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J Thorac Cardiovasc Surg 1999;118:674-678
© 1999 Mosby, Inc.

SURGERY FOR CONGENITAL HEART DISEASE

COMPARISON OF RESULTS AND COMPLICATIONS OF SURGICAL AND AMPLATZER DEVICE CLOSURE OF ATRIAL SEPTAL DEFECTS

From the Klinik für Angeborene Herzfehler^a und Klinik für Herz-, Thorax- und Gefäßchirurgie,^b Deutsches Herzzentrum, Berlin, Germany.

Address for reprints: Felix Berger, MD, Deutsches Herzzentrum, Augustenburger Platz 1, 13353 Berlin, Germany (E-mail: fberger{at}dhzb.de).

	Abstract

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Objectives: Results and complications of surgical versus transcatheter treatment of atrial septal defect in the current era are compared.
Methods: All consecutive patients with a secundum atrial septal defect and a pulmonary/systemic flow ratio of 1.5:1 or more who presented between May 1997 and June 1998 were enrolled in this study. All patients except those who initially had defects not feasible for interventional occlusion were catheterized to allow interventional closure of the defects. All patients in whom interventional closure could not be performed underwent surgical closure.
Results: Sixty-one patients underwent surgery at a median age of 20 years (0.5-74 years) and 61 had the defect closed with an Amplatzer device (AGA Medical Corporation, Golden Valley, Minn) at a median age of 12 years (0.8-77.7 years) (P > .2). Hospital stay in surgically treated patients was 8 days (6-19 days) versus 3 days (3-14 days) in interventionally treated patients (P < .001). Atrial septal defect and shunt sizes were larger in the surgical group ( P < .001). Closure rates in the 2 groups were identical (98%). One patient (68 years) in the surgical group had a perforated duodenal ulcer that necessitated an operation 8 days after closure of the atrial septal defect, and 1 (26 years) had an infected lateral thoracotomy wound necessitating plastic surgery. Embolization of the Amplatzer device to the left ventricle was observed in 1 patient (29 years). The device could be retrieved from the heart, but vascular surgery was required to extract it from the femoral artery.
Conclusions: As complete closure rates and complications are identical, but duration of hospital stay is shorter with less morbidity, we prefer implantation of an Amplatzer septal occluder to surgery wherever possible.

	Introduction

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Cardiac surgery for closure of atrial septal defects (ASDs) has been practiced for more than 45 years and is the method of choice in most centers in which patients with ASDs are treated. Recently, a variety of devices for transcatheter closure of ASDs have become available ^1-6 and an increasing number of patients are treated with this alternative to surgery. ⁷

Complete closure of ASDs has been achieved less frequently with transcatheter techniques than with surgery. ⁸ On the other hand, surgery results in a significant morbidity. ⁹ However, no formal comparison has been reported concerning results, closure rates, morbidity, and complications of transcatheter and surgical closure of ASDs performed at the same time and in the same institution. The purpose of our study was to compare results and complications of both treatment modalities in patients with a defect in the oval fossa (ostium secundum ASD) with a pulmonary/systemic flow ratio (Qp/Qs) of 1.5:1 or larger who were treated during a 1-year period.

	Methods

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Patient selection.
This study comprised all consecutive patients referred to our hospital during the 1-year period starting on May 7, 1997 (the day of the first implantation of an Amplatzer septal occluder device [AGA Medical Corporation, Golden Valley, Minn] in our institution), with an isolated ASD located in the oval fossa (so-called secundum ASD) and a left-to-right shunt with a Qp/Qs of 1.5:1 or larger. Patients with associated partial anomalous pulmonary venous drainage or atrioventricular valve abnormalities were excluded. We also excluded patients with patent foramen ovale associated with a history of stroke or transient ischemic attacks, a small ASD with a left-to-right shunt (Qp/Qs) of less than 1.5:1, or a residual ASD after a previous operation.

