What are the indications, risks, and treatment options for Atrial Septal Defect (ASD) closures?

Atrial Septal Defect (ASD) Closures: Indications, Risks, and Treatment Options

Closure of an ASD either percutaneously or surgically is indicated for right atrial and right ventricular enlargement with or without symptoms. 1 This intervention is essential to prevent long-term complications that significantly impact morbidity and mortality.

Types of ASDs and Closure Methods

ASD Types

• Secundum ASD: Most common type, located in the middle of the atrial septum
• Sinus venosus ASD: Located high in the atrial septum
• Primum ASD: Located low in the atrial septum
• Coronary sinus ASD: Defect in the roof of the coronary sinus

Closure Method Selection

1. Percutaneous closure:

   • First-line treatment for most secundum ASDs 2
   • Advantages: Avoids cardiopulmonary bypass, no sternotomy scar, shorter hospitalization 3

2. Surgical closure:

   • Required for sinus venosus, coronary sinus, and primum ASDs 1
   • Indicated when secundum ASD has unfavorable anatomy for device closure
   • Necessary when concomitant tricuspid valve repair/replacement is needed 1

Indications for ASD Closure

Class I Indications (Strongly Recommended) 1

• Right atrial and RV enlargement with or without symptoms
• Evidence of significant left-to-right shunting

Class IIa Indications (Reasonable) 1

• Paradoxical embolism
• Documented orthodeoxia-platypnea (positional hypoxemia)

Class IIb Indications (May Be Considered) 1

• Net left-to-right shunting with pulmonary artery pressure less than two-thirds systemic levels
• PVR less than two-thirds systemic vascular resistance
• Responsive to pulmonary vasodilator therapy or test occlusion

Contraindications (Class III) 1

• Severe irreversible pulmonary arterial hypertension (PAH) with no evidence of left-to-right shunt

Risks and Complications

Percutaneous Device Closure Complications 3, 4

• Early complications (6.5% overall rate):

  • Device dislocation/embolization
  • Transient ST-segment elevation
  • TIA/stroke
  • Hemoptysis
  • Pericardial effusion

• Late complications:

  • Device thrombosis (potentially life-threatening)
  • Cardiac erosion (rare but potentially fatal)
  • Atrial arrhythmias (most common)
  • Nickel allergy
  • Cardiac conduction abnormalities
  • Valvular damage
  • Device endocarditis

Surgical Closure Complications 1

• Early mortality approximately 1% (in absence of PAH)
• Postpericardiotomy syndrome with tamponade
• Atrial arrhythmias (may occur de novo after repair)
• Superior vena cava stenosis (after sinus venosus ASD repair)
• Pulmonary vein stenosis (after sinus venosus ASD repair)

Follow-up After ASD Closure

Post-Percutaneous Closure 1

• Echocardiographic follow-up at 24 hours, 1 month, 6 months, and 1 year
• Evaluation for device migration, erosion at 3 months to 1 year and periodically thereafter
• Anticoagulation therapy for approximately 6 months 5

Post-Surgical Closure 1

• Monitor for postpericardiotomy syndrome (fever, fatigue, chest pain)
• Annual clinical follow-up if:
  • PAH persists or develops
  • Atrial arrhythmias persist or develop
  • RV or LV dysfunction persists or develops
  • Coexisting valvular or other cardiac lesions exist

Important Clinical Pearls

• Small ASDs (<5 mm) without RV volume overload generally don't require closure unless associated with paradoxical embolism 1
• Larger defects typically cause symptoms in the third decade of life 1
• Closure benefits (symptomatic improvement and survival) are inversely related to patient age and presence of PAH 2
• Atrial arrhythmias should be treated to restore and maintain sinus rhythm when possible 1
• If atrial fibrillation occurs, both antiarrhythmic therapy and anticoagulation are recommended 1
• Chest pain or syncope after device closure may indicate device erosion and requires urgent evaluation 1

Pitfalls to Avoid

• Failing to recognize sinus venosus ASDs on transthoracic echocardiography (TTE) - use TEE or other advanced imaging when RV volume overload is present without clear cause 1
• Attempting device closure for unsuitable ASD types (sinus venosus, primum, or coronary sinus)
• Closing ASDs in patients with severe irreversible PAH without left-to-right shunting
• Inadequate follow-up after device closure, potentially missing late complications
• Underestimating the importance of specialized expertise - surgeons and interventional cardiologists with specific training in CHD should perform these procedures 1