From the Guidelines
This case of a 77-year-old woman with an uncorrected secundum atrial septal defect (ASD) who developed heart failure with reduced ejection fraction (HFrEF) and atrial fibrillation (AFib) with rapid ventricular response (RVR) in her 70s, followed by transcatheter ASD closure with partial ejection fraction recovery but persistent AFib, is moderately clinically significant and potentially publication-worthy. The case is notable because ASD closure is typically performed much earlier in life, and the development of HFrEF in this setting represents an uncommon complication of long-standing uncorrected ASD, as suggested by the 2018 AHA/ACC guideline for the management of adults with congenital heart disease 1.
Key Points
- The teaching value lies in demonstrating that even elderly patients with long-standing ASDs can benefit from closure, particularly when they develop complications like heart failure, with studies showing improvement in functional status and right ventricular size and function after repair 1.
- The partial recovery of ejection fraction after closure in an elderly patient illustrates that intervention can still be beneficial despite advanced age and chronicity of the defect.
- The persistent AFib despite closure highlights the irreversible atrial remodeling that occurs with long-standing volume overload, as noted in a systematic review of interventional therapy versus medical therapy for secundum ASD 1.
- For publication, the case would be strengthened by including detailed hemodynamic data before and after closure, cardiac MRI findings if available, and long-term follow-up data showing the durability of the heart failure improvement.
Research and Teaching Value
The research value includes contributing to our understanding of the natural history of uncorrected ASDs into late adulthood and the potential benefits of intervention even at advanced ages when complications develop, with recent guidelines emphasizing the importance of considering closure in adults with significant shunting and symptoms 1. Some key considerations for management and potential publication include:
- The impact of ASD closure on atrial arrhythmias, with studies suggesting that closure may not significantly reduce the incidence of AFib in patients over 50 years of age 1.
- The role of cardiac catheterization in evaluating patients with ASD, particularly in determining detailed hemodynamics for decision-making or clarifying discrepant noninvasive imaging data 1.
From the Research
Clinical Significance
- The case of a 77-year-old woman with an uncorrected secundum ASD, who developed HFrEF and atrial fibrillation with RVR in her 70s, then underwent transcatheter ASD closure with partial EF recovery but persistent AFib, is clinically significant due to the coexistence of atrial fibrillation and heart failure with reduced ejection fraction, which is associated with worse outcomes 2, 3, 4.
- The patient's condition is unique in that she underwent transcatheter ASD closure, which is a relatively rare procedure in patients with HFrEF and atrial fibrillation, and experienced partial EF recovery but persistent AFib.
Teaching and Research Values
- This case has teaching value as it highlights the importance of considering the type of heart failure and its impact on prognosis in patients with atrial fibrillation 2.
- The case also has research value as it contributes to the understanding of the relationship between atrial fibrillation, heart failure with reduced ejection fraction, and transcatheter ASD closure, which is an area of ongoing research 3, 4, 5.
- The patient's outcome, including partial EF recovery but persistent AFib, raises questions about the optimal management of atrial fibrillation in patients with HFrEF and the potential benefits and limitations of transcatheter ASD closure in this population 6, 5.
Publication-Worthiness
- The case may be considered publication-worthy due to its unique combination of conditions and the patient's outcome, which could contribute to the existing literature on the management of atrial fibrillation and heart failure with reduced ejection fraction 2, 3, 4, 5.
- The case could be published as a case report or a retrospective study, highlighting the clinical significance and teaching and research values of the patient's condition and outcome.