The following patients were referred immediately to the surgeon without cardiac catheterization: (1) those in whom echocardiography revealed a single defect too large for occlusion, multiple defects unsuitable for interventional closure, or a defect too close to the superior vena cava, pulmonary veins, coronary sinus, or atrioventricular valves (predictable failure of interventional closure) and (2) those patients who objected to closure by a device (missing consent declaration). All others underwent cardiac catheterization with angiography and balloon sizing of the ASD so that interventional occlusion could be performed.

At cardiac catheterization, standard fluid-filled catheters were used and the Qp/Qs flow ratio was measured by oximetry by means of the Fick principle. The size of the ASD was determined with balloon catheters. To determine the size of the ASD, we used the size of the balloon deformed by the ASD monitored by transesophageal echocardiography as it was pulled through the ASD in all 108 patients who went to the catheterization laboratory. The largest balloon that could be pulled through the defect was considered to represent the balloon-stretched size of the ASD. ¹⁰ In the remaining 14 patients, who did not undergo cardiac catheterization, the size of the ASD was measured only by transesophageal echocardiography before the operation, but without balloon sizing.

All patients gave written informed consent to Amplatzer device closure, and the implantation protocol had been approved by the local institutional review board. The technical details of the implantation of the Amplatzer device have been described elsewhere. ^6,7,11 A 7F or 8F long sheath was used to deliver the Amplatzer device. Transesophageal echocardiography with a multiplane transesophageal probe interfaced with a Vingmed 800 (Vingmed Sound, Horten, Norway) sector scanner or a monoplane probe interfaced with a Siemens Sonoline 1200 (Siemens, Erlangen, Germany) sector scanner to monitor device placement was performed in all. The following patients were referred to the surgeon: patients with a single ASD and a balloon-stretched ASD diameter of more than 26 mm, those with multiple ASDs, and those with a distance of less than 5 mm between the margins of the ASD and the mitral or tricuspid valves, superior vena cava, right upper pulmonary vein, and coronary sinus. All patients were sedated with intravenous midazolam in a dose of 0.1 to 0.2 mg/kg 30 minutes before entering the catheterization laboratory. This dose was followed by a continuous infusion of propofol (3-5 mg/kg per hour) during the procedure. Neither endotracheal intubation nor mechanical ventilation was required in any patient.

Patients who underwent surgery were operated on under general anesthesia with the aid of cardiopulmonary bypass. The right atrium was opened after a median thoracotomy. The ASD was closed either by direct suture (n = 9) or by a pericardial patch (n = 52). In 13 (41%) of 29 female patients older than 12 years, a lateral thoracotomy was used. Before hospital discharge all patients underwent complete physical examination, color Doppler echocardiographic study, and chest radiography. In the patients with Amplatzer occluder treatment, chest radiography was repeated at the 3-month follow-up visit. A residual ASD was considered to be present if color Doppler flow mapping performed on the day of hospital discharge revealed a left-to-right shunt across the atrial septum.

Statistical analysis.
Results are expressed as median, range, and 25% and 75% quartiles, respectively. Also, the differences between the medians have been calculated, as has an estimate of the 95% confidence interval around that difference. A bootstrap method was used to calculate that 95% confidence interval. ¹² The Mann-Whitney U test was used to compare the group treated by surgery with the one treated by catheter intervention. Only ASDs that had been measured by balloon sizing were compared between the 2 groups. To prove both methods, the 95% confidence interval for a difference of event rates was calculated by means of the Fleiss formula. ¹³ The surgical and interventional methods showed equivalent success with respect to frequency of atrial arrhythmias and evidence of residual shunt if the 95% confidence interval lies between –0.1 and 0.1. ¹⁴

	Results

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Among the 122 unselected consecutive patients with an ASD, 14 were primarily referred to the surgeon without cardiac catheterization (1) because of the predictable failure of interventional closure (large single ASD or multiple ASDs unsuitable for interventional closure by echocardiography, n = 8; ASD close to the superior vena cava, n = 2) or (2) because the patient did not consent to interventional closure (n = 4). The other 108 patients were sent to the catheterization laboratory with the intention to treat the ASD by device closure. In 61 patients device closure was successful, and in 47 device closure was impossible because of the large size of the defect (n = 28), multiple defects (n = 8), or location of the defect too close to the inferior vena cava (n = 5), too close to the superior vena cava (n = 2), too close to the coronary sinus (n = 2), or too close to the atrioventricular valves (n = 2).

