atrial septal defect the - circulation

Atrial Septal Defect in the Older Patient

A Clinical and Hemodynamic Study in Patients

Operated on After Age 35

By FRANKLIN B. SAKSENA, M.D., C.M., F.R.C.P. (C),

AND HARoLD E. ALDRIDGE, M.B., B.S. (LoND.), C.R.C.P. (C)

SUMMARYTwenty-four patients over 35 years of age with a secundum atrial septal defect

(ASD) had a clinical and hemodynamic assessment prior to surgical closure and a

follow-up assessment an average of 6 years afterward. All were initially in functionalclass III or IV. Twenty-three patients had a moderate to large left-to-right shunt.Five had elevated pulmonary vascular resistance (PVR); all had moderate to severe

pulmonary hypertension. Left ventricular dysfunction (LVD) was found in 17.Following surgical closure, 22 patients showed sustained clinical improvement and

were in class I or II. The mean pulmonary artery pressure fell to normal or mildlyelevated values in 21. The PVR was now elevated in 14 patients, suggesting con-

tinued progression of obliterative pulmonary vascular disease. Three had small resid-ual shunts. LVD, however, persisted after operation, which may reflect underlyingmyocardial pathology unrelated to the ASD.

Operative closure of ASD, therefore, is recommended for disabled patients over 35,even if they have moderate pulmonary hypertension or congestive heart failure.

Additional Indexing Words:Pulmonary hypertension PulmonaryElectrocardiographic data Left

vascular resistanceventricular function

Left-to-right shunt

ATRIAL septal defect (ASD) is one of thecommonest forms of congenital heart

disease in adults.' It often remains relativelyasymptomatic until atrial fibrillation or pul-monary hypertension develops. Although anumber of studies have been published on thelong-term effects of surgical closure of an ASDin patients over the age of 35,2-8 only limiteddata are available on patients over 35 whowere in functional class III or IV (New YorkHeart Association) prior to operation.4 8

This paper presents a long-term study of 24severely disabled patients over the age of 35who had surgical closure of a secundum ASD.

From the Department of Medicine, University ofToronto and the Cardiovascular Unit of TorontoGeneral Hospital, Toronto, Canada.

Supported by a grant from the Ontario HeartFoundation.

Received May 26, 1970; revision accepted forpublication August 10, 1970.

Csrculation, Volume XLII, December 1970

Its purposes are: (1) to describe the hemody-namic effects of operation on the pulmonaryvascular bed; (2) to assess resting left ven-tricular function before and after operation;and (3) to discuss factors affecting the resultsof surgery.

MethodsThirty-nine patients had a secundum ASD

closed between 1958 and 1966 utilizing cardio-pulmonary bypass technic. They formed part of alarger study which has been previously reported.9At the time of operation all were in functionalclass III or IV of the New York Heart Associationclassification.

This study is confined to 24 of these patientswho had a clinical assessment (history, physicalexamination, chest roentgenogram, electrocardio-gram and hemogram) and cardiac catheterizationperformed prior to surgery and 2 to 10 yearsafterward (average, 6 years). Sixteen patientswere female and eight were male. The agesranged from 38 to 63 years with a median of 51years. Ten of these patients had associated

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SAKSENA, ALDRIDGE

cardiac disease that would influence the directionof the shunt: mild mitral stenosis in three (cases2, 16, and 19), cor triatriatum in one (case 15),partial anomalous pulmonary venous drainage in

systolic pressure, s = duration of systole inseconds, and HR = heart rate in beats/min.(normal, 1,200 to 3,000 mm Hg-sec/min).12

(c) Left ventricular minute-work index:

LVMWI (LVSP - LVEDP) x 1.055 x CI x 13.61,000

three (cases 3, 15, and 24), coronary arterydisease in two (cases 11 and 23). Tricuspidinsufficiency was present in one (case 22) andpulmonary stenosis in one (case 12). The firstfour of these lesions tend to increase the degree ofleft-to-right shunting, whereas the last two wouldtend to decrease it.10Of the remaining 15 patients, five had died;

five could not be located (there is no record oftheir death in the files of the Registrar General ofOntario, but they may have left the province),five patients had only a clinical follow-upexamination and were in functional class I orII.

where LVEDP = left ventricular end-diastolicpressure, CI = cardiac index (normal, 4.97 +1.15 kg-m/min/M2).13

(d) Systolic ejection rate (SER) = LVSI/SEP where LVSI = LV stroke index andSEP = systolic ejection period (normal, 159 +39 cc/systolic sec/M2).14

(e) Distensibility index (DI) =LVSI/LVEDP (normal, 3.8 to 4.8 cc/mm Hg).15

(f) Resting myocardial efficiency index(MEI) = LVMWI/TTI (normal, 2.0-5 X 10-3)kg-m/min/m2/mm Hg-sec/min).

