Circulation Journal
Online ISSN : 1347-4820
Print ISSN : 1346-9843
ISSN-L : 1346-9843
Pediatric Cardiology and Adult Congenital Heart Disease
Comparison of Clinical Outcomes After Transcatheter vs. Minimally Invasive Cardiac Surgery Closure for Atrial Septal Defect
Masaki KodairaAkio KawamuraKazuma OkamotoHideaki KanazawaYugo MinakataMitsushige MurataHideyuki ShimizuKeiichi Fukuda
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Supplementary material

2017 Volume 81 Issue 4 Pages 543-551

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Abstract

Background: Percutaneous closure has replaced surgery for the majority of cases of secundum atrial septal defect (ASD). However, technological advances have made contemporary minimally invasive cardiac surgery (MICS) less invasive than conventional surgery. The aim of this study was to compare clinical outcomes of percutaneous closure of secundum ASD with those of contemporary MICS.

Methods and Results: We conducted a single-center retrospective study of 354 patients with ASD treated either with the Amplatzer Septal Occluder (134 patients) or MICS (220 patients) between 2000 and 2013. Success rates and the incidence of complications were compared. The success rates were 98% for percutaneous closure and 100% for MICS. There were no deaths in either group. Major complications occurred in 2 patients (1.5%) who underwent percutaneous closure and in 8 patients (3.6%) treated with MICS (P=0.16). Minor complications occurred in 15 patients (11.2%) who underwent percutaneous closure and in 46 patients (20.9%) treated with MICS (P=0.02). On multivariate analysis, MICS (odds ratio [OR]: 2.91, 95% confidence interval [CI]: 1.46–5.81; P=0.002) and age >70 years (OR: 3.50, 95% CI: 1.40–8.75; P=0.008) were independent predictors of complications.

Conclusions: Percutaneous closure and MICS had high success rates without deaths. For ASD patients with a suitable anatomy, percutaneous closure can be considered as the first therapeutic option.

Secundum atrial septal defect (ASD) is one of the most common congenital cardiac malformations.1 Guidelines recommend closure of ASD in patients with right ventricular enlargement, regardless of symptoms.2 Surgical closure was performed for the first time in 1953 and has been the gold standard for decades. Percutaneous ASD closure, on the other hand, was introduced in 1975.3 In 2002, a non-randomized multicenter study compared percutaneous closure with surgery, and demonstrated comparable success rates. Notably, minor complication rates were significantly higher with surgery than with percutaneous closure, and the hospital stay was shorter with percutaneous closure.4 Percutaneous closure has been widely performed and has replaced surgery, except in cases of large defects, insufficient rims, or a left atrium too small to accommodate a device.2,5 However, concern remains regarding the requirement for prosthetic device implantation, which could eventually lead to delayed complications such as cardiac erosion, device thromboembolic events and nickel allergy.6,7

Technological advances have made contemporary surgery less invasive than classical surgery using full sternotomy. Cardiac surgery performed without full sternotomy is called minimally invasive cardiac surgery (MICS).8 Advantages of MICS are swift recovery and reduction of pain and sternal wound infection. Furthermore, it is cosmetically appealing, considering the higher prevalence of women and the relatively young population of patients with ASD compared with the typical surgical population.9 MICS for ASD has been shown to be a safe procedure with satisfactory long-term outcomes.10,11 More recently, MICS has used endoscopy through a small skin incision in the right chest wall, and is called a right mini-thoracotomy MICS.12

The aim of this study was to compare percutaneous closure with right mini-thoracotomy MICS for secundum ASD because to date, no direct comparison has been made in terms of efficacy and safety. We also report data on the risk predictors of complications occurring during hospitalization for ASD closure.

Methods

This was an observational retrospective study from an institutional cohort of isolated secundum ASD cases from 2000 to 2013. The cohort included all patients who underwent percutaneous or surgical closure of isolated secundum ASD. Therefore, we excluded patients with associated cardiac anomalies requiring additional surgical repair including 1 case of mitral valve regurgitation (treated by mitral valve repair) and 3 cases of partial anomalous pulmonary venous drainage (treated by Warden procedure). To restrict our data to a typical secundum ASD population treated in our adult cardiac surgery team and interventional cardiology division, patients less than 10 years old (n=44) were excluded. Patients’ characteristics, in-hospital outcomes, and post-discharge outcomes at 1 month were retrospectively collected. The institutional review board approved the protocol.

