COMPARISON OF SURGICAL AND MEDICAL THERAPY FOR ATRIAL SEPTAL-DEFECT IN ADULTS

Background. The surgical closure of an atrial septal defect is frequen tly recommended for patients over 40 years of age. However, the progno sis for such patients with unrepaired defects is largely unknown, and the outcome for patients operated on after the fourth decade of life h as not yet been compared with that for medically treated patients in a controlled follow-up study, Methods. In a retrospective study, we exa mined the clinical course of 179 consecutive patients with isolated at rial septal defects diagnosed after the age of 40, The 84 patients (47 percent) who underwent surgical repair were compared with the 95 pati ents (53 percent) who were treated medically. The mean (+/-SD) follow- up period was 8.9+/-5.2 years (range, 1 to 26). Results. Multivariate analysis revealed that surgical closure of the defect significantly re duced mortality from ail causes (relative risk, 0.31; 95 percent confi dence interval, 0.11 to 0.85). The adjusted 10-year survival rate of s urgically treated patients was 95 percent, as compared with 84 percent for the medically treated patients, In addition, surgical treatment p revented functional deterioration, as measured by the New York Heart A ssociation class (relative risk, 0.21; 95 percent confidence interval, 0.08 to 0.55), However, the incidence of new atrial arrhythmias or of cerebrovascular insults in the two groups was not significantly diffe rent. Conclusions. The surgical repair of an atrial septal defect in p atients over 40 years of age, as compared with medical therapy, increa ses long-term survival and limits the deterioration of function due to heart failure, However, surgically treated patients should be followe d closely for the onset of atrial arrhythmias so as to reduce the risk of thromboembolic complications.