Management of Large Ostium Secundum ASD with Moderate PAH Before Clavicular Fracture Surgery
Proceed with clavicular fracture surgery under careful anesthetic management while deferring definitive ASD closure until after comprehensive hemodynamic assessment and potential PAH-targeted therapy. The presence of moderate PAH with a left-to-right shunt indicates the ASD should ultimately be closed, but the timing should be optimized around the urgent orthopedic need. 1
Immediate Perioperative Management for Clavicular Fracture Surgery
Anesthetic Considerations
Use standard ASA monitors plus arterial line for continuous blood pressure monitoring and central venous catheter for hemodynamic monitoring. 2 This is critical given the moderate PAH and need to maintain stable hemodynamics during the orthopedic procedure.
Avoid significant changes in pulmonary vascular resistance during anesthesia. 2 Maintain normocapnia, avoid hypoxia, hypothermia, and acidosis—all of which can acutely worsen PAH.
Maintain preload carefully as these patients depend on adequate right ventricular filling. Hypovolemia can precipitate acute decompensation in the setting of elevated pulmonary vascular resistance.
Key Perioperative Pitfalls
Do not assume the PAH is purely from the ASD shunt. Moderate PAH in an ASD patient may represent early pulmonary vascular disease, and acute increases in right ventricular afterload during surgery could precipitate right heart failure. 1
Monitor for arrhythmias closely as ASD patients are prone to atrial tachyarrhythmias, which can be poorly tolerated in the setting of PAH. 1 Have antiarrhythmic medications readily available. 2
Post-Surgical ASD Management Strategy
Hemodynamic Assessment Requirements
Cardiac catheterization is reasonable to assess PAH severity and test vasoreactivity before considering ASD closure. 1 This is essential because:
ASD closure may be considered if pulmonary artery pressure is less than two-thirds systemic levels and PVR is less than two-thirds systemic vascular resistance. 1
The shunt must remain predominantly left-to-right despite the elevated pulmonary pressures. 1 If the shunt has reversed or become bidirectional, this indicates more severe pulmonary vascular disease.
Measure Qp:Qs ratio to confirm hemodynamically significant shunting (typically ≥1.5:1). 1
Treatment Algorithm Based on Hemodynamics
If moderate PAH with preserved left-to-right shunt and favorable hemodynamics:
- Closure of the ASD either percutaneously or surgically is indicated for right atrial and RV enlargement. 1 The presence of RV volume overload on echocardiography supports closure even with moderate PAH.
If moderate-to-severe PAH with borderline hemodynamics:
Consider a "treat-and-repair" strategy with PAH-specific medications followed by reassessment. 3, 4 Recent evidence shows that pretreatment with PAH therapies (endothelin receptor antagonists, PDE-5 inhibitors, prostacyclins) with demonstrated reduction in PVR >20% portends favorable prognosis after ASD closure. 1
Perform vasoreactivity testing and trial balloon occlusion to assess tolerance of ASD closure. 1 This helps identify patients who will decompensate with closure.
If severe irreversible PAH without left-to-right shunt:
- Do not close the ASD. 1 Patients with severe irreversible PAH and no evidence of left-to-right shunt should not undergo ASD closure as this is associated with prohibitively high morbidity and mortality. 1
Specific Closure Considerations
Ostium secundum defects can be closed percutaneously if anatomy is favorable. 1 However:
Surgical closure is reasonable when concomitant tricuspid valve repair is needed for significant tricuspid regurgitation, which may be present with chronic RV volume overload. 1
Surgeons with training and expertise in congenital heart disease should perform the closure. 1 This is not a procedure for general cardiac surgeons unfamiliar with adult congenital heart disease.
Critical Warning About Left Ventricular Diastolic Dysfunction
Evaluate for left atrial hypertension from LV diastolic dysfunction before closure. 1 Older adults with ASD may have developed restrictive LV physiology from chronic underfilling. Closing the ASD in these patients can cause life-threatening acute pulmonary edema because the left atrium can no longer decompress into the right atrium. 1, 5
- Prepare high-risk patients with diuretics and vasodilators prior to closure. 5
- Consider perforated device closure in borderline cases to allow continued decompression while reducing shunt volume. 5
Follow-Up Timing
Defer comprehensive ASD evaluation until 4-6 weeks after clavicular fracture surgery to allow orthopedic healing and avoid confounding acute surgical stress on hemodynamic assessment. The ASD has been present chronically and waiting several weeks will not significantly alter outcomes, whereas attempting simultaneous procedures increases risk substantially.
Maintain close cardiology follow-up with repeat echocardiography every 2-3 years if closure is deferred, monitoring for progression of PAH, RV dysfunction, or development of arrhythmias. 1