Surgical Repair Of Atrial Septal Defect Research Articles

A boy with fatigue and heart block: what's the mechanism?

When the atrioventricular node is damaged, accessory pathways can perform primary atrioventricular conduction but may spontaneously degrade during childhood. After surgical atrial septal defect repair during infancy, an adolescent male presented with fatigue due to iatrogenic complete atrioventricular node block with a degrading antegrade accessory pathway resulting in symptomatic bradyarrhythmia.

Anterolateral minithoracotomy versus median sternotomy for the surgical treatment of atrial septal defects: a meta-analysis and systematic review

BackgroundTo compare the short-term safety and efficacy of right anterolateral minithoracotomy (ALMT) and median sternotomy (MS) for the surgical treatment of atrial septal defects (ASDs).MethodsThe PubMed, EMBASE, Web of Science, and Cochrane Library databases were searched for comparative studies focusing on surgical repair of ASDs via ALMT or MS published up to the end of April 27, 2020. We used random-effect or fixed-effect models to obtain pooled estimates.ResultsA total of 7 publications, including 665 patients (ALMT 296 and MS 369), were included. Age (WMD: 1.80 years, 95% CI 0.31–3.29), weight (WMD: − 0.91 kg, 95% CI − 5.57 to 3.75), sex distribution (OR: 1.00, 95% CI 0.74–1.35) and surgical type (patch or direct closure) (OR: 1.00, 95% CI 0.67–1.49) were comparable in the ALMT group and MS group. No significant differences in the success rate (OR 0.23; 95% CI 0.05–1.07) or severe complication rate (OR 1.46; 95% CI 0.41–5.22) were found between the ALMT group and the MS group. In addition, the differences in the cardiopulmonary bypass (CPB) time (WMD 6.33; 95% CI − 1.92 to 14.58 min, p = 0.13) and the operation time (WMD 5.23; 95% CI − 12.49 to 22.96 min, p = 0.56) between the ALMT group and the MS group were not statistically significant. However, the ALMT group had a significantly longer aortic cross-clamp time (2.37 min more, 95% CI 1.07–3.67 min, p = 0.0003). The intubation time was 1.82 h shorter (95% CI − 3.10 to − 0.55 h; p = 0.005), the intensive care unit (ICU) stay was 0.24 days shorter (95% CI − 0.44 to − 0.04 days; p = 0.02), and the postoperative hospital stay was 2.45 days shorter (95% CI − 3.01 to − 1.88 days; p < 0.00001) in the ALMT group than in the MS group. Furthermore, the incision length was significantly shortened by 8.97 cm in the ALMT group compared with the MS group (95% CI − 9.36 to − 8.58 cm; p < 0.00001).ConclusionsIn the surgical treatment of ASD, ALMT and MS are equally safe and effective in terms of success rates and severe complication rates. The surgical procedures are equally difficult, but ALMT is associated with a faster functional recovery and better cosmetic results. Compared to MS, ALMT is the better choice for select ASD patients.

Experience of Minimal Invasive Cardiac Surgery for repair of Atrial Septal Defects- A Single Center Study

Background: Atrial Septal Defects (ASD) can be closed surgically using conventional midline sternotomy or minimal invasive technique. This study was done to evaluate the outcome and safety of the minimal invasive cardiac surgical (MICS) approach using right vertical infra axillary incision (RVAI) for the repair of ASD. Methods: We performed a prospective observational cross-sectional analysis on 50 patients who were diagnosed as ASD of various types and not amenable to device closure. Their surgery was done RVAI using central cardiopulmonary bypass. Outcome of the study was evaluated using the following variables: length of the incision, satisfaction of patients, mortality, infection of surgical site, blood transfusion, duration of total operation, intensive care unit (ICU) stay, mechanical ventilation, hospital stay and aortic occlusion. Operations were done between December 2013 to December 2020. All the recruited patients were treated through RVAI as per patient’s choice. Results: Mean age was 11.4± 6.4 years. 18(36%) were male and 32(64%) were female. Body weight ranged from 10 to 65 kg. Mean length of incision was 6.2±0.8 cm. Mean aortic occlusion time was 42±14 min. ASD closed directly, using autologous treated pericardial patch or dacron patch. Mean total operation time was 4.08±0.6 hours and mean mechanical ventilation time was 8.3±5 hours. Average ICU stay was 35.6±6 hours and total hospital stay was 7.2±0.9 days. There was no significant blood loss. Only 10 patients required intravenous (IV) analgesics in the post-operative period. One patient required re-exploration, one conversion to median sternotomy and one suffered from superficial skin infection. There were no operative or late mortalities. Patient satisfaction was excellent. Conclusions: MICS technique using RVAI for surgical repair of ASD revealed a safe procedure and could be performed with excellent cosmetic and clinical outcomes. It provided a good alternative to the standard median sternotomy. Cardiovasc j 2021; 14(1): 37-43

