What is the recommended treatment for an 18-year history of atrial septal defect (hole in the heart)?

Treatment Recommendations for Atrial Septal Defect (ASD) with 18-Year History

Surgical or percutaneous closure is strongly recommended for adults with atrial septal defects causing right heart volume overload, regardless of symptom status. 1

Assessment and Indications for Intervention

• Comprehensive evaluation should include assessment of:

  • Right ventricular (RV) size and function 1
  • Pulmonary arterial pressure 1
  • Left ventricular (LV) function 1
  • Presence of associated anomalies 1

• Closure is indicated when there is:

  • Significant RV volume overload 1
  • Evidence of right heart enlargement 1
  • Symptoms attributable to the ASD 1

• Pooled data analysis shows significant benefits of ASD closure including:

  • Improved New York Heart Association (NYHA) functional class (OR 13.78,95% CI 3.33-57.08) 1
  • Reduction in right ventricular systolic pressure 1
  • Improved peak oxygen consumption (VO₂) 1
  • Decreased right ventricular end-diastolic diameter (RVEDD) 1

Treatment Options

Percutaneous Device Closure

• First-line option for secundum ASD when anatomically suitable 1
• Advantages:
  • Less invasive procedure 2
  • Shorter hospital stay 2
  • Quicker recovery time 2
• Requirements:
  • Adequate rim of tissue surrounding the defect (typically ≥5mm except at aortic side) 1
  • No significant associated anomalies requiring surgical repair 1

Surgical Closure

• Indicated for:
  • ASDs not amenable to device closure (large defects, inadequate rims) 1
  • Primum ASDs, sinus venosus defects, or coronary sinus defects 2
  • When associated anomalies require surgical correction 1
  • Significant pulmonary venous anomalies 1

Timing Considerations

• Earlier intervention is associated with better outcomes 3
• Mortality benefit is demonstrated with ASD closure (adjusted mortality HR 0.28,95% CI 0.13-0.58) 1
• Delaying closure increases risk of:
  • Atrial arrhythmias 4
  • Right ventricular dysfunction 4
  • Pulmonary hypertension 4
  • Reduced exercise capacity 1

Contraindications and Special Considerations

• Eisenmenger syndrome (irreversible pulmonary hypertension with right-to-left shunting) is an absolute contraindication to ASD closure 1
• Pulmonary vascular resistance testing is recommended in cases of suspected elevated pulmonary pressures 1
• Female patients have higher risk of developing pulmonary vascular disease if left untreated 4

Post-Closure Management and Follow-up

• Lifelong regular follow-up is recommended for all patients with ASD (both operated and unoperated) 1
• Follow-up should include:
  • Assessment for residual shunts 1
  • Monitoring of AV valve function 1
  • Evaluation of ventricular size and function 1
  • Screening for pulmonary arterial pressure elevation 1
  • Detection of arrhythmias 1
• Frequency of follow-up:
  • Every 2-3 years for repaired ASDs without significant residual abnormalities 1
  • More frequent monitoring for those with residual abnormalities 1

Outcomes and Prognosis

• When performed before age 25, surgical closure is associated with normal life expectancy 4
• Older adults with untreated defects have increased risk of:
  • Exercise intolerance 4
  • Atrial tachyarrhythmias 4
  • Right ventricular dysfunction 4
  • Pulmonary hypertension 4
• Non-operated patients fare significantly worse in all hemodynamic aspects compared to those with closed defects 3

Conclusion

For an 18-year history of ASD, the evidence strongly supports closure (either percutaneous or surgical depending on anatomical considerations) to prevent long-term complications and improve quality of life, particularly when there is evidence of right heart volume overload or enlargement.