Elsevier

International Journal of Cardiology

Volume 241, 15 August 2017, Pages 149-155
International Journal of Cardiology

Treatment options for the closure of secundum atrial septal defects: A systematic review and meta-analysis,☆☆

https://doi.org/10.1016/j.ijcard.2017.03.073Get rights and content

Highlights

  • TCC of ASDs is associated with lower mortality, complications and LOS as opposed to SC, which has lower residual shunts.

  • Percutaneous closure of ASDs presents an attractive alternative to surgical closure in the appropriately selected patient.

  • SC remains a very important role for ASD closures, especially in patients with an anatomy that may not be favorable for TCC.

Abstract

Background

Secundum atrial septal defects (ASDs) are treated by surgical closure (SC) or transcatheter device closure (TCC). Due to a scarcity of data directly comparing these approaches, it remains unclear which is superior. This meta-analysis compares the clinical outcomes of the two treatment options.

Methods

A literature search was performed in MEDLINE, Embase, PubMed, Google Search, and Cochrane databases for studies directly comparing SC and TCC of ASDs. Outcomes studied were major and minor acute complications, all-cause mortality, residual shunt, reinterventions, and length of stay (LOS). Relative risk (RR), difference in mean (DM) and 95% confidence intervals (CI) were calculated using the Mantel-Haenszel method with a fixed effect model. In cases of heterogeneity (defined as I2 > 25%), random effect models were used. Sensitivity and meta-regression analyses were performed for each outcome.

Results

Of the 1742 manuscripts screened, 26 observational studies fulfilled the inclusion criteria (total n = 14,559 patients). TCC was superior to SC for the following outcomes: all-cause mortality (RR, 0.66; 95% CI 0.64–0.99), total complications (RR, 0.48; 95% CI 0.35–0.65), major complications (RR, 0.57; 95% CI 0.40–0.81), minor complications (RR, 0.35; 95% CI 0.23–0.53), and LOS (DM, − 2.92; 95% CI − 3.25 to (− 2.58)). Residual shunts were more common with TCC (RR, 3.35; 95% CI 1.72–6.51). No difference was observed regarding the need of reintervention (RR, 1.45; 95% CI 0.60–3.51). Meta-regression analysis showed that older age increases the risk of death and complications in patients undergoing TCC.

Conclusions

Though both approaches are effective, TCC is associated with lower mortality, complications, and LOS while SC has a lower rate of residual shunting.

Introduction

Congenital defects of the atrial septum are common, accounting for 10% to 17% of congenital heart disease [1]. The secundum type atrial septal defect (ASD) is the most common subtype with an estimated incidence of 1 in 1500 live births, accounting for approximately 75% of all ASDs [2]. Though ASDs can be initially asymptomatic, guidelines recommend ASD closure if there is right atrial and/or right ventricular enlargement, even for asymptomatic patients (Class I) [3].

Historically, surgical closure (SC) had been considered the standard of care with excellent long-term results [4], [5]. Over the past few decades, the popularity of transcatheter device closure (TCC) has increased as studies have demonstrated its safety and efficacy [2].

There are few studies comparing SC to TCC, and no clear superiority of one technique over the other is known. Therefore, we performed a systematic review and meta-analysis to assess the efficacy and safety with direct comparisons between TCC and SC approaches for ASD closure.

Section snippets

Methods

A protocol for this systematic review was created, which we posted online and registered in PROSPERO (CRD42016045528). We followed the guidelines outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [6]; see in Appendix A.

Results

The initial search strategy identified a total of 1742 potential articles (see Appendix A Fig. 1). After removing duplicates and articles not meeting inclusion criteria, we screened 319 titles and abstracts. Only 26 observational studies [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33] satisfied inclusion criteria, and all manuscripts were published in journals written in English; no RCT was

Discussion

Although several studies have shown similar results previously [8], [10], they were mostly small, single institution studies without the significant power to draw appropriate conclusions. To our knowledge, this is the largest-scale meta-analysis that examines the outcomes of TCC vs. SC for secundum ASDs involving 14,559 patients. The analysis provides a comprehensive review of the available evidence to date, doubling the number of studies published in a prior meta-analysis [34].

This

Limitations

Our meta-analysis has several potential limitations. First, a major limitation of this review is the lack of a RCT in the literature. A RCT would have been difficult, given that patients had the prerogative of choice in the treatment options available. As anticipated, the observational studies possessed significant selection bias that could explain, in part, the methodological heterogeneity. Every effort was made to present the outcomes as stratified analyses, however, potential biases are

Conclusions

Closure of ASD using percutaneous therapies is associated with lower mortality, complications and LOS as opposed to surgical closure, which has lower risk of residual shunt. Percutaneous closure of ASDs presents an attractive alternative to surgical closure in the appropriately selected patient. There still remains a very important role for SC of ASD closures, especially in patients with anatomies that may not be favorable for TCC.

Conflict of interest

The authors report no relationships that could be construed as a conflict of interest.

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    These authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

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    The paper is not under consideration elsewhere. None of the paper's contents have been previously published. All authors have read and approved the manuscript. Authors have no conflict of interest.

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