Heparin Duration After ASD Device Closure
Heparin administration should be discontinued immediately after ASD device closure procedure, with no routine post-procedural intravenous heparin administration recommended. 1
Evidence-Based Approach to Post-ASD Closure Anticoagulation
Intra-procedural Anticoagulation
- All patients undergoing ASD device closure should receive at least 100 U/kg unfractionated heparin (UFH) (up to 5000-U maximum dose) at the time of implantation 1
- This ensures adequate anticoagulation during the procedure when the risk of thrombus formation is highest
Post-procedural Anticoagulation
- Routine post-procedural intravenous heparin administration is not recommended following ASD device closure 1
- Continuing intravenous heparin after the procedure shows no definite benefits and increases the risk of bleeding complications, particularly at the site of vascular access 1
Special Circumstances for Extended Heparin
Heparin may be continued for 24-48 hours post-procedure only in specific high-risk situations:
- Patients with angiographically visible dissections
- Presence of mural thrombosis
- Development of new or progressive neurological symptoms 1
- In these cases, heparin should be administered to maintain APTTs of 1.5 to 2.3 times the control values 1
Transition to Oral Antithrombotic Therapy
After discontinuation of heparin, patients should receive:
- Children: Low-dose aspirin for at least 6 months after implantation 1
- Adults: Either aspirin alone (325 mg daily) for 6 months or a combination of aspirin and clopidogrel (75 mg daily) initially, followed by aspirin alone to complete 6 months 1
- For older children and adults, another anticoagulant may be considered in addition to aspirin for 3-6 months after implantation 1
Rationale and Clinical Considerations
Low Risk of Device Thrombosis
- Device thrombosis is an extremely rare complication in ASD closure when appropriate antiplatelet therapy is used 1
- The incidence of device thrombosis is particularly low or nonexistent in large series using modern devices 1
Endothelialization Process
- The duration of thromboprophylaxis should theoretically extend until complete device endothelialization is achieved 1
- Standard of care is to provide oral antiplatelet thromboprophylaxis for 6 months 1
- Endothelialization is typically complete within this timeframe, making extended heparin unnecessary
Monitoring After Device Closure
- Follow-up should include clinical assessment for symptoms of arrhythmia, chest pain, or embolic events 1
- Echocardiographic surveillance for device position, residual shunting, and complications such as thrombus formation 1
- Typical echocardiographic follow-up schedule: 24 hours, 1 month, 6 months, and 1 year after the procedure 1
Important Caveats and Pitfalls
Residual Defects: If complete defect closure is not achieved (residual defect after device implantation), complete endothelialization may not occur, and some centers elect to continue thromboprophylaxis beyond 6 months 1
Pre-existing Thrombophilia: In patients with hereditary thrombophilic disorders, anticoagulation management should be individualized and may require more intensive or prolonged therapy 1, 2
Device Erosion: Monitor for device erosion, which may present with chest pain or syncope and warrants urgent evaluation 1
Fenestrated Devices: For patients with fenestrated ASD closure devices (used in elderly patients or those with restrictive left ventricular physiology), heparin may be administered for 48 hours after the procedure 3
In conclusion, while heparin is essential during the ASD device closure procedure, routine post-procedural heparin administration is unnecessary and potentially increases bleeding risk. The focus should be on appropriate oral antiplatelet therapy for 6 months to prevent device-related thrombosis while endothelialization occurs.