Is ASD (Atrial Septal Defect) creation or a fenestrated device indicated in patients with VSD (Ventricular Septal Defect) and moderate pulmonary hypertension?

ASD Creation or Fenestrated Device in VSD with Moderate Pulmonary Hypertension

Fenestrated devices or fenestrated surgical patches are indicated for VSD closure in patients with large defects and pulmonary arterial hypertension who demonstrate a net left-to-right shunt, allowing controlled right heart decompression while avoiding complete closure that carries prohibitive mortality risk. 1

Primary Indication: VSD with PAH and Preserved Left-to-Right Shunt

The 2018 ACC/AHA guidelines specifically address this scenario for adults with large VSD and pulmonary arterial hypertension:

• Fenestrated closure may benefit patients with large VSD and PAH who maintain a net left-to-right shunt either at baseline or after initiation of PAH-targeted therapies 1
• The fenestration leaves a small residual shunt that functions as a "pop-off" mechanism, allowing right heart decompression when RV pressures become critically elevated 1
• This approach evolved after early attempts at complete surgical closure in Eisenmenger patients resulted in unacceptably high mortality rates 1

Critical Hemodynamic Requirements

Before considering fenestrated closure, you must document:

• Net left-to-right shunting (Qp:Qs ≥1.5:1) either at rest or with PAH therapy challenge 1
• Evidence that pulmonary vascular resistance decreases with PAH medications 1
• Cardiac catheterization is mandatory to assess these parameters accurately 1

Absolute Contraindication

Complete or fenestrated VSD closure should NOT be performed in patients with Eisenmenger syndrome who lack demonstrable left-to-right shunting and show no decline in pulmonary vascular resistance with PAH therapies - this carries high mortality risk 1

Fenestrated ASD Devices: A Related but Distinct Application

While your question asks about ASD creation in VSD patients, the evidence primarily supports fenestrated VSD closure rather than creating an ASD. However, fenestrated ASD devices have proven utility in different contexts:

For Primary ASD with Severe PAH:

• Fenestrated ASD closure (not creation) is safe and effective in patients with existing ASD and severe pulmonary hypertension 2, 3, 4
• Studies show improvement in NYHA class, decreased pulmonary artery pressures, and reduced pulmonary vascular resistance when combined with vasodilator therapy 2
• The fenestration allows bidirectional overflow during episodes of ventricular dysfunction 3, 4

For Progressive Pediatric PH:

• The 2025 ATS guidelines suggest ASD intervention (creation/enlargement) for children with progressive PH and RV failure despite optimal therapy, though this is a conditional recommendation with very low certainty evidence 1
• This represents palliative therapy for end-stage disease, not treatment of VSD with moderate PAH 1

Practical Algorithm for Your Patient

For a patient with VSD and moderate pulmonary hypertension:

1. Perform cardiac catheterization to measure:

   • Qp:Qs ratio (need ≥1.5:1 for consideration) 1
   • Baseline pulmonary artery pressures and resistance 1
   • Response to PAH vasodilator challenge 1

2. If net left-to-right shunt persists (with or without PAH therapy):

   • Consider fenestrated VSD closure (surgical patch or device) 1
   • Initiate or optimize PAH-targeted medical therapy before closure 1
   • The fenestration size should allow controlled decompression 1

3. If shunt has reversed to right-to-left or becomes balanced:

   • VSD closure (fenestrated or complete) is contraindicated 1
   • Continue medical management only 1

Important Caveats

• "Moderate" pulmonary hypertension is vague - you need specific hemodynamic data (PA systolic pressure as percentage of systemic, pulmonary vascular resistance in Wood units) to make this decision safely 1
• The evidence for fenestrated VSD closure comes primarily from observational data and expert opinion (Class C evidence) 1
• Creating a new ASD in a patient with VSD and PAH is not supported by the guidelines - the intervention targets the VSD itself with fenestrated closure 1
• Surgical expertise at a congenital heart disease center is essential, as these are high-risk procedures requiring multidisciplinary discussion 1