Atrial Septal Defect in Patients over the Age of Forty Years

The fate of 62 patients with atrial septal defect (ASD) who were 40 years of age and older was analyzed in detail. All patients were studied hemodynamically, those who underwent operation were recatheterized postoperatively, and the subsequent clinical courses of the entire group were determined. Cardiorespiratory symptoms were reported by 94% of the patients; 45% were in functional class III or IV. Fifty-four patients had moderate or large left-to-right shunts; pulmonary arterial (PA) hypertension was present in 69% of these patients, and was severe in 28%. PA hypertension or a large left-to-right shunt, or both were found in all 28 patients in functional classes III and IV. Eight patients (13%) exhibited evidence of severe obliterative pulmonary vascular disease, with balanced or predominantly right-to-left shunting. Operative correction of the ASD was performed in 48 patients. The overall operative mortality of 12.5% was reduced to 6.5% in the 31 patients operated upon after 1961. At the initial follow-up, which averaged 8 months postoperatively, 29 of 41 patients, including all those in classes III and IV, were improved by at least one functional class. No patient was worse, and only four of 20 patients in class II failed to benefit symptomatically. PA hypertension was abolished in 15 of 25 patients, and in the remainder an average reduction in systolic PA pressure of 20 mm Hg occurred. Symptomatic benefit has been sustained in all but three of 37 patients in whom late (average, 5 years) follow-up information after operation was obtained. It is concluded that operative treatment of ASD may be undertaken with a relatively low operative mortality in patients in the fifth decade, despite the presence of PA hypertension, large left-to-right shunt, or congestive heart failure, and that sustained clinical and hemodynamic benefit may be anticipated, even in patients with advanced symptomatic disability.