Role of Transesophageal Echocardiography in Retrieval of Dislodged Atrial Septal Defect Device Occluder

AbstractTranscatheter atrial septal defect (ASD) device closure has emerged as a safe and effective alternative procedure for surgical ASD repair. However, ASD device malposition and embolization has been reported with an incidence of 0.5 to 1.1%. We report here a case of a 32-year-old male, who presented to the hospital 5 months after ASD device closure for routine follow-up. This case reports highlights the significance of transesophageal echocardiography (TEE) evaluation in successful surgical retrieval of a dislodged ASD Amplatzer device.

Transcatheter and intraoperative device closure and surgical repair for atrial septal defect

BackgroundTranscatheter and intraoperative device closure for atrial septal defect (ASD) are widely applied to reduce the incision size and the potential for injury during cardiopulmonary bypass (CPB) in conventional surgical repair. No studies had been conducted to compare the safety and efficiency of these three treatments.MethodsFrom January 2018 to April 2018, 87 patients with an isolated ASD who had undergone transcatheter device closure (n = 45), intraoperative device closure (n = 22) and surgical repair (n = 20) were retrospectively reviewed and further analyzed to compare these three treatments.ResultsThe successful closure rate was similar in the three groups. There was a significant difference in aortic cross-clamping time, CPB duration and operative time between the surgical group and the device groups. The length of intensive care unit stay, postoperative mechanical ventilation time and length of hospital stay were shorter in the two device groups than in the surgical group. The incision was the most extended in the surgical group. Regarding major adverse events, no significant differences were found among the three groups.ConclusionsTranscatheter and intraoperative device closure and surgical repair for ASD are all safe and effective. Considering their respective disadvantages and advantages, the transcatheter approach may be the first choice for an isolated secundum ASD, the intraoperative approach may be the second choice, and surgical repair may be the last resort.

Incidence and Causes of 30-day Readmissions after Surgical Versus Percutaneous Secundum Atrial Septal Defect Closure: A United States Nationwide Analysis

ABSTRACT Background: The preferred approach for secundum atrial septal defect (ASD) closure has evolved from surgical repair to the current standard of practice being percutaneous closure. Although studies have highlighted a reduction in procedural complications with the percutaneous method, there is a paucity of data on readmissions after ASD closure. We evaluated the incidence and reasons for 30-day hospital readmissions in patients undergoing secundum ASD repair via surgical versus percutaneous approach. Methods: Data for hospitalizations for surgical or percutaneous closure of secundum ASD, during the years 2013–2014, were obtained from the Nationwide Readmissions Database (NRD). Hospitalization characteristics and relevant comorbidities were identified using the corresponding International Classification of Diseases, Ninth Edition, Clinical Modification [ICD-CM 9] codes. Propensity score matching was conducted to evaluate the 30-day rates and causes of readmission following surgical repair compared with percutaneous closure. Results: Of 4,616 hospital stays for adult patients undergoing ASD closure (3,004 percutaneous and 1,612 surgical), 163 were readmitted within 30 days from their index hospitalization. The unadjusted incidence of readmission was higher in the surgical group (5.2% vs. 2.7%, OR = 1.99, 95% CI 1.08–3.69, p = 0.028). Atrial fibrillation/flutter and post-pericardiotomy syndrome were the most common reasons for readmission after percutaneous and surgical closures, respectively. Patients who underwent surgical ASD repair had a higher median length of stay (8.8 vs. 5.2 days, p < 0.001) and cost of index hospitalization ($169,513 vs. $105,189, p < 0.001). Conclusions: Percutaneous ASD closure is associated with lower rates of 30-day readmissions, mean length of hospital stay, and hospital charges as compared with surgical closure.

