ASD Device Closure
Primary Treatment Recommendation
Percutaneous device closure is the first-line treatment for secundum atrial septal defects when anatomically suitable, indicated for patients with right atrial and right ventricular enlargement regardless of symptoms. 1, 2
Indications for Device Closure
Class I Indications (Must Close)
- Right atrial and RV enlargement with or without symptoms 1, 2
- Hemodynamically significant shunt with Qp:Qs ≥1.5:1 1, 3
- Signs of RV volume overload on echocardiography 1, 2
Class IIa Indications (Should Close)
Class IIb Indications (May Consider)
- Net left-to-right shunt with pulmonary artery pressure <2/3 systemic levels 1
- PVR <2/3 systemic vascular resistance or responsive to vasodilator therapy 1
Anatomic Suitability for Device Closure
Suitable for Percutaneous Approach
- Secundum ASDs only - all other types require surgery 1
- Stretched diameter ≤38 mm 1
- Adequate septal rim ≥5 mm (except toward aorta) 1
- Single defect or limited fenestrations 1
Requires Surgical Closure
- Sinus venosus defects 1, 4
- Primum (partial AVSD) defects 1
- Coronary sinus defects 1
- Large septal aneurysm or multifenestrated septum 1
- Concomitant tricuspid valve repair needed 1, 3
Available Devices in the United States
AMPLATZER Septal Occluder
- Nitinol wire mesh with Dacron fabric 1
- Suitable for defects up to 38 mm diameter 1
- Self-centering with left and right atrial disks 1
- Repositionable before release 1
Gore HELEX Occluder
- Single nitinol strand with ePTFE membrane 1
- Suitable for small to moderate defects ≤18 mm 1
- Repositionable even after release 1
- Lower erosion risk but higher wire fracture rate (5-7%) 1
Procedural Considerations
Patient Selection
- Minimum weight 15 kg preferred for technical ease 1
- Can be performed in children ≥2 years of age 1
- Echocardiographic guidance (TEE or intracardiac) essential 1
Success and Efficacy Rates
- Device closure success rate: 97-98% 5, 6
- Complete closure rate: >99% at follow-up 5, 6
- Surgical closure success rate: 99.8% 5
Complications and Risks
Major Complications (1.6% with AMPLATZER)
- Device embolization requiring surgical removal 1
- Cardiac erosion/perforation leading to tamponade and death - most serious late complication 1, 7
- Cerebral embolism 1
- Atrioventricular block 1
Minor Complications (6.1% with AMPLATZER)
- Transient arrhythmias (most common) 1, 7
- Device thrombosis 1, 7
- Wire frame fracture (HELEX: 5-7%) 1
- Allergic reactions 1
Overall Complication Rates
- Device closure: 7.1% total complications 5
- Surgical closure: 16.2% total complications 5
- Mortality: approximately 0% for device closure, 1% for surgery 1, 6
Post-Procedure Management
Immediate Follow-up (First 3 Months)
- Antiplatelet therapy for minimum 6 months (aspirin 100 mg daily) 1
- Echocardiography at 3 months to 1 year to evaluate device position, migration, and erosion 1
- Monitor for chest pain or syncope suggesting device erosion - requires urgent evaluation 1
Long-term Surveillance
- Annual follow-up if ASD repaired as adult with persistent PAH, atrial arrhythmias, RV/LV dysfunction, or coexisting valvular lesions 1
- Periodic echocardiography for device position, residual shunting, thrombus formation, and pericardial effusion 1
- Monitor for late arrhythmias, particularly atrial fibrillation/flutter 1, 7
Absolute Contraindications
Class III (Must Not Close)
- Severe irreversible pulmonary arterial hypertension with no left-to-right shunt (Eisenmenger physiology) 1, 3
- PVR ≥2/3 systemic vascular resistance without vasodilator response 1, 3
- Pulmonary artery pressure ≥2/3 systemic pressure 3
Critical Pitfalls to Avoid
Device Selection Errors
- Oversizing device relative to defect increases erosion risk 7
- Inadequate rim assessment leads to device instability and embolization 1, 8
- Attempting device closure in unsuitable anatomy (non-secundum defects) 1
Clinical Assessment Errors
- Failing to exclude severe PAH before closure - fatal if present 3
- Delaying closure based on absence of symptoms - symptoms lag behind hemodynamic dysfunction 2
- Underestimating arrhythmia risk in older patients (>40 years) 1, 4
Post-Procedure Monitoring Gaps
- Missing early signs of device erosion (chest pain, syncope) 1
- Inadequate antiplatelet therapy duration (<6 months) 1
- Failing to monitor for late complications beyond first year 7
Comparative Outcomes: Device vs Surgery
Advantages of Device Closure
- Shorter hospital stay (1.3 vs 5.6 days) 5
- Lower overall complication rate (7.1% vs 16.2%) 5
- No sternotomy scar or cardiopulmonary bypass 7, 9
- Faster recovery and return to activities 9