All patients underwent transthoracic and transesophageal echocardiography to define the anatomy of the ASD. A total of 134 patients were treated with percutaneous closure between 2011 and 2013, and 220 patients underwent right mini-thoracotomy MICS between 2000 and 2013 (Figure 1). Percutaneous closure of secundum ASD was introduced in Japan in 2005. Until 2010, the procedure was available only in pediatric cardiology hospitals. We started to perform percutaneous closure in 2011, when the procedure was approved for adult cardiology programs. Thus, before 2011, the only treatment option for patients with secundum ASD was surgery.

Figure 1.

Number of procedures by calendar year. Bar chart demonstrating the number of procedures in 2 groups: percutaneous (device) closure and minimally invasive cardiac surgery (MICS) for secundum atrial septal defect.

Since 2011, the selection of the most appropriate treatment was based on consensus decision of the hospital’s Heart Team, consisting of interventional cardiologists, cardiac surgeons, and cardiologists performing cardiac ultrasonography. Patient selection was mainly based on the location of the ASD and the presence of rims around it on transesophageal echocardiographic evaluation.13 In particular, for those patients with (1) multiple ASDs unsuitable for percutaneous closure, (2) an ASD too large for percutaneous closure, specifically with a diameter >38 mm, or (3) deficient rims, specifically a rim diameter <5 mm (except for patients with single absence of anterior rim), surgical closure was preferred.

For percutaneous closure, we used the Amplatzer Septal Occluder (St. Jude Medical, St. Paul, MN, USA). Aspirin (100 mg) and clopidogrel (75 mg) were started on the day before the procedure and continued for 6 months. We used transesophageal or intracardiac echocardiography as an ultrasonographic imaging tool during the procedure.

Right mini-thoracotomy MICS was performed under general anesthesia with transesophageal echocardiographic guidance. The main working port was made at the 4th right intercostal space with a 6- to 8-cm skin incision. An additional port for the surgical endoscope was placed. Carbon dioxide was instilled in the chest cavity and cardiopulmonary bypass was established with peripheral cannulations through the femoral artery and vein. An additional superior vena cava drainage cannula was placed directly through the working port or with percutaneous cannulation of the right internal jugular vein. The pericardium was opened, avoiding the phrenic nerve. The ascending aorta was cross-clamped with a flexible direct clamp, and antegrade cardioplegia was given to achieve cardiac arrest. After control of the superior and inferior venae cavae, the right atrium was opened and the ASD was exposed with a retractor or retraction suture. The ASD was closed with either a fresh autologous pericardial patch or direct suture. Following a leak check with lung inflation, the right atrium was closed. The ascending aorta was unclamped and cardiopulmonary bypass was weaned off (Figure 2).

Figure 2.

Intraoperative photograph of minimally invasive cardiac surgery for secundum atrial septal defect. The cardiac surgeons work through the port, while looking at the monitor screen onto which the image is projected from a camera inserted through the port (A). The main working port (black arrow) was made in the 4th right intercostal space and an additional port (white arrow) was for the surgical endoscope (B).

Definitions

Mortality was defined as death at any time before discharge from the hospital or within 30 days of treatment. Patients were considered to have successful ASD closure if they had no, trivial, or small residual shunts assessed by color Doppler echocardiography at 1 month after discharge. Major complications included myocardial infarction, cerebral infarction, cardiac perforation with tamponade, pulmonary edema, repeat operation, wound infection, device embolism, bradyarrhythmia requiring permanent pacemaker implantation, or new-onset atrial arrhythmia requiring electronic or pharmacologic cardioversion. Minor complications included anemia requiring blood transfusion, pericardial effusion, pneumothorax, pleural effusion requiring thoracentesis, transient atrial arrhythmia, wound hematoma, and respiratory infection. Details about the definitions of complications are in Appendix S1. Tricuspid regurgitation (TR) was graded according to American Society of Echocardiography recommendations on a 3-point scale: grade 0, no TR; grade 1, mild TR; grade 2, moderate TR; grade 3, severe TR.

