What are the risks of open heart surgery versus catheterization (cath) lab procedure with device placement to close Atrial Septal Defect (ASD) in a 4-year-old?

From the Guidelines

For a 4-year-old with an atrial septal defect (ASD), catheter-based device closure is generally the preferred treatment option when anatomically suitable, due to its less invasive nature and lower risk of complications compared to open heart surgery. This procedure carries risks including device embolization (0.5-1%), cardiac perforation (<1%), arrhythmias (1-4%), and minimal radiation exposure, but typically requires only 1-2 days of hospitalization with faster recovery 1. Open heart surgery, on the other hand, involves more significant risks including infection (2-5%), bleeding requiring transfusion (5-10%), longer ICU stay (2-3 days), longer overall hospitalization (5-7 days), post-pericardiotomy syndrome (10-15%), and visible chest scarring. However, surgery may be necessary for larger defects (>38mm), those with insufficient rim tissue, or multiple defects. The decision should be based on the specific ASD anatomy, the child's size, and other cardiac conditions.

Key Considerations

• The size and anatomy of the ASD are crucial in determining the suitability of catheter-based closure, with defects larger than 38mm or those with insufficient rim tissue potentially requiring surgical intervention 1.
• The child's age and weight are also important factors, with a weight of 15 kg often considered a threshold for technical advantages in catheter-based procedures 1.
• Both approaches have excellent long-term success rates exceeding 95%, but the catheter approach, when appropriate, generally offers quicker recovery with less physical trauma for the child.

Risks and Benefits

• Catheter-based device closure:
  • Risks: device embolization, cardiac perforation, arrhythmias, minimal radiation exposure
  • Benefits: less invasive, shorter hospitalization, faster recovery
• Open heart surgery:
  • Risks: infection, bleeding, longer ICU stay, longer hospitalization, post-pericardiotomy syndrome, visible chest scarring
  • Benefits: may be necessary for larger or more complex defects, excellent long-term success rates

Current Guidelines

• The 2018 AHA/ACC guideline for the management of adults with congenital heart disease recommends percutaneous or surgical closure for asymptomatic patients with unoperated secundum ASD and RV dilatation, with the goal of improving outcomes 1.
• The American Heart Association and other organizations have published guidelines and recommendations for the management of ASD, emphasizing the importance of individualized decision-making based on patient anatomy, size, and other cardiac conditions 1.

From the Research

Risks of Open Heart Surgery vs Cath Lab Procedure

The risks associated with open heart surgery and cath lab procedure for closing an atrial septal defect (ASD) in a 4-year-old child are as follows:