Cardiovascular Journal of Africa: Vol 27 No 4 (July/August 2016)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 27, No 4, July/August 2016 260 AFRICA
of arrhythmia increases due to right atrial volume overload
and atrial remodelling related to atrial hypertrophy.3 One of
the indications of ASD closure is to avoid arrhythmia, which
increases the risk of morbidity and mortality.2,7 The risk
of atrial arrhythmia decreases with recovery of right atrial
dilatation and electrophysiological changes after surgical
closure of the ASD.9
In our study, we compared the effects of two surgical
techniques on atrial conduction pathways and remodelling
caused by inflammatory fibrosis, by analysis of the P wave.
In both primary repair and patch plasty groups, Pmax and Pmin
values increased but Pd values did not change. Increase in Pmax
and Pmin values in the third month may have been related to early
remodelling, however because of the unchanged Pd, we believe
that the risk of arrhythmia will not increase in the long term.
In the postoperative period, the Pd value decreased in patients
who had regressed right atrial dilatation. However, Pmax and Pd
were longer in patients with persistent atrial dilatation.10 From
the results of Fang et al.,10 longer Pd values in patients with
permanent atrial dilatation support the notion that Pd may
be used as a non-invasive parameter for prediction of atrial
arrhythmia.
Our findings showed that the risk of atrial arrhythmia was
similar in both primary closure and patch plasty techniques,
since there was no difference between Pd values. By contrast,
Thilen et al.11 declared that increased P-wave duration did not
decrease with surgical repair in older patients and it was not
related to atrial dilatation. In haemodynamically significant
ASD, the increase in P-wave duration may depend on regional
damage of the atrial conduction pathways rather than atrial
enlargement.12,13
In our study, we were able to obtain three-month follow-up
records of the patients. During the follow up, although Pmax
values had increased, Pd values did not change and there was no
arrhythmia. From our results, we believe that in repair of ASD
in adults, the Pd value could be a more meaningful predictor for
the risk of arrhythmia.
The age of the patient at ASD closure may be a risk factor
for the development of arrhythmia in the follow-up period.11,14
ASD repair in childhood prevents permanent changes in the
atrial myocardium and regresses Pmax and Pd, thus decreasing the
risk for atrial fibrillation in older patients.2,15 In adult patients,
the chance of returning to normal atrial size is lower with ASD
repair. Repair of ASD after 25 years of age is a risk factor for the
development of atrial fibrillation in the long term.14,16
In our study we investigated 101 patients who had had
a diagnosis of ASD. Ninety of them were younger than 25
years and their mean age was 21.9 ± 2.8 years. None of the
patients had arrhythmia before the surgery and none had atrial
arrhythmia during the three-month follow-up period. In our
patients, the Pd value did not change after surgical repair and the
rate of returning normal atrial size may have been higher since
most of our patients were young adults.
The ASD closure technique did not affect the P wave in a
comparison of different percutaneous techniques, or surgical
repair and percutaneous techniques in previous studies.3,11
Javadzadegan et al.3 suggested that in both percutaneous ASD
closure and surgical treatment, the P-wave durationwas decreased
at six months’ follow up and this decrease was not related to the
defect size. In comparison, surgical and transcatheter ASD
closure, Baspınar et al .7 declared that in the surgical group,
decrease in the Pd was more meaningful in the early period.
We compared primary closure and patch plasty techniques
as two different surgical techniques, to analyse the effects on the
P wave, and there were no differences between the two surgical
techniques. When considering the anatomy of the right atrial
electrophysiological conduction pathway, there are no significant
conduction pathways into the atrial septum. We believe that
different surgical closure techniques do not affect the Pd value or
cause changes.
In long-term follow up after ASD closure, increase in Pd
values could be a sign of atrial arrhythmia.2 In ASD repair of
young adults, there was no increase in Pd values following ASD
closure. Neither primary repair nor patch plasty techniques had
any effect on the P-wave length or dispersion. Both surgical
techniques can therefore be performed, depending on the defect
anatomy and size.
There are limitations to this study. The majority of patients
were young and they were in the second and third decades of
their lives. After three months’ postoperative period, we had
limited access to long-term follow-up records, because they were
carried out in their homelands. We need long-term results to
assess whether the increased Pmax and Pd values in the first three
months continue in the long term and whether these changes led
to arrhythmias in the follow-up period.
Conclusion
In this study we compared patch plasty and primary repair for
the surgical closure of ASD in the early to mid-postoperative
period. No differences were found between the methods in terms
of postoperative P-wave changes, and we concluded that both
surgical procedures can be performed in adult ASDs.
References
1. Berger F, Vogel M, Kretschmar O, Dave H, Prêtre R, Dodge-Khatami
A. Arrhythmias in patients with surgically treated atrial septal defects.
Swiss Med Wkly 2005; 135: 175–178.
2. Guray U, Guray Y, Mecit B, Yilmaz MB, Sasmaz H, Korkmaz S.
Maximum p wave duration and p wave dispersion in adult patients
with secundum atrial septal defect: the impact of surgical repair. Ann
Noninvasive Electrocardiol 2004; 9: 136–141.
3. Javadzadegan H, Toufan M, Sadighi AR, Chang JM, Nader ND.
Comparative effects of surgical and percutaneous repair on P-wave and
Table 5. Comparison of primary repair procedure and
pericardial patch plasty procedure for ASD closure
Primary repair Patch plasty p-value
Pre-operative
Pmax 205.9 ± 29.4 219.4 ± 37.7 0.1112
Pmin 108.1 ± 29.4 108.8 ± 28.7 0.9436
Pd 97.2 ± 33.1 110.6 ± 43.6 0.1742
Postoperative 5th day
Pmax 220.6 ± 31.5 236.1 ± 39.4 0.5805
Pmin 121.2 ± 32.7 120.3 ± 27.7 0.983
Pd 98.8 ± 35.9 115.9 ± 39.9 0.0929
Postoperative 3rd month
Pmax 231.1 ± 39.4 254.3 ± 51.1 0.0639
Pmin 129.5 ± 36.9 132.7 ± 35.6 0.6696
Pd 101.7 ± 42.2 121.7 ± 47.9 0.0711