

Conclusion

• ASD closure significantly improves survival

and functional class

• All ASD in adult patients should be closed early after diagnosis and assessment.

• Does not prevent the onset of late atrial arrhythmias

• In the presence of atrial arrhythmia concomitant

anti arrhythmic intervention may be beneficial

Conclusion

• Pulmonary odema may occur following ASD closure in the presence of poor LV compliance

• Fenestrated ASD closure should be considered in patients with poor right /left ventricle compliance or in the presence of pulmonary hypertension.

What would be the treatment options 1. Medical therapy 2. Surgical closure and tricuspid annuloplasty 3. Surgical closure and tricuspid annuloplasty +MAZE 4. Transcatheter closure of ASD 5. Fenestrated ASD closure

Fenestrated surgical ASD closure , tricuspid annuloplasty + MAZE

Patient 1: 65 yrs old female

Diagnosis: secundum ASD

Co morbidities: Hyperactive airway

NYHA functional class ll

Pink, resting Sao2 98%

Lungs: clear

Murmur: ESM Upper L sternal edge

ECG: atrial fibrillation , rate 94 resting

CXR: cardiomegaly, plethora

ECHO: RA, RA dilated and

large secundum ASD 29mm

severe TR , PG 50mmhg

moderate MR, LA 4.9cm

LVEF : 55%

Grade 2 LV diastolic dysfunction

Depressed RV function

Cardiac cath:

Ao : 138/63/95 PA: 57/6/30

LVedp :11mmhg , RV edp 11 mmhg

LA mean 13mmhg , RA mean 12

Ao sat 97%, PA :89%, LA :97%

Qp:Qs 3.37 , PVR : 2.09 wood unit , TPG : 19

What would be the treatment options 1. Medical therapy 2. Surgical closure, TAP, MV repair +\- MAZE 3. Transcatheter closure of ASD 4. Fenestrated ASD closure

konstantinides

ASD closure: functional capacity

Surgical vs Medical therapy in patient age more than 40 years

• Conclusion:

– Increases long term survival

– Limits the deterioration of cardiac function due to heart failure

– Significant reduction in overall mortality

BUT: Cardiac arrhythmias related morbidity remained no different.

Konstantinides S. N Engl J Med 1995

Surgical Treatment for Secundum Atrial Septal Defects in Patients >40 Years Old

A randomised control trial

Conclusion

Surgical closure of ASD improves

• composite of major cardiovascular events

• overall mortality in patients >40 years old.

• does not significantly reduce the risk of arrhythmias

• Age at diagnosis, mPAP >35mmhg and medical treatment is an independent risk marker

Attie et al JACC 2001

Post surgical closure of ASD

• Mid-term outcome

– Return to sinus rhythm from atrial flutter is possible BUT unlikely for fibrillation

– Significant morbidity and mortality as a result of atrial arrhythmias.

– Data was not long enough to determine the fate of atrial arrhythmias after surgery.

– Perhaps, Maze procedure may be beneficial.

Atrial flutter or fibrillation at follow up

Variable Group A Group B Group C Group D P value All patients No. of patients 24 16 5 168 Age at repair (yr) 63+9 53+11 69+3 36+12 <0.001 Duration of follow up (yr) 4.2+2.6 2.3 +2.4 4.2+2.6 3.9+2.5 0.10 Age at repair >40/<40 (no) 24/0 12/4 5/0 62/106 <0.001 Patients who underwent cardiac catheterization No. of patients 23 16 5 105 Left-to-right shunt (Qp:Qs ratio) 2.4+0.6 2.5+0.8 2.2+0.6 2.4+0.7 0.09 Pulmonary arterial pressure (mmHg) 24.9+7.4 25.1+12.6 31+4.6 18.7+7.4<0.001 Pulmonary arterial wedge pressure (mmHg) 13.5+5.5 9.9+2.4 9+2.8 9.7+4.2 0.19

Gatzoulis, N Engl J Med 1999

Characteristics (>40)

No PHT(n=38) PHT (n=19) p value

M:F 0.33 0.25 0.735

Age 52.48 ± 7.9 49.56 ± 7.5 0.237

Size 22.88 ± 4.5 24.86 ± 6.2 0.308

Sinus rhythm Y:N 77.70% 56.25% 0.137

Symptomatic Y:N 74.1% 87.5% 0.446

Low ET 29.6% 50.0% 0.182

Dyspnoea 25.9% 37.5% 0.424

Palpitation 48.7% 25.0% 0.742

Syncope 11.1% 12.5% 0.892

NYHA I 37.0% 12.5% 0.181

NYHA II 51.9% 75.0%

NYHA III 11.1% 12.5%

Comparison of Cath Data

Non PHT PHT

Mean PAP (<40) 17.7 ± 6.5 mmHg 60.5 ± 17.0 mmHg

(>40) 20.4 ± 6.2 mmHg 53.4 ± 22.5 mmHg

Qp:Qs (<40) 4.12 ± 2.2 2.22 ± 1.4

(>40) 4.53 ± 3.5 3.60 ± 3.9

PVR (<40) 1.25 ± 1.1 Wu/m2 10.1 ± 6.4Wu/m2

(>40) 1.85 ± 1.0 Wu/m2 7.4 ± 7.3Wu/m2

PA:Ao (<40) 0.24 ± 0.08 0.71 ± 0.2

(>40) 0.28 ± 0.07 0.94 ± 0.16

P values not significant