Skip Navigation



European Heart Journal Advance Access published online on July 10, 2007
European Heart Journal, doi:10.1093/eurheartj/ehm268
This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow All Versions of this Article:
28/16/2001    most recent
ehm268v1
Right arrow E-letters: Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when E-letters are posted
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Bostan, O. M.
Right arrow Articles by Ercan, I.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Bostan, O. M.
Right arrow Articles by Ercan, I.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?

© The European Society of Cardiology 2007. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org

The prospective follow-up of the natural course of interatrial communications diagnosed in 847 newborns

Ozlem M. Bostan*, Ergun Cil and Ilker Ercan

Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Uludag University, Görükle, 16059 Bursa, Turkey

Received 3 November 2006; revised 20 April 2007; accepted 31 May 2007.

* Corresponding author. Tel: +90 224 4428143; fax: +90 224 4428143. E-mail address: ombostan{at}uludag.edu.tr


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 References
 
Aims: The aim of this study was to evaluate the prevalance of interatrial communications (IACs) and IAC types in a large series of newborns, to establish the incidence of spontaneous closure of IACs, to determine the relationship between spontaneous closure and the size and type of IACs, and to investigate the incidence of mitral valve prolapse (MVP) and atrial arrhythmia in newborn infants with atrial septal aneurysm (ASA).

Methods and results: Between 2000 and 2001, a total of 1100 asymptomatic and term newborns were evaluated. Those who had congenital heart diseases and failed to attend the follow-up visits were excluded from the study. The remaining 847 newborns were followed until the closure time or in those where closure did not occur, for a maximum time of 45 months (mean 25 ± 3 months, range 1–45 months). The mean age at diagnosis was 1.7 ± 1.4 days (range 1–7 days). According to echocardiographic evaluation, cases were classified into four groups based on the initial size of IAC and into three groups based on the type of IAC. At the end of the 45th month IACs were closed spontaneously in 98.6% of the cases. There was significant relationship between the diameter of IAC and the timing of the closure (P < 0.01). The closure time in the cases with ASA was significantly longer than the cases with valve-like opening and multiple fenestration (P < 0.01). In female newborns, the defects remained open for a significantly longer period than male newborns (P = 0.0397). There was no significant relationship between ASA and atrial arrhythmias (P = 0.294). None of the newborns had MVP.

Conclusion: The cases with IACs <3 mm do not need follow-up. However, the cases with IACs >3 mm do need to be followed until the defect closes completely. Those with ASA should be followed-up regularly, because these defects can remain open. Spontaneous closure occurs significantly earlier in cases with valve-like opening and multiple fenestration.

Key Words: Interatrial communications • Atrial septal aneurysm • Newborn


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 References
 
The widespread recent use of Doppler echocardiography and colour flow mapping screening in healthy newborns referred for innocent heart murmurs has shown that the incidence of interatrial communications (IACs) and shunts in the newborn period may be fairly high.1,2 Although previous studies have documented the natural course of IACs, most studies have not included large series of newborns.1,3–7 Therefore, the aim of this study, including a large series of newborns and a long follow-up period (45 months), was to evaluate the prevalance of IACs and types of IACs, to establish the incidence of spontaneous closure of IACs, to determine the relationship between spontaneous closure and the size and type of IACs, and to investigate the incidence of mitral valve prolapse (MVP) and atrial arrhythmia in newborn infants with atrial septal aneurysms (ASAs).


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 References
 
Subjects
The study group consisted of 1100 consecutive asymptomatic and term newborns born in the department of obstetric and gynaecology of our institution between January 2000 and October 2001. Informed consent was obtained from the parents in each case. The pre-natal, natal, and post-natal data were obtained from each newborn's chart. Data regarding gestational age, birth weight, and Apgar scores were recorded. All cases had a complete physical examination, and electrocardiographic and echocardiographic evaluation. Ten newborns who had congenital heart disease (except for a patent ductus arteriosus, peripheral pulmonic stenosis, or tricuspid insufficiency), and 243 newborns who failed to attend the follow-up visits were excluded from the study.