This has been derived from the equation:

Pressure work + kinetic workC (Total resting) cardiac 02 consumption

Right heart catheterization was performed inall 39 patients undergoing operation. In the 24patients considered in the present study, the leftatrium was entered via the defect in 15 patients,and in 11 the left ventricular pressures wererecorded. All 24 patients had left and right heartcatheterization after operation. Pressures weremeasured with the zero reference 10 cm from theback. Dye-dilution curves were performed bysuperior vena caval injection of indocyanine greenand sampling in a systemic vessel. The cardiacoutput was measured by the direct Fickmethod.

Left ventricular (LV) function was assessed asfollows:

(a) Dp/dt or the maximal rate of rise of LVpressure was obtained graphically using a fluid-

in which the kinetic factor of cardiac work (=5% atrest) and resting cardiac 02 consumption havebeen ignored and the TTI considered a functionof total myocardial 02 consumption.LV function was considered abnormal if one or

more of the following were present: (1) CI < 2.5L/min/m2; (2) SER < 120 cc/systolic sec/M2;(3) dp/dt < 800 mm Hg/sec; (4) MEI < 2;(5) LVEDP > 12 mm Hg; (6) preoperativemean RA pressure > 7 mm Hg.

Right ventricular (RV) function was assessedas follows:

(a) RV distensibility index = RVSI/RVEDPwhere RVSI = RV stroke index andRVEDP = RV end-diastolic pressure (normal,7.6 to 12.0 cc/mm Hg).15

(b) Right ventricular minute-work index:

RVMWI =(RVSP - RVEDP) x CI x 1.055 x 13.61,000

filled catheter and extemal transducer. In vivocomparison of this method and a catheter-tiptransducer at heart rates of 75 to 150/min hasshown that the two methods of measurementcorrespond closely up to a value of 2,000 mmHg/sec" (normal, 841 to 1,696 mm Hg/sec).

(b) Tension-time index (TTI) = LVSP xs x HR, where LVSP = left ventricular mean

where RVSP = RV mean systolic pressure andRVEDP = RV end-diastolic pressure (normal,0.73 + 0.20 kg-m/min/m2).13In the postoperative hemodynamic data, values

for pulmonary vascular resistance (PVR) wereavailable in 19 patients. In the remaining fivepatients an estimate of the mean pulmonarywedge pressure (and hence the PVR) wasobtained by equating it to the LVEDP.

Circulation, Volume XLII, December 1970

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ATRIAL SEPTAL DEFECT

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NO. PATIENTS

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Figure 1

The incidence of preoperative andclinical manifestations in 24 patients wh(of a secundum atrial septal defect.

Results

Preoperative and Postoperative CliniClinical Manifestations (Figs. 1 and 2)

Preoperatively all patients had peasy fatigability, and dyspnea.repeated upper respiratory tractSeven patients were in functional

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J P9o1Atotxns the New York Heart Association, and theremaining 17 were in class III (fig. 2). All

) Esy patients had been symptomatic for 1 to 20Futigob//ity years (average, 7 years) prior to operation.

There was a history of congestive heart failurein eight (cases 4, 5, 13, 15, 17, 19, 22, and 24),

rweDO#ivf angina pectoris in two (cases 11 and 23);significant coronary artery disease noted oncoronary angiography in one (case 11); andportal cirrhosis and obstructive lung disease inone (case 17).

All 24 patients improved symptomaticallyimmediately after operation. On follow-upexamination, eight patients were bothered by

;4 occasional palpitations, and five complained ofvery mild ankle edema. Twenty-two patientswere now in functional class I or II. In one ofthese 22 patients (case 2) the ASD hadreopened (it measured 13 cm2 at operationpostoperative and was closed by direct suture). The remain-

o had closureing two patients were now in class III or IV(cases 19 and 22; fig. 2). In both, the atrialseptal defects had reopened (closed by direct

cal Findings suture), 5 and 9 years, respectively, afteroperation. In addition, both patients had atrial

palpitations, fibrillation, progression of pulmonary hyper-Five had tension, and congestive heart failure. Patientinfections. 22 also had severe tricuspid insufficiency in

class IV of spite of an initial tricuspid valve annuloplasty.

PreoperaivePostoperative

6 12 18 24

NO. PATIENTSFigure 2

The severity of dyspnea (NYHA classification) in 24 patients before and after closure ofa secundum atrial septal defect.

Cifculation, Volume XLII, December 1970

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SAKSENA, ALDRIDGE

r 3Preopatiw

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Figure 3

Preoperative and postoperative physical findings in 24patients who had closure of a secundum atrial septaldefect.

Physical Examination (Fig. 3)Preoperatively, there were a palpable right

ventricular lift in most instances (95%), anincrease in intensity of the first heart sound in10096 of cases, fixed splitting of the secondsound demonstrable on phonocardiography in85%, and a grade II to III/VI pulmonaryejection systolic murmur in 100%. On follow-up a palpable right ventricular lift and a loudfirst heart sound were less frequently present(45% and 30%). Seventy-nine per cent ofpatients now had physiologic splitting of thesecond sound. A pulmonary systolic ejectionmurmur persisted in 41% of the cases but wasof decreased intensity (grade II/VI).Chest X-Rays

All patients had an enlarged main pulmo-nary artery, a hilar dance on chest fluoroscopy,and varying degrees of pulmonary plethorabefore operation. The average cardiothoracicratio (C/T) was 60% (SD, + 7), being greaterthan 50% in all patients and over 60% ineight.

