How do you manage an atrial septal defect (ASD)?

Management of Atrial Septal Defects

Closure of an atrial septal defect (ASD) is indicated for patients with right atrial and right ventricular enlargement with or without symptoms to prevent long-term complications. 1, 2

Types of ASDs and Closure Approaches

• Secundum ASDs (most common type) can be closed percutaneously with a device when anatomically suitable 1, 2, 3
• Sinus venosus, coronary sinus, and primum ASDs require surgical closure rather than percutaneous approaches 1, 4
• Small ASDs (<5 mm) without evidence of RV volume overload generally do not require closure unless associated with paradoxical embolism 1, 2

Indications for ASD Closure

• Presence of right atrial and right ventricular enlargement (with or without symptoms) 1
• Prevention of long-term complications including:
  • Atrial arrhythmias
  • Reduced exercise tolerance
  • Hemodynamically significant tricuspid regurgitation
  • Right-to-left shunting and embolism during pregnancy
  • Congestive heart failure
  • Pulmonary vascular disease (develops in 5-10% of affected individuals, mainly females) 1
• Paradoxical embolism 1, 2
• Documented orthodeoxia-platypnea (positional hypoxemia) 1

Contraindications to Closure

• Severe irreversible pulmonary arterial hypertension (PAH) with no evidence of left-to-right shunt (Eisenmenger physiology) 1, 4

Percutaneous Device Closure

• Preferred for secundum ASDs when anatomically suitable 2, 3
• Benefits over surgical closure include:
  • Shorter hospital stay
  • Avoidance of sternotomy
  • Lower cost
  • More rapid recovery 3, 5
• FDA-approved devices include:
  • Amplatzer® Septal Occluder (most commonly used)
  • Amplatzer® Cribriform device (for fenestrated ASDs)
  • Gore HELEX® device (useful for small to medium-sized defects) 3, 6

Surgical Closure

• Indicated for:
  • Sinus venosus, coronary sinus, or primum ASDs 1, 4
  • Secundum ASDs when concomitant surgical repair/replacement of tricuspid valve is needed 1
  • When anatomy precludes use of percutaneous device 1
• Should be performed by surgeons with training and expertise in congenital heart disease 1, 4
• Surgical approaches include:
  • Pericardial patch closure
  • Direct suture closure 1, 7
• Concomitant Maze procedure may be considered for intermittent or chronic atrial tachyarrhythmias 1

Special Considerations

• Patients with pulmonary hypertension but with net left-to-right shunting may be considered for closure if:
  • Pulmonary artery pressure is less than two-thirds systemic levels
  • Pulmonary vascular resistance is less than two-thirds systemic vascular resistance
  • Patient is responsive to pulmonary vasodilator therapy or test occlusion of the defect 1
• Patients with atrial arrhythmias and ASD should undergo both arrhythmia management and ASD closure 1
• Earlier closure (before age 25) results in better long-term outcomes and lower incidence of atrial arrhythmias 1

Post-Procedure Management

• Monitor for early postoperative symptoms of undue fever, fatigue, vomiting, chest pain, or abdominal pain which may indicate postpericardiotomy syndrome with tamponade 1, 2
• Annual clinical follow-up is recommended for patients with:
  • Pulmonary arterial hypertension
  • Atrial arrhythmias
  • Right or left ventricular dysfunction
  • Coexisting valvular or other cardiac lesions 1
• Evaluation for possible device migration, erosion, or other complications 3 months to 1 year after device closure and periodically thereafter 1, 5
• Monitor for potential late complications after device closure including:
  • Device thrombosis
  • Cardiac erosion
  • Atrial arrhythmias (most common)
  • Nickel allergy
  • Cardiac conduction abnormalities
  • Valvular damage
  • Device endocarditis 5, 8

Outcomes

• Early mortality is approximately 1% in the absence of PAH or other major comorbidities 1, 2
• Long-term follow-up shows excellent results with decrease or resolution of preoperative symptoms 1, 8
• Closure is associated with improvement in functional class, right ventricular pressure, volumes, and dimensions 2, 8