Statistical Analysis

Continuous variables are expressed as mean±SD or as median (interquartile range) for non-normally distributed data. Categorical variables are expressed as frequencies and percentages. Student’s t-test was used to compare continuous variables that were then confirmed using Mann-Whitney U tests for non-normally distributed data. A chi-square analysis or the Fisher exact test was used to compare categorical variables. The Mann-Whitney U test was used to compare ordinal variables. A P-value <0.05 was considered statistically significant. Multiple logistic regression modeling was performed to determine the independent predictors of major and minor complications, with purposeful selection of covariates. Variables with a P-value <0.1 in the univariate analysis and those judged to be of clinical importance from previous published reports were included in the multivariate model using forward selection. Results are reported as odds ratios (OR) with associated 95% confidence interval (CI) and P-values. Statistical analysis was performed using SPSS software (version 22.0, SPSS Inc., Chicago, IL, USA).

Results

Patients’ Characteristics

Baseline clinical characteristics are shown in Table 1. Patients in the percutaneous group were older. The size of the ASD was larger and the Qp/Qs ratio was higher in the MICS group. There were more female patients in the MICS group. Patients treated with percutaneous closure were more likely to have congestive heart failure before treatment, and had a higher incidence of hypertension.

Table 1. Baseline Data Before Atrial Septal Defect Closure
  Amplatzer
(n=134)
MICS
(n=220)
P value
Age (years) 52.4±19.7 40.6±15.7 <0.001
 >70 years, n (%) 28 (21) 6 (3) <0.001
Female, n (%) 82 (61) 165 (75) 0.006
Height (cm) 159.3±11.3 160.0±8.5 0.8
Weight (kg) 55.0±13.5 55.3±11.2 0.9
Medical history
 CHF, n (%) 53 (40) 52 (24) 0.001
 CAD, n (%) 8 (6) 6 (3) 0.1
 TIA/stroke, n (%) 4 (3) 4 (2) 0.4
 Hypertension, n (%) 23 (17) 18 (8) 0.01
 Diabetes mellitus, n (%) 7 (5) 5 (2) 0.2
 Preexisting AF/AFL, n (%) 23 (17) 24 (11) 0.11
Right heart catheterization data
 Qp/Qs 2.2±0.8 2.8±1.0 <0.001
 PA systolic pressure (mmHg) 31.5±10.4 29.2±9.5 0.110
Echocardiographic data
 ASD size (mm) 17.7±6.3 21.1±7.7 <0.001
 LVEDD (mm) 41.1±5.7 39.1±4.4 <0.001
 LVESD (mm) 25.9±5.2 25.0±3.6 0.071
 TR grade 1.8±0.7 1.7±0.7 0.415
 Mild TR, n (%) 65 (48.5) 112 (50.9) 0.661
 Moderate TR, n (%) 20 (14.9) 26 (11.8) 0.399
 Severe TR, n (%) 3 (2.2) 2 (0.9) 0.304
 Multiple ASD, n (%) 3 (2) 12 (5) 0.1

Data are shown as the mean±standard deviation or as n (%). AF, atrial fibrillation; AFL, atrial flutter; ASD, atrial septal defect; CAD, coronary artery disease; CHF, congestive heart failure; LVEDD, left ventricular end-diastolic diameter; LVESD, left ventricular end-systolic diameter; MICS, minimally invasive cardiac surgery; PA, pulmonary artery; TIA, transient ischemic attack; TR, tricuspid regurgitation.

