Atrial Fibrillation/Flutter After Transcatheter Device vs. Surgical Closure of Atrial Septal Defect in a Korean Nationwide Cohort

BACKGROUND AND OBJECTIVES: Atrial fibrillation/flutter (AF/AFL) is a common long-term complication after atrial septal defect (ASD) closure. We compared the incidence of new-onset AF/AFL and clinical outcomes between surgical and device closure. METHODS: Using the Korean National Health Insurance Service database (2009-2021), we identified adults undergoing ASD closure without prior atrial arrhythmias. The primary outcome was new-onset AF/AFL. Secondary outcomes included all-cause mortality, ischemic stroke, and catheter ablation. Propensity score (PS) matching was performed to minimize confounding. RESULTS: Among 11,133 patients (3,747 surgical; 7,386 device), 6,310 were included in the PS-matched cohort. During a median follow-up of 5.5 years, the device closure group showed a significantly lower risk of AF/AFL (hazard ratio [HR], 0.73; 95% confidence interval [CI], 0.59-0.91) and all-cause mortality (HR, 0.65; 95% CI, 0.52-0.81) compared to the surgical group in the matched cohort. Conversely, the device group was associated with a higher risk of ischemic stroke (HR, 1.50; 95% CI, 1.13-1.98). Catheter ablation for AFL was performed significantly more frequently in the surgical group (12.0% vs. 3.5%, p=0.048). Surgical closure, male sex, heart failure and older age at closure were associated with higher risk of AF/AFL after ASD closure. CONCLUSIONS: Among ASD patients without prior AF/AFL, device closure was associated with lower long-term AF/AFL, whereas AFL ablation was performed more frequently after surgical closure. TRIAL REGISTRATION: Clinical Research Information Service Identifier: KCT0010486.