What is the recommended management for Atrial Septal Defect (ASD) repair in patients with a history of Cerebrovascular Accident (CVA) or at high risk for one?

Management of Atrial Septal Defect in Patients with History of CVA

Closure of an ASD, either percutaneously or surgically, is strongly recommended in patients with a history of paradoxical embolism or CVA. 1

Indications for ASD Closure in CVA Patients

The 2008 ACC/AHA guidelines for adults with congenital heart disease provide clear direction for managing ASDs in patients with cerebrovascular events:

• Class IIa recommendation (Level of Evidence: C): Closure of an ASD is reasonable in the presence of paradoxical embolism 1
• This recommendation applies regardless of the size of the defect, even for small ASDs (<5mm) that might otherwise not require closure

Device Selection Based on ASD Type

The appropriate closure method depends on the specific type of ASD:

1. Secundum ASD:

   • Preferred approach: Percutaneous transcatheter closure for most patients
   • This is currently the standard for uncomplicated secundum ASDs with appropriate morphology 1

2. Sinus venosus, coronary sinus, or primum ASD:

   • Must be repaired surgically (Class I recommendation, Level of Evidence: B) 1
   • These defects are not amenable to device closure

3. Special anatomical considerations:

   • Surgical closure is reasonable when the anatomy of the defect precludes the use of a percutaneous device 1
   • ASDs with large septal aneurysms or multifenestrated atrial septums require careful evaluation before device closure 1

Procedural Considerations for CVA Patients

For patients with history of CVA or at high risk for one:

• Anticoagulation: Patients should receive appropriate anticoagulation before, during, and after the procedure
• Timing: Consider expedited closure after CVA to prevent recurrent events 2
• Device selection: The device should provide complete closure with minimal residual shunting to prevent recurrent paradoxical embolism 3
• Follow-up: More intensive monitoring for thrombus formation or device-related complications may be warranted 4

Post-Procedure Management

After ASD closure in patients with history of CVA:

• Antiplatelet therapy: Most patients receive acetylsalicylic acid (5-10 mg/kg/day) for approximately 12 weeks following device implantation 3
• Echocardiographic follow-up: Recommended at 24 hours, 1 month, 6 months, and 1 year to assess for:
  • Device position
  • Residual shunting
  • Complications such as thrombus formation 1
• Arrhythmia monitoring: Regular assessment for atrial arrhythmias, which may increase stroke risk

Potential Complications to Monitor

Patients with history of CVA require vigilant monitoring for complications:

• Device-related complications: Migration, erosion, or embolization 4
• Thrombus formation: Can occur on the device surface, particularly on the left atrial disc 4
• Residual shunting: Even small residual shunts could potentially allow paradoxical embolism 3
• Atrial arrhythmias: May develop even after successful closure and increase stroke risk 1

Special Considerations

• Elderly patients: ASD repair has been shown to be safe and effective even in patients over 60 years of age, with significant clinical improvement and low morbidity 5
• Multiple defects: In cases of multi-fenestrated ASDs, careful device selection is crucial to ensure complete closure 6
• Concomitant procedures: Consider a Maze procedure for patients with intermittent or chronic atrial tachyarrhythmias (Class IIb recommendation) 1

Contraindications

• Severe irreversible pulmonary arterial hypertension (PAH) with no evidence of left-to-right shunt is a contraindication for ASD closure (Class III recommendation, Level of Evidence: B) 1

ASD closure in patients with history of CVA should be performed by experienced operators at centers with expertise in adult congenital heart disease to minimize complications and optimize outcomes.