What is the optimal time for Atrial Septal Defect (ASD) closure?

Optimal Timing for ASD Closure

ASD closure should be performed once right ventricular volume overload is documented, regardless of symptoms, with optimal outcomes achieved when repair occurs before age 25 years. 1

Primary Indication for Closure Timing

Patients with significant shunt (signs of RV volume overload) and pulmonary vascular resistance (PVR) <5 Wood units should undergo ASD closure regardless of symptoms (Class I, Level B). 1 This represents the fundamental indication that drives timing decisions, as RV volume overload on echocardiography is the key hemodynamic finding that characterizes defect significance. 1

Age-Based Outcomes and Timing Considerations

Optimal Age Window (Before 25 Years)

• Outcome is best with repair at age <25 years, with patients repaired in this age range without relevant sequelae not requiring regular follow-up. 1
• Patients repaired under age 25 years without residual shunt, normal pulmonary artery pressure, normal RV, and no arrhythmias have excellent long-term outcomes. 1

Closure Between Ages 25-40 Years

• Patients still benefit significantly from closure with regard to morbidity (exercise capacity, shortness of breath, right heart failure). 1
• Functional capacity improves substantially, with patients having 14 times the odds of being in NYHA class I after closure. 1
• RV remodeling occurs consistently, with significant decreases in RV end-diastolic dimension and volume. 1

Closure After Age 40 Years

• ASD closure after age 40 years does not affect the frequency of arrhythmia development during follow-up, as atrial fibrillation and flutter become more common regardless of closure. 1
• However, patients still benefit from closure at any age regarding morbidity (exercise capacity, dyspnea, right heart failure), particularly with catheter intervention. 1
• Mortality may be higher in elderly patients and those with comorbidities, requiring careful risk-benefit assessment. 1
• Individual surgical risk from comorbidities must be weighed against potential benefits in advanced age. 1

Special Timing Considerations in Pediatric Populations

Infants and Young Children (<2 Years)

• Early closure is indicated for symptomatic patients with failure to thrive, persistent respiratory symptoms, or pulmonary hypertension, particularly when underlying pulmonary abnormalities (such as bronchopulmonary dysplasia) are present. 2
• Risk factors necessitating early closure include preterm birth (OR 2.4), chromosomal abnormalities (OR 3.4), pulmonary hypertension (OR 5.8), and additional congenital heart defects (OR 2.6). 3
• Surgical closure is safe and beneficial in this age group when clinical deterioration occurs despite medical management. 2

Children Ages 2-4 Years

• Percutaneous closure can be safely performed in children under 3 years of age with low risk of complications when technically feasible. 4
• An ASD size-to-patient weight ratio <1.2 predicts successful percutaneous closure (hazard ratio 9.5). 5
• Standard elective closure is typically recommended during preschool ages (4-5 years) for asymptomatic patients. 3

Contraindications to Closure

ASD closure must be avoided in patients with Eisenmenger physiology (Class III, Level C). 1 Patients with severe irreversible pulmonary arterial hypertension and no evidence of left-to-right shunt should not undergo closure. 1

Device vs. Surgical Closure Timing Considerations

Device closure is the method of choice for secundum ASD closure when applicable (Class I, Level C), with feasibility determined by stretched diameter <38 mm and sufficient rim of 5 mm (except toward the aorta). 1 This applies to approximately 80% of patients. 1

Sinus venosus, coronary sinus, and primum defects require surgical closure and cannot be closed percutaneously. 1

Critical Pitfalls

• Do not delay closure waiting for symptoms to develop in patients with documented RV volume overload, as this represents the primary indication regardless of symptom status. 1
• Do not assume arrhythmia prevention as a benefit of closure after age 40, as late arrhythmias occur at similar rates whether closure is performed or not. 1
• Do not close ASDs in patients with established Eisenmenger physiology, as this worsens outcomes. 1
• In patients with elevated pulmonary artery pressure, cardiac catheterization is required to determine PVR before proceeding with closure. 1