Clinical Outcomes in the Percutaneous and MICS Groups

The success rate was 98% for the percutaneous group and 100% for the MICS group. For the percutaneous group, the ASD was too large for the available device in one case, and the atrial rim was insufficient in the other case. These 2 patients were later treated with MICS. In the MICS group, there was no conversion to a full sternotomy. Tricuspid annuloplasty (TAP) was performed in 17 cases (7.8%) of severe or moderate TR. Total cardiopulmonary bypass time averaged 49±20 min (95% CI: 47–52). The length of hospital stay was significantly shorter with percutaneous closure than with MICS (3.6 vs. 7.3 days, P<0.001) (Figure 3). TR grade improved equally (P=0.240) after closure in the MICS group (1.7±0.7 vs. 1.3±0.6), and the percutaneous group (1.8±0.7 vs. 1.4±0.6). The incidence of persistent TR, more than moderate, was limited to 2% in both groups (Figure 4).

Figure 3.

Bar chart showing the length of hospital stay in 2 groups: percutaneous (device) closure and minimally invasive cardiac surgery (MICS) for secundum atrial septal defect.

Figure 4.

Changes in the severity of tricuspid regurgitation in 2 groups: percutaneous (device) closure and minimally invasive cardiac surgery (MICS) for secundum atrial septal defect. Stacked bar chart demonstrating the percentage change in severity before and after atrial septal defect closure in the 2 groups.

Major complications in the groups are shown in Table 2. There were no deaths in either group. Major complications occurred in 2 patients (1.5%) in the percutaneous group and in 8 patients (3.6%) in the MICS group (P=0.2). In the device group, there was 1 case of pulmonary edema requiring intravenous diuretics after the procedure. Device embolization occurred in 1 case on the day of the procedure. The device was percutaneously retrieved with a snare device and a new device was successfully implanted. There were no cases of device-related cardiac tamponade or device embolism requiring surgery. In the MICS group, cerebral infarction occurred in 3 patients (1.4%) and 1 patient (0.5%) required repeat surgery for bleeding.

Table 2. Major Complications After Atrial Septal Defect Closure
  Amplatzer
(n=134)
MICS
(n=220)
P value
Mortality, n 0 0 >0.9
Major complications (total), n (%) 2 (1.5) 8 (3.6) 0.33
Permanent pacemaker implantation, n (%) 0 1 (0.5) 1
Atrial arrhythmia (requiring cardioversion), n (%) 0 1 (0.5) 1
Device embolism (requiring surgery), n (%) 0 0 >0.9
Device embolism (percutaneous removal), n (%) 1 0 0.379
Cerebral infarction, n (%) 0 3 (1.4) 0.30
Cardiac tamponade, n (%) 0 0 >0.9
Pulmonary edema, n (%) 1 (0.7) 2 (0.9) 1
Repeat surgery, n (%) 0 1 (0.5) 1
Wound infection, n (%) 0 2 (0.9) 0.50
Procedural MI, n (%) 0 1 (0.5) 1

Data are shown as n (%). MI, myocardial infarction; MICS, minimally invasive cardiac surgery.

Minor complications were significantly fewer with percutaneous closure than with MICS (Table 3) (11.2% vs. 20.9%, P=0.02). The most common minor complication was cardiac arrhythmia in the MICS group and access site hematoma in the percutaneous group.

Table 3. Minor Complications After Atrial Septal Defect Closure
  Amplatzer
(n=134)
MICS
(n=220)
P value
Minor complications (total) 15 (11.2) 46 (20.9) 0.02
Transient atrial arrhythmias, n (%) 4 (3.0) 18 (8.2) 0.05
Device embolism (percutaneous removal), n (%) 0 0 1
Pericardial effusion, n (%) 0 3 (1.4) 0.3
Pneumothorax, n (%) 0 8 (3.6) 0.03
Hematoma, n (%) 5 (3.7) 6 (2.7) 0.8
Blood transfusion, n (%) 1 (0.7) 5 (2.3) 0.4
Respiratory infection, n (%) 2 (1.5) 4 (1.5) 1
Pleural effusion, n (%) 0 5 (2.2) 0.2
Headaches, n (%) 4 (3.0) 0 0.020

Data are shown as n (%). MICS, minimally invasive cardiac surgery.

