Benefits of Percutaneous ASD Occlusion in Patients Older than 60

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1 Benefits of Percutaneous ASD Occlusion in Patients Older than 60 WONG, Yam Hong MBBS (HKU), MRCP (UK), FHKCP, FHKAM (Medicine) Cardiology Team, Medicine and Geriatrics Dept., Tuen Mun Hospital Hospital Authority, Hong Kong No conflicts of interest, in the process of this study or the authorship of this paper!

2 Benefits of ASD closure Well demonstrated at young age <25 y.o. Current guidelines advocate early closure when evidence of Rt heart volume overload is present

3 Percutaneous ASD Occlusion Minimally invasive 97% success Allow ASD repair in a much older population But is it still good for geriatric patients? No well established evidence

Predisposing Conditions for Atrial Fibrillation in Atrial Septal Defect With and Without Operative Closure José María Oliver, MD, Pastora Gallego, MD, Ana González, MD, Fernando Benito, MD, José

and to evaluate the influence of age at surgical repair. The study population consisted of 286 adults with ASD (mean age 39.5 19 years).

Analyzed variables were entered into univariate (Mann-Whitney U) and multivariate (stepwise logistic regression) models to assess independent predictors for AF.

4 Predisposing Conditions for Atrial Fibrillation in Atrial Septal Defect With and Without Operative Closure José María Oliver, MD, Pastora Gallego, MD, Ana González, MD, Fernando Benito, MD, José María Mesa, MD, and José Antonio Sobrino, MD The aims of this study were to determine the prevalence and predisposing conditions for atrial fibrillation (AF) in adults with atrial septal defect (ASD) and to evaluate the influence of age at surgical repair. The study population consisted of 286 adults with ASD (mean age years). All patients had >1 follow-up visit and a Doppler echocardiographic study. One hundred ninety-two of the patients underwent surgical closure 1 to 34 years before the study. Analyzed variables were entered into univariate (Mann-Whitney U) and multivariate (stepwise logistic regression) models to assess independent predictors for AF. The prevalence of AF was similar in surgically treated patients (15.6%) and in the nonsurgical group (13.8%) (p 0.69). Multivariate analysis showed that current age (RR 1.9 per each decade of age, A 95% confidence interval [CI] 1.3 to 2.7, p 0.001), mitral regurgitation (RR 3.0 per each degree of regurgitation, 95% CI 1.6 to 5.8, p 0.001), left atrial enlargement (RR 2.8 per each 10 mm increase in size, 95% CI 1.5 to 5.2, p 0.001), and tricuspid regurgitation (RR 1.9 per each degree of regurgitation, 95% CI 1.0 to 3.7, p 0.04) were independent predictors of AF; however, gender, anatomic type, defect size, Qp:Qs, pulmonary artery pressure, right ventricular dimension, left ventricular shortening fraction, and prior surgical repair were not related to late AF development. In the surgical group, age >25 years at the time of surgery was the only predictor for AF independent of age at the time of the study (p 0.02) by Excerpta Medica, Inc. (Am J Cardiol 2002;89:39 43) Abstract Some older patients develop symptoms of clinical heart failure after closure of an atrial septal defect (ASD). The present study tested the hypothesis that baseline hemodynamics and hemodynamic changes induced by transcatheter ASD closure are different between younger and older patients due to age-related differences in left ventricular (LV) diastolic dysfunction. Forty-three consecutive patients (27.7 ± 16.3 years of age, range 5 63, median 25) who underwent device closure for ASD were divided into younger (age B25, n = 24, 15.1 ± 1.2 years) and older ([ 25 years, n = 19, 43.7 ± 2.2 years) groups. Echocardiographic evaluations were performed 1 day before and 2 days after ASD closure. Before ASD repair, early diastolic mitral annular velocity (e 0 ) on lateral, an index of ventricular relaxation, showed an age-related decrease. After closure, e 0 decreased by similar amount in both groups (p \ 0.05). In addition, E/e 0, an index of LV filling pressure, was relatively unchanged in the younger group (from 5.4 to 5.9) but significantly increased (p \ 0.05) in the older group (from 6.3 to 8.1) over similar increase of normalized LV diastolic dimension. In older patients, ASD closure resulted in further deterioration of baseline impairment in LV relaxation and the increased LV stiffness caused a more marked rise in LV filling pressure, compared to the younger group. Thus, ASD should be closed at a younger age before the development of agerelated LV diastolic dysfunction.

