This document discusses atrial septal defects (ASD) in elderly patients and whether surgery or medical management is preferred. It notes that while early surgery leads to good outcomes in youth, results are less favorable in adults. For elderly patients, ASD closure can improve symptoms but risks precipitating acute heart failure due to abrupt rise in left ventricular preload. Device closure has lower risks than surgery and also yields benefits like reduced right heart volumes. For elderly patients with elevated left heart pressures, balloon occlusion testing and fenestrated closures may prevent heart failure following closure. The conclusion is that given lower risks, device closure is generally preferable to surgery for treating ASDs in elderly patients.

1. ASD In Elderly-
Surgery Or Leave It
Alone?
Dr. Rahul Arora
1st Year PDT
Department Of Cardiology

2. Case 1
 A child of 10 years age with shunt Qp/Qs
=2:1with features of right volume overload.
what to do?

3. Case 2
 A female of 40 years age with shunt Qp/Qs
=2:1with volume overload but without any
other complication. what to do?

4. Case 3
 A male of 70 years age with shunt Qp/Qs
=2:1with atrial arhythmia. what to do?

5. HIGHLIGHTS
 Types of ASD?
 How elderly differ from young in
pathophysiology ?
 Clinical features difference
 Effects of comorbidities & pathophysiology on
treatment ?
 What type of asd is device closurable ?
 What type require surgery ?
 What type to be considered to be leave it
alone?

6. Introduction
 Secundum-type atrial septal defect (ASD) is
the most commonly encountered congenital
heart lesion in the elderly patient. 1
 There are three types of ASDs with three
different anatomical features: ostium
secundum, ostium primum and sinus venosus
ASDs.
 Early surgical repair results in excellent long
term outcome in young but less favourable
results were seen, when intervention was
carried out in adults. 2

7. Physiologic Consequences
 Shunt Flow
 Size of defect
 Relative compliance of ventricles
 Relative resistance of pulmonary/systemic circulation
 LR shunting results in diastolic overload of RV
and increased pulmonary blood flow
 RV dilatation/failure and rarely severe pulm HTN
(Eisenmenger’s) may ensue over time ~5%
 With age, deterioration chiefly due to 3
 decrease LV compliance, increased LR shunt
 increase in atrial arrhythmias
 pulm HTN develops, RV volume + pressure OL

8.  Elderly patients have high filling pressures d/t
 LV diastolic dysfunction
 HTN
 IHD
 Renal disease
 ASD provides a protective effect by acting as a
pop up valve in this hemodynamic setting.

9. Clinical Symptoms
 Often asymptomatic until 3-4th decade for moderate-
large ASD, may present later in life for initially smaller
ASD
 Fatigue
 DOE
 Atrial arrhythmias
 Paradoxical Embolus
 Recurrent Pulmonary infections
Humenberger et al reported that elderly(>60 years)
patients had higher prevelance of symptoms, atrial
fibrillation, tricuspid regurgitation, comorbidities and
also had higher PA pressures as compared to young
patients. 4

10. Treatment
 Medical : diuretics, ACEI, Aldactone
 Repair
 Consider when sxs, Qp:Qs>1.5
 Surgical
 Mortality 1-3% in most series
 PVR > 6-8 Woods Units - Contraindication
 Interventional
 Only for secundum defects
 94-96% success (Amplatzer)

11. Asd closure vs medical
management
 Adult patients with unrepaired ASDs are at
increased risk of cardiovascular events.
 Rosas et al followed 200 unoperated adult
patients for 1.6 to 22 years and observed 37
events(18.5%) of which 5 were due to sudden
death, 7 had heart failure, 13 had severe
pulmonary infections, 5 had embolic events
and 4 had strokes.
 Age at presentation, pulmonary HTN and
arterial O2 saturation were predictors of poor
outcome.

12. Asd closure in elderly: harm or
benefit?
 Harjula et al reported operative mortality of 6%
and major postoperative complications in 24 % of
patients older than 60.
 However there was symptomatic improvement
and significant reduction in mean PA pressure in
all surviving patients.
 Another study compared 3 different patient age
groups (<40 years;78 patients, 40 to 60 years;84
patients and > 60 years;74 patients)undergoing
transcatheter asd closure and showed an
improvement in symptoms in all groups with
reduction of PA pressure and RV size without
increase in mortality.

