Atrial Fibrillation/Flutter After Transcatheter Device vs. Surgical Closure of Atrial Septal Defect in a Korean Nationwide Cohort

Atrial fibrillation/flutter (AF/AFL) is a common long-term complication after atrial septal defect (ASD) closure. We compared the incidence of new-onset AF/AFL and clinical outcomes between surgical and device closure. Using the Korean National Health Insurance Service database (2009–2021), we identified adults undergoing ASD closure without prior atrial arrhythmias. The primary outcome was new-onset AF/AFL. Secondary outcomes included all-cause mortality, ischemic stroke, and catheter ablation. Propensity score (PS) matching was performed to minimize confounding. Among 11,133 patients (3,747 surgical; 7,386 device), 6,310 were included in the PS-matched cohort. During a median follow-up of 5.5 years, the device closure group showed a significantly lower risk of AF/AFL (hazard ratio [HR], 0.73; 95% confidence interval [CI], 0.59–0.91) and all-cause mortality (HR, 0.65; 95% CI, 0.52–0.81) compared to the surgical group in the matched cohort. Conversely, the device group was associated with a higher risk of ischemic stroke (HR, 1.50; 95% CI, 1.13–1.98). Catheter ablation for AFL was performed significantly more frequently in the surgical group (12.0% vs. 3.5%, p=0.048). Surgical closure, male sex, heart failure and older age at closure were associated with higher risk of AF/AFL after ASD closure. Among ASD patients without prior AF/AFL, device closure was associated with lower long-term AF/AFL, whereas AFL ablation was performed more frequently after surgical closure.