What are the indications for atrial septal defect (ASD) closure?

Indications for Atrial Septal Defect (ASD) Closure

Closure of an ASD is indicated for patients with right atrial and right ventricular enlargement with or without symptoms (Class I recommendation). 1, 2

Primary Indications for ASD Closure

• Evidence of right ventricular volume overload - The most important indication regardless of symptoms 1
• Significant left-to-right shunt (Qp:Qs ratio ≥1.5:1) 2
• Defect size - Larger defects (>5mm) with evidence of RV volume overload typically require closure 1
• Paradoxical embolism (Class IIa recommendation) 1
• Documented orthodeoxia-platypnea (positional desaturation) (Class IIa recommendation) 1

Closure Method Selection Algorithm

Percutaneous Device Closure

Indicated for:

• Secundum ASD only 1, 2
• Defects with adequate rims for device anchoring 2, 3
• Defects typically <38mm in diameter 2, 3

Surgical Closure

Indicated for:

• Sinus venosus, coronary sinus, or primum ASDs (Class I recommendation) 1, 2
• Large secundum ASDs (>38mm) 2, 3
• Defects with deficient rims 2, 3
• When concomitant tricuspid valve repair/replacement is needed (Class IIa recommendation) 1
• When anatomy precludes device closure 1

Special Considerations

Pulmonary Hypertension

• Mild to moderate PAH: ASD closure may be considered with pulmonary artery pressure less than two-thirds systemic levels and PVR less than two-thirds systemic vascular resistance (Class IIb recommendation) 1
• Severe irreversible PAH: ASD closure is contraindicated if there is no evidence of left-to-right shunt (Class III recommendation) 1
• Test occlusion: For borderline cases, temporary test occlusion with hemodynamic measurements can help determine closure candidacy 1

Atrial Arrhythmias

• Concomitant Maze procedure may be considered for patients with intermittent or chronic atrial tachyarrhythmias (Class IIb recommendation) 1
• Earlier closure (before age 25) is associated with lower incidence of arrhythmias 2

Left Ventricular Dysfunction

• Requires careful evaluation due to risk of acute changes in left-sided pressures after closure 4
• Gradual closure strategies may be considered to allow the left ventricle to adapt 4

Timing of Closure

• Children: Elective closure recommended around 4 years of age 2, 5
• Adults: Closure recommended at time of presentation regardless of age 5
• Earlier closure is associated with better outcomes and lower incidence of complications 2

Contraindications for ASD Closure

• Severe irreversible PAH with right-to-left shunting (Eisenmenger syndrome) 1, 2
• Small ASDs (<5mm) without evidence of RV volume overload or clinical significance 1

Post-Closure Follow-up

• Annual clinical follow-up recommended for patients with:
  • Persistent/residual pulmonary arterial hypertension 1
  • Atrial arrhythmias 1
  • RV or LV dysfunction 1
  • Coexisting valvular or other cardiac lesions 1
• Evaluation for device complications at 3 months to 1 year after closure and periodically thereafter 1

Expected Outcomes After Closure

• Normalization of right ventricular and right atrial volumes 6
• Increase in left ventricular volumes due to improved filling 6
• Improvement in functional status 2
• Prevention of long-term complications such as atrial arrhythmias, reduced exercise tolerance, and pulmonary vascular disease 1, 2

ASD closure decisions should be made by physicians with expertise in adult congenital heart disease, with careful consideration of defect characteristics, hemodynamic impact, and associated conditions.