Mannam, GopiChand

Pathuri, S

Raju, D S Bhaskara

Rao Sajja, Lokeswara

Rao, N K

Sompalli, S

Ussiri, E V

Viswanath, J

English

AJOL - African Journals Online

 East and Central African Journal of Surgery Volume 12 Number 1                April  2007  148Clinico-Surgical Outcome of Repair of Isolated Atrial Septal Defect At Care Hospital, Banjara Hills-Hyderabad India, 2004-2006.  E.V. Ussiri1, GopiChand Mannam2, Lokeswara Rao Sajja3, J. Viswanath3, D.S. Bhaskara Raju3, S. Pathuri3, S. Sompalli4, N.K. Rao5   1Surgeon-Muhimbili National Hospital, Trainee-India, 2Chief-Cardiothoracic Surgery CARE Hospital, Hyderabad-India, 3Consultant, Cardiothoracic Surgeon, CARE Hospital, 4Cardiac Anaesthesiologist & Critical Care, CARE Hospital, 5Cardiology, Paediatric Cardiology-Australia, Consultant Paediatric Cardiologist CARE Hospital Correspondence to: Dr. Ussiri EV, CARE Hospital, Rd no.1 Banjara Hills, Hyderabad 500034 India.                                    E-mail: eussiri@yahoo.com Introduction  Atrial septal defect (ASD) is the second commonest congenital heart disease accounting for 8% - 13% following ventricular septal defects (1). ASD is classified into three major types which include ostium secundum, ostium primum and sinus venosus. Among all ASDs, ostium secundum account for 70%-80% 1,,2. Small defects, less than 5 mm diameter are asymptomatic and may decrease in size or close spontaneously whereas large defects, 12 mm or more they enlarge further3,4. Anita et al3 when evaluating 52 patients with secundum ASD in the first year of life with a follow-up of 2 – 3 years found that 46% of patients had decrease in the size of ASD with complete closure in 14 patients, 25 % the defects remained the same and 29% enlarged. Similar study was done by Mc Mahon CJ et al4 when evaluating the natural history of 104 patients with ostium secundum ASD revealed that the defects in 65% of patients increased in size and 4 % had spontaneous closure. The increase in size was attributed to the initial size of the defect rather than age at diagnosis.  Small to moderate ASDs may remain asymptomatic till 4th decade of life while large defects may present early in life with heart failure, recurrent respiratory tract infection and failure to thrive3. Several studies revealed that surgical closure of ASD at young age have good outcome compared to those done in adults5,6,7. Roos-Hesselink et al5 followed-up 135 patients after surgical closure of ASD to evaluate the long- term outcome results in terms of arrhythmias, pulmonary artery hypertension and left ventricle dysfunction for 21-33 years. It was concluded that ASD closure at young age, less than 11 years have excellent survival and low morbidity than when done at adult age. Similar results were obtained by Murphy JG et al6 when evaluating early repair of ASD in terms of sinus node dysfunction, atrial flutter or fibrillation, right ventricle dilatation, pulmonary artery hypertension and left ventricle dysfunction. Shah D et al7 did a comparative study on 72 patients with secundum ASD first diagnosed after the age of 25 years.   The results concluded that there was no difference in survival or symptoms between those treated medically and those who underwent surgical closure. Also, the long-term outcome in terms of arrhythmias, stroke or emboli and heart failure was not improved by surgical closure.Retrospective study was done to evaluate the clinical presentation and outcome of the surgical closure of isolated ASD at CARE Hospital, Banjara Hills- Hyderabad, India. The aim of this study was to determine the clinical presentation and outcome of the surgical repair of isolated ASD. The Specific objectives were:  1. To determine the prevalence of isolated ASD with respect to age and sex of presentation 2. To determine the clinical presentation in terms of the presenting symptoms.   3. To determine the indications for cardiac catheterization, surgical techniques and indications for patch closure. 4. To determine the outcome of surgical repair of isolated ASD in terms of the durationof ICU stay, duration of mechanical ventilation, duration and type of cardiac supports, development of the atrial fibrillation, development of pulmonary hypertension, residual 5. ASD, hospital stay and mortality.To compare the clinical presentation and surgical outcome with respect to age group.  Patients and Methods  Retrospective study for two and half years was done from January 2004 to June 2006 at CARE  East and Central African Journal of Surgery Volume 12 Number 1                April  2007  149Hospital, Banjara Hills-Hyderabad India. Study included all patients who underwent surgical closure of the isolated ASD, either by direct suture or patch closure, both sexes and all age groups.       