In the follow-up examination, the pulmo-nary plethora and main pulmonary arteryenlargement were all less pronounced. The

cardiothoracic ratio had decreased significant-ly (P < 0.005) to an average of 54%(SD, 8%). Seven patients now had a normalC/T ratio, and in only five was it over 60%.

ElectrocardiogramsAtrial arrhythmias occurred in 13 patients,

11 of whom had atrial fibrillation (cases 2, 4, 6,14-19, 21, 22). Atrial fibrillation persisted afteroperation in all 11 patients. Eight of these 11patients were over 52 years old.The average initial frontal QRS axis was

+970 (SD, +580); 10 of the patients hadvalues > 110°. On follow-up, it was signifi-cantly less rightward (P <0.02), averaging+ 770 (SD, +390); only four patients had aQRS axis >1100. In the three patients whoseASDs had reopened, a leftward shift of theQRS occurred, but values were still > + 900.Of the 13 patients with right ventricular

hypertrophy (RVH) before operation, ninehad persistent RVH after operation.Of the nine patients who had an R' in lead

V, preoperatively, the average R' height fellfrom 8 to 5 mm. Two of these nine patientswhose ASDs had reopened had no decreasein the amplitude of R'.

Operative Procedure, Findings,and Complications

All 24 patients underwent cardiopulmonarybypass between 1958 and 1966. A secundumdefect was found in each instance. There wasa sinus venosus defect in three, two of whomhad partial anomalous pulmonary venousdrainage; 18 had a mid-atrial defect, and threehad a low defect.The mean area as measured at operation

was 12 cm2 (range, 2.4 to 39 cm2). Sixteen(66%) were closed by direct suture and eight(33%) with a patch.Associated lesions (mitral stenosis, pulmo-

nary stenosis, cor triatriatum, tricuspid insuffi-ciency, and anomalous pulmonary venousdrainage) were corrected at operation.Two patients (cases 5 and 13) had systemic

embolization after operation. Both recovereduneventfully after a course of anticoagulanttherapy.Oximetry studies done immediately after


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operation demonstrated that the ASD wasclosed in all patients.Of the original 39 patients operated on, five

died (a surgical mortality rate of 13%). Threeof these patients had severe pulmonaryhypertension and died within the first weekafter operation; two of these three hadcerebrovascular complications, and one had aright hemothorax. The remaining two patientsdied of unrelated causes: one died of aperforated diverticulitis within a month ofoperation, and the other, who did well afteroperation, died suddenly 1 year later ofunknown cause.

Hemodynamic Findings (Tables 1 and 2)

Intravascular and Intracardiac PressuresThe average right atrial pressure (RA) was

slightly increased preoperatively but did notchange significantly on recatheterization. Thir-teen patients had elevated preoperative values(> 7mmHg).A significant fall of the mean pulmonary

artery (PA) pressure by 6 mm Hg to 24.5 mmHg occurred after operation. All but four pa-

MenPAPressuremmHg

> 50(seveei)

41-50 2

3Z-40 4 E

2/3</2 A /0

Pre-Op Post-OpFigure 4

The preoperative and postoperative changes in meanpulmonary artery pressure in 24 patients who hadclosure of a secundum atrial septal defect. The num-ber in each box refers to the number of patients ina given range of pulmonary artery pressure.


tients had a decrease from their preoperativevalues (fig. 4).A small diastolic gradient was present

across the mitral valve in four patientspreoperatively (patient 15 had cor triatriatum,and patients 2, 16, and 19 had mild mitralstenosis confirmed at operation). None had asignificant gradient on recatheterization.

Pulmonary and Systemic Blood Flow (Table 3)The average preoperative pulmonary blood

flow (Qp) was 2.84 times the systemic bloodflow (Q8). Only one patient (case 12) had aQp,/Q < 1, and she had moderate pulmonarystenosis which favors right-to-left shunting.Her ASD measured 5 cm2 at operation, andthere was a step-up of 4.41 vol% in RA 02content.

Five patients had moderate shunts (Qp/Qs =1.2 to 2), 10 were large (Qp/Qs= 2.1 to 3),and eight were very large (Qp/Qs > 3).After operation, the Qp fell significantly to

one third of its original value. Three patients(cases 2, 19, and 22) had residual shunts(Qp/Qs of 1.7, 1.02, and 1.3). All had theirdefects closed by direct suture, and two of thethree had increased disappearance time tobuild-up time ratios ( > 2.3/1) as seen ontheir forward dye-dilution curves. The normalvalue of this ratio is 1.6 ± 0.1.16The Q8 remained within normal limits after

operation.

