What is the management approach for a spontaneous atrial septal defect (ASD)?

From the Guidelines

Management of a spontaneous atrial septal defect (ASD) depends on the defect size, hemodynamic impact, and patient symptoms, with closure typically recommended for moderate to large ASDs with significant left-to-right shunting to prevent long-term complications. The approach to managing ASDs has evolved, with a focus on preventing long-term complications such as pulmonary hypertension, right heart failure, and arrhythmias 1. Key considerations include:

• Defect size and hemodynamic impact: Small ASDs (less than 5-8 mm) without significant shunting may be managed conservatively, while larger defects require closure 1.
• Patient symptoms: Even asymptomatic patients with significant left-to-right shunting may benefit from closure to prevent long-term complications 1.
• Closure options: Transcatheter device closure is preferred for secundum ASDs with adequate rims, while surgical repair is recommended for primum ASDs, sinus venosus defects, or secundum ASDs unsuitable for device closure 1.
• Post-closure management: Patients require antiplatelet therapy and endocarditis prophylaxis, with follow-up echocardiography to assess device position and residual shunting 1.
• Long-term outcomes: Patients with repaired ASDs generally have excellent long-term outcomes with normal life expectancy when closure is performed before significant pulmonary hypertension develops 1. It is essential to prioritize the most recent and highest quality evidence when making management decisions for ASDs, considering the potential benefits and risks of different approaches 1.

From the Research

Management Approach for Spontaneous Atrial Septal Defect (ASD)

The management approach for a spontaneous atrial septal defect (ASD) involves several considerations, including the size of the defect, the age of diagnosis, and the presence of symptoms.

• Small defects may spontaneously close, as seen in a study where a moderately sized 6-mm ASD closed spontaneously without intervention 2.
• The primary indication for ASD closure is right heart volume overload, whether symptoms are present or not 3.
• ASD closure may also be reasonable in other contexts, such as paradoxical embolism 3.

Closure Methods

There are two main methods for closing an ASD: percutaneous closure and surgical closure.

• Percutaneous closure is a minimally invasive procedure that uses a catheter to implant a device to close the defect 4, 5.
• Surgical closure is a more invasive procedure that requires open-heart surgery to close the defect 5.
• The choice of closure method depends on the type of ASD, the size of the defect, and the presence of other heart defects 3, 5.

Considerations for Closure

Several factors need to be considered when deciding whether to close an ASD, including:

• The size of the defect: smaller defects are more likely to close spontaneously 2.
• The age of diagnosis: earlier diagnosis is associated with a higher likelihood of spontaneous closure 2.
• The presence of symptoms: symptoms such as shortness of breath, fatigue, and palpitations may indicate the need for closure 3, 5.
• The presence of other heart defects: other defects may need to be addressed at the same time as the ASD closure 3, 5.

Outcome of Closure

The outcome of ASD closure is generally good, with most patients experiencing significant improvement in symptoms and quality of life 5.

• Percutaneous closure has been shown to be effective and safe, with a low risk of complications 4, 5.
• Surgical closure is also effective, but may be associated with a higher risk of complications and a longer recovery time 5.