What is the recommended workup for a patient on post-operative day 1 (POD 1) following Atrial Septal Defect (ADS) device closure?

Post-Operative Day 1 Workup Following ASD Device Closure

On post-operative day 1 following Atrial Septal Defect (ASD) device closure, a comprehensive echocardiographic evaluation is essential to assess device position, residual shunting, and potential complications such as pericardial effusion or thrombus formation. 1

Clinical Assessment

• Evaluate for symptoms of arrhythmia, chest pain, embolic events, fever, fatigue, vomiting, or abdominal pain, as these may indicate complications such as postpericardiotomy syndrome with tamponade 1
• Perform clinical examination to assess for signs of cardiac tamponade or other complications 1
• Obtain ECG to monitor for new-onset or recurrent arrhythmias 1

Imaging Studies

Transthoracic Echocardiography (TTE)

• TTE is the primary imaging modality for POD 1 evaluation and is rated as "Appropriate" by ACC/AHA guidelines 1
• Assessment should include:
  • Device position and stability 1
  • Presence of residual shunting 1
  • Evidence of thrombus formation on the device 1
  • Evaluation for pericardial effusion or tamponade 1
  • Assessment of pulmonary artery pressure 1
  • Right ventricular size and function 1
  • Tricuspid valve function 1

Special Considerations

• If the patient exhibits concerning symptoms such as chest pain, syncope, or hemodynamic instability, urgent evaluation for device erosion is warranted 1
• For patients with poor acoustic windows on TTE, alternative imaging with transesophageal echocardiography (TEE) may be necessary 2
• Intracardiac echocardiography (ICE) has shown advantages in some centers for evaluating device position and complications 3

Follow-up Schedule

After the POD 1 assessment, the recommended echocardiographic follow-up schedule is:

• 1 month post-procedure 1
• 3-6 months post-procedure 1
• 1 year post-procedure 1
• Periodically thereafter (typically every 2-4 years) 1

Specific Populations Requiring More Intensive Monitoring

More frequent follow-up is recommended for patients with:

• Pulmonary arterial hypertension (PAH) 1
• Atrial arrhythmias 1
• Right or left ventricular dysfunction 1
• Coexisting valvular or other cardiac lesions 1
• ASD repair performed in adulthood 1

Common Pitfalls and Caveats

• Pericardial effusions and cardiac tamponade may develop up to several weeks after ASD closure, so patients and primary care physicians should be instructed to report concerning symptoms promptly 1
• Device erosion, while rare, is a serious complication that may present with chest pain or syncope and requires urgent evaluation 1
• Patients with left ventricular assist devices may develop significant hypoxemia due to right-to-left shunting across residual or iatrogenic ASDs 4
• Endocarditis prophylaxis is indicated for the first 6 months after ASD closure but not thereafter unless there are other indications 1