TCT-554 Comparison of Transcatheter and Surgical Repair of Atrial Septal Defect: Analysis from Nationwide Inpatient Sample

Atrial septal defect (ASD) belongs to one of the most common congenital cardiac lesion. ASD repair is definitive treatment preventing major complications of persistent ASD. Alongside standard open surgical ASD repair (OSR), transcatheter/closed procedure (TCP) is an attractive modality applied in

Does Prophylactic Ibuprofen After Surgical Atrial Septal Defect Repair Decrease the Rate of Post-Pericardiotomy Syndrome?

Post-pericardiotomy syndrome (PPS) is an inflammatory process involving the pleura, pericardium, or both and occurs after cardiothoracic surgery. Surgical atrial septal defect (ASD) closure is associated with higher incidence of PPS post-operatively as compared to other operations. Reported incidence of PPS varies from 1 to 40%. NSAIDs are often used to treat PPS and in our center, some practitioners have prescribed ibuprofen prophylactically. This study sought to investigate the impact of prophylactic treatment with ibuprofen on the development and severity of PPS following surgical ASD closure, with particular attention to secundum-type ASDs. We retrospectively reviewed clinical and operative data of all surgical ASD repairs in our center from 1/2007 to 7/2017. ASDs were grouped by subtype. PPS was considered positive if the primary cardiologist diagnosed and documented clinical signs of PPS on post-operative outpatient follow-up. Records were reviewed to confirm documented diagnosis of PPS. A total of 245 cases were reviewed with 207 having sufficient data. Median age was 2years (range 4months-27years), female 57%. Overall incidence of PPS was 10%. There was no difference in incidence of PPS in those prescribed ibuprofen as compared to those who were not. This was true for both the entire cohort and the subgroup analysis (P = 1.0). Four patients overall required pericardiocentesis, none of whom received prophylactic ibuprofen. Prophylactic ibuprofen prescription following surgical ASD repair did not reduce the rate of PPS in our cohort.

Incidence and risk factors for postoperative vomiting following atrial septal defect repair in children.

The incidence and risk factors for postoperative vomiting (POV) after pediatric cardiac surgery has not been studied. This study sought to assess the incidence and risk factors for POV in children undergoing surgical repair of an atrial septal defect (ASD). We retrospectively collected perioperative data from 160 patients who underwent surgical repair of an ASD and met early extubation criteria. Demographic and clinical data that could potentially influence the incidence of POV were collected. Univariate analysis was performed using Student t-test or Wilcoxon rank test to identify factors associated with POV. Continuous variables were dichotomized based on the cutoff values derived from the receiver operating characteristic (ROC) curve analysis and the Youden-J index. We used multivariate logistic regression analysis using backward selection to determine the independent predictors using a univariate cutoff of P < 0.10 for inclusion and P > 0.05 for removal to determine factors independently associated with POV. The accuracy of our multivariate model was assessed by the area under the ROC curve (AUC). Overall the incidence of POV was 37.5% in all the children who underwent surgical ASD repair. POV did not significantly differ between patients who received and did not receive antiemetics intraoperatively. Age of ≥4 years and cardiopulmonary bypass (CPB) time ≥51 min were identified as independent risk predictors for POV and the AUC of logistic regression model was 0.650 (95% confidence interval; 0.565-0.735). The incidence of POV in children undergoing surgical ASD repair was 37.5%. Age ≥4 years and CPB time ≥51 min were identified as independent predictors.

Ventricular myocardial deformation in adults after early surgical repair of atrial septal defect.

It is unknown whether right-ventricular (RV) volume overload caused by an atrial septal defect (ASD) still has its effect on RV deformation long after repair. We evaluated RV and left-ventricular (LV) deformation beyond 30 years after surgical ASD repair in childhood, and studied relationships with conventional diagnostic parameters. In this prospective study, we included 102 subjects: 51 patients with repaired ASD (39% male, age 43.3 ± 4.9 years, age at repair 7.9 ± 3.6 years) and 51 healthy controls of similar age and sex. All subjects underwent echocardiography and electrocardiography. Additionally, ASD patients underwent cardiac magnetic resonance imaging (CMR), bicycle ergometry, and NT-proBNP measurement. With speckle-tracking echocardiography, we analysed peak systolic longitudinal strain of the RV lateral wall, LV lateral wall, and septum. RV lateral wall global longitudinal strain (GLS) was lower in patients (-20.4 ± 2.7%) than controls (-26.8 ± 4.2%, P < 0.001), due mainly to decreased apical strain (-19.3 ± 6.2 vs. -28.8 ± 8.3%, P < 0.001). RV lateral wall GLS correlated with CMR-derived RV and LV end-diastolic volumes (ρ = 0.49, P = 0.014; ρ = 0.53, P = 0.005), and with RV and LV end-systolic volumes (ρ = 0.43, P = 0.034; ρ = 0.46, P = 0.019). LV GLS was similar between patients and controls (P = 0.144). No significant correlations were found with NT-proBNP or exercise capacity. Although ASD repair was already performed in childhood, RV longitudinal strain, especially of the apical segment, is decreased in patients 35 years after surgery. This suggests that RV function has still been affected in the long run, probably due to the early RV volume overload, but possibly also as sequel of surgery.

