Cardiology in the Young 2010; Page 1 of 4
r Cambridge University Press, 2010
P-wave dispersion between transcatheter and surgical closure
of secundum-type atrial septal defect in childhood
Osman Baspinar,1Murat Sucu,2Senem Koruk,3Mehmet Kervancioglu,1Hasim Ustunsoy,4
Hayati Deniz,4Metin Kilinc1
1Clinic of Pediatric Cardiology;2Clinic of Cardiology;3Clinic of Anesthesiology;4Clinic of Cardiothoracic Surgery,
Gaziantep University Medical Faculty, Gaziantep, Turkey
Abstract Patients with atrial septal defect have an increased risk for atrial fibrillation. Increased P-wave
dispersion predicts the development of atrial fibrillation. The aim of this study was to determine difference in
P dispersion between transcatheter closure with Amplatzer septal occluder and surgical closure in childhood.
A total of 68 children (the mean age was 7.2 plus or minus 3.3 years; the mean secundum atrial septal defects
diameter was 17.3 plus or minus 5.4 millimetres) were evaluated in this study. Transcatheter closure was
attempted in 41 children with secundum atrial septal defects, and the defect in 27 patients was closed by
surgical techniques. P maximum, P minimum and P dispersion were measured by the 12-lead surface
electrocardiography. P maximum, P minimum and P dispersion were found to be similar in patients with pre-
and post-procedure (98.0 plus or minus 19.3 versus 95.1 plus or minus 23.0 milliseconds; 68.0 plus or minus
20.8 versus 67.6 plus or minus 24.3 milliseconds, 29.9 plus or minus 11.0 versus 27.1 plus or minus 12.1
milliseconds, respectively). There was no statistical significance in the comparison of P dispersion between the
two groups. But in the surgical group, P-wave dispersion was decreased more significantly compared with
baseline values (p-value equal to 0.03). In conclusion, there is no P dispersion between transcatheter closure
with Amplatzer septal occluder and surgical closure of secundum atrial septal defect.
Keywords: P-wave dispersion; transcatheter closure; surgical closure; Amplatzer device; childhood
Received: 31 March 2010; Accepted: 25 July 2010
arrhythmias. Atrial arrhythmias are responsible
for significant morbidity and mortality. Two simple
electrocardiographic markers, P-wave maximal dura-
tion and P-wave dispersion, have been used to evaluate
the intra-atrial and inter-atrial conduction times and
the inhomogeneous propagation of sinus impulses,
which are well-known electrophysiological character-
istics of the atrium prone to fibrillation.1,2In atrial
septal defects, the right atrial pressure increases, and
the right atrium stretches and becomes more
surgical or transcatheter closure of secun-
dum atrial septal defects is to prevent atrial
OFTHEREASONS FOR RECOMMENDING
enlarged.3Thus, the depolarisation of the right atrium
is prolonged and this causes an increase in P
dispersion.4In children with secundum atrial septal
defect, P maximum and P dispersion analysed and
compared between transcatheter and post-operative
closure of the defects. We studied the dynamicity
of P duration and dispersion changes; therefore,
measurements were made before the procedure and
1 week after the procedure.
Materials and methods
Sixty-eight children having transcatheter or surgical
atrial septal defect closure at Gaziantep University,
Gaziantep, Turkey, were evaluated for enrolment in
the study. The study protocol was approved by the
Correspondence to: O. Baspinar, Medical Faculty, Department of Pediatric
Cardiology, Gaziantep University, 27310 Gaziantep, Turkey. Tel: 0 90 532 345
54 77; Fax: 0 90 342 360 39 28; E-mail: email@example.com
medical ethics committee of the university. Written
informed consent was obtained from all patients. All
the patients had normal sinus rhythm. Patients with
other congenital cardiac defects associated with atrial
septal defect were also excluded. A 12-lead electro-
cardiography with a paper speed of 50 millimetres per
second and 1 millivolt per centimetre standardisa-
tion was obtained the day before and 1 week after the
procedure. P-wave duration was measured by using an
electronic digital compass with a sensitivity of 0.001
millimetre in all 12 leads by one observer in order to
exclude inter-observer variability. At each derivation,
the distance between the points of the earliest and
latest P-wave activity was recorded as P-wave duration.