Patients’ data are summarized in Table I. Median age at intervention in the 61 patients undergoing Amplatzer device closure was 12 years (0.8–77.7 years), with 19 patients being older than 18 years, whereas in the patients undergoing surgery the median age was 20 years (0.5–74.0 years), with 34 patients being in the adult age group (P > .2). Duration of follow-up in the group treated by surgery was 8 months (2-13 months) and in the group treated by intervention, 7 months (1-13 months) (P = .19). The 5 patients who were treated by either method in the first 2 years of life had symptoms consisting of failure to thrive, frequent chest infections, or both. The patients who underwent surgery had a larger ASD with a larger shunt than those who had an Amplatzer device implanted (Table I). In the surgical group, shunt size could be calculated in only 47 of the 61 patients who underwent cardiac catheterization; the other 14 patients were not catheterized before the operation. Complete closure of the ASD was achieved in 98% of patients with both methods (Table I).

Complications of surgery and Amplatzer implantation were rare and are summarized in Table II. Only those atrial arrhythmias that occurred de novo from sinus rhythm before closure were considered a complication of treatment. The 10 patients with arrhythmias were successfully treated by cardioversion (n = 4) or administration of verapamil (n = 2) and sotalol (n = 2). Two patients have persistent atrial fibrillation and are receiving warfarin sodium.

	Discussion

Top Abstract Introduction Methods Results Discussion Conclusions References

 
Our data show that 50% of unselected secundum ASDs with a minimum Qp/Qs ratio of 1.5:1 can be successfully treated by Amplatzer device implantation in patients ranging from infancy to more than 70 years old. The closure rate is identical for the 2 methods, and the residual ASDs were trivial and of no hemodynamic significance. As the closure rate with the new Amplatzer device is identical to that of surgery, comparison of the 2 methods should focus on morbidity. Prevalence of serious complications was identical, but absence of the need for blood products, morbidity, and length of hospital stay are in favor of Amplatzer device closure.

Complications of surgery.
Mortality and morbidity of surgical closure of ASDs in the current era has recently been reported in detail. ⁹ As in our series, incomplete closure of the ASD after surgery is rare. ⁹ Mortality and serious morbidity are also rarely seen. ⁹ In the present series, surgical complications (Table II) occurred because of attempted minimally invasive repair with a lateral thoracotomy. ¹⁵ The exacerbation of a duodenal ulcer under stress in the hospital, however, could have happened without regard to the type of ASD closure. A minor but frequently observed morbidity is associated with the postpericardiotomy syndrome, ¹⁶ which did not lead to pericardial tamponade or the need for pericardiocentesis in our series. The occurrence of atrial flutter/fibrillation after closure of an intra-atrial communication was slightly more frequent in patients treated surgically (Table II), is known to increase with age, ¹⁷ as in the present series, and is probably related to the pre-treatment distention of the right atrium. ¹⁸ Morbidity unique to surgical therapy is related to the possible risks of blood transfusions, which were not required in patients undergoing Amplatzer device closure. Morbidity related to endotracheal intubation and general anesthesia required for surgery was not apparent in our patient group but is a potential hazard.

Complications of nonoperative closure.
Real and potential problems with device closure of ASDs have been reported, including early death after the procedure, possibly related to dislodgment of an iliac vein thrombus while the sheath was being advanced, ¹ late device dislocation with left atrial thrombus formation and systemic embolism, ¹⁹ failure to retrieve a misplaced device necessitating surgery, ²⁰ and incomplete closure of the ASD. ^1,2,3,7,11 The fact that previous experience with smaller patient numbers treated with the novel Amplatzer device ^7,6,11 did not include device embolization illustrates the need for multicenter studies in a large number of patients. The complication could not be attributed to our learning curve, because it occurred late in our experience after implantation of more than 100 Amplatzer devices. Embolization has previously been reported with the use of other devices ²¹ and, as in our case, was not associated with particularly large defects. Retrospectively, we assume that the rim of the ASD was too floppy to secure the device.

