Long-Term Effect of Atrial Septal Defect Closure on Clinical Outcomes and Mortality: A Nationwide Population-Based Cohort Study

Abstract

Background: It is unclear whether atrial septal defect (ASD) closure has long-term clinical benefits and whether its impact substantially differs according to age. Methods: Using the Korean National Health Insurance Service database, we identified patients with isolated ASDs diagnosed between January 1, 2003 and December 31, 2006. We compared outcomes between patients who underwent surgical ASD closure and those who did not. The outcomes of interest were incidences of atrial flutter/fibrillation (AFF), ischemic stroke, and all-cause mortality. Findings: Overall, 2023 patients without a history of AFF or stroke who underwent ASD closure and 2023 propensity score-matched patients who did not undergo closure were included. The mean follow-up period was 12·5 years. Patients who underwent ASD closure had lower risks of AFF (6·2 vs. 10·5 events per 1000 person-years; hazard ratio [HR] 0·60; P<0·001), ischemic stroke (0·6 vs. 1·3; HR 0·49; P=0·0148), and mortality (2·8 vs. 5·8; HR 0·47; P<0·001) than those who did not undergo this procedure. Subgroup analysis according to age showed that ASD closure significantly lowered the risk of AFF in patients younger than 60 years and lowered the risk of death in patients aged 20 years and above. In patients aged between 40 and 59 years, compared to non-closure, ASD closure significantly reduced the risks of AFF, ischemic stroke, and death. Interpretation: In this large, real-world population with ASD, in patients with no history of clinical events, ASD closure was associated with significantly lower risks of AFF, ischemic stroke, and mortality during the long clinical follow-up period. Our data suggest that timely ASD closure without delay is necessary in all ASD patients regardless of age. Funding Statement: This study was supported by a grant (Jungwook Hong) from the Asan Institute for Life Sciences and Corporate Relations of Asan Medical Center, Seoul, Korea. Declaration of Interests: The authors have no conflicts of interest to declare. Ethics Approval Statement: This study was approved by the institutional review board of Asan Medical Center (approval number: 2018-1392). This study was based on nationwide claims data from the NHIS (NHIS-2019-1-046), so the requirement for informed consent was waived as the NHIS database was constructed after anonymization according to strict confidentiality guidelines.