02 Content (Table 3)The mixed venous 02 content (mean of

superior and inferior vena caval samples)averaged 12.31 vol%. This method of calculat-ing mixed venous oxygen content is numerical-ly similar to other methods: 12.21 vol%17 and12.36 vol%.18

All except patients 3, 5, and 22 had a step-up of over 2 volI 02 content in the RA ascompared to the mixed venous sample. Afteroperation no patient had a significant step-upin oxygen content in the RA. The values for astep-up in 02 content in the RA in the threepatients (cases 2, 19, and 22) whose ASDshad reopened were 1.79, 1.37, and 1.91 vol%,respectively.

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SAKSENA, ALDRIDGE

Table 1

Hemodynamic Findings in All PatientsPressure(mm Hg)

Exam Years RA RV PA PAW LA LV AoPatient Age, sex Class no.* postop mean S/ED S/D; mean mean mean S/ED S/D; mean

1 38 F III 1II 2

2 38 M IV 1I 2

3 39 F III 1II 2

4 40 F IV 1II 2

5 42 F IV 1II 2

6 44 M III 1II 2

7 44 F IIIII 2

8 45F III 1I 2

9 46 F III 1I 2

10 48 M III 1I 2

11 49 M III 1

II 212 50 F III 1

I 213 52 M III 1

I 214 53 F III 1

I 215 53 F IV 1

II 216 54 F III 1

I 217 54 M III 1

II 218 57 F IV 1

II 219 58 M III 1

III 220 59 M IV 1

I 221 59 F IV 1

II 222 59 F III 1

IV 223 60 F III 1

I 224 63 F III 1

I 2

7 50/8 38/18;293 5 25/ 5 24/ 9;17

11 70/10 67/30;414 12 39/ 7 39/15;26

5 44/ 8 317 7 39/ 7 38/18;26

13 39/12 39/17;314 13 37/12 36/19;28

5 41/ 8 36/12;216 8 34/ 8 33/11;20

5 86/ 7 84/37;537 12 78/13 48

7 30/12 25/13;176 12 34/ 9 33/14;23

5 99/11 98/41;687 2 31/ 4 30/16;23

8 42/10 40/18;263 5 27/ 6 26/13;20

6 39/ 9 34/13;195 4 19/ 7 20/ 8;17

10 45/ 4 40/17;248 8 26/ 8 25/10;16

4 51/ 6 146 7 66/ 9 40/15;26

6 60/11 60/17;307 7 28/ 4 26/15;21

6 36/ 4 25/17;252 7 28/ 6 17

3 38/ 0 36/10;188 6 34/ 4 33/17;26

11 57/12 55/23;324 8 33/ 9 33/17;22

10 87/10 87/33;517 19 68/16 67/32;50

2 65/ 2 63/-;267 8 36/ 6 31/12;23

15 69/11 66/24;3810 16 71/16 67/32;46

9 44/ 8 37/18;245 5 18/ 4 18/ 9;14

12 60/12 48/15;238 6 26/ 7 25/13;18

20 80/17 77/25;428 5 43/ 5 42/20;29

8 44/ 4 33/16;257 6 25/ 5 24/14;16

11 38/ 6 30/16;215 7 28/ 7 28/12;16

7 134/8 133/ 95;11213 133/12 130/ 80; 96

11 110/10 110/ 75; 8216 180/ 7 155/101;1218 147/13 1099 126/11 125/ 66; 86

16 149/16 8717 129/15 128/ 77; 98

5 80/ 60; 6613 100/10 91/ 55; 749 4 120/ 80; 93

122/10 121/ 82; 978 119/ 63; 86

12 120/15 117/ 63; 8010 10 99/12 11017 130/12 128/ 79; 94

8 99/11 95/ 60; 7210 94/ 9 90/ 52; 727 7 126/ 83;10110 142/13 140/ 80;10315 143/ 85;11010 9 107/10 106/ 66; 925 5 153/ 7 150/ 81;104

157/17 155/ 80;1089 7 125/ 80; 95

17 115/ 70; 848 6 115/ 7 112/ 75; 87

138/ 8 137/ 63; 969 8 110/ 80; 9016 153/ 7 152/ 92;12017 110/ 70; 83

124/11 118/ 61; 8513 140/ 80;100

19 130/17 125/ 64; 8217 150/ 90;1109 7 122/ 7 121/ 71; 9016 15 127/10 77

20 165/17 165/ 96;13511 10 100/ 70; 8010 106/ 5 101/ 71; 7312 150/ 90;11113 167/13 165/ 80;14023 22 130/13 130/ 75;10215 15 114/13 112/ 65; 8311 8 110/ 70; 847 71/ 6 70/ 50; 63

14 140/11 132/ 71; 91165/12 151/ 71; 98

*Examination 1 was before operation; examination 2, after operation.tObtained by substituting LVEDP for PAW.Abbreviations: RA = right atrium; RV = right ventricle; S/ED = systolic/end-diastolic; S/D = systolic/diastolic; PA

= pulmonary artery; PAW = pulmonary artery wedge; LA = left atrium; LV = left ventricle; Ao = aorta; Qp = pul-monary blood flow; Q. = systemic blood flow; PVR = pulmonary vascular resistance; TPR = total pulmonary resistance;SVR = systemic vascular resistance; dp/dt = rate of rise of LV pressure during isometric contraction; TTI = tension-time index; LVMWI = left ventricular minute-work index; MEI = myocardial efficiency index.