Incomplete closure can occur with the use of different devices, ^1,2,8 and its incidence may not be different with the Amplatzer septal occluder. ^6,7,11 This study, however, demonstrated a closure rate identical to that of surgery. One of the potential advantages of the Amplatzer septal occluder is the previously reported retrievability. ^6,11 Although retrieval was necessary in 1 patient, we were able to extract the embolized device from the left ventricle without damage to the cardiac valves; vascular surgery was necessary to retrieve it from the peripheral vessel.

Compared with published reports on alternative devices, ^2,5,21 the fluoroscopy time needed to implant the Amplatzer device appears to be short ⁶ (Table I). This time can be reduced further if more Amplatzer devices will be implanted with echocardiographic guidance alone without the need for fluoroscopy, completely avoiding any potential morbidity to the patient or operator from irradiation. ²²

In the future it may become possible to close multiple defects and those with a diameter larger than 26 mm. ²³

Limitations of this study.
We could not perform a randomized study designing patients to a particular treatment protocol, because the patients treated with surgery had larger defects, multiple defects, or defects too close to the atrioventricular valves, coronary sinus, and superior or inferior venae cavae. Second, access to the heart in the surgically treated patients was achieved in a different manner depending on age and sex of the individual patient and the individual surgeon’s preference. Third, the difference in shunt size may have influenced the incidence of postoperative atrial flutter/fibrillation. Fourth, the length of hospital stay after closure may vary from country to country, so that our result of a significant difference in length of hospital stay after surgery cannot necessarily be extrapolated to the medical systems of other countries.

This is a nonrandomized study with evidence of significant patient selection bias, which limits the possibility of comparing the 2 strategies and may influence our conclusions.

	Conclusions

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Despite the described limitations of this study, we conclude that Amplatzer device closure of ASDs is preferable to surgical closure whenever the anatomy of the ASD is suitable; closure rates of nonoperative ASD occlusion are identical to those of surgical closure, and complications with the 2 methods are comparable. We believe that transcatheter closure of ASDs with the Amplatzer septal occluder is a definite alternative to surgery in an increasing number of selected patients.

	Acknowledgments

 
We thank Dr Ulrich Mansmann of the Institute of Medical Statistics Epidemiology and Informatics at the Free University of Berlin for assistance with the statistical evaluation of the paper and Silke Uhlmann for aid in finishing the manuscript.

	References

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1. Rome JJ, Keane JF, Perry SB, Spevak PJ, Lock JE. Double-umbrella closure of atrial defects: initial clinical applications. Circulation 1990;82:751-8.[Abstract/Free Full Text]
   
2. Sideris EB, Sideris SE, Thanopoulos BD, Ehly RL, Fowlkes JP. Transvenous atrial septal defect occlusion by the buttoned device. Am J Cardiol 1990;66:1524-6.[Medline]
   
3. Das GS, Voss G, Jarvis G, Wyche K, Gunther R, Wilson RF. Experimental atrial septal defect closure with a new, transcatheter, self-centering device. Circulation 1993;88:1754-64.[Abstract/Free Full Text]
   
4. Pavcnik D, Wright KC, Wallace S. Monodisk: device for percutaneous transcatheter closure of cardiac septal defects. Cardiovasc Intervent Radiol 1993;16:308-12.[Medline]
   
5. Hausdorf G, Schneider M, Franzbach B, Kampmann C, Kargus K, Goeldner B. Transcatheter closure of secundum atrial septal defects with the atrial septal defect occlusion system (ASDOS): initial experience in children. Heart 1996;75:83-8.[Abstract/Free Full Text]
   