At each electrocardiography, the longest P-wave
measurement was noted as P maximum and the
shortest measurements as P minimum. P dispersion
was defined as the difference between the P maximum
and P minimum. Acceptable electrocardiography was
defined by the ability to measure P-wave duration in
at least 8 of the 12 electrocardiographic leads that
were recorded simultaneously.
In the transcatheter group, we used Amplatzer
septal occluder (AGA Medical Corporation, Golden
Valley, Minnesota, United States of America). These
Amplatzer devices have a nitinol-braided skeleton
with a thrombogenic effect provided by polyester
dacron fibres made up of double discs with self-
expanding and self-centring features and a connect-
ing waist joining these double discs. Surgical
closure was by direct suturing or by patch. The
surgical group operated before starting transcatheter
therapy in our institute or their defects were not
suitable for transcatheter closure (very large defect,
deficient rims, etc.). Pulmonary-to-systemic flow
ratio was calculated from cardiac catheterisation by
the Fick method from the transcatheter group. But
in the surgical group, the shunt ratio was generally
calculated by echocardiographic measurements.
Data were expressed as median, means plus or minus
the standard deviations. Student’s t-test and x2tests
were used for the differences in numerical data between
the groups; p-value of less than 0.05 was considered to
be statistically significant. For the comparison of the
values at baseline and after the procedure, paired t-tests
were used. The SPSS 10.0 statistical software package
(SPSS Inc., Chicago, Illinois, United States of America)
was used for all calculations.
A total of 68 children (42 girls, 26 boys; the mean
age was 7.2 plus or minus 3.3 years, with a range
from 3 to 16 years; the mean weight was 23.1 plus or
minus 12.1kilograms, with a range from 10 to 75.5
kilograms; the mean secundum atrial septal defects
diameter was 17.3 plus or minus 5.4 millimetres,
with a range from 7 to 30 millimetres) were evaluated
in this study. None of the children had documented
arrhythmias during the post-operative follow-up, or
any other clinically significant adverse events regard-
less of therapy. The transcatheter closure group was of
41 patients. The surgical group was of 27 patients.
Clinical and echocardiographic characteristics of the
groups are shown in Table 1.
There were no significant differences between the
groups with regard to patient numbers, age and
weight (p greater than 0.05). But the diameter of the
secundum atrial septal defects and systemic/pulmo-
nic flow ratio were significantly different. P max-
imum, P minimum and P dispersion were found to
be similar in patients with pre- and post-procedure
(98.0 plus or minus 19.3 versus 95.1 plus or minus
23.0 milliseconds; 68.0 plus or minus 20.8 versus
67.6 plus or minus 24.3 milliseconds; and 29.9 plus
or minus 11.0 versus 27.1 plus or minus 12.1
milliseconds, respectively). There was no significant
difference in P-wave measurements in all the patients
throughout the follow-up as compared both before
and after the procedure (p values 0.415, 0.926 and
0.149, respectively; Fig 1).
There was also a similarity in the P maximum, P
minimum and P dispersion between the transcatheter
and surgical closure groups before the procedure. After
the procedure, P maximum and P minimum were not
significantly different between the groups (p greater
Table 1. Clinical characteristics of the patients.
CharacteristicsTranscatheter groupSurgical group
ASD diameters (mm)
41 (25 girls, 16 boys)
27 (17 girls, 10 boys)
ASD5atrial septal defect
*p less than 0.05, statistically significant
Cardiology in the Young
than 0.05). But P dispersion was significantly different
between the transcatheter and surgical patients in the
post-procedure period (29.5 plus or minus 11.6 versus
23.5 plus or minus 12 milliseconds; p-value is equal
to 0.043; Table 2). P dispersion value was more
decreased in the post-surgical group.