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ATRIAL SEPTAL DEFECT 11

LV functionFlow ResistanceTI MW(L/min) (dynes sec cm-5) dp/dt (mm Hgs LV(gmmWin ME

QP Q. ~~QP/Q. PVR TPR SVR (mm Hg/sec) min) in2) X 1O3

2.6

1.0

3.0

1.7

2.2

1.0

3.3

1.0

1.8

1. 0

1.4

1.0

3.0

1.0

2.0

1.0

3.5

1.0

3.0

1.0

3.2

1.0

0.97

1.00

3.0

1.0

3.6

1.0

2.9

1.0

4.4

1.0

3.0

1.0

1.7

1.0

3.7

1.02

4.6

1.0

4.0

1.0

3.0

1.3

3.0

1.0

1.6

1.0

107

61

144

89

67

222

53

169

131

103

650

700J*38

162

480

90

100

162

72

120

28

168

168t

95

59

102

104t69

253

62

200t

185

262

58

197

213

383f

64

95

85

114

100

315

106

250

150

200

141

258

196

230

91

337

109

430

172

292

785

136i071

340

563

349

145

323

113

291

85

253

262

357

136

315

135

490

124

656

128

455

245

422

165

267

350

678

117

333

176

365

210

650

188

444

450

278

1315

1450

1020

1650

665

1020

865

1300

905

1020

1830

2420

989

1000

1750

1380

1255

1080

1640

1700

1110

1322

1840

1368

1210

1150

1570

2570

1735

2790

1280

1600

1280

532

1165

950

2120

1790

1810

1620

3140

3050

1205

2420

1725

1580

2780

1590

1325

1900

948

1311

1339

1032

448

800

490

698

1180

1787

677

2185

838

1760

830

2399

1845

1220

1220

1780

3840

2450

2213

3920

3940

3440

4800

7410

2130

2680

5820

2380

1950

2220

3180

2260

1850

2304

3190

2600

2940

3270

925 2150

538 2560

850

816

1400

1401

1778

1017

608

592

2050

1805

3060

3960

1860

3100

2600

2100

1700

6050

5.35

3.74

3.17

4.78

9.15

3.54

4.37

3.90

1.39

1.53

1.33

1.22

2.22

1.03

0.91

0.53

2.82

1.84

2.64

2.32

3.89

2.12

2.98

3.78

3.17

4.06

4.42

2.62

3.07

2.30

3.29

2.68

3.96

4.67

1.16

4.65

2.05

3.59

4.22

1.68

1.61

1.11

3.26

1.33

0.69

0.46

0.89

1.99

0.96

0.94

1.68

1.69

1.76

1.38

1.18

0.79

1.01

1.25

1.55

2.58

0.38

1.17

1.10

1.15

1.62

0.80

0.95

0.54

Cssrculation, Volume XLII, December 1970

16.415.27

16.709.00

27.306.15

22.735.109.805.485.402.8219.005.429.605.3214.394.9513.404.66

23.005.064.285.8317.605.35

14.662.7811.603.16

20.003.85

16.859.46

12.556.908.665.42

16.323.36

10.303.5015.903.5610.602.883.724.63

6.395.275.585.28

12.506.156.835.105.045.483.852.826.405.424.805.324.074.954.624.667.205.064.045.835.875.354.132.784.013.164.483.855.619.467.46.902.345.323.533.362.503.505.302.743.532.882.304.63

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Table 2Summary of Preoperative and Postoperative Intracardiac and Intravascular Pressure Data

Preop pressure Postop pressureSite No. (mm Hg i SD) (mm Hg i SD) t P

RA 24 8.3 4.1 8.1 3.8 NS

RVSP 24 53.1 18.4 37.2 16.9 4.64 <0.001RVEDP 24 8.1 4.1 7.6 3.4 NS

PASP 20 50.5 20.3 32.9 13.2 4.63 <0.001PA 24 30.5 13.3 24.5" 10.0 2.75 <0.02PAW or LA 19 11.3 4.4 13.6 - 4.5 NS

ART 24 93.0 i 13.2 94.0 - 19.1 NS

Abbreviations: RA = mean right atrial pressure; RVSP = right ventricular systolic pressure;RVEDP = right ventricular end-diastolic pressure; PASP = pulmonary artery systolic pressure;PA = mean pulmonary artery pressure; PAW = mean pulmonary artery wedge pressure; LA =mean left atrial pressure; ART = mean systemic arterial pressure; NS = not significant (P >0.05).

