1. Secundum atrial septal defect repair: long-term surgical outcome and the problem of the late mitral regurgitation;Speechly-Dick, M.E.; John, R.; Pugsley, W.B.; Sturridge, M.F.; Swanton, R.H.;Postgrad Med J,1993
2. Atrial septal defect in the aged;Rodstein, M.; Zaman, F.D.; Gerber, I.E.;Circulation
3. The prognosis of atrial septal defect;Campbell, M.; Neill, C.; Susman, S.;Br Med J
4. Ostium secundum atrial septal defect in the elderly;Lani, F.; Cipriani, L.; Cocchi, A.; Zuccala, G.; Carbonin, P.;J Am Geriat Soc; I read with interest the report by Speechly-Dick et al.' on the long-term surgical outcome of secundum atrial septal defect repair. The association ofmitral valve prolapse and atrial septal defect is an interesting one, although the exact cause-and-effect relation is not well understood. The most likely explanation is the altered relation between the size of the left ventricle and that of the mitral valve apparatus in secundum atrial septal defect.2 Owing to the left-to-right atrial shunt in atrial septal defect, less blood enters the left ventricle than the right ventricle. Consequently, the left ventricle in subjects with an atrial septal defect tends to be underdeveloped. When the mitral valve becomes relatively 'too big' to be accommodated by the 'small' left ventricle during systole, mitral valve prolapse ensues.2 When one waits too long before repairing the atrial septal defect, mitral valve prolapse and the accompanying mitral regurgitation may become irreversible,1991
5. Another reason why atrial septal defect once diagnosed should be repaired as early as possible is the risk of atrial fibrillation which is a common late complication of atrial septal defect.3 Once atrial fibrillation develops in patients with atrial septal defect, it is usually permanent, as was well shown by Speechly-Dick et al. who reported that atrial fibrillation persisted postoperatively in all of their patients with the arrhythmia preoperatively. The association ofatrial fibrillation and stroke is a distinct risk which threatens the long-term prognosis of patients with atrial septal defect,3 and lifelong anticoagulant therapy is indicated.4