J Thorac Cardiovasc Surg 1999;118:679-680
© 1999 Mosby, Inc.
SURGERY FOR CONGENITAL HEART DISEASE |
Commentary
Jonathan J. Rome, MD,
Philadelphia, Pennsylvania
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Introduction
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It has been more than 20 years since the first report of successful transcatheter device closure of atrial septal defects (ASDs).
1 In the past decade, at least 6 different devices have been in widespread clinical trials; several are now approved for use in many countries. Past reports have compared catheter closure of ASDs with historical surgical series. Berger and associates are to be commended, because theirs is the first study in which an attempt has been made to compare concurrent results of surgical and device closure of ASDs. Surgery and device closure were each performed on 61 patients. Complications and efficacy of the 2 procedures were similar at hospital discharge except for a higher incidence of postprocedure atrial arrhythmias in the surgical group.
The limitations of this study highlight the difficulties in performing such a comparison at 1 center. The surgical group was composed entirely of patients who were deemed inappropriate for the Amplatzer device, in most cases because their ASDs were too large or had an inadequate rim of septum to secure the device. Over two thirds of the patients who ultimately underwent surgical closure had previously gone to the catheterization laboratory with the intent of device closure. Not surprisingly, patients who underwent surgery were older, had larger defects, and had bigger shunts than those who underwent device closure. The differences between the 2 treatment groups are of more than academic importance. As the authors note, they may be implicated as a cause for the higher incidence of atrial flutter and fibrillation after surgery. Even accepting the fact that there were major differences in patient population between the arms of this study, it seems very unlikely that surgery in a comparable group would have been associated with significantly fewer complications than device closure.
Although the limited follow-up of most reports may make it a bit overly enthusiastic to conclude that device closure is now the preferred method of ASD repair, it is reasonable and appropriate to conclude that device closure is a viable and acceptable means of closing appropriately selected ASDs. The fact that such a statement can be made is a testament to the remarkable advances made in the design and application of ASD closure devices over the past 10 years. Improvements that current devices incorporate include systems deliverable through sheaths small enough for very small children, materials increasingly resistant to fatigue, and self-centering characteristics that have reduced residual leaks after device closure. The diversity of designs should permit an increasing percentage of secundum defects to be successfully closed.
We can anticipate continued refinement of ASD closure devices in the near future. Along with improvements in technology, the field requires parallel improvements in our ability to select patients appropriate for device closure, minimizing the number who undergo catheterization unnecessarily. The thoughtful evaluation of these procedures demands carefully constructed prospective comparisons of catheter and surgical ASD closure. This is particularly true in light of recent changes in the surgical approach to ASD closure. Such studies cannot be accomplished by a single center and will be costly. Because they should not be restricted to a single type of device, industry will not support them. Thus such studies are likely to be conducted only with governmental funding.
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References
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King TD, Mills NL. Secundum atrial septal defect: nonoperative closure during cardiac catheterization. JAMA 1976;235:2506-9. [Abstract]
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Introduction
References