Resistance Measurements (Table 3)Pulmonary Vascular Resistance (PVR). The

mean PVR was slightly increased beforeoperation but increased further after opera-

tion (P<0.05).Preoperatively, values were normal ( < 150

dynes sec cm-5) in 19 patients, mildly elevated(151 to 250 dynes sec cm-5) in three, andmarkedly increased ( >400 dynes sec cm-5)in two. On follow-up examination, of the 19with normal preoperative values, nine hadunchanged values, eight had mildly elevated,and two had moderately elevated values. Of

the five patients with elevated preoperativelevels, the level of three had a further in-crease, that of one remained unchanged, andone fell to normal limits.

Total Pulmonary Resistance (TPR). Theaverage TPR was increased preoperatively( > 250 dynes sec cm-5) in only five patientsbut had increased significantly after operationso that there were now 23 patients with valuesover 250 dynes sec cm-5.

Systemic Vascular Resistance (SVR). TheSVR remained within normal limits afteroperation. There was a significant rise in

Table 3Summary of Preoperative and Postoperative Resistance, BloodContent Data (Mean 1 SD)

Flow, and Oxygen

Measurement No. Preop Postop t P

Blood flow (L/min)QP 24 14.20 1.86 4.99 - 1.72 7.7 <0.001Q" 24 5.11 2.13 4.80 - 1.58 NS

Oxygen content (vol %)Rise in RA 24 3.0 1.4 0.6 0.6 7.5 <0.001A-V 02 diff 23 4.43 1.23 4.58 1.27 NSSystemic sat (%) 24 93.0 3.2 94.0 +3.2 NS

Resistance (dynes sec cm-5)PVR 24 138 141 196 136 2.3 <0.05TPR 24 215 168 424 *236 5.6 <0.001SVR 24 1508 578 1597 625 NSTPR/SVR 24 0.14 0.09 0.28 0.14 5.5 <0.001

Abbreviations: Q, = pulmonary blood flow; Q. = systemic blood flow; RA = right atrium;NS = not significant (P> 0.05); PVR = pulmonary vascular resistance; TPR = total pulmonaryresistance; SVR = systemic vascular resistance.


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Table 4Summary of Preoperative and Postoperative Data on Left and Right Ventricular FunctionTests (Mean + 1 SD)

Measurement No. Preop Postop t P

Left ventricledp/dt (mm Hg/sec) 10 1348 *612 1163 458 NSSER (cc/syst sec/min/m2) 10 122.3 47.0 111.0 22.0 NSCI (L/min/m2) 11 3.10 1.52 2.83 0.58 NSLVDI (cc/mm Hg) 11 3.47 1.70 3.18 0.99 NSLVEDP (mm Hg) 11 10.7 2.8 12.1 3.2 NSTTI (mm Hg-sec/min) 10 2996 897 3454 1550 NSLVMWI (kg-m/min/M2) 11 3.65 2.26 3.59 0.96 NSMEI X 103 10 1.26 0.52 1.14 0.42 NS

Right ventricleRVMWI (kg-m/min/M2) 11 3.06 - 1.36 0.78 = 0.31 6.04 <0.001RVDI (cc/mm Hg) 11 13.35 - 8.59 6.01 - 2.36 2.69 <0.025

Abbreviations: dp/dt = rate of rise of left ventricular isometric contraction; SER = systolicejection rate; CI = cardiac index; LVDI = left ventricular distensibility index; LVEDP = leftventricular end-diastolic pressure; TTI = tension-time index; LVMWI = left ventricular minute-work index; MEI = myocardial efficiency index; RVMWI = right ventricular minute-workindex; RVDI = right ventricular distensibility index.

TPR/SVR after operation due to the markedincrease in TPR.

Left Ventricular Function (Tables 1 and 4)Detailed Preoperative and Postoperative

Data on 11 Patients. There was preoperativeevidence of LV dysfunction in 10 of 11patients: five had low MEI, and SER, andelevated RA pressure (two of these patientsalso had low dp/dt), two had low MEI andelevated RA pressure, and three had low MEIassociated with either elevated LVEDP or lowSER. Postoperatively there was no significantimprovement in SER, dp/dt, and MEI.Detailed Postoperative Data in the Remain-

ing 13 Patients for Whom There Are Incom-plete PreoPerative Data (Table 1). Pre-operatively seven patients had presumptiveevidence of LV dysfunction on the basis of anelevated RA mean pressure.'9' 20 LV dysfunc-tion was, however, definitely present in theseseven patients postoperatively: seven had alow MEI; five had a reduced SER; three had alow dpidt; and two had elevated LVEDP.The remaining six patients had a normal RA

mean pressure preoperatively, but detailedpostoperative studies of LV function revealedabnormalities in five: two had low MEL, SER,and dp/dt; two had low MEI associated withCirculation, Volume XLII, December 1970

either elevated LVEDP or reduced SER andone had a reduced stroke-work index (2.62 kg-m/min/m2). Thus LV dysfunction was pres-ent in at least 17 patients preoperatively andin 22 patients postoperatively.Right Ventricular Function (Table 4)As expected, there was a significant fall in

RVMWI and RVDI after closure of the septaldefect. Of the three patients whose defect hadreopened, two still had slightly elevatedpostoperative RVMWI ( 1.36 in case 2; and1.24 kg-m/min/m2 in case 19).