Data were obtained from the Operating Room Registry and Medical Records and included  age, sex, duration of symptoms, presenting symptom(s), intra-operative type  of the defect, duration of ICU stay, duration of mechanical ventilation, duration and type of cardiac support used, development of atrial fibrillation, pre- and post-operative echocardiography findings, indications for cardiac catheterization where applicable, types of surgical techniques used and indications for patch closure, hospital stay and mortality. Data were analyzed using Epi-info 6 program for statistical significance. Echocardiography Definitions: • Pulmonary Hypertension by measuring Right Ventricular Systolic Pressure (RVSP): mild < 45 mmHg, moderate = 45-70mmHg, severe > 70 mmHg. • Pericardial effusion: Mild (small) effusion- less than 10mm thickness, often localized and usually posterior. • Moderate effusion-10 to 20mm thickness, anterior and posterior, during diastole completely surrounding the heart. • Severe effusion- greater than 20mm thickness, swinging heart.  Results  The study revealed a total of 124 (58.8%) patients with an isolated ASD. The other associated conditions commonly included anomalous pulmonary venous connection, atrio-ventricular canal, pulmonary stenosis, mitral valve disease and ventricular septal defect (Table 1). Females had higher predominance than males and ostium secundum was the commonest type of ASD accounting for 92.7% (Table 2 & 3).  The commonest symptoms included shortness of breath, recurrent respiratory tract infection, failure to thrive and poor feeding in children Table 1. Proportion of Isolated ASD and other associated conditions Isolated ASD 124 (58.8%)  ASD with Partial Anomalous Pulmonary Venous Connection  27 ASD with Total Anomalous Pulmonary Venous Connection 17 ASD with Partial or Complete Atrio-Ventricular Canal  18 ASD with Pulmonary Stenosis 8 ASD with Mitral Valve Disease 7 ASD with Ventricular Septal Defect 6 ASD with Patent Ductus Arteriosus 2 ASD with Aortic Stenosis 1 ASD with Coronary Artery Disease 1 Total 211  Table 2. Proportion of Isolated ASD per age group (years) and sex Age group/sex Male Female Total (%)  1 4 2 6   (4.8) 2 – 5 18 16 34 (27.4) 6 – 10 9 16 25 (20.2)  11 25 34 59 (47.6) Total 56 (45.2%) 68 (54.8%) 124  (100)  Table 3. Proportion of Intra-operative Type of Isolated ASD Type Number (%)  Ostium Secundum ASD 115  (92.7) Superior Vena Cava (Sinus venosus) ASD 5  (4.0) Ostium Primum ASD 2  (1.6) Mixed ASDs 2  (1.6) Total 124 (100)  East and Central African Journal of Surgery Volume 12 Number 1                April  2007  150Table 4. The Proportion of the Commonest Symptoms for Isolated ASD  Symptom Number (%)  Shortness of breath  79 (63.7) Recurrent respiratory tract infection 69 (55.6) Failure to thrive  39 (31.5) Poor feeding 18 (14.5) Palpitation 12 (9.7) Chest pain 8 (6.5) Febrile convulsion 1 (0.8) Asymptomatic 13 (10.5)    Table 5. The proportion of the pre-operative pulmonary hypertension  Pulmonary hypertension Number (%)  Mild 18 (14.5) Moderate 7 (5.6) Severe 2 (1.6) Total 27 (21.7)   Table 6. Indications for Cardiac Catheterization in isolated ASD  Indication Number (%)  Inconclusive echocardiography results 3 (2.4) Severe Pulmonary Hypertension  2 (1.6) Age above 40  13 (10.5) Not Applicable 106 (85.5) Total 124 (100)    Table 7. The Surgical Technique used to repair isolated ASD  Type of Technique Number (%) Direct suturing 80 (64.5) Patch closure 44 (35.5) Total 124 (100)    Table 8. Indications for Patch closure  Indication Number (%)  Friable margins 10 (8.1) Ill-defined margins 34 (27.4) Not applicable 80 (64.5) Total 124 (100)   East and Central African Journal of Surgery Volume 12 Number 1                April  2007  151Table 9. The Surgical Out-come of isolated ASD closure Surgical outcome Number Means duration of mechanical ventilation (hours) 5.5     (Std Dev =4.8) Proportion of the use of Cardiac Support (%) 89 (71.8%) Type of Cardiac Support used  *NTG alone=56 (62.9%)  **NTG+DOB=33 (37.1%) Means duration of Cardiac Support (hours) 13.04    (Std Dev=9.7) Development of Pulmonary Hypertension (%) 1 (0.8%) Development of Atrial Fibrillation (%) 1 (0.8%) Means duration of ICU stay (days) 1.8  (Std Dev=4.3) Post-operative pericardial effusion (%) 10 (8.1%) Post-operative Residual ASD 0   (0.0%) Means duration of Hospital stay (days) 5.9 (Std Dev=1.9)                     Mortality (%) 1 (0.8%)            * NTG=Sodium Nitroglycerine. ** DOB=Dobutamine  Table 10. Comparison of clinical and surgical outcome with respect to age group Feature   10 years 11years p-value Means duration of symptoms (months) (Overall mean=43.9) 49.5 (Std Dev.