Evaluation Study
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Transcatheter closure of atrial septal defects in adults > or =40 years of age: immediate and follow-up results.

BACKGROUND: Controversy still exists regarding closure of atrial septal defects (ASDs) in patients >40 years of age who are largely asymptomatic or do not have large shunts (LS). If left unrepaired, the majority of patients will experience symptoms and will have a shorter life span compared to patients who undergo repair. This study presents the outcomes of closure of ASDs in adults >40 years using the Amplatzer septal occluder.

METHODS: A total of 113 patients (79F/34M) with a mean age of 57.9 years (SD 11.9) who had indications for closure (right ventricular [RV] enlargement by echocardiograpy, clinically symptomatic) underwent an attempt of transcatheter closure. The mean size of ASD as measured by transesophageal echocardiography (TEE) (30 patients) or intracardiac echocardiography (83 patients) was 17.2 mm (SD 7.3) with mean Qp:Qs of 2.2:1 (SD 1.1). Follow-up at 24 hours, 6 month, and yearly thereafter included physical examination, TEE, and/or transthoracic echocardiography; furthermore, chart review (n = 112) as well as telephone interviews (n = 56) were conducted to determine clinical symptomatic status.

RESULTS: The procedure was successful in 112 patients and 1 patient failed due to the presence of a large defect (44 mm). One hundred four patients had a single device implanted, 7 had two, and 1 had three. Following the procedure, 96 patients had immediate complete closure (CC), 3 had trivial shunt (TS), 11 had small shunt (SS), and 2 had moderate shunt (MS). At 24 hours postprocedure, 100 patients had CC, 7 had TS, 3 had SS, 1 had MS, and 1 had LS. Four patients had complications: one had device migration within 24 hours, two had atrial arrhythmias (supraventricular tachycardia, atrial tachycardia), and one had large hematoma. At 6 months postprocedure, 100 patients had CC, 6 had TS, 5 had SS, and 1 had MS. At 6-month follow-up, the right ventricle end-diastolic dimension decreased from 35.3 mm (SD 7.6) preprocedure to 23.8 mm (SD 6.6) (P < 0.001) and the majority of patients reported improvement in their symptoms.

CONCLUSIONS: ASD closure is safe and effective in patients over 40 years of age with minimal complications. The procedure resulted in a decrease in the RV size that was accompanied by improvement in clinical symptoms. Our findings suggest that device closure of ASDs in adult patients >40 years of age should be the first option of management.

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