J Thorac Cardiovasc Surg 1999;118:678-679
© 1999 Mosby, Inc.
SURGERY FOR CONGENITAL HEART DISEASE |
Commentary
Fred A. Crawford, Jr, MD,
Charleston, South Carolina
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Introduction
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 Introduction
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Interventional catheter device closure of secundum atrial septal defects (ASDs) has become consistently feasible in recent years. Although it is logical that this technique might offer advantages over surgical closure, no real comparison of the 2 methods has been previously reported. As current catheter devices were being developed and refined, traditional surgical approaches were also being altered by the development of less invasive techniques such as partial sternotomies and much smaller skin incisions. Berger and colleagues have evaluated a consecutive series of 102 patients who underwent ASD closure with surgery (n = 61) or an Amplatzer device (n = 61) during a 1-year interval beginning May 1997. Their series begins with the first patient to undergo device closure in their institution. Although this evaluation was prospective, the patients were not randomized. The patients undergoing surgery were older and had larger defects and larger shunts. In fact, the surgical series essentially consisted of those patients in whom device closure was not possible. In addition, the median age of the patients in both groups was much older than that of the usual patient currently undergoing ASD closure. The ASD closure rate was 98% in each group, and there were no deaths. Two patients undergoing surgical treatment had significant complications, and in 1 patient the Amplatzer device embolized, requiring surgical retrieval. Length of stay was shorter in the patients receiving the Amplatzer device (3 days) than in those treated surgically (8 days). On the basis of the similar outcomes, the absence of need for blood products, and the decreased length of stay, the authors conclude that the Amplatzer device is preferable to surgical closure of ASDs.
Despite the fact that the series are concurrent and from the same institution, the report is flawed by the fact that the 2 groups are not comparable, as is pointed out by the authors. True randomization into comparable series could have been achieved by including only those patients who were suitable for either surgical or device closure, and the results would have been more meaningful. Most patients undergoing surgical closure of ASD now are discharged in 3 days or less, and it is unfair to use decreased length of stay in this series as a reason for the superiority of the Amplatzer device. However, in our institution, as noted below, most patients receiving the device are discharged in 24 hours. The authors have fairly presented one of the major complications of device closure, that is, embolization. Although uncommon, it is potentially the cause of a very unsatisfactory outcome (stroke or death) in a patient with a relatively benign defect. Despite these criticisms, the authors have indeed demonstrated the ability to successfully close secundum ASDs in about half of the patients with this problem.
At the Medical University of South Carolina over the past 23 months, 60 patients (aged 2-75 years) have undergone successful device closure of ASDs, and 97% were discharged in less than 24 hours (W. Radtke, personal communication). No significant complications have occurred. During the same interval, 16 patients were evaluated by echocardiography (without the need for catheterization, as in the series reported by Berger and associates) and were believed to be unsuitable for device closure. Because catheter device closure is much less invasive, this approach probably will become increasingly popular with pediatric cardiologists, patients, and families. With further experience and device evolution, this technique will become applicable in a larger proportion of patients with these defects than the 50% reported here. It is likely, however, that a significant subset will continue to have defects unsuitable for device closure; thus surgical intervention will still be required in that group. Surgical closure should continue to provide excellent results as in the past, but less invasive techniques offer the possibility of decreasing morbidity.