DiscussionPulmonary Hypertension

In the present study, increasing age of thepatient and size of the shunt were notsignificantly related to the level of thepulmonary artery pressure. This implies that achronically elevated pulmonary blood flow perse cannot account for the development ofpulmonary hypertension. Our findings are thusin agreement with several authors10' 21, 22 butnot others.2326

In only one of our patients (case 17) waspulmonary thrombosis secondary to repeatedpulmonary infections,27 25 a significant factorin the development of pulmonary hyperten-sion.

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A significant fall in PA pressure followingoperation was seen in most series4 8, 29-32 butnot in others.3337 This fall did not appear tobe related to the patient's age or severity ofthe initial pulmonary hypertension.A significant postoperative rise in TPR was

noted in the present study and confirmedelsewhere.2, 35, 36 A smaller but significant risein the postoperative values for PVR andTPR/SVR ratio was found in our series and byothers.4 7 These findings imply that there islittle reversal of the pulmonary vasculardisease after closure of the defect, especiallyin the older age group.7' 8,32,38 Only one pa-tient (case 17) had coexistent chronic ob-structive lung disease that could account inpart for a residual elevation in PVR.Confirming evidence that the pulmonary

vascular bed remains abnormal after closureof the atrial septal defect is the further rise inPVR in response to exercise.8 27, 37, 38 For PVRvalues under 200 dynes sec cm-5 there was norelationship to work capacity, size of thepreoperative shunt, or cardiac size.27 A moremarked postoperative elevation in PVR( > 600 dynes sec cm-5) was associated withpatients who had a large preoperative shuntand left ventricular failure.8

Left Ventricular FunctionAt least 17 of 24 patients had LV dysfunc-

tion preoperatively. The two most useful cri-teria for detecting LV dysfunction were a lowMEI (10 of 11 patients) and an elevated meanRA pressure (13 of 24 patients). The 11 pa-tients who had a reduced postoperative MEIbut for whom preoperative data were lackingmay well have had a similarly reduced MEIprior to surgery. A normal MEI of 4.5 wascalculated by us from Siltanen's pooled data7on 28 patients with atrial septal defect whowere over 40 years old, but this normal MEImay be due to the fact that 40% of his patientshad less severe functional disability than ourpatients. Nevertheless, further measurementsof the MEI to assess LV function appearwarranted.Resting values of the cardiac index may not

be sensitive enough to detect LV dysfunctionpreoperatively, as in the present series where a

normal cardiac index was found. This result isin contrast to the findings of others21' 39, 40 whofound reduced values, although only Flamm'sgroup40 took into account the effect of age oncardiac output.Other series37' 40 have demonstrated impair-

ment of LV function in patients with ASD inresponse to exercise.

After closure of the ASD there was nosignificant improvement of LV function in anyof the 11 patients for whom detailed datawere available, two (cases 19 and 22) ofwhom were now in functional class III to IV.These findings are against Flamm's hypothe-sis40 that LV dysfunction is due to overloadand failure of RV, since LV function shouldimprove after closure of the ASD because of areduction in RV load. The most likely reasonfor LV dysfunction and its persistence afterclosure of an ASD in the older patient isoccult coronary artery disease (only two of 24patients had angina). Coronary angiographyand LV angiography would, however, berequired to corroborate this hypothesis.Surgical Treatment

Surgical closure of an uncomplicated atrialseptal defect can now be carried out with alow mortality rate,5 6, 25, 28, 41-44 and its placeappears to be well established in the treat-ment of most patients.Old age,45 pulmonary hypertension, and

congestive heart failure46 are factors that mayadversely influence the outcome of surgery.According to Wolfs group45 it is doubtful

whether significant postoperative improve-ment occurs in patients over the age of45. This has been at variance with ourown clinical experience and that ofothers.3 4 6, 7, 36, 41, 46, 47 In the absence ofcongestive heart failure or pulmonary hyper-tension, the mortality rate was only 2% inpatients over 45 as compared to 0.7% inpatients under 45.6The present study, which included 39

patients initially, confirms4' 6 the unfavorableeffect of pulmonary hypertension on thesurgical mortality rate: three of six patientswith PA> 50 mm Hg died. This finding issimilar to the results reported by Rahimtoola


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and associates6 who noted a mortality rate of50% in patients who had TPR > 640 dynes seccm-5.

Congestive heart failure prior to operationin patients over the age of 35 did not ptecludeclinical improvement after surgical closure ofthe defect, as seen in the present study (sevenof seven improved to class I to II) and thoseof others.4 8 In larger series, however, it hasbeen reported that the surgical mortality rateis 10 to 14% if there was prior congestiveheart failure.4 6

Thus, in view of the decreased life span4852of patients with an atrial septal defect,operative closure is recommended for disabledpatients over 35 years of age, even if there ismoderate hypertension or congestive heartfailure. Medical management may be advis-able, however, if the PVR exceeds 400 dynessec cm-5 because of the high surgical mortalitvamong such patients.

