J Thorac Cardiovasc Surg 2005;130:1483
© 2005 The American Association for Thoracic Surgery
Reply to the Editor
Astrid Lammers,
John Hess, MD, FESC
Klinik für Kinderkardiologie und angeborene Herzfehler Deutsches Herzzentrum München Technische Universität München Munich, Germany
We appreciate Dr Raja's interest in our recent study.
1
We agree that in asymptomatic children closure of an isolated secundum-type atrial septal defect (ASD II) should be undertaken after 4 to 5 years of age because this might allow for spontaneous closure and facilitate interventional closure in some patients. However, we describe a specific group of patients in whom symptoms have been at least in part related to the presence of an ASD II. In these patients with compromised lungs and rarefied pulmonary vasculature, even a minor left-to-right shunt is poorly tolerated, and early surgical closure could be beneficial.
Our catheter data showed that the majority of the children had a left-to-right shunt that varied in magnitude, as is demonstrated by the Qp/Qs ratio. The actual effect of the left-to-right shunt on the infant's clinical condition is difficult to assess. However, the ASD is an additional factor compromising the child's situation. One cannot treat lung hypoplasia or severe chronic lung disease, but an ASD is amenable to treatment.
There might be a subgroup of patients in whom closure of an ASD is contraindicated. In the presence of progressive pulmonary vascular disease, the existence of an ASD can improve survival.
2
Dr Raja suggests that surgical ASD closure in infancy should only be performed after all other compromising factors are corrected. Yet even in the current era of better ventilator management and use of antenatal corticosteroids, nitric oxide, and surfactant leading to improved survival of infants, correction of the lung-compromising factors is not always possible. Moreover, long-term hospitalization and prolonged ventilation of these children is associated with substantial morbidity, including barotrauma, hospital-acquired infections, and immobilization. Therefore we contend that a subgroup of infants can indeed benefit from early ASD closure. Careful patient selection, however, remains a clinical challenge and requires a multidisciplinary approach involving cardiologists, intensivists, and cardiothoracic surgeons to determine the right timing of ASD closure for each individual child.
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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]
- Rozkovec A, Montanes P, Oakley CM. Factors that influence the outcome of primary pulmonary hypertension. Br Heart J 1986;55:449-458.[Abstract/Free Full Text]
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