The unnatural history of an atrial septal defect: Longitudinal 35 year follow up after surgical closure at young age

ObjectiveTo describe the very long-term outcome after surgical closure of an atrial septal defect (ASD).DesignLongitudinal cohort study of 135 consecutive patients who underwent surgical ASD repair at age <15 years...

Isthmus-dependent right atrial flutter as the leading cause of atrial tachycardias after surgical atrial septal defect repair

The purpose of this study was to evaluate clinical and electrophysiologic characteristics of AT in patients after surgical ASD repair as well as outcome after ablation. Atrial tachycardias (AT) are a common complication after surgical closure of an atrial septal defect (ASD). From a prospective ablation database we analyzed data of patients with a history of ASD repair who presented to our institution for AT ablation. We investigated ECG characteristics and the electrophysiologic mechanism of AT in this collective and analyzed follow-up data. Data of 54 patients (47.3 ± 14.5 years, 35 females) were included. In 30 patients (55.6%) ASD had been closed by direct suture, 24 patients (44.4%) had a patch for ASD repair without significant difference in terms of gender and age at the time of the procedure (p=0.234, p=0.231). In 42 patients (77.8%), electrophysiological studies were performed in AT. All patients had right atrial macro-reentrant AT. The leading mechanism was isthmus-dependent right atrial flutter in 29 patients (69.0%) with clockwise atrial activation in 41%. The mechanism of AT (typical atrial flutter (n=29), atriotomy-dependent flutter (n=7), and double loop flutter (n=5)) did not differ with regard to type of surgery. Only 70.6% of patients with proven isthmus dependent counter-clockwise atrial flutter presented with an ECG morphology typical for this mechanism. However, all clockwise typical atrial flutter patients showed the characteristic positive P-waves in the inferior leads. Of note, 83.3% of clockwise typical flutter ECGs had long isoelectric lines (mean 74.5 ms). Follow-up was complete in 45 of 54 patients. During a mean follow-up of 7.7 ± 3.7 years, 27 patients (60%) remained free of any arrhythmia, two patients had AT recurrence with different mechanisms compared to the first procedure and underwent successful ablation. Five patients (11%) developed atrial fibrillation. Isthmus dependent right atrial flutter is the leading AT mechanism in patients with a history of ASD repair. The mechanism of atrial flutter did not differ in relation to the mode of ASD closure (direct suture versus patch closure). ECG characteristics of the tachycardia may be misleading as they are more often atypical in patients after ASD repair.

Totally Endoscopic Atrial Septal Repair with or without Robotic Assistance: A Systematic Review and Meta-analysis of Case Series

To evaluate the safety and efficacy of totally endoscopic repair of atrial septal defect (ASD). A review of the literature was conducted. Studies were obtained from the following sources: MEDLINE, EMBASE, Web of Science and CENTRAL Library. Inclusion criteria were: (1) randomised controlled trials, non-randomised trials, observational studies, case series, and full text conference proceedings; (2) use of totally endoscopy closure of ASD; and (3) outcomes reported as clinical efficacy. When available, we also quantified the complication rates from each included study. Meta-analysis was performed on outcomes with a random-effects model. Six studies met all inclusion criteria. The pooled average success rate of totally endoscopic ASD repair was 94.8% from a total of 114 cases (95% CI, 88.0% to 97.8%), with a minimal heterogeneity in the group of studies (Q value x(2)=1.807, I(2)=0.000). In the studies with no robotic assistance, an average success rate of totally endoscopic ASD repair was 96.9% (95% CI, 85.9-99.4%), with a minimal heterogeneity in the two studies (Q value x(2)=0.683, I(2)=0.000). There were few complications for totally endoscopic ASD repair in the studies with and without robotic assistance. There were no statistically significant differences in success rates between robotically and non-robotically assisted totally endoscopic repairs (p>0.05). Totally endoscopic ASD repair was associated with a high success rate and a low complication rate. There is a need for prospective controlled clinical trials comparing totally endoscopic and conventional surgical repair of ASD.

