Gatzoulis M A, Freeman M A, Siu S C, Webb G D, Harris L
University of Toronto Congenital Cardiac Centre for Adults, Toronto Hospital, Department of Medicine, University of Toronto, ON, Canada.
N Engl J Med. 1999 Mar 18;340(11):839-46. doi: 10.1056/NEJM199903183401103.
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.
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.
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 (59+/-11 vs. 37+/-13 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.
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.
心房扑动和心房颤动是成人房间隔缺损患者发病的原因。在本研究中，我们试图确定房间隔缺损手术闭合前后心房扑动和颤动的危险因素。
我们在1986年至1997年期间于多伦多医院对213例因症状、明显的左向右分流（肺循环与体循环血流量之比>1.5:1）或两者兼而有之而接受房间隔缺损手术闭合的成年患者（82例男性和131例女性）进行术前和术后心房扑动或颤动的筛查。
40例患者（19%）术前有持续性心房扑动或颤动。与术前没有心房扑动或颤动的患者相比，有此类情况的患者年龄更大（59±11岁对37±13岁，P<0.001），平均肺动脉压更高（25.0±9.7对19.7±8.2 mmHg，P=0.001）。围手术期无死亡病例。平均随访3.8±2.5年后，40例患者中有24例（60%）仍有心房扑动或颤动。这些患者的平均年龄大于转为窦性心律的16例患者（P=0.02）。手术时年龄大于40岁的患者在随访中比40岁及以下的患者更易发生新发心房扑动或心房颤动（67例中有5例，106例中无，P=0.008）。晚期事件（发生在手术后一个月以上）包括6例患者发生中风（除1例无心房扑动或颤动外，其余均有，其中1例死亡）和2例患者死于非心脏原因。多因素分析显示，手术时年龄较大（>40岁）（P=0.001）、术前存在心房扑动或颤动（P<0.001）以及术后存在心房扑动或颤动或交界性心律（P=0.02）可预测术后晚期心房扑动或颤动。
成人房间隔缺损患者发生心房扑动或颤动的风险与手术修复时的年龄和肺动脉压有关。为降低与心房扑动和颤动相关的发病率，有必要及时闭合房间隔缺损。
