There is a matter of debate regarding benefits of percutaneous ASD closure in the elderly 4,19−21. The present study confirmed the advantage of percutaneous ASDC in adults, particularly those of advanced age in a short-to-mid‑term period in real-world clinical practice. The results from our study also revealed the presence of residual pulmonary hypertension after ASDC, even after 1 year, and the prognostic value of pre-intervention PASP in the prediction of this state.
Clinical benefits and changes in RV and PASP in the elderly has shown in several studies 5,22−26. Nyboe et al. 24 investigated symptoms, presence of atrial fibrillation, and RV dilation in 220 adult patients treated for ASD in both surgery and percutaneous catheter closure, of which 79 patients were over 50 years old. The authors found that the absolute risk reduction in dyspnea, RV dilation, and atrial fibrillation was 49% (p < 0.001), 52% (p < 0.001), and 20% (p < 0.001), respectively in the group aged ≥ 50 years old undergoing percutaneous ASDC. Swan et al. 22 reported greater baseline values of RV size and RV systolic pressure in the older group (aged > 60 years, n = 50) compared with the younger (n = 134) and echocardiographic improvement following 6 weeks after ASD device closure procedure in reduction of RV size and PASP in the older group. In recent study23, Giordano at al. studied 68 patients aged above 60 years at a mean follow-up of 4.3 years, reporting a greater reduction in RV dimension (mid-cavity 40.5 ± 5.4 mm vs. 35.6 ± 5.4 mm; p < 0.01), PASP (44.3 ± 12.2 mmHg vs. 34.9 ± 8.8 mmHg; p < 0.01) and a significant improvement of NYHA class (pre-interventional NYHA III-IV 21.5% vs. post- interventional NYHA III-IV 4.6%, p < 0.01). Similarly, Humenberger et al. 5 studied 236 patients undergoing percutaneous ASDC with a mean follow-up time was 2.3 years, 74 patients older than 60 years, has shown symptomatic improvement after 3–6 months with 66% (n = 49) being asymptomatic post-interventionally when compared with 16% (n = 12) before (NYHA class I). Authors also found post-interventionally regression of RV size (45 ± 6mm to 37 ± 5 mm, p < 0.0001), PASP (53 ± 17 mmHg to 43 ± 14 mmHg, p < 0.0001), and severe TR rate (from 7 patients originally to 2 patients). These results were consistent with our study.
Percutaneous ASD closure has the advantage of being significantly less invasive and decreased complication rates and shorter hospital stays than surgery 2–4, 27. In a systematic review 3 including 13 observational studies with a total of 3082 patients, compared short-term follow-up outcomes (up to 18 months) following surgical and percutaneous ASDC, surgery was associated with a higher rate of total early complications and longer hospital stays than in the percutaneous group [31% vs. 6.6%; OR 5.4, 95% CI 2.96–9.84, p < 0.0001 and 2.6 days, 95% CI 2.2 to 3.1 days, p < 0.001, respectively]. The safety and efficacy of percutaneous ASD closure have reported previously, even in elderly patients (≥ 60 years) 12,28. Majunke et al. 28 analyzed the results of ASD closure in 650 patients, and 144 patients older than 60 years. During mean time follow-up of 36.3 months, complete closure was achieved in 96% of patients with a single ASD (547 of 572), and procedural complications were observed in 3 (0.5%) patients, including device embolization and transient ST depression. Pericardial effusion was not observed in this study unless within 30 days after the procedure occurred in 5 (0.8%) patients, contrary to our results. Device closure of ASD has also demonstrated efficacy even in elderly patients (≥ 60 years old) complicated with permanent atrial fibrillation. In the study by Taniguchi et al. 29, 9 elderly patients (≥ 60 years old) with permanent atrial fibrillation after ASD device closure has shown a symptomatic improvement (from 0 patients originally with NYHA I before to 8 patient after intervention) and significant improvement in RV dimension (42.8 ± 6 4.0 to 33.3 ± 6 3.4 mm, p = 0.008, respectively), whereas LV dimension and LVEF did not change statistic significantly after 6 months. No hemodynamic and thromboembolic complications were observed during the follow-up period (mean 10.6 months). In the SWEDCON registry (Swedish National Registry on Congenital Heart Disease) from 1997 to 2014, the clinical and echocardiographic outcomes of percutaneous ASDC in148 patients ≥ 65 years of age (71.6% female) were reported 25. At the one-year follow-up, the NYHA witnessed significant improvement in functional class (NYHA I from 34–61%, p < 0.001), and this improvement persisted to the latest follow-up more than 4 years after the intervention. Also were observed improvements in RV remodeling and reduction of PASP. Worsening of NYHA was found in 9 patients at the one-year follow-up compared to pre-intervention. Interestingly, this was not associated with gender, arterial hypertension, or atrial fibrillation but, with age. The authors explained by the presence of diastolic dysfunction that may be developed as result of heart failure with preserved LVEF, which was not aimed at our study.
