What are the management options for secundum Atrial Septal Defect (ASD)?

Management of Secundum Atrial Septal Defect (ASD)

Closure of secundum ASD is indicated for patients with right atrial and right ventricular enlargement, with or without symptoms, to prevent long-term complications such as atrial arrhythmias, reduced exercise tolerance, and pulmonary vascular disease. 1

Indications for Closure

Class I Indications (Strongly Recommended)

• Closure is indicated for patients with right atrial and right ventricular enlargement with or without symptoms 1
• Percutaneous device closure is preferred for secundum ASD when anatomically suitable 1
• Surgical closure is indicated for sinus venosus, coronary sinus, or primum ASD as these are not amenable to device closure 1

Class IIa Indications (Reasonable)

• Closure is reasonable in the presence of paradoxical embolism 1
• Closure is reasonable in the presence of documented orthodeoxia-platypnea (oxygen desaturation and dyspnea when upright) 1
• Surgical closure is reasonable when concomitant surgical repair/replacement of tricuspid valve is needed 1
• Closure is reasonable to reduce RV volume and/or improve functional capacity when pulmonary artery pressure is less than 50% of systemic pressure and pulmonary vascular resistance is less than one-third systemic resistance 1

Class IIb Indications (May Be Considered)

• Closure may be considered when pulmonary artery pressure is 50% or more of systemic pressure and/or pulmonary vascular resistance is greater than one-third of systemic resistance 1
• Concomitant Maze procedure may be considered for patients with intermittent or chronic atrial tachyarrhythmias 1

Contraindications (Class III)

• Patients with severe irreversible pulmonary arterial hypertension (PAH) and no evidence of left-to-right shunt should not undergo ASD closure 1
• Closure should not be performed when pulmonary artery systolic pressure is greater than two-thirds systemic with a net right-to-left shunt 1

Closure Methods

Percutaneous Device Closure

• First-line treatment for most secundum ASDs in both adults and children 2
• Advantages include:
  • Avoidance of cardiopulmonary bypass 2, 3
  • Avoidance of sternotomy scar 2, 3
  • Shorter hospitalization (1.0 ± 0.3 days vs. 3.4 ± 1.2 days for surgery) 3
  • Lower complication rate (6.6% vs. 31% for surgery) 4
• Not suitable for:
  • Sinus venosus, coronary sinus, and primum defects 1, 5
  • Very large ASDs (>38mm) without adequate rims 6
  • ASDs with complex anatomy requiring surgical intervention 5, 6

Surgical Closure

• Indicated for:
  • Sinus venosus, coronary sinus, and primum defects 1, 5
  • Secundum ASDs not amenable to device closure 1
  • When concomitant cardiac surgery is being performed 1
• Techniques include:
  • Pericardial patch closure 1
  • Direct suture closure 1
  • Warden procedure for sinus venosus ASD with anomalous pulmonary venous drainage 1

Post-Procedure Management

Immediate Post-Procedure Care

• Monitor for symptoms of undue fever, fatigue, vomiting, chest pain, or abdominal pain which may indicate postpericardiotomy syndrome with tamponade 1, 7
• Perform echocardiography to assess:
  • Device position and stability (for device closure) 1, 7
  • Residual shunting 1, 7
  • Pericardial effusion 1, 7
  • Right ventricular function 1, 7

Follow-up Schedule

• Evaluation at 24 hours, 1 month, 6 months, and 1 year post-procedure 1, 7
• Annual clinical follow-up for patients with:
  • Pulmonary arterial hypertension 1, 7
  • Atrial arrhythmias 1, 7
  • Right or left ventricular dysfunction 1, 7
  • Coexisting valvular or other cardiac lesions 1, 7
  • ASD repair performed in adulthood 1, 7

Potential Complications

Device-Related Complications

• Device migration or erosion (may present with chest pain or syncope) 1, 7, 2
• Device thrombosis 2
• Nickel allergy 2
• Cardiac conduction abnormalities 2
• Device endocarditis 2

Surgical Complications

• Postpericardiotomy syndrome 1
• Pericardial effusion and cardiac tamponade 1, 7
• Atrial arrhythmias 1
• Superior vena cava stenosis or pulmonary vein stenosis (after sinus venosus ASD repair) 1

Clinical Outcomes

• Pooled analysis shows improvement in:
  • New York Heart Association functional class 1
  • Right ventricular systolic pressure, volumes, and dimensions 1
• Closure is associated with a weak protective effect on adjusted mortality rate 1
• Early mortality is approximately 1% in the absence of PAH or other major comorbidities 1
• Long-term follow-up shows excellent results with decrease or resolution of preoperative symptoms 1

Special Considerations

• Small ASDs (<5 mm) without evidence of RV volume overload generally do not require closure unless associated with paradoxical embolism 1
• Larger defects with RV volume overload typically cause symptoms in the third decade of life 1
• Closure is usually indicated to prevent long-term complications such as atrial arrhythmias, reduced exercise tolerance, and pulmonary vascular disease 1
• Patients with severe pulmonary hypertension require careful evaluation by providers with expertise in pulmonary hypertensive syndromes before considering closure 1