The rush to atrial septal defect closure: is the introduction of percutaneous closure driving utilization?

Abstract

Background: Surgical repair of isolated atrial septal defect (ASD) and patent foramen ovale (PFO) has been largely supplanted by percutaneous closure. Whether the perceived benefit of percutaneous closure has lowered thresholds for intervention and thus increased overall utilization rates is unknown. We sought to determine nationwide trends in the use of percutaneous compared with surgical closure and their respective outcomes over an 18-year period.

Methods: Using the Nationwide Inpatient Sample and International Classification of Diseases, Ninth Revision, procedure and diagnosis codes, we identified all ASD/PFO closures performed from 1988 to 2005. National estimates and their standard deviations were calculated. Logistic regression analysis identified determinants of closure type.

Results: We identified 15,482 secundum ASD/PFO closures between 1988 and 2005, yielding a national estimate of 79,841 cases. Of these, 5,495 (national estimate, 27,554 +/- 2,526) were percutaneous, 10,278 (national estimate, 53,710 +/- 1,451) were surgical. The ASD/PFO closures per capita increased dramatically from 1.08 per 100,000 population in 1988 to 2.59 per 100,000 population in 2005, an increase of 139%. When analyzed by closure type, surgical closure increased by only 24% (from 0.86 per 100,000 population in 1988 to 1.07 per 100,000 in 2005) whereas percutaneous closure increased by 3,475% (from 0.04 per 100,000 population in 1988 to 1.43 per 100,000 in 2005). A marked shift in repair type occurred in 2001. Estimated mortality rates remained near 1% for both closure types over time.

Conclusions: Nationwide utilization of ASD/PFO repair has increased over time, largely attributable to the dramatic rise in percutaneous closure. Despite the substantial increase in utilization, mortality has remained constant. In the absence of meaningful benchmarks, prospective studies comparing outcomes and criteria for surgical versus percutaneous closure are needed to determine whether the increased rates of ASD closure are justified.