J Thorac Cardiovasc Surg 2005;130:1483
© 2005 The American Association for Thoracic Surgery
Atrial septal defect in infancy: To close or not to close?
Shahzad G. Raja, MRCS
Department of Cardiac Surgery, Royal Hospital for Sick Children, Yorkhill NHS Trust, Dalnair St Glasgow G3 8SJ, United Kingdom
To the Editor:
I read with great interest the article by Lammers and associates
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advocating that closure of an atrial septal defect (ASD) should not be postponed to a later age if clinical problems that can be attributed at least in part to the ASD are present. However, a closer look at the historical cohort of Lammers and associates reveals that it is composed mainly of premature syndromic infants in whom the major issue is bronchopulmonary dysplasia and pulmonary hypertension rather than left-to-right shunt across the ASD.
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Hence the suggestion of the authors, in the opinion of this reader, is controversial.
Although ASD is the second most common congenital heart disease in children,
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there are still few unanswered questions related to the appropriate timing of closure. Because patients with even large ASDs are mostly asymptomatic, closure is recommended around 3 to 5 years of age, before the child goes to school. Postponing surgical intervention to this age also allows for spontaneous closure of the ASD in some children.
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In fact, there does not appear to be any significant benefit in ASD closure before 3 to 5 years of age in small- to moderate-sized defects.
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In the opinion of this reader, in the present era of better ventilator equipment and styles of ventilator management, along with widespread use of corticosteroids prenatally and surfactant, nitric oxide, and pulmonary vasodilator therapy postnatally, surgical ASD closure can be postponed in patients with compromised lung function unless all available means of improving lung function have been tried. Only when pulmonary compromising factors have been corrected will an attempt at surgical ASD closure in infancy be valid because even though mortality for major operations with cardiopulmonary bypass in infants with low weight has become low, a definite morbidity still persists.
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References
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- Lammers A, Hager A, Eicken A, Lange R, Hauser M, Hess J. Need for closure of secundum atrial septal defect in infancy. J Thorac Cardiovasc Surg 2005;129:1353-1357.[Abstract/Free Full Text]
- Dammann O, Leviton A, Gappa M, Dammann CE. Lung and brain damage in preterm newborns, and their association with gestational age, prematurity subgroup, infection/inflammation and long term outcome. BJOG 2005;112(suppl 1):4-9.[Medline]
- Radzik D, Davignon A, van Doesburg N, Fournier A, Marchand T, Ducharme G. Predictive factors for spontaneous closure of atrial septal defects diagnosed in the first 3 months of life. J Am Coll Cardiol 1993;22:851-853.[Abstract]
- Saxena A, Divekar A, Soni NR. Natural history of secundum atrial septal defect revisited in the era of transcatheter closure. Indian Heart J 2005;57:35-38.[Medline]
- McMahon CJ, Feltes TF, Fraley JK, Bricker JT, Grifka RG, Tortoriello TA, et al. Natural history of growth of secundum atrial septal defects and implications for transcatheter closure. Heart 2002;87:256-259.[Abstract/Free Full Text]
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