Risk Factors for Pulmonary Hypertension in Adults Post-ASD Closure

CH interior of chest cavity, heart, lungs
Investigators examined the prevalence of pulmonary hypertension in adults before and after atrial septal defect closure and sought to determine common traits between the two.

The prevalence of pulmonary hypertension (PH) decreased from 13.1% before atrial septal defect closure to 5% after atrial septal defect (ASD) closure, according to retrospective study results published in The American Journal of Cardiology.

Researchers analyzed the prevalence of PH before and after ASD closure and the patient characteristics associated with PH after the procedure. Data collection included demographic records, clinical evaluations, and transthoracic echocardiograms. Pulmonary hypertension was defined according to the European Society of Cardiology/European Respiratory Society guidelines.

Of the 198 patients who had an ASD closure completed, 75% were women, 33% were on cardiac medication, 5% had pulmonary disease, and 44% had the closure completed surgically. Patients had an average body mass index of 25 kg/m² and an average age of 45 years old at closure.

Before the closure, 13.1% of patients were classified as having PH, and after a median follow-up of 15 months after ASD closure, 5% of patients were classified as having PH. Of these 10 patients who still had PH, 7 were suspected to have pulmonary atrial hypertension and 3 were suspected to have left ventricular diastolic dysfunction.

At follow-up, the Cox proportional hazards regression showed the New York Heart Association functional class III-IV (hazard ratio [HR] 11.07; 95% CI, 3.12-39.3, P <.001), the presence of pulmonary disease (HR 10.43; 95% CI, 2.12-51.2; P =.004), the use of cardiac medication (HR 3.96; 95% CI, 1.02-15.3; P =.047), the tricuspid regurgitation maximum velocity (HR 7.36; 95% CI, 2.92-18.5; P <.001), the right ventricular fractional area change (HR 0.87; 95% CI, 0.81-0.93; P <.001), the tricuspid annular plane systolic excursion (HR 0.75; 95% CI, 0.59-0.95; P =.018), and having PH before closure (HR 23.03; 95% CI, 3.39-157; P =.001) were significantly associated with PH.

Survival information during the follow-up showed 9 patients had died, with 5 of these patients not categorized as having PH.

Limitations of this study included observation and retrospective biases, diagnosis of PH by echocardiographic measurements rather than right heart catheterization, and limited sample size so multivariable Cox regression could not be calculated.

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The researchers concluded that although PH did remain in 5% of the study population who were categorized before closure, “adult patients with low pulmonary pressures before ASD closure are not at risk for the development of PH after ASD closure during a follow-up period of 15 months.”


Zwijnenburg RD, Baggen VJM, Witsenburg M, Boersma E, Roos-Hesselink JW, van den Bosch AE. Risk factors for pulmonary hypertension in adults after atrial septal defect closure [published online January 24, 2019]. Am J Cardiol. doi: 10.1016/j.amjcard.2019.01.011