Echocardiographic examination
Two-dimensional, M-mode, continuous Doppler, and colour Doppler echocardiography were performed on all cases using a 3–7 MHz ultraband transducer with Hewlett-Packard 5500. The echocardiographic examination comprised a complete sequential segmental analysis of each case. IAC diameters obtained by both two-dimensional and colour flow end-systolic mapping were measured in subcostal four-chamber and sagittal views. In some cases, the width of the colour jet obtained by colour Doppler mapping was considered to represent the size of the defect when the small defect could not be well visualized by two-dimensional echocardiography. Standard parasternal short axis and suprasternal views were used to confirm the patency of the ductus.

The newborns were classified into four groups based on the initial size of IACs.

Group 1: <3 mm; Group 2: 3–4 mm; Group 3: 5–7 mm; Group 4: ≥8 mm.

In addition, the cases were also divided into three groups according to the type of IAC. These were valve-like opening, multiple fenestrations, and ASA.

Criteria of Gallet et al.8 were used for the diagnosis of ASA:

(1) protrusion of the interatrial septum, or part of it, into either of the atrias >6 mm beyond the plane of the septum; or
(2) phasic excursion of the protrusion ≥6 mm during the cardiac cycle; and
(3) base of the protruding portion of the septum measuring at least 6 mm.

In multiple fenestration type of IACs, the sum of the measured opening sizes was considered as the size of the defect.

In the newborns with ASA and the control group, including the other newborns without ASA, criteria of Nascimento et al.9 were used for the diagnosis of MVP. Mitral valve morphology was evaluated from parasternal long-axis, apical 5–4, and 2-chamber views by two-dimensional and parasternal long-axis by M-mode. Two-dimensional diagnostic criteria for prolapse were posterosuperior motion of one or both mitral leaflets beyond the annular plane in the parasternal long-axis view or of the posterior leaflet in any view. M-mode recordings were obtained at the tips of mitral leaflets under direct two-dimensional echocardiographic control. Diagnostic criteria for prolapse included ≥3 mm abrupt late systolic posterior motion of the mitral valve.

All examinations were done by the same paediatric cardiologist and all studies were recorded on videotape for later analysis.

Follow-up
The 847 newborns were prospectively followed. The control visits were performed at the first month, third month, and every 3 months for a maximum time of 45 months. At each visit, all cases had a physical examination and echocardiographic evaluation. Electrocardiographic evaluation was only performed in the cases of arrhythmia. Each case was followed until the closure time and resolution of the arrhythmia or, in those where closure did not occur, for a maximum time of 45 months.

Statistical analysis
The results were expressed as mean ± standard deviation. {chi}2 and Fisher's exact tests were used for comparisons. A Kaplan–Meier survival function was used to produce a graphic representation of the closure of IACs as a function of time. A log-rank test was used for comparison of the curves. P-values of <0.05 were considered statistically significant.


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 References
 
The mean age at diagnosis was 1.7 ± 1.4 days (range 1–7 days). The mean gestational age was 39 ± 0.9 weeks (range 38–42). The mean birth weight was 3.3 ± 0.47 kg (range 2.5–5). The mean follow-up duration was 25 ± 3 months (range 1–45 months). Of the cases, 419 (49.4%) were male and 428 (50.6%) female. The mean echocardiographic examination was 4 ± 2 echocardiograms (range 2–15) per case.