Multivariate Analysis for Predictors of Complications

The results of multivariate logistic analysis of overall complications are shown in Table 4A. On logistic regression multivariate analysis, MICS (OR: 2.91, 95% CI: 1.46–5.81; P=0.002) and age >70 years (OR: 3.50, 95% CI: 1.40–8.75; P=0.008) were independent predictors of combined major and minor complications. Next, to evaluate the effect of changes in the quality of MICS in the past decade, we also performed multivariate analysis of patients who underwent either surgery or percutaneous closure after 2011. The results were consistent with the overall cohort (Table 4B).

Table 4. Univariate and Multivariate Analysis of All Complications After Atrial Septal Defect Closure (A), Subanalysis of ASD Patients After 2011 (B)
  Univariate Multivariate
OR 95% CI P value OR 95% CI P value
(A)            
MICS 2.13 1.17–3.87 0.01 2.91 1.46–5.81 0.002
Age >70 1.84 0.84–4.06 0.13 3.50 1.40–8.75 0.008
Female sex 1.01 0.57–1.79 0.99      
Weight (kg) 1.01 0.99–1.03 0.50      
CAD 0.60 0.18–1.94 0.39      
Hypertension 1.00 0.44–2.27 0.99      
Diabetes mellitus 0.72 0.19–2.72 0.63      
CHF 0.88 0.50–1.55 0.65      
Qp/Qs 1.29 0.99–1.66 0.05      
PA systolic pressure (mmHg) 1.03 1.00–1.05 0.05      
Preexisting AF/AFL 0.58 0.29–1.18 0.13      
ASD size (mm) 1.0 0.97–1.05 0.99      
(B)            
MICS 2.47 0.99–6.19 0.05 3.47 1.28–9.38 0.014
Age >70 2.56 0.98–6.64 0.05 3.50 1.29–10.27 0.014
Female sex 1.22 0.49–3.01 0.66      
Weight (kg) 0.98 0.94–1.01 0.29      
CAD 1.39 0.27–6.97 0.68      
Hypertension 0.94 0.29–6.97 0.68      
Diabetes mellitus 0 0 0.99      
CHF 1.00 0.41–2.42 0.99      
Qp/Qs 1.36 0.89–2.07 0.14      
PA systolic pressure (mmHg) 1.03 0.99–1.07 0.12      
Preexisting AF/AFL 2.01 0.75–5.34 0.16      
ASD size (mm) 0.97 0.90–1.04 0.41      

Univariate analysis was performed with all the variables listed in the Table. Multivariate logistic regression was performed by forward selection to calculate the OR and 95% CIs. CIs, confidence intervals; OR, odds ratio. Other abbreviations as in Tables 1,2.

Discussion

Our study had 5 major findings. First, both percutaneous closure and MICS had high success rates without deaths. Second, the length of hospital stay was shorter with percutaneous closure. Third, the occurrence of major complications tended to be higher with MICS. Fourth, the incidence of minor complications was significantly lower with percutaneous closure. Fifth, age over 70 years and MICS closure were independent predictors of total complications.

Specific Complications in the 2 Groups

Several studies have compared standard surgical closure with percutaneous closure, and reported lower rates of complications and shorter hospital stay with percutaneous closure.4,1416 In 2011, Butera et al reported in a meta-analysis that treatment by percutaneous approach had a significantly lower rate of early complications compared with surgery.14 The results of our study confirm the results of these previous studies. The difference in the occurrence of complications between the percutaneous closure and MICS groups could be attributed to the higher incidence of atrial arrhythmia in the MICS group. In a 2012 report comparing transcatheter and surgical closure, the odds of significant arrhythmia tended to be greater with surgical closure.17 Atrial tachycardia is common after surgical closure, and isthmus-dependent atrial flutter was reported to be one of the predominant mechanisms.18 Surgical incision of the atrial myocardium may result in scar tissue formation, which can induce various atrial arrhythmias.

In the MICS group, the incidence of pneumothorax was 3.6%. Sebastian et al reported similar results.19 Dabritz et al reported 4 complications (right pleural effusion, right pneumothorax, and atelectasis of the right lung) in 87 patients treated with right thoracotomy MICS.20 These complications are related to right thoracotomy and the inherent disadvantages of MICS. Right thoracotomy MICS was intended to minimize surgical invasion by avoiding full sternotomy, but still requires cardiopulmonary bypass, thoracotomy, and cardiotomy, which could lead to the occurrence of these complications.