Atrial septal defect repair by inversion of a juxtaposed left atrial appendage

A 7-year-old child was noted to have dextrojuxtaposition of the left atrial appendage at the time of surgical atrial septal defect repair. Given the favourable anatomic location and size of the atrial appendage, it was inverted and used to close the atrial defect. This is the first report of atrial septal defect repair using a juxtaposed atrial appendage. The cardiac anatomy and theoretical benefits of this repair are discussed.

Transpulmonary thermodilution in a pediatric patient with an intracardiac left-to-right shunt

Monitoring of cardiac output (CO) in the perioperative period and in seriously ill pediatric patients is of major importance for medical management. Hemodynamic monitoring, using transpulmonary thermodilution (TPTD) via a single thermal indicator injection, allows for measurements of CO, volumetric variables and extravascular lung water (EVLW). We describe and explain the influence of a left-to-right shunt on TPTD curve characteristics and EVLW measurements in a young child undergoing a surgical atrial septal defect repair. We suggest that these specific changes in the TPTD curve and the overestimation of EVLW detected by current device, in absence of gas exchange abnormalities, could be indicators of existing circulatory shunts in pediatric patients.

Long‐term Outcome Following Ablation of Atrial Flutter Occurring Late after Atrial Septal Defect Repair

In patients with surgical atrial septal defect (ASD) repair, late atrial flutters (AFLs), including cavotricuspid isthmus (CTI)-dependent and non-CTI-dependent scar-related flutter (AFL), are common. Radiofrequency ablation (RFA) of these arrhythmias has a high acute success rate. We aimed to characterize the long-term freedom from atrial arrhythmias in this population. Twenty consecutive patients undergoing RFA for AFL late after ASD repair were included. Electrophysiological assessment included multipolar activation, entrainment, and electroanatomic mapping. Clinical, electrocardiograph, and Holter monitoring follow-up was conducted every 6 months. Mean age was 53 ± 13 years. Time from surgical repair to RFA was 29 ± 15 years. All patients had CTI-dependent AFL (20/20). There were 1.6 ± 0.7 arrhythmias per patient; other arrhythmias included non-CTI-dependent AFL (14), focal atrial tachycardia (two), and atrioventricular nodal reentry tachycardia (two) . Acute success was obtained in 100%. Five patients with recurrent AFL (three CTI dependent, two non-CTI dependent) at 13 ± 8 months had successful repeat RFA. At 3.2 ± 1.6 years follow-up since the last procedure, 90% of patients with successful RFA for AFL remained free of their clinical arrhythmia. However, 30% of the original 20 patients had documented atrial fibrillation (AF) 2.1 ± 1.6 years after the last procedure; five (25%) required AF intervention. One stroke (5%) occurred in the context of late AF. RFA of AFL occurring late after surgical ASD repair has a low long-term risk of recurrence, although 25% of patients required two procedures. However, there is a high late incidence of AF (30%), with an additional 25% of patients requiring intervention for AF.

Long Term Outcome Following Ablation of Atrial “Flutter” Late after Surgical Atrial Septal Defect Repair: High Incidence of Late AF

Long Term Outcome Following Ablation of Atrial “Flutter” Late after Surgical Atrial Septal Defect Repair: High Incidence of Late AF

Cierre quirúrgico de la comunicación interauricular antes o después de los 25 años de edad. Comparación con la evolución natural en pacientes no operados

