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Closure of atrial septal defect: is the debate over?

U.J. Thilen
DOI: http://dx.doi.org/10.1016/S0195-668X(03)00474-3 1797 First published online: 1 October 2003

Swan and Gatzoulis put the question above in their editorial1related to the study by Roos-Hesselink and co-workers in the same issue.2They state that early closure of an atrial septal defect is the key to prevention of late arrhythmia and the end goes ‘Yes, close it and yes, do it soon’. Well, there are a number of good reasons for closing a significant atrial septal defect, but so far scientific proof that closure influences the occurrence ofarrhythmia is lacking. Thus, the postulation that early closure is the key to prevention of late arrhythmia in atrial septal defect is certainly debatable.

Several reports on the late result of closure of atrial septal defects have repeated the same message; pre-closure arrhythmia and age at time of repair strongly correlates to the development of late arrhythmia.3–5However, no or very low attention has been given the fact that due to a similar follow-up time in these studies there is a very straight relation between age at time of repair and the age at follow-up (=age at repair+follow-up time). Thus, the important determinant of late arrhythmia could might well be the age at follow-up rather than the age at closure of the defect.

There is no doubt that atrial septal defect is associated with a highly increased risk of atrial fibrillation (and flutter) in the long run. However, even very early closure (during childhood) does not seem to change that.3There is a pattern, although at a different level, similar to that of the general population; the prevalence of atrial fibrillation increases exponentially with age. The study population of Roos-Hesselink had a mean age of 33 years at follow-up and there was a 3% prevalence of atrial fibrillation, similar to what was reported by Murphy et al in an equivalent age group.3This is a frequency around 100 times higher than found in the general population in those aged 45–49. When the patients of Roos-Hesselink have reached that age the prevalence of atrial fibrillation has certainly increased and might well be 15 or 30%. To compare the prevalence of atrial fibrillation to that of studies on the natural history is not fair as these are old studies from an era when diagnosis was less simple and therefore likely to contain a large portion of highly symptomatic (including arrhythmia) patients.

The study of Roos-Hesselink gives a lot of important information for employability and insurability. Furthermore, it shows that atrial septal defect closure at young age is associated with excellent survival and low morbidity. That part of the debate is over, but when it comes to atrial septal defect and atrial fibrillation the debate remains. Still the mechanism(s) of atrial fibrillation in atrial septal defect is obscure.6,7Further basic studies as well as long-term follow-up studies focused on atrial arrhythmia are warranted.