Copyright © 2003 by the European Society of Cardiology.
Letter to the Editor
Response to the letter by ThilenASD closure: please don't lose the message
Received 30 April 2003; accepted 20 June 2003
Dear Sir/Madam
It is saddened that we are continuing to indulge in debate over the timing of ASD closure and fear, that in doing so, we may jeopardise an important clinical message.
Thilen highlights the limited data regarding the effects of ASD closure on atrial arrhythmias. We would be the first to agree that the available data is far from perfect – a point we make at length in our editorial.1We also accept that the point he raises regarding age at follow-up is a valuable one. However the amelioration of atrial fibrillation is not the prime indication for defect closure. By focusing on rhythm disturbance the wider message of right heart function, exercise intolerance, pulmonary hypertension and premature death is at risk of being overlooked.
The issue of atrial arrhythmias in adults is a difficult one. Circumstantial evidence would suggest that age at closure is important. For example at the time of surgery the chance of reversion to sinus rhythm is related to age—a factor not influence by follow-up duration.2
It is true that late defect closure does little to the incidence of atrial fibrillation3but we would not agree with Thilen's comments that the same is true in children. We do not suggest that early closure returns a subject to the ‘arrhythmogenic risk’ of someone with a structurally normal heart but that their risk is less than that of an individual with no closure or closure several decades later.4
As with many clinical dilemmas it is easy to point to deficiencies in the data or deride historical control cohorts. However, one has to advice care on the best available data. We will, therefore, continue to sing from the same hymn sheet: ‘The remaining unresolved issues should not detract from the implementation of what we already know. Yes, close it and yes, do it soon’.
References
- Swan L, Gatzoulis MA. Closure of atrial septal defects: is the debate over? Eur Heart J. 2003;24:130–132.
[Free Full Text] - Gatzoulis MA, Freeman MA, Siu SC et al. Atrial arrhythmia after surgical closure of atrial septal defects in adults. N Engl J Med. 1999;340(11):839–846.
[Abstract/Free Full Text] - Attie F, Rosas M, Granados N et al. Anatomical closure for secundum atrial septal defect in patients aged over 40 years. A randomised clinical trial. JACC. 2001;38(7):2035–2042.
[Abstract/Free Full Text] - Murphy JG, Gersh BJ, McGoon MD et al. N Engl J Med. 1990;323:1645–1650.[Abstract]
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