13. Surgery vs medical
 A prospective randomized trial compared surgical and
medical therapy in 473 patients (> 40 years)followed
for median duration of 7.3 years. There was trend
towards higher sudden death, congestive heart failure
and overall mortality in medical arm.
 In another retrospective study( mean age 54+/-years),
the surgical closure of the defect significantly reduced
mortality from all causes.(RR 0.31).
 The adjusted 10 year survival rate of surgically treated
patients was 95% as compared to 84% for medically
treated patients.
 Importantly, incidence of new atrial arrythmia or of
cerebrovascular insults in the two groups was not
significantly different.

14.  Hanninen et al followed 67 patients( 19%
surgical closure and 81% device closure) with
mean age of 68 years( range 60-86 years) for
3.3 years.
 Asd closure was associated with
 quality of life comparable to age matched healthy
controls,
 ↓RVEDd,
 ↑LVEDd and
 improvement in biventricular function and NYHA
class
 but no change in prevelance of atrial arrhythmias

15.  Nyboe et al showed that symptoms, atrial
arrhytmias and RV dilatation were more
pronounced in the elderly(> 50 years), but
reversibilty is the same as in the young (<50
years)
 They also found 20 % absolute risk reduction
of atrial fibrillation in patients > 50 years age.
 Wilson et al also reported resolution of AF in
half of the patients post device closure.

16. AHF After ASD closure
 ↑ed risk due to abrupt elevation of lv preload
especially in elderly with LV dysfunction and ↑ed
LVED pressure.
 Temporary ballon occlusion : screeening tool to
predict any adverse hemodynamic changes that
would preclude closure of the ASD.
 Fenestrated closure: preserves the offloading
properties of the ASD, prevent secondary
pulmonary hypertension and possible pulmonary
edema.

17. Surgery vs device closure
 Surgery has higher mortality and complication
rates in elderly as compared to young.
 The study by jategaonkar et al assessed 96
patients older than 60 years who underwent
transcatheter ASD closure and demonstrated
limited but significant (mean 1 to 2 ml/kg per
min increase in peak oxygen consumption,
improvement in exercise capacity, post closure
reduction in RV enlargement as measured by
transthoracic echocardiography, and reduction
in functional class.

18.  Hanninen et al reported major complication rates
were 23% and 7% in the surgical and device
closure group, respectively. The beneficial effects
were similar in both groups with no procedural
related deaths.
 Rosas et al showed significantly higher primary
event rate( 25 % vs 13% ) drivent by moderate
bleeding, mild respiratory infection and
arrhythmias in surgical group as compared to
device closure. The event rate was higher in older
patients and those with systolic PA presssure > 50
mm Hg, but there was no mortality

19. Conclusion
 Elderly patients with ASDs almost always have
significant associated comorbidities.
 ASD closure is associated with significant improvement
in symptoms and is associated positive cardiac
remodeling even in elderly patients.
 Defect closure in patients with raised LV end diastolic
pressure may precipitate acute CHF in few patients.
 Test ballon occlusion may reliably predict the
hemodynamic consequences of ASD closure.
 Periprocedural anticongestive therapy and fenestrated
ASD closure should be considered in these patients.
 ASD closure decreases morbidity by improvement in
functional class and reduced respiratory infections and
may prevent paradoxical embolism, but with no
significant mortality benefit.

20. Final Verdict…………….
 Given the success rate of percutaneous
closure devices and lower complication rate as
compared to surgery, device closure may be
preferable in the elderly.

21. references
1. Lindsey JB, Hillis LD. Clinical update: atrial
septal defects in adults.Lancet.
2007;369:1244-46.
2. Murphy JG, Gersh BJ, McGoon MD, et al.
Long term outcome after surgical repair of
isolated atrial septal defect. Follow up at 27
to 32 years.N Engl J Med.1990;323:1645-50.
3. Perloff, NEJM 1995.
4. Humenberger M, Rosenhek R, Gabriel H, et
al.benefit of atrial septal defect closure in
adults: impact of age. Eur Heart
J2011;32:553-60.

22. THANK
YOU