5 Benefits of percutaneous ASD occlusion in patients older than 60 A retrospective comparison of ASD occlusion results between younger and older age groups WONG, Yam Hong MBBS (HKU), MRCP (UK), FHKCP, FHKAM (Medicine) Cardiology Team, Medicine and Geriatrics Dept., Tuen Mun Hospital Hospital Authority, Hong Kong Hypothesis: ASD patients who are older then 60 years of age, could still benefit from ASD occlusion, at least as much as the younger adults, with a reasonable safety profile.

e. RVID Last pre-op and earliest post-op Echo measurements Secondary Endpoints Subjective symptomatic

6 Study Design Conducted in two cardiac centers in Hong Kong All-comers design Pre-op Pre-op < 60 years Compare Cross exam Compare 60 years Post-op Post-op Primary Endpoints Pulmonary HT i.e. PASP RV dilation i.e. RVID Last pre-op and earliest post-op Echo measurements Secondary Endpoints Subjective symptomatic improvements New onset atrial arrhythmias Thromboembolism Bleeding complications Residual shunts

7 Table 1. Patient baseline characteristics * Characteristic Younger (< 60 years) N = 54 Older ( 60 years) N = 19 P value Age years ± ± Male sex number (%) 12 (22.22) 6 (31.58) Hypertension number (%) 12 (22.22) 9 (47.37) Diabetes mellitus number (%) 4 (7.41) 4 (21.05) Chronic lung disease number (%) 1 (1.85) 3 (15.79) HAS-BLED (modified) score 0.28 ± ± 0.71 <0.001 ASD* diameter cm 1.88 ± ± Qp/Qs ratio 2.03 ± ± Baseline PASP mmhg ± ± Baseline RVID cm 3.54 ± ± Pre-existing atrial arrhythmias number (%) Pre-existing heart failure symptoms number (%) 3 (5.56) 11 (57.89) < (35.19) 12 (63.16) * Plus minus values are means ± standard deviations. ASD, PASP and RVID refer to atrial septal defect, pulmonary arterial systolic pressure, and right ventricular internal diastolic diameter respectively. Chronic lung disease were defined as chronic obstructive airway disease, bronchiectasis or restrictive lung disease. HAS-BLED score used here was modified, excluding the use of antiplatelet agents, which is required routinely after ASD occlusion. ASD diameter refers to the longest diameter of the defect, measured in pre-operative trans-oesophageal echocardiogram. Qp/Qs, the pulmonary-systemic shunt ratio, was measured in pre-operative trans-thoracic or trans-oesophageal echocardiogram.

8 !")"$%$$'" "!")"$%$$'" " Figure 1. Change of PASP* in patient < 60 years, after ASD* occlusion (n = 39) Figure 2. Change of PASP* in patient! 60 years, after ASD* occlusion (n = 18) PASP improvements: Younger: from ± mmhg => ± 9.71 mmhg (mean of time lapsed days) Older: from ± mmhg => ± mmhg (mean of time lapsed days) * PASP and ASD denote pulmonary arterial systolic pressure, and atrial septal defect, respectively. Absolute improvements in PASP: Younger:10.16 ± 7.84 mmhg Older: ± mmhg!"#"$%&'(" Figure 3. PASP* improvements in younger (< 60 years) versus older (! 60 years) patients, after ASD* occlusion * PASP and ASD denote pulmonary arterial systolic pressure, and atrial septal defect, respectively.