In the surgical group, the diameter and the shunt
ratio of the secundum atrial septal defects were
greater than the transcatheter group, with a p-value
less than 0.05. But both P maximum and P
dispersion were similar in both groups (Table 2). In
order to investigate the effect of surgical repair
on P dispersion, the before and post-operative
electrocardiographic values of the children were
compared (Table 3). Data indicate that P dispersion
significantly decreased within 1 week after surgery
when compared with baseline values – p-value is equal
to 0.03. After transcatheter closure with Amplatzer
septal occluder, both P maximum and P dispersion
were not significantly different compared with before
closure values – p-value is greater than 0.05.
Atrial fibrillation is a common arrhythmia found in
conjunction with atrial septal defects in adults and
P-wave measurements in the groups (TG5transcatheter group; SG5surgical group; Pmax5P maximum; Pmin5P minimum; Pd5P
dispersion; HR5heart rate).
Table 2. P-wave measurements in between groups.
Before procedureAfter procedure
*p less than 0.05, statistically significantly
Table 3. P-wave measurements between groups.
Transcatheter groupSurgical group
*p less than 0.05, statistically significantly
Baspinar et al: P-wave dispersion between transcatheter and post-operative surgical closure
is a significant cause of morbidity.4,5Oliver et al6
demonstrated that advanced age is the most
important condition related to the presence of atrial
fibrillation in patients with atrial septal defect both
before and after surgical closure. P-wave dispersion
is greatest on days 2 and 3 after open-heart surgery,
finding that it coincides with the time of greatest
risk for atrial fibrillation.7Therefore, we calculated
P dispersion at 1 week after any procedure.
We have demonstrated that in children with
secundum atrial septal defects and normal sinus
rhythm, P maximum and P dispersion are insignif-
icantly changed compared with transcatheter clo-
sure with Amplatzer septal occluder and surgical
closure. P dispersion is decreased significantly after
surgery among children with atrial septal defect.
We think that earlier closure of the defect might
result in more homogeneous and organised conduc-
tion of the atrial impulse.
Ho et al8demonstrated that P dispersion was
higher in children with atrial septal defect. Guray
et al9also demonstrated a reduction in P dispersion
after surgical atrial septal defect closure in adult
patients. In addition, like us, Yavuz et al10found a
significant decrease in P maximum and P dispersion
after surgical repair in children. In the transcatheter
group, P dispersion was not changed, but may be it
was related to the mass effect and metal configura-
tion of the device.
Increased P dispersion is correlated with the size of
defect and the degree of right atrial dilation in children
with secundum atrial septal defects. P-wave dispersion
could be used for the prediction of idiopathic paroxys-
mal atrial fibrillation. In normal healthy children,
normal P dispersion was described as 27.0 plus or
minus 5.4 milliseconds.1,2,11Dilaveris et al1used 40
milliseconds; Aytemir et al2used 36 milliseconds as a
cut-off value for P dispersion for the risk of atrial
fibrillation. We found that P dispersion in 16 patients
was greater than 36 milliseconds before the procedure
and greater than 36 milliseconds after the procedure in
15 patients. Patient numbers with their P dispersion
values in the clinical important range are not increased.
We did not find a difference in P maximum and P
dispersion values compared with transcatheter and
surgical closure groups. Although the surgery group
had a lower level of P dispersion values, closure of
transcatheter atrial septal defects in childhood can
reverse electrical and mechanical changes in the atrial
myocardium and cause a subsequent reduction in P
maximum and P dispersion times.
In conclusion, P-wave dispersion is a simple and
useful parameter for the prediction of atrial arrhyth-
mias. After surgical closure of the atrial septal defect,
significant decrease in P-dispersion indices may be
related to a lower risk of atrial fibrillation. There is no
difference in P dispersion for transcatheter closure
with Amplatzer septal occluder.
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