Pulmonary Hypertension Linked to Mortality After Atrial Septal Defect Repair

ASD, atrial septal defect, congenital heart disease
Persistent pulmonary hypertension is strong predictor of mortality in older patients who underwent ASD closure.

For patients undergoing atrial septal defects closure, pulmonary hypertension is an important clinical factor and predictor of mortality in older patients, according to a study published in The American Journal of Cardiology.

The aim of this study was to assess how survival rates of transcatheter atrial septal defect closures are affected by pulmonary hypertension status, age of intervention, and echocardiographic changes. Data obtained from the Cleveland Clinic database were used to identify patients who had a transcatheter atrial septal defect closure performed between 2000 and 2011, and included basic demographics, clinical data, and echocardiographic images. Pulmonary hypertension was defined as a mean artery pressure ≥25 mm Hg or a right ventricular systolic pressure <40 mm Hg; atrial septal defect size was measured by balloon diameter needed to occlude blood flow. Patients were stratified into 2 cohorts, a younger and an older cohort, based on their age at intervention.

Of the 228 patients included in this study, 31.1% were men, 63.4% were white, the mean age at closure was 49.1 years old, and 21.1% had baseline pulmonary hypertension. The younger cohort consisted of 113 patients who were ≤48 years old and the older cohort consisted of 115 patients >48 years old. When comparing the 2 cohorts, the older cohort was more likely to have pulmonary hypertension (31.3% vs 10.6%, P <.01), diabetes (10.4% vs 2.7%, P =.02), hyperlipidemia (49.6% vs 12.4%, P <.01), and systemic hypertension (55.7% vs 15.0%, P <.01).

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Both cohorts had similar sized atrial septal defects (P =.35), and the size of the defect was not associated with pulmonary hypertension.

Following atrial septal defect closure, the mean right ventricular systolic pressure after 3 months was 32.4 mm Hg, with 34.7% of patients measuring ≤40 mm Hg, and there was a significant difference in mean right ventricular systolic pressure and in its rate of change 3 months post device closure in the pulmonary hypertension and control groups (P <.001, for both). At 3 months, the mean right ventricular systolic pressure in the pulmonary hypertension group was 39.5 mm Hg vs 30.1 mm Hg in the no-pulmonary-hypertension group.

During the mean follow-up of 7.4 years, older age and pulmonary hypertension increased the risk of mortality (P <.001, for both), with the occurrence of pulmonary hypertension increasing the risk of mortality 5-fold over 10 years among the older cohort (P <.01). Resolution of pulmonary hypertension 3 months after closure mitigated the risk of mortality. If resolution did not occur, the increased risk of mortality remained (P <.01).

Limitations of this study include its retrospective nature and the fact that not all patients completed all of the follow-up appointments.

The researchers concluded that “[pulmonary hypertension] is a major co-morbidity for those with an [atrial septal defect] and is a strong predictor of future mortality in older patients who underwent device closure.” Furthermore, the researchers found that “there is a significantly increased risk of mortality in those [pulmonary hypertension] patients who do not show echocardiographic resolution of [pulmonary hypertension] 3 months following device closure.”

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.


Ranard LS, Mallah WE, Awerbach JD, et al. Impact of pulmonary hypertension on survival following device closure of atrial septal defects [published online August 7, 2019]. Am J Cardiol. doi: 10.1016/j.amjcard.2019.07.042