Management of Palpitations After ASD Closure
Patients experiencing palpitations after ASD closure require annual clinical follow-up with ECG monitoring and echocardiography to detect atrial arrhythmias, which occur in approximately 15-25% of adult patients post-closure and represent a significant cause of morbidity. 1, 2
Immediate Evaluation
When palpitations develop after ASD closure, perform the following assessment:
- Obtain a 12-lead ECG to identify the specific arrhythmia type (atrial fibrillation, atrial flutter, or other supraventricular tachycardia) 3
- Perform transthoracic echocardiography to evaluate device position, residual shunting, pericardial effusion, right ventricular function, and pulmonary artery pressures 3
- Assess for postpericardiotomy syndrome if accompanied by fever, fatigue, chest pain, or abdominal pain, as this may indicate tamponade requiring urgent intervention 1, 3
Risk Stratification
The likelihood of persistent or recurrent arrhythmias depends on several key factors:
- Age at closure >40 years: Patients repaired after age 40 have significantly higher rates of new-onset and persistent atrial arrhythmias (60% of those with preoperative arrhythmias continue to have them) 1
- Pre-existing arrhythmias: History of atrial tachyarrhythmias before closure increases risk 35-fold for post-closure arrhythmias 2, 4
- Mean pulmonary artery pressure ≥25 mmHg: This is an independent predictor of late atrial arrhythmia (HR 3.72) and should raise awareness for ongoing monitoring 5
- Early post-closure arrhythmias: Arrhythmias occurring within 1 month after repair predict late arrhythmias (HR 2.08) 5
Treatment Approach
For CTI-Dependent Atrial Flutter
Catheter ablation is the preferred treatment for cavotricuspid isthmus (CTI)-dependent atrial flutter in post-ASD closure patients, as this mechanism is common and highly amenable to ablation 1
For Non-CTI-Dependent or Incisional Arrhythmias
- Refer to an experienced electrophysiology center with three-dimensional mapping capabilities, as both CTI-dependent and scar-related ("incisional") atrial flutter can coexist after surgical repair 1
- Consider that surgical patients have higher rates of non-CTI-dependent mechanisms requiring advanced mapping 1
For Atrial Fibrillation
- Implement rate control and anticoagulation as standard management 1
- Consider rhythm control strategies, particularly in younger patients or those with recent-onset arrhythmias 1
- Patients with persistent atrial fibrillation before closure typically remain in arrhythmia despite successful ASD repair 1, 2
Surgical Arrhythmia Management
If arrhythmias were present before closure but not addressed:
- Irrigated radiofrequency ablation (Cox-Maze III or right-sided Maze) can be highly effective when performed concomitantly with ASD closure, with 93.5% of patients maintaining sinus rhythm at 24-month follow-up 6
- This option is no longer available post-closure but demonstrates the importance of addressing arrhythmias at the time of repair 1
Long-Term Monitoring
Annual follow-up is mandatory for all adult patients with post-closure arrhythmias, including: 1
- Clinical assessment for symptoms
- ECG monitoring
- Echocardiography to assess right ventricular function and pulmonary pressures
- More frequent monitoring (every 3-6 months) if pulmonary hypertension, ventricular dysfunction, or recurrent arrhythmias are present 1, 3
Critical Pitfalls
- Device erosion is rare but serious; new chest pain or syncope with palpitations requires urgent evaluation 3
- Patients <40 years at closure without pre-existing arrhythmias have the best prognosis, with minimal risk of new arrhythmias (0% in some series during 3.8-year follow-up) 1
- Patients ≥55 years at closure have 5.6-fold increased risk of post-closure arrhythmias and warrant closer surveillance 2
- Arrhythmia-specific treatment strategies should be implemented in addition to shunt relief, as closure alone does not eliminate arrhythmia risk in high-risk patients 4