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Long-term survival after transcatheter closure of secundum atrial septal defects (ASD) is similar to that achieved after surgical closure, but the former method is far more likely to require reintervention, according to a registry study published online April 17, 2013, ahead of print in JACC: Cardiovascular Interventions.

Investigators led by Ariane J. Marelli, MD, MPH, of McGill University Health Centre (Montreal, Canada), retrospectively analyzed outcomes of 718 adult patients who underwent surgical (n = 383) or transcatheter (beginning in 1998; n = 335) ASD closure in Québec, Canada, between 1988 and 2005, drawing on the Québec Congenital Heart Disease database.

No Difference in Mortality

At 30 days and 5 years, there was no difference in mortality rates between the 2 procedures, although at 1 year a trend emerged toward reduced mortality with transcatheter closure (table 1).

Table 1. Mortality: Surgical vs. Transcatheter ASD Closure

In a Cox analysis, mortality risk with transcatheter closure (HR 0.278; 95% CI 0.095-0.810) was unchanged by adjustment for age (HR 0.190) or history of pulmonary hypertension (HR 0.293). When patients who underwent closure in the pretranscatheter era were excluded, a trend toward reduced mortality was seen in the transcatheter group (HR 0.283; 95% CI 0.079-1.015; P = 0.053).

In the year after closure, there was no difference between the surgical and transcatheter groups in rates of new-onset congestive heart failure (CHF) or stroke/TIA. In terms of healthcare resource use, individual transcatheter patients had fewer outpatient physician visits and spent fewer days in critical care, with a similar number of ED visits. However, transcatheter patients underwent more frequent echocardiograms (table 2).

Table 2. Outcomes, Healthcare Use at 1 Year

 According to the authors, the study data “support the current practice of using transcatheter closure whenever technically feasible.”

Throughout the study period, only 2 reinterventions occurred in the surgical group: 1 surgical intervention on the first postop day and 1 percutaneous intervention almost 13 years after the index procedure. This yielded a 30-day reintervention rate of 0.3%, which remained unchanged at 5 years.

By contrast, reintervention rates in the transcatheter group were 1.8% after 30 days (P = 0.053 vs. surgery), 4.6% after 1 year (P < 0.0001), and 7.9% after 5 years (P = 0.0038). Seventeen of the 18 transcatheter patients who required reintervention (94%) had surgery, with no periprocedural deaths. Analysis limited to patients who underwent transcatheter closure later in in the study period, when operators were more experienced, showed a trend toward a lower reintervention rate, the investigators say.

They note that instances of failed transcatheter closure may be due to problems with device position or stability, which requires elective surgical closure at a later date. Or a patient may experience a complication, such as device embolization, that demands urgent reintervention. Regardless, Dr. Marelli and colleagues say, the majority of reinterventions occur within the first year; after that, the rate is low and comparable to that of surgical closure. They note that this finding supports the 2008 American College of Cardiology/American Heart Association recommendation that transcatheter patients should undergo regular echocardiographic follow-up during the first year after device implantation but only periodically thereafter.  

High Transcatheter Reintervention Rate Questionable

Ziyad M. Hijazi, MD, MPH, of Rush University Medical Center (Chicago, IL), called the substantially higher rate of reintervention with transcatheter closure a surprise. “I have not seen that,” he told TCTMD in a telephone interview. “In my hands, reintervention after device closure is very rare.

This discrepancy highlights an important drawback of the study, Dr. Hijazi asserted. Due to use of administrative data, the reasons for surgical reintervention are unknown.  Reintervention may be unrelated to the ASD closure or a patient may have had a residual shunt, he suggested. “But nowadays we can close a residual shunt with a second device,” he said. “In fact, in 15 years, I think I’ve only sent 1 such patient to surgery.”

Dr. Hijazi noted that the study compares a relatively new, percutaneous technique, performed by operators with a range of experience, with a surgical procedure with a 50-year history that was likely performed by highly skilled surgeons.

Nonetheless, he called the trend toward reduced mortality with the transcatheter approach in the first year after ASD closure “encouraging news.” Also, the similar rates of CHF and stroke/TIA indicate that transcatheter closure is “just as effective as surgical closure, which has been the gold standard,” he added.

Dr. Hijazi questioned the appropriateness of labeling 5-year mortality ‘long-term,’ adding, “I would like to see 10-, 15-, 20-year follow-up. Nonetheless, it is reassuring that device closure is as safe as surgery.”

He seconded the authors’ recommendation to use transcatheter ASD closure whenever possible, commenting, “In skilled hands, device closure is safer and has fewer complications,” he said. “It’s the treatment of choice.”

Study Details

Transcatheter patients were older and had more comorbidities, with the exception of pulmonary hypertension, which was more common in the surgical group. Median follow-up was 10 years for surgery patients vs. 3 years for transcatheter patients (P < 0.001).

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