=38.1) 37.9 (Std Dev.=60.5) p=0.0008 Shortness of breath (%) 37 (46.8) 42 (53.2) p=0.1004 Recurrent respiratory tract infection (%) 58 (84.1) 11 (15.9) p=0.0000 Pre-op. Pulmonary Hypertension (%) 9 (33.3) 18 (66.7) p=0.0253 Means duration of mechanical ventilation (hours) 5.3 (Std Dev.=4.1) 5.8 (Std Dev.=4.3) p=0.0683 Use of Cardiac Support (N=89) 51.7% 48.3% p=0.7949 Means duration of cardiac support (hours) 11.4(Std Dev=8.9) 14.8(Std Dev.=10.3) p=0.0571 Means hospital stay (days) 5.6 (Std Dev.=1.9) 6.3 (Std Dev=2.0) p=0.0027  Among 124 patients, only 14.5% had cardiac catheterization done for preoperative assessment while the rest were diagnosed by clinical examination and echocardiography only.   Surgical repair for these defects included direct suturing (64.5%) and 0.5% glutarldehyde treated autologous pericardial patch (35.5%). Pericardial patch closure was applied for defects with friable margins and ill-defined margins including one patient with common atrium.  The surgical outcome for these patients revealed a mean duration of mechanical ventilation of 5.5 hours (Std Dev. = 4.2), 71.8% of all patients were maintained on a post operative cardiac support with a mean duration of 13.0 hours (Std Dev. = 9.7). Commonly used cardiac supports included NTG alone (45.2%) and a combination of NTG and Dobutamine (26.6%). Mean duration of ICU stay was 1.8 days (Std Dev. = 4.3) and mean duration of hospital stay was 5.9 days (Std Dev. = 1.9). Mild to moderate post-operative pericardial effusion was observed in 8.1% of the patients and this recovered spontaneously. One patient with severe post-operative pulmonary hypertension was managed medically with oral Sildenafil, Milirinone, NTG, Sodium Nitroprusside and Frusemide with good recovery. Mortality rate was 0.8% in this study for one patient who was 45 years old developed atrial fibrillation and low output syndrome on the third post-operative day. The necessary resuscitation measure, cardiac supports and expertise consultation were done but patient died of multiple organs failure on the eleventh post-operative day.    When comparing the clinico-surgical outcome between the age-group 10 or less and above 11 years it was found that there was a significant difference in the means duration of symptoms, 49.5 months (Std Dev.=50.1) vs. 37.9 months (Std Dev.=60) respectively, (p=0.0008), significant proportion of recurrent respiratory tract infection, 84.1% vs. 15.9% respectively(p=0.0000) and significant mean hospital stay 5.6 days (Std Dev.=1.8)  vs. 6.3 days (Std Dev.=2) respectively  East and Central African Journal of Surgery Volume 12 Number 1                April  2007  152(p=0.0027). Clinically the incidence of preoperative pulmonary hypertension was increasing with age although statistically it was not significant (33.3% vs. 66.7% respectively, p=0.0253).  Discussion  The study revealed that females had higher predominance than males and ostium secundum was the commonest type of ASD accounting for 92.7%. Similar results were obtained by the other studies1,2,8.  Adult patients presented with palpitation, shortness of breath and chest pain. Anita et al3 found the similar symptoms.  Cardiac catheterization is only indicated in patients with ASD to evaluate severe pulmonary artery pressure, left heart function and haemodynamics, co-morbid anomalies, coronary artery for patients above 40 years or for percutaneous closure of ostium secundum ASDs9.  Echocardiography is the primary imaging modality used in the evaluation of ASDs because of its high sensitivity and specificity, low cost and easy accessibility10.  The necessary resuscitation measure, cardiac supports and expertise consultation were done but patient died of multiple organs failure on the eleventh post-operative day. The above findings were similar to other studies8,11,12,13,14,15.  Clinically the incidence of preoperative pulmonary hypertension was increasing with age although statistically it was not significant (33.3% vs. 66.7% respectively, p=0.0253). There was no significant difference between the two groups in terms of mean duration of mechanical ventilation, use of cardiac support, mean duration of cardiac support and ICU stay. Several studies2,5,6,7,8,13,16,17 concluded  that  surgical repair of ASD has a good outcome when done during childhood than in adults in terms of atrial fibrillation, thrombo-embolic phenomena, left ventricle systolic function, degree of mitral and tricuspid valve regurgitation.  