All newborns had normal Apgar scores and normal findings on physical examination. IAC was found in all cases. On echocardiographic examination, valve-like opening was determined in 745 newborns (88%), multiple fenestrations in 59 newborns (7%), and ASA in 43 newborns (5%). At the end of the 45th month, IACs were closed spontaneously in 98.6% of the cases (Figure 1). In the IACs which were smaller than 3 mm, the incidence of spontaneous closure was 100%. The incidence of spontaneous closure was 99% in Group 2 (3–4 mm), 71% in Group 3 (5–7 mm), and none in Group 4 (≥8 mm) (Figure 2). There was a significant relationship between the diameter of the IACs and the timing of closure (P < 0.01) (Figure 3). The mean follow-up duration was similar for Group 1 (<3 mm) and Group 2 (3–4 mm), but was significantly longer for Group 3 (5–7 mm) and Group 4 (≥8 mm) (P = 0.0356). The incidence of spontaneous closure was 100% in multiple fenestrations type of IAC, 99.6% in valve-like opening type, and 79% in ASA. The closure time in the cases with ASA was significantly longer than the cases with valve-like opening and multiple fenestrations (P < 0.01) (Figure 4). The IACs remained open for a significantly longer period in girls compared with boys (P = 0.0397). Patent ductus arteriosus was determined in 343 newborns (40.5%). During follow-up, ductus arteriosus did not close in only one case. There was no significant relationship between spontaneous closure of IAC and ductus arteriosus (P = 0.347).


Figure 1
View larger version (6K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 1 Proportion of interatrial communications remaining open as a function of time for total group of 847 newborns.

 

Figure 2
View larger version (10K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 2 The percent of spontaneous closure of interatrial communications according to initial diameters at the end of 45 months.

 

Figure 3
View larger version (8K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 3 Proportion of interatrial communications remaining open as a function of time for the total group of 847 newborns according to the initial diameter.

 

Figure 4
View larger version (9K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 4 Proportion of interatrial communications remaining open as a function of time for the total group of 847 newborns according to the type of IAC.

 
In this study, atrial arrhythmia was determined in seven cases. Only one of whom had ASA. There was no significant relationship between ASA and atrial arrhythmia (P = 0.294). None of the newborns had MVP.


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
References
 
In this study, IAC was found in all cases and 98.6% of those closed spontaneously in a period of 45 months. The incidence of spontaneous closure of IAC was found highest during the first 3 months of life (Figure 1). In previous studies, the incidence of spontaneous closure of IACs was reported to range from 14 to 98.7%.1–3,5,6 The studies done in the newborn period reported a higher incidence of spontaneous closure.1,5,6 Some of these studies which reported the lower incidence of spontaneous closure had focused on cases aged above 1 year at the time of diagnosis, whereas the highest incidence of spontaneous closure probably occurred earlier.10,11

The size of IAC at initial examination was the most important predictive factor. The smaller the diameter, the more likely and the earlier was defect closure. In our study, IACs closed spontaneously in all cases of Group 1 (<3 mm). The previous echocardiographic studies also supported the earlier outcomes.1,5,6 We considered that most cases of Group 1 probably had foramen ovale, and spontaneous closure of the defect in all cases in this group favours this opinion. However, Ghisla et al.3 reported that spontaneous closure may be observed in larger defect. We observed a 65% rate of spontaneous closure in cases with IAC larger than 5 mm at the end of 45 months follow-up.

In this study, the type of IAC was also found to be an important predictive factor. The incidence of spontaneous closure of valve-like openings was established as 99.6%. Senocak et al.6 also reported that spontaneous closure incidence in valve-like opening was higher. Probably, these openings were also a patent foramen ovale, because there was an atrial septal tissue flap originating from anatomical septum primum. Multiple fenestrations were determined in 7% of the cases. There was no information about multiple fenestrations in previous studies. However, the presence of these openings was reported in the literature.12,13 This type of openings probably occur as a result of programmed cell death in particular areas of the septum primum during embryogenesis.14 The spontaneous closure rate of these openings was 100%.