6. Berger F, Ewert P, Stiller B, Dahnert I, Krings G, Vogel M, et al. Initial clinical results with the Amplatzer Septal Occluder—a self-centering double-disc device for the occlusion of atrial septal defects. Z Kardiol 1998;87:185-90.[Medline]
   
7. Masura J, Gavora P, Formanek A, Hijazi ZM. Transcatheter closure of secundum atrial septal defects using the new self-centering Amplatzer septal occluder: initial human experience. Cathet Cardiovasc Diagn 1997;42:388-93.[Medline]
   
8. Rao PS. Transcatheter closure of atrial septal defect: Are we there yet? J Am Coll Cardiol 1998;31:1117-9.[Free Full Text]
   
9. Galal MO, Wobst A, Halees Z, Hatle L, Schmaltz AA, Khougeer F, et al. Peri-operative complications following surgical closure of atrial septal defect type II in 232 patients—a baseline study. Eur Heart J 1994;15:1381-4.[Abstract/Free Full Text]
   
10. Rao PS, Langhough R, Beekman RH, Lloyd TR, Sideris EB. Echocardiographic estimation of balloon-stretched diameter of secundum atrial septal defect for transcatheter occlusion. Am Heart J 1992;124:172-5. [Medline]
    
11. Thanopoulos BD, Laskari CV, Tsaousis GS, Zarayelyan A, Vekiou A, Papadopoulos GS. Closure of atrial septal defects with the Amplatzer occlusion device: preliminary results. J Am Coll Cardiol 1998;31:1110-6.[Abstract/Free Full Text]
    
12. Efron B, Diaconis P. Computer-intensive methods in statistics. Sci Am 1983;May:116-30.
    
13. Fleiss JL. In: Statistical methods for rates and proportions. 2nd ed. New York: Wiley & Sons; 1981. p. 79.
    
14. CPMP guidelines, CPMP/ICH/363/96. Note for guidance on statistical principles for clinical trials. London: The European Medicines Evaluation Agency; 1998. p. 3.3.2.
    
15. Black MD, Freedom RM. Minimally invasive repair of atrial septal defects. Ann Thorac Surg 1998;65:765-7.[Abstract/Free Full Text]
    
16. Yip AS, Chau EM, Chow WH, Kwok OH, Cheung KL. Pericardial effusion in adults undergoing surgical repair of atrial septal defect. Am J Cardiol 1997;79:1706-8.[Medline]
    
17. 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;333:469-73. [Abstract/Free Full Text]
    
18. Leier CV, Meacham JA, Schaal SF. Prolonged atrial conduction: a major predisposing factor for the development of atrial flutter. Circulation 1978;57:213-6.[Abstract/Free Full Text]
    
19. Lambert V, Losay J, Piot JD, Chevalier B, Bourdin T, Mace L, et al. Late complications of percutaneous closure of atrial septal defects with the Sideris occluder. Arch Mal Coeur Vaiss 1997;90:245-51.[Medline]
    
20. Agarwal SK, Ghosh PK, Mittal PK. Failure of devices used for closure of atrial septal defects: mechanisms and management. J Thorac Cardiovasc Surg 1996;112:21-6.[Abstract/Free Full Text]
    
21. Bridges ND, Hellenbrand W, Latson L, Filiano J, Newburger JW, Lock JE. Transcatheter closure of patent foramen ovale after presumed paradoxical embolism. Circulation 1992;86:1902-8.[Abstract/Free Full Text]
    
22. Ewert P, Daehnert I, Berger F, Kaestner A, Vogel M, Lange PE. Feasibility and safety of transcatheter closure of atrial septal defects under echocardiographic guidance without fluoroscopy. Cardiol Young 1999;9:136-40.[Medline]
    
23. Sideris EB, Leung M, Yoon JH, Chen CR, Lochan R, Worms AM, et al. Occlusion of large atrial septal defects with a centering buttoned device: early clinical experience. Am Heart J 1996;131:356-9.[Medline]
    

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