Clinical outcome in patients of atrial septal defects concurrent with severe pulmonary hypertension
Authors: Ji Zhenchun , Yu Changhui , Han Liying , musha kadeerjiang , saimi baihetiya , Huang Haoyue , Shen zhenya 
Published: October 2024

Objective
This study aims to retrospectively analyze the clinical outcomes of patients with atrial septal defects (ASDs) concurrent with severe pulmonary hypertension (pulmonary artery systolic pressure (PASP) ≥ 60 mmHg as measured by which estimated by echocardiography).
Methods
Clinical and examination data from a total of 229 patients with ASDs treated at our two hospitals from January 2018 to December 2023 were collected. Patients were categorized into a non-severe pulmonary hypertension group (189 patients) and a severe pulmonary hypertension group (40 patients) based on whether the PSAP was severe pulmonary hypertension or not. The clinical, surgery-related, and follow-up data between the two groups were compared to assess the clinical outcomes between the two groups. The primary endpoint event was death from cardiovascular complications, re-hospitalization due to heart failure, and arrhythmic complications. Kaplan-Meier curve was used to analyze the primary endpoint event. The log-rank test was used to compare differences between the two groups. COX proportional hazards regression models was applied to analyze the risk factors for the primary endpoint event at postoperative follow-up, and receiver operating characteristic (ROC)curve was applied to analyze the PASP to assess the threshold for contraindications to ASD surgery.
Results
The severe pulmonary hypertension group had significantly higher rates of atrial arrhythmias, grade II tricuspid regurgitation, proportion of cardiac function ≥ III, and right atrial and right ventricular diameters compared to the non-severe pulmonary hypertension group. The duration of hospitalization for operated patients in the severe pulmonary hypertension group was longer than that of the non-severe pulmonary hypertension group (P < 0.05). A total of 69 cases across both groups had primary endpoint event. There were 27 cases in the severe pulmonary hypertension group, including 4 deaths, and 42 cases in the non-severe pulmonary hypertension group, including 1 death. Kaplan-Meier curves showed a statistically significant difference (HR = 1.93, 95% CI, 1.11–1.32, P < 0.01), and Cox proportional hazards regression models analysis showed that severe pulmonary hypertension was an independent risk factor for the primary endpoint event in patients with ASD (HR = 2.3, 95% CI, 1.04–5.06, P < 0.01). The threshold for PASP to assess contraindications to surgery for ASD using ROC curve analysis was 65.5 mm Hg.
Conclusion
Our study confirms that ASD concurrent with severe pulmonary hypertension (≥ 60 mmHg) have an incidence of comorbidities and primary endpoint events. Reducing pulmonary artery pressure followed by occlusion or surgical repair can lead to better clinical outcomes. However, severe pulmonary hypertension must be avoided. A PASP of 65.5 mmHg may serve as a threshold for contraindication to surgery. Large prospective studies are required to validate this study’s findings.