9 Pulmonary HT Improvements highly significant in both age groups PASP still significantly improves to a similar extent, even if ASD occlusion is done > 60 years Compatible with existing few pieces of evidence

10 !")"$%$$'" "!")"$%$$'" " Figure 4. Change of RVID* in patient < 60 years, after ASD* occlusion (n = 54) Figure 5. Change of RVID* in patient! 60 years, after ASD* occlusion (n = 19) RVID improvements Younger: 3.54 ± 0.86 cm to 2.67 ± 0.66 cm (mean of time lapsed days) Older: 3.85 ± 0.68 cm to 3.02 ± 0.71 cm (mean of time lapsed days) * RVID and ASD denote right ventricular internal diastolic diameter, and atrial septal defect, respectively.!"#"$%*+," Absolute improvements in RVID: Younger: 0.87 ± 0.60 cm Older: 0.82 ± 0.47 cm Figure 6. RVID* reductions in younger (< 60 years) versus older (! 60 years) patients, after ASD* occlusion * RVID and ASD denote right ventricular internal diastolic diameter, and atrial septal defect, respectively.

11 RV dilation Improvements highly significant in both age groups RVID still significantly improves to a similar extent, even if ASD occlusion is done > 60 years Compatible with existing few pieces of evidence

12 !"#"$%--("!"#"$%-*." Figure 7. Subjective symptom improvements in younger (< 60 years) versus older (! 60 years) patients, after ASD* occlusion * ASD denotes atrial septal defect. Parameters of diastolic function were assessed by echocardiographic Subjective symptoms improvements: Younger: 34.62% (75.0%) Older: 47.37% (90%) (Figures after excluding patient who were assymptomatic all along)

13 Subjective symptoms Majority of the patients who had symptoms, such as exertional dysponea or right heart faiure symptoms, experienced symptomatic improvements after ASD occlusion One single patient with deterioration of ET: menorrhagia on dual antiplatelet agent and therefore significant anaemic symptoms Only 5 patients in total (amongst all patients with pre-existing symptoms) experienced no improvements

14 Table 2. Secondary endpoints Endpoints Subjective symptomatic improvements (All patients) Younger (< 60 years) N = 54 Older ( 60 years) N = 19 P value Yes 18 (34.62%) 9 (47.37%) Subjective symptomatic improvements (excluding patient who are asymptomatic all along) New onset atrial arrhythmias Thromboembolism Bleeding complications Residual shunt No 34 (65.38%) 10 (52.63%) Yes 18 (90.00%) 9 (75.00%) No 2 (10.00%) 3 (25.00%) Yes 2 (4.08%) 2 (25.00%) No 47 (95.91%) 6 (75.00%) Yes 1 (1.92%) 0 (0.00%) No 51 (98.08%) 19 (100.00%) Yes 1 (1.92%) 0 (0.00%) No 51 (98.08%) 19 (100.00%) Yes 3 (5.56%) 0 (0.00%) No 51 (94.44%) 19 (100.00%) * Plus minus values are means ± standard deviations. ASD, PASP and RVID refer to atrial septal defect, pulmonary arterial systolic pressure, and right ventricular internal diastolic diameter respectively. ASD diameter refers to the longest diameter of the defect, measured in pre-operative trans-oesophageal echocardiogram. Qp/Qs, the pulmonary-systemic shunt ratio, was measured in pre-operative trans-thoracic or trans-oesophageal echocardiogram.

15 Conclusion Echocardiographic as well as clinical improvements after percutaneous transcatheter ASD closure are significant even if the procedure is done after the age of 60 Safe procedure even in geriatric patients ASD occlusion should therefore be recommended to patients when evidence of right heart volume overload is present, even after the age of 60 Add to the growing body of evidence supporting ASD occlusion in elderly patients

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