We experienced a 1.4% (3 patients) incidence of postoperative cerebral infarction in the MICS group, which is similar to past reports of MICS for mitral valve surgery.21 These events could be related to the endo-clamp, mode of perfusion and peripheral vessel cannulation. Glauber et al demonstrated a 4-fold increase in postoperative cerebral infarction and delirium with the use of retrograde perfusion compared with anterograde perfusion.21 Peripheral perfusion has been well established as the cardiopulmonary bypass of choice for MICS.22 Our cardiac surgeons’ group recently reported the safety of alternative perfusion access including the right subclavian artery, a side-arm graft for femoral cannulation, and central aortic cannulation to avoid the risk of postoperative cerebral infarction.23 However, the mode of perfusion is unlikely to be the cause of cerebral infarction in our study, because all 3 patients developed cerebral infarction more than 1 day after MICS operation.

One possible explanation could be embolic strokes caused by perioperative atrial fibrillation (AF). Patients who developed postoperative cerebral infarction in our study had paroxysmal AF before the MICS operation. The relationship between perioperative AF and cerebral infarction has been clearly established and the emboli primarily arise from thrombus originating in the left atrial appendage.24,25

The Cox-Maze procedure with surgical left atrial appendage closure, which was only performed in 16% of the patients with preoperative AF in our study, may have prevented postoperative stroke.2628 However, these procedures would be challenging during the MICS operation from a small right mini-thoracotomy. Likewise, Gammie et al reported a lower rate of AF correction surgery among patients undergoing less-invasive mitral valve surgery compared with those undergoing conventional mitral surgery.29 Pulmonary vein isolation or left atrial appendage closure in these patients could have prevented these events. Currently, as a preventive measure, we prescribe warfarin for 3 months to every patient after MICS surgery. In addition, we recommend patients undergo catheter ablation before ASD closure, which has been proven as an effective strategy,30 although freedom from AF was reported to be lower than with the Maze procedure.31 It should be also noted that the importance of concurrent Maze or catheter ablation depends on the type of preoperative AF. Although hemodynamic correction after ASD closure succeeded in maintaining sinus rhythm in 88% of patients with paroxysmal AF, it was not effective for patients with persistent AF, with an 18% success rate.32

On the other hand, cardiac erosion and device embolization are 2 serious complications of device closure.33,34 Cardiac erosion is a rare, but serious complication with an incidence of 0.1–0.3%.35 The majority of erosions occur within 5 days of the procedure. Therefore, we keep patients in hospital during this period. However, erosions can occur years after implantation.36 Deficient atrial rims and the use of oversized devices have been reported as risk factors of erosion.37 In our study, there were no cardiac erosions, but we experienced 1 case of device embolization. The incidence of device embolization was reported to be 0.55% in the Amplatzer device proctors survey.25 Undersizing of the device and inadequate rims around the ASD are predominant causes of complications. In our case, the first device was clearly undersized. Operators should be well-versed in bailout techniques.

The occurrence of new-onset migraine attacks after device closure is another limitation of the technique, and is reported to occur in approximately 15% of cases following the procedure.3840 Rodes-Cabau et al demonstrated in a randomized trial that the use of clopidogrel and aspirin, compared with aspirin alone, resulted in a lower frequency of migraine attacks.41 In our study, the occurrence of migraine attacks was merely 3%, all of which were mild. The standardization of dual antiplatelet therapy in our practice could have reduced the migraine attacks.