The prevalence of PAH is reported in 6 to 35% of patients with ASD, both open and closed 30–32. In our study, its prevalence before ASD closure was 86.3% and decreased to 25.5% after ASD closure and 19.6% after 1 year. In the study by Świątkiewicz at al. 33 in 184 transcatheter ASD closure, PAH (PASP ≥ 40 mmHg) was observed in 107 (58.1%) before ASDC, decreased to 46% (n = 86) 24 h after ASDC and 36% (n = 60) after 6 months. Veldtman et al. 34 demonstrated a persistent elevation in PASP after percutaneous ASDC in 29% of their patients (n = 40) at 12 months of follow-up. In the study by Humenberger et al. 5, this feature was observed up to 51% of patients over 60 years old (n = 74). These results suggest a proportion of patients have elevated pulmonary vascular resistance before ASD closure, which may negatively affect the improvement of PASP and clinical symptoms after the procedure.
The relationship between age and persisted post-interventionally PASP has been found in several studies 5,35 33. Humenberger et al. 5 showed a moderate correlation between age and persisted post-interventionally PAP (r = 0.63, p < 0.0001), and indicated that elderly patients (≥ 60 years) were most likely to be left with persistently elevated PAP after 6 months. In our study, factors associated with residual PAH at 1 year after ASDC were age, pre-intervention RV size, pre-intervention PASP, and severe TR. Young et al. 35 studied risk factors associated with PAH in 215 patients with attempted percutaneous ASD closure in 15 months median duration of follow-up, they found that older age (OR: 1.1, 95% CI 1.06–1.11, p < 0.001), larger ASD (OR: 1.13, 95% CI 1.04–1.23, p = 0.0052), female sex (OR: 3.9, 95% CI 1.1–13.2, p = 0.0313), and at least moderate tricuspid regurgitation (OR: 3.6, 95% CI 1.5–8.8, p = 0.0043) were independent predictors of moderate or severe PAH (PASP ≥ 50 mmHg). These results were partly consistent with our results in univariate analysis. However, after adjusting LVEF and ASD size, we only found that pre-intervention PASP served as a unique factor associated with PAH at one year and demonstrated excellent discrimination power.
Elderly patients with ASD can present a high prevalence of comorbidities with advancing age. Cardiovascular risk factors such as arterial hypertension, and dyslipidemia was observed frequently in our study, which was comparable with other studies 5,22,28. The prevalence of arterial hypertension was found to be 30–60% in patients with ASD closure 36–38. It raised the question about its impact on hemodynamics and clinical outcome. However, in our study, we did not reveal a correlation between hypertension and residual PAH. In addition, less common other cardiovascular risk factors, such as diabetes mellitus or coronary artery disease were observed in our study, which was consistent with previous studies 2–5, 39,40. Atrial fibrillation was registered less frequently in our study, less than 10%, in contrast to the study by Humenberger et al. 5 and Swan et al. 22being 51.3% (n = 38) and 20% (n = 10), respectively. This can be explained by the fact that our patients were in an earlier stage of cardiac remodeling with a small number of patients with LA enlargement. However, the presence of concomitant cardiovascular risk factors could affect the clinical status and outcome in the short-to- long-term period in patients with ASD, hence it is reasonable to manage these conditions according to appropriate guidelines.
Limitations. First, as a retrospective nature of the study, some cofounders and medical management could potentially influence the change of functional status and echocardiographic feature after percutaneous ASDC. Second, this was a single-center study, not all patients are followed up in our clinic. Data at the end of 1-year follow-up were available in 37/51 (73%) patients, which may affect the accuracy in the assessment of the prognostic value of pre-intervention PASP. However, echocardiographic characteristics of lost to follow-up were similar to those with late follow-up data. Third, cardiac catheterization and pulmonary function tests were not performed due to study design and ethical issues, the diagnosis of PAH based on echocardiography was less accurate than the reference ones. Fourth, this study aimed to focus on functional status and echocardiographic features after ASD closure. Therefore, a comprehensive assessment of early and late complications was not taken into account. Future studies should therefore involve larger multicenter patient cohorts to permit a more detailed assessment of complications and factors related to residual PAH after ASD closure.