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Lammers et al

Surgery for Congenital Heart Disease

Need for closure of secundum atrial septal defect in infancy
Astrid Lammers,a Alfred Hager, MD,a Andreas Eicken, MD,a Rüdiger Lange, MD,b Michael Hauser, MD,a and John Hess, MD, FESCa Objectives: Closure of isolated secundum atrial septal defect is generally recommended at the age of 4 to 5 years. However, there are children with isolatedsecundum atrial septal defect in whom early closure should be performed. We aimed to assess the underlying conditions that led to earlier closure in this special patient group and to analyze the outcome. Methods and Results: From January 1990 through August 2002, 24 infants with isolated secundum atrial septal defect underwent surgical closure within the first year of life. All children weresymptomatic. Signs of pulmonary hyperperfusion, such as tachydyspnea, failure to thrive, recurrent respiratory infections, or heart failure, were present. Four infants required artificial ventilation. Ten patients had additional problems, such as prematurity with chronic lung disease, hepatoomphalocele and congenital diaphragmatic hernia, which were present in 1 patient each. Eleven patients had defineddysmorphic syndromes. All but 1 infant underwent preoperative invasive hemodynamic evaluation. Thirteen patients had pulmonary hypertension preoperatively. The follow-up time was 46 33 months (range, 4-125 months). At follow-up, pulmonary artery pressure proved to be normal in 11 of the 13 children who had pulmonary hypertension previously. One patient died of persistent pulmonary hypertension.Clinical performance, growth, and development improved in nearly all patients. All ventilator-dependent children could be weaned shortly after atrial septal defect closure. Conclusions: If lungs are compromised, even a minor left-to-right shunt might be poorly tolerated in infancy. In these children early surgical closure of an isolated secundum atrial septal defect should be performed to supportthrive and growth and to prevent the onset of irreversible changes of the pulmonary vasculature.

Astrid Lammers

From Klinik für Kinderkardiologie und Angeborene Herzfehlera and Klinik für Herzund Gefä chirurgie,b Deutsches Herzzentrum München, Technische Universität München, Munich, Germany. Received for publication June 18, 2004; revisions received Sept 30, 2004; accepted for publication Oct11, 2004. Address for reprints: Astrid Lammers, Klinik für Kinderkardiologie und Angeborene, Herzfehler, Deutsches Herzzentrum München, Lazarettstrasse 36, 80636 München, Germany (E-mail: astridlammers@gmx. de). J Thorac Cardiovasc Surg 2005;129:1353-7 0022-5223/$30.00 Copyright © 2005 by The American Association for Thoracic Surgery doi:10.1016/j.jtcvs.2004.10.007


trial septal defect (ASD)is a common congenital heart defect with an incidence of 7%.1 Atrial left-to-right shunting is well tolerated in otherwise healthy children, and the majority of patients with isolated secundum atrial septal defect (ASD II) remain asymptomatic in infancy and childhood. Usually there is neither pulmonary hypertension nor an increase of pulmonary vascular resistance (PVR) at that age. Typically,closure of isolated ASD II is undertaken in the fourth or fifth year of life, preferably through interventional device closure.2 However, there is a group of patients who undergo ASD closure much earlier in life. These patients present with severe problems during infancy, such as recurrent respiratory infections, failure to thrive, heart failure, and respiratory insufficiency necessitating artificialventilation. This study was initiated to describe the conditions that led to the decision of early closure and to determine whether these conditions were resolved by means of closure of the defect. Because device closure in the first year of life is not feasible, early closure refers to surgical intervention.

The Journal of Thoracic and Cardiovascular Surgery ● Volume 129, Number 6

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