Changes in TR Severity

Our echocardiographic results on TR agreed with the fact that both strategies were effective in decreasing TR severity.42 Tricuspid valve repair is recommended for patients with significant TR, undergoing surgical ASD closure,2 wherein persistent tricuspid insufficiency, more than moderate, after ASD closure has been suggested to be related to poor prognosis.43,44 However, in accordance with the study by Nakagawa et al,45 in the present study, for those patients who had moderate or severe TR before percutaneous closure, TR severity was improved for most (87%; 21 of 23) of the patients. The incidence of persistent TR in our study was lower than that reported by Toyono et al in 2009.42 This difference could be attributed to the comparatively lower systolic pulmonary artery pressure before closure seen in our study (31.5±10.4 vs. 45±15 mmHg before percutaneous closure and 29.2±9.5 vs. 41±10 mmHg before surgery), because a pulmonary artery pressure >60 mmHg was considered to be a predictor of persistent TR.42 Our finding may lend support to the view that TR severity does not necessarily become an exclusion criterion for the choice of percutaneous closure.45 Preferably, we currently base our decision on multiple aspects, such as age and tricuspid valve anatomy, upon deciding whether concomitant tricuspid valve repair surgery is required.

Effect of Age

Patients treated with the MICS procedure had a larger defect, yet the percutaneous group more frequently had congestive heart failure before closure. This could be largely ascribed to the fact that the patients in the percutaneous group were older. In patients with secundum ASDs, pulmonary hypertension and heart failure develop slowly.46 In ASD patients with decompensated heart failure, AF or atrial flutter is frequently associated, and typically occur at >40 years of age.47

In our study, older age was an independent predictor of complications. Masutani et al reported that percutaneous closure of the ASD in the elderly resulted in deterioration of left ventricular relaxation and a marked rise in left ventricular filling pressure.48 Thus, whether percutaneous or surgical closure is chosen, ASD patients with right ventricular enlargement should be treated at a younger age, before the development of age-related left ventricular diastolic dysfunction.

To the best of our knowledge, this study is the first to directly compare contemporary MICS and percutaneous closure. We hope that this study contributes to improved risk assessment of patients undergoing ASD closure and provides guidance in determining management. Based on these findings, patients are likely to benefit from percutaneous closure because of the avoidance of procedural complications. Device closure is less invasive than MICS, but not all ASDs are amenable to percutaneous closure. In cases of insufficient rims around the ASD, MICS is the treatment of choice.

Study Limitations

First, this was an observational retrospective study. As it was not a randomized study, there was clearly a selection bias. Therefore, we cannot exclude residual selection bias, which might have affected our results. A large, randomized clinical trial is necessary to compare strategies without bias. However, such a trial would be difficult to conduct for ethical and pragmatic reasons. Second, as we do not have complete data on longer-term follow up, we were only able to report in-hospital and short-term outcomes. The lack of long-term data is a significant limitation. Third, the study population was limited to Japanese patients, and our results may not be directly applicable to other ethnic groups. Furthermore, as this was a single-center study, the results may not be generalizable to other settings/institutions. Therefore, differences in the patterns of practice may have influenced the observed results. For example, the length of hospital stay was longer in both groups compared with previous reports from Western countries. Physicians in Japan prefer to keep their patients longer in hospitals to monitor postoperative complications. However, we should make an effort to shorten the length of hospital stay with respect to the hospital expenses. Finally, data currency is a potential concern because we used data from 2000 to 2013 for the MICS patients. However, it is debatable as to whether the MICS procedure has changed enough over the past decade to expect important differences in our results if we had restricted our study to more recent data. Despite these limitations, we believe that this study contributes to the decision making of the choice of closure strategy for secundum ASD.

Conclusions

Percutaneous closure and MICS had high success rates without deaths. Percutaneous closure was associated with fewer complications and shorter hospital stay. Our study confirms the superiority of percutaneous closure of secundum ASD with anatomically suitable features. MICS ASD closure and older age were associated with increased risk for procedural complications.

Disclosures

The authors have no conflicts of interest to disclose.

Acknowledgments

The authors thank the cardiac echo laboratory and cardiac catheterization laboratory staff for their support.

Funding Sources

None declared.

Conflict of Interest

No relationship with industry.

Supplementary Files

Supplementary File 1

Appendix S1. Definitions of major and minor complications after atrial septal defect closure

Please find supplementary file(s);

http://dx.doi.org/10.1253/circj.CJ-16-0904

References
 
© 2017 THE JAPANESE CIRCULATION SOCIETY
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