References1. CooLEY DA, HALLMAN GL, HAMMAM AS:

Congenital cardiovascular anomalies in adults:Results of surgical treatment in 167 patientsover the age of 35. Amer J Cardiol 17: 303,1966

2. COHN LH, MoRRow AG, BRAuNwA.D E:Operative treatment of atrial septal defects:Clinical and haemodynamic assessments in 175patients. Brit Heart J 29: 725, 1967

3. DIACOFF GR, BRANDENBURG RO, KnuKuN JW:Results of operation for atrial septal defect inpatients 45 years of age and older. Circulation35 (suppl I): 1-143, 1967

4. GAULT JH, MORROW AG, GAY WA JR, ET AL:Atrial septal defect in patients over the age offorty years. Circulation 37: 261, 1968

5. LIDDLE HV, MEYER BW, JONES JC: The resultsof surgical correction of atrial septal defectcomplicated by pulmonary hypertension. JThorac Cardiovasc Surg 39: 35, 1960

6. RAmHmrooLA SH, KIuKUN JW, BuRcwIuL HB:Atrial septal defect. Circulation 38 (suppl V):V-2, 1968

7. SILTANEN P: Atrial septal defect of secundumtype in adults: Clinical and hemodynamicstudies of 129 cases before and after surgicalcorrection under cardiopulmonary bypass. ActaMed Scand Suppl 497, 1968

8. TIKOFF G, KEITH TB, NELSON RM, ET AL:Clinical and hemodynamic observations aftersurgical closure of large atrial septal defects


complicated by heart failure. Amer J Cardiol28: 810, 1969

9. ALDRIDGE HE, YAO J: Secundum atrial septaldefects in the adult: Repair using cardiopul-monary bypass in 133 patients. Canad Med AssJ 97: 269, 1967

10. DAVDSEN HG: Atrial septal defect: An investiga-tion into the natural history of a congenitalheart disease. (Thesis) Munksgaard, Copen-hagen 1960

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12. SARNOFF SJ, BRAUNWALD E, WELCH GH, ET AL:Hemodynamic determinants of oxygen con-sumption of the heart with special reference tothe time tension index. Amer J Physiol 192:148, 1958

13. DEXTER L, WHITTENBERGER JL, HAYNES FW, ETAL: Effect of exercise on circulatory dynamicsof normal individuals. J Appl PhysiQl 3: 439,1951

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21. CRAG RJ, SELzs A: Natural history andprognosis of atrial septal defect. Circulation37: 805, 1968

22. Fowisx NO: Cardiac Diagnosis. New York,Harper & Row, 1968, p 540

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24. FRY DL: Acute vascular endothelial changesassociated with increased blood velocity gradi-ents. Circulation Research 22: 165, 1968

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26. RUDOLPH AM, NADAS AS: The pulmonarycirculation in congenital heart disease. NewEng J Med 267: 1022, 1962

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28. BESTERMAN E: Atrial septal defect with pulmo-nary hypertension. Brit Heart J 23: 587,1961

29. ARNFRED E: A clinical and hemodynamicevaluation of the results of surgical correctionof atrial septal defect. J Cardiovasc Surg 8:93, 1967

30. WINCHELL P, BASHOuR F: Physiological featuresof atrial septal defect: Observations on 38adult patients. Amer J Cardiol 2: 687, 1968

31. BRAUNWALD NS, BRAUNWALD E, MoRRow AG:The effect of surgical abolition of left to rightshunts on the pulmonary vascular dynamics ofpatients with pulmonary hypertension. Circula-tion 26: 1270, 1962

32. KIMBAML KG, McILRoy MB: Pulmonary hyper-tension in patients with congenital heartdisease. Amer J Med 41: 883, 1966

33. BLOUNT SG JR, GENSINI G, McCoRD M: Atrialseptal defect: Clinical and physiologic responseto complete closure in 5 patients. Circulation9: 801, 1954

34. DAVIDSEN HG: Closed surgery in atrial septaldefect. Acta Chir Scand 115: 343, 1958

35. GOLDBERG H, DOWNING DF: The physiologicaland clinical changes following closure of atrialseptal defects by atrioseptopexy. Amer Heart J49: 862, 1955

36. KIRKLIN JW, WEIDMAN WH, BuRROUGHS JT, ETAL: The hemodynamic results of surgicalcorrection of atrial septal defects. Circulation13: 825, 1956

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40. FLAMM MD, COHN KE, HANCOCK EW: Ventricu-lar function in atrial septal defect. Amer J Med48: 286, 1970

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42. SELLERS RD, FERLic RM, STERNS LP, ET AL:Secundum type atrial septal defects: Early andlate results of surgical repair using extracor-poreal circulation in 275 patients. Surgery 59:155, 1966

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FRANKLIN B. SAKSENA and HAROLD E. ALDRIDGEPatients Operated on After Age 35

Atrial Septal Defect in the Older Patient: A Clinical and Hemodynamic Study in

Print ISSN: 0009-7322. Online ISSN: 1524-4539 Copyright © 1970 American Heart Association, Inc. All rights reserved.

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