Surgical closure of an atrial septal defect (ASD) before the age of 25 years has been demonstrated to reduce complications during adulthood. However, the outcome for patients operated after the age of 25 is still debated. In a retrospective study we examined the outcome of early and late surgical repair of ASD in adults, as compared with the natural evolution of unoperated patients. The study population was 280 patients (mean age 40 18 years) with non-restrictive ASD: 102 patients (group 1) underwent surgery before the age of 25 years, 90 patients (group 2) underwent surgery after the age of 25 years, and 88 unoperated patients were older than 25 years at the time of study (group 3). The variables analyzed were left ventricular systolic function, left atrial dimensions, systolic pulmonary pressure, right ventricular dimensions, the degree of mitral and tricuspid regurgitation, and the prevalence of late atrial fibrillation. Left ventricular systolic function and the degree of mitral regurgitation were not statistically different between groups. Compared with the patients in group 2, the patients in group 1 had a significantly lower systolic pulmonary arterial pressure (p < 0.001) and less dilated right ventricle (p < 0.001) and left atrium (p < 0.001). The degree of tricuspid regurgitation (p < 0.001) and prevalence of atrial fibrillation (p < 0.001) were significantly higher in the patients of group 2. Compared with group 3, the patients in group 2 had a significantly lower systolic pulmonary arterial pressure (p < 0.001) and less dilated right ventricle (p < 0.001). However, the left atrial dimensions, degree of tricuspid regurgitation, and prevalence of atrial fibrillation did not differ in a statistically significant way between the two groups. Surgical repair of an atrial septal defect in patients over 25 years of age does not fully prevent hemodynamic deterioration and the development of atrial arrhythmias. Therefore it seems that the surgical closure of ASD before adulthood should be strongly recommended.

Serum N-terminal atrial natriuretic peptide in adult patients late after surgical repair of atrial septal defect.

The purpose of surgical closure of atrial septal defect (ASD) is to relieve the cardiovascular system from a haemodynamic burden. Excessive amounts of atrial peptides are released in congestive heart failure, valvular diseases and congenital heart diseases. To examine whether patients after surgical repair of ASD have higher concentrations of N-terminal atrial natriuretic peptide (ANP-N) than age-, sex- and body mass index (BMI)-matched control subjects. Medical history, physical examination, standard 12-lead electrocardiogram, and ANP-N concentrations were obtained in 65 adult patients operated for ASD at the age of 21+/-13 years (mean+/-standard deviation), 21+/-6 years after surgical closure of ASD. Sixty-seven healthy subjects matched for age, sex and BMI served as controls. In the patients serum ANP-N was higher than in the control subjects 0.41+/-0.32 nmol/l, median 0.31 nmol/l, interquartile range (IQR) 0.21-0.49 nmol/l vs. 0.24+/-0.12 nmol/l, median 0.23 nmol/l, IQR 0.17-0.29 nmol/l, (P=0.0003). Patients with concomitant diseases had higher ANP-N concentrations (0.51+/-0.39 nmol/l, median 0.34, IQR 0.26-0.73 nmol/l) than ASD patients without any history or signs of disease (0.28+/-0.16 nmol/l, median 0.27, IQR 0.17-0.40 nmol/l, P=0.01). The 'healthy' ASD patients had higher hormone concentrations than age-, sex- and BMI-matched control subjects (0.28+/-0.16 median 0.27 nmol/l, IQR 0. 17-0.40 nmol/l and 0.21+/-0.07 nmol/l, median 0.20 nmol/l, IQR 0. 15-0.27 nmol/l, P=0.01). Multiple stepwise linear regression analysis showed that age at operation was strongly associated with the post-operative ANP-N concentration (r(2)=0.25, P=0.0002). ASD patients have higher ANP-N concentrations late after surgical repair. Hormone levels correlate with age at operation. Our finding supports the clinical praxis of operating on these patients in their childhood and adolescence.

Atrial Septal Defect.

The 1990s have seen considerable growth in our knowledge of outcomes in patients with atrial septal defect (ASD), improved techniques for imaging and diagnosing ASD, and advances in the treatment of ASD. Exciting new surgical procedures, such as minimally invasive surgery, the Cox-Maze procedure for patients with atrial fibrillation, and lung transplantation for patients with severe pulmonary artery hypertension, are now available. In my opinion, echocardiography is the procedure of choice for the diagnosis and characterization of ASD. Children and adults with ASD should undergo surgical repair unless there are contraindications. Surgical repair "early" in life prolongs survival and may prevent atrial fibrillation. Surgical repair in "older" adults prolongs survival and alleviates symptoms but will not abolish sustained or paroxysmal atrial fibrillation. Patients with ASD and atrial fibrillation (sustained or paroxysmal) should undergo surgical repair of ASD and a Cox-Maze procedure.