Management of Sinus Venosus Atrial Septal Defect in a 65-Year-Old Female
Surgical closure is the recommended treatment for sinus venosus atrial septal defect (ASD) in a 65-year-old female, as this type of ASD is not amenable to percutaneous device closure. 1
Diagnostic Evaluation
Before proceeding with treatment, a comprehensive diagnostic evaluation should include:
- Transthoracic echocardiography to assess right ventricular (RV) size, function, and pulmonary artery pressure 1
- Transesophageal echocardiography (TEE) for definitive diagnosis and detailed anatomical assessment, as sinus venosus ASDs are often poorly visualized on transthoracic imaging 2
- Assessment for associated partial anomalous pulmonary venous connections, which are present in approximately 90% of sinus venosus ASDs 3
- Cardiac catheterization for patients with risk factors for coronary artery disease or echocardiographic evidence of pulmonary hypertension 1
Indications for Closure
Closure is indicated in this 65-year-old patient if any of the following are present:
- Right atrial and RV enlargement (with or without symptoms) 1
- Qp:Qs ratio ≥1.5:1 1
- Symptoms including dyspnea, orthopnea, or paradoxical embolism 1
- Presence of anomalous pulmonary venous return, which increases left-to-right shunt and accelerates the onset of pulmonary hypertension 1
Surgical Approach
- Surgical closure with patch repair is the standard treatment for sinus venosus ASD, as this type cannot be closed percutaneously 1
- The procedure should be performed by surgeons with training and expertise in congenital heart disease 1
- Double-patch technique may offer better results than single-patch technique in terms of reducing superior vena cava narrowing and gradient across the pulmonary vein 4
- Minimally invasive approaches (anterolateral mini-thoracotomy) can be considered as an alternative to median sternotomy in selected patients 3
- In recent studies, a novel transcatheter approach has been developed for selected patients with superior sinus venosus ASD, showing comparable efficacy with shorter hospital stays and fewer complications compared to surgery 5
Special Considerations for Older Patients
- Surgical closure in elderly patients (>60 years) demonstrates equivalent survival to younger patients, albeit with slightly higher complication rates (23% vs. 12-20%) 1
- Common complications in elderly patients include pneumothorax, heart failure, and pneumonia 1
- Despite higher complication rates, there were no operative deaths reported in elderly cohorts 1
- Postoperative echocardiographic indices of RV size and function typically show significant improvement from preoperative values 1
- Functional capacity, as measured by standardized survey instruments, also significantly improves after closure 1
Contraindications to Closure
- Severe irreversible pulmonary arterial hypertension (PAH) with no evidence of left-to-right shunt (Eisenmenger physiology) 1
- However, patients with moderate PAH who are responsive to pulmonary vasodilator therapy may still be candidates for closure 6
Post-Procedure Management
- Monitoring for symptoms of undue fever, fatigue, chest pain, or abdominal pain which may indicate postpericardiotomy syndrome 7
- Echocardiography to assess patch position, residual shunting, pericardial effusion, and right ventricular function 7
- Surveillance for potential arrhythmias, particularly atrial fibrillation or flutter 1
- Follow-up at 1 month, 3-6 months, and 1 year post-procedure, with periodic follow-up thereafter 8
Pitfalls to Avoid
- Failure to recognize associated partial anomalous pulmonary venous connections, which are present in most sinus venosus ASDs 3
- Underestimating the risk of postoperative arrhythmias, particularly in older patients 1
- Overlooking the potential for pericardial effusions and cardiac tamponade, which may develop up to several weeks after closure 8
- Proceeding with closure in patients with severe irreversible PAH and Eisenmenger physiology 1