Conclusion  • Children with a significant ASD lesion present with shortness of breath, recurrent respiratory tract infection, failure to thrive and poor feeding compared to palpitation, shortness of breath and chest pain in adults. • Diagnosis of ASD is mainly done by clinical examination and echocardiography. • Clinically the incidence of pulmonary hypertension increases with age in patient with ASD and therefore early repair is advised for good outcome.  Acknowledgement   Special thanks to the Administration of CARE Hospital, Banjara Hills, Hyderabad-India for allowing this study, Mr. Sashidhar DSL and Ms  Jhansi of Records Department-CARE Hospital, all staffs of Old Cardiothoracic theatre and ICU and Mr. Mayunga F of Muhimbili University College of Health Sciences, Department of Epidemiology and Biostatistics  for statistical analysis.     References  1. Symasundar Rao P. Diagnosis and Management of acyanotic heart disease: Part II left to right shunt lesions. The Indian J Pediatrics (Symposium on Pediatric Cardiology-1) 2005; 72: 503- 512 2. Jose M Oliver, Pastora Gallego, Ana E Gonzalez, Fernando Benito, Ernesto Sanz,Angel Arocal, Jose M Mesa and Jose A Sobrino. Surgical closure of ASD before or after the age of 25 years. Comparison with the natural history of un-operated patients.Rev. Esp. Cardiol. 2002; 55: 553-961 3. Anita Saxena, Abhay Divekar, Nandini R. Soni. Natural history of secundum ASD revisited in the era of transcatheter closure. Indian Heart Journal 2005; 57: 35-38 4. Mc Mahon CJ, Felters TF, Fraley JK, Bricker JT, Grifka RG,Tortoriello TA, Blake R, and Bezold LI et al. Natural history of growth of secundum ASD and implications for transcatheter closure. Heart 2000; 87: 256-259 5. Roos-Hesselink JW, Meiboom FJ, Spitaels SEC, van-Domburg R, EMH van Rijen, EMWJ Utons, AJJC Bogers, and ML Simons. Excellent survival and low incidence of arrhythmias, stroke and heart failure, long-term after surgical ASD  East and Central African Journal of Surgery Volume 12 Number 1                April  2007  153closure at young age. European Heart Journal 2002; 24: 190-197 6. Murphy JG, Gersh BJ, McGoon MD, Mair DD, CJ Porter, Ilstrup DM, McGoon DC, Puga FJ, Kirkilin JW and Danielson GK. Long-term outcome after surgical repair of isolated ASD. N Engl J Med 1990; 323: 1645- 1650 7. Shah D, Azhar M, Oakley CM, Cleland JG, Nihoyannopoulous P. Natural history of  secundum ASD in adults after medical or surgical treatment: A historical prospective study. Br Heart J 1994; 71: 224-228 8. Heta PN, Eero VJ, Heikki IS. Late results of Paediatric Cardiac Surgery in Finland. Circulation 2001; 104: 570-584 9. Garry W, Michael AG. Atrial Septal Defects in the adult. Circulation 2006; 114:1645-1653 10. Wang ZJ, Reddy GP, Gotway MB, Yen BM, Higgins CB. Cardiovascular shunts: MR Imaging Evaluation. Radiographics 2003; 23: s181-s194 11. Juan-Miguel G, Marcos M, Arturo G, Luis M, Ramon VMG. Comparative Study of Thoracic Approaches in Atrial Septal Defect Closure. Rev. Esp. Cardiol 2005; 55:1213-1216 12. Aaron LT, Emilio BL, Felipe U, Phillip JH, Charles TK, Thomas DM, Edward DS, Thomas MB. Oral Sildenafil Reduces Pulmonary Hypertension after Cardiac Surgery. Ann Thorac Surg 2005; 79:194-197 13. Teresa SMT, Marion EB, Sharonne NH, William KF, Joseph AD, Sara LOB, James BS. Clinical and Echocardiographic Characteristics of Significant Pericardial Effusions following Cardiothoracic Surgery and Outcomes of Echo-guided Pericardiocentesis for Management. Chest 1999; 116: 322-331.  14. Zhong-Dong DU, Ziyad MH, Kleinman CS, Silverman NH, Larntz K. Comparison between transcatheter and surgical closure of secundum atrial septal defect in children and adults. J Am Coll Cardiol 2002; 39: 1836-1844 15. Butera G, Carminati M, Chessa M, Youssef R, Drago M, Giambeti A, Pome G, Bossone E, Frigiola A. Percutenous versus Surgical closure of secundum atrial septal defect: Comparison of early results and complications. 16. Garry W. Do patient over 40 years of age benefit from closure of an atrial septal defect? Heart 2001; 85: 249- 250 17. Perloff JK. Surgical Closure of Atrial Septal Defect in Adults. NEJMed 1995; 333:513-514 

Clinico-Surgical Outcome of Repair of Isolated Atrial Septal Defect At Care Hospital, Banjara Hills-Hyderabad India, 2004-2006

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Clinico-Surgical Outcome of Repair of Isolated Atrial Septal Defect At Care Hospital, Banjara Hills-Hyderabad India, 2004-2006

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