ASA is an uncommon congenital malformation of the interatrial septum. Several studies reported that an aneurysm formation was observed at the localization of fossa ovalis in spontaneous closure cases.1,3,6 In our study, ASA was established in 43 newborn infants (5%) and interatrial shunt was shown in all cases with ASA. Unlike previous studies, the closure time in cases with ASA was significantly longer than the other types, and at the end of 45 months the defect remained open in 21%. The aneurysm disappeared in cases with ASA who had spontaneous closure of the opening but persisted in all cases whose opening did not close. The investigations performed in adults demonstrated that ASA was associated with mitral valve prolapse.15,16 Moreover, several recent publications have noted an increased incidence of atrial arrhythmia in cases with ASA.17 Rice et al.18 who evaluated 105 consecutive foetuses with foetal echocardiograpy found that the association of ASA with atrial arrhythmia was highly significant. Casta et al.19 also reported ASA in four foetuses with supraventricular tachycardia. In the intrauterine period, the frequent occurrence of ASA can be considered as a stage of the normal embryogenic development. Brand et al.20 prospectively evaluated the incidence of ASA in 3500 children, aged 1 day to 15 years, and found in 35 children (1%). In these cases with ASA, MVP was not observed, and atrial arrhythmia was found in only three newborns. In our study, atrial arrhythmia was established in one of the cases with ASA, but no MVP was observed. There was no significant relationship between ASA and arrhythmia. Considering all these studies, this relationship between ASA and arrhythmia can require echocardiographic evaluation of the newborn with arrhythmia with respect to ASA.

In this study, patent ductus arteriosus was observed in 40.5% of the cases. During follow-up, ductus arteriosus did not close in only one case. There was no significant relationship between spontaneous closure of IAC and ductus arteriosus (P = 0.347). Rigss et al.21 reported that ductus arteriosus did not have any significant effect on spontaneous closure of IAC in the studies comparing term and preterm newborns. However, in preterm infants it was observed that ductus arteriosus delayed the spontaneous closure.

In our study, it was found that spontaneous closure of IACs between 5–8 mm in female newborns was lower than that in male newborns (P = 0.0342). In other studies, there was no significant difference in spontaneous closure of IACs between female and male newborns.1,5,6 Senocak et al.6 reported that defects more than 5 mm were present more in female newborns. However, in their study there was no significant difference between female and male newborns.

In conclusion, some features of IACs diagnosed in the newborn period gave us some ideas about its natural course. These results suggest that the cases with IAC <3 mm do not need follow-up. However, the cases with IACs of more than 3 mm do need to be followed until complete closure. The type of IACs was also found as an important predictive factor. Those with ASA should be followed-up regularly because these defects can remain open. Spontaneous closure occurs significantly earlier in cases with valve-like opening and multiple fenestration. We think that these results are important to determine the natural course of IAC and to inform the parents about the prognosis of the defect.

Conflict of interest: none declared.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 

  1. Fukazawa M, Fukushige J, Ueda K. Atrial septal defects in neonates with reference to spontaneous closure. Am Heart J (1988) 116:123–127.[CrossRef][Web of Science][Medline]
  2. Hansen LK, Oxhoj H. High prevalence of interatrial communications during the first three months of life. Pediatr Cardiol (1997) 18:83–85.[CrossRef][Web of Science][Medline]
  3. Ghisla RP, Hannon DW, Meyer RA, Kaplan S. Spontaneous closure of isolated secundum atrial septal defects in infants: An echocardiographic study. Am Heart J (1985) 109:1327–1333.[CrossRef][Web of Science][Medline]
  4. Mody MR. Serial hemodynamic observations in secundum atrial septal defect with special reference to spontaneous closure. Am J Cardiol (1973) 32:978–981.[Web of Science][Medline]
  5. Radzik D, Davignon A, Doesburg N, Fourmier A, Marchand T, Ducharme G. Predictive factors for spontaneous closure of atrial septal defects diagnosed in the first 3 months of life. J Am Coll Cardiol (1993) 22:851–853.[Abstract]
  6. Senocak F, Karademir S, Çabuk F, Onat N, Koç S, Duman A. Spontaneous closure of interatrial septal openings in infants: an echocardiographic study. Int J Cardiol (1996) 53:221–226.[CrossRef][Web of Science][Medline]
  7. Helgason H, Jonsdottir G. Spontaneous closure of atrial septal defects. Pediatr Cardiol (1999) 20:195–199.[CrossRef][Web of Science][Medline]
  8. Gallet B, Malergue MC, Adams C, Saudemont JP, Collot AM, Druon MC, Hiltgen M. Atrial septal aneurysms-a potential cause of systemic embolism. An echocardiographic study. Br Heart J (1985) 53:292–297.[Abstract/Free Full Text]
  9. Nascimento R, Freitas A, Teixeira F, Pereira D, Cardoso A, Dinis M, Mendonça I. Is mitral valve prolapse a congenital or acquired disease? Am J Cardiol (1997) 79:226–227.[CrossRef][Web of Science][Medline]
  10. Mahoney LT, Truesdell SC, Krzmarzick TR, Lauer RM. Atrial septal defects that present in infancy. AJDC (1986) 140:1115–1118.[Medline]
  11. Hoffman JIE, Rudolph AM, Danilowicz D. Left to right atrial shunts in infants. Am J Cardiol (1972) 30:868–874.[CrossRef][Web of Science][Medline]
  12. Porter CJ, Feldt RH, Edwards WD, Seward JB, Schaff HV. Atrial Septal Defects. In: Heart Disease in Infants, Children, and Adolescent—Emmanouilides G, Riemenschneider TA, Allen HD, Gutgesell HP, eds. (1995) Vol. 1, 5th ed. Baltimore: Williams and Wilkins. p687–703.
  13. Vick GW. Defects of the atrial septum including atrioventricular septal defects. In: The Science and Practice of Pediatric Cardiology—Garson A, Bricker JT, Fisher DJ, Neish SR, eds. (1998) Vol. 1, 2nd ed. Baltimore: Williams and Wilkins. p1141–1179.
  14. Larsen WJ. Development of the heart. In: Human Embryology (1993) Singapore: Churchill Livingstone. p131–165.
  15. Iliceto S, Papa A, Sorino M, Rizzon P. Combined atrial septal aneurysm and mitral valve prolapse: Detection by two-dimensional echocardiography. Am J Cardiol (1984) 54:1151–1153.[CrossRef][Web of Science][Medline]
  16. Roberts WC. Aneurysm (Redundancy) of the atrial septum (Fossa ovale membrane) prolapse (Redundancy) of the mitral valve. Am J Cardiol (1984) 54:1153–1154.[CrossRef][Web of Science][Medline]
  17. Morelli S, Voci P, Morabito G, Sgreccia A, Marzio P, Marzano F, Giordano M. Atrial septal aneurysm cardiac arrhythmias. Int J Cardiol (1995) 49:257–265.[CrossRef][Web of Science][Medline]
  18. Rice MJ, Mc Donald RW, Reller MD. Fetal atrial aneurysm: A cause of fetal atrial arrhythmias. J Am Coll Cardiol (1988) 12:1292–1297.[Abstract]
  19. Casta A, Wolf WJ, Sapire DW. Atrial septal aneurysms and tachycardia in fetuses and newborn infants. Clin Res (1988) 36:36–49.
  20. Brand A, Keren A, Branski D, Abrahamov A, Stern S. Natural course of atrial septal aneurysm in children and the potential for spontaneous closure of associated septal defect. Am J Cardiol (1989) 64:996–1001.[CrossRef][Web of Science][Medline]
  21. Riggs T, Sharp SE, Batton D, Hussey ME, Weinhouse E. Spontaneous closure of atrial septal defects in premature vs. full-term neonates. Pediatr Cardiol (2000) 21:129–134.[CrossRef][Web of Science][Medline]

Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us    What's this?



This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow All Versions of this Article:
28/16/2001    most recent
ehm268v1
Right arrow E-letters: Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when E-letters are posted
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Bostan, O. M.
Right arrow Articles by Ercan, I.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Bostan, O. M.
Right arrow Articles by Ercan, I.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?