Atrial arrhythmia after surgical closure of atrial septal defects in adults

Background Atrial flutter and atrial fibrillation are causes of morbidity in adults with an atrial septal defect. In this study, we attempted to identify risk factors for atrial flutter and fibrillation both before and after the surgical closure of an atrial septal defect. Methods We searched for preoperative and postoperative atrial flutter or fibrillation in 213 adult patients (82 men and 131 women) who underwent surgical closure of atrial septal defects because of symptoms, a substantial left-to-right shunt (ratio of pulmonary to systemic blood flow, >1.5:1), or both at Toronto Hospital between 1986 and 1997. Results Forty patients (19 percent) had sustained atrial flutter or fibrillation before surgery. As compared with the patients who did not have atrial flutter or fibrillation before surgery, those who did were older (mean [+/-SD] age, 59+/-11 vs. 37+/-3 years, P<0.001) and had higher mean pulmonary arterial pressures (25.0+/-9.7 vs. 19.7+/-8.2 mm Hg, P=0.001). There were no perioperative deaths. After a mean follow-up period of 3.8+/-2.5 years, 24 of the 40 patients (60 percent) continued to have atrial flutter or fibrillation. The mean age of these patients was greater than that of the 16 who converted to sinus rhythm (P=0.02). New-onset atrial flutter or atrial fibrillation was more likely to have developed at follow-up in patients who were older than 40 years at the time of surgery than in those who were 40 or younger (5 of 67 vs. 0 of 106, P=0.008). Late events (those occurring more than one month after surgery) included stroke in six patients (all but one with atrial flutter or fibrillation, one of whom died) and death from noncardiac causes in two patients. Multivariate analysis showed that older age (>40 years) at the time of surgery (P=0.001), the presence of preoperative atrial flutter or fibrillation (P<0.001), and the presence of postoperative atrial flutter or fibrillation or junctional rhythm (P=0.02) were predictive of late postoperative atrial flutter or fibrillation. Conclusions The risk of atrial flutter or atrial fibrillation in adults with atrial septal defects is related to the age at the time of surgical repair and the pulmonary arterial pressure. To reduce the morbidity associated with atrial flutter and fibrillation, the timely closure of atrial septal defects is warranted. (N Engl J Med 1999;340:839-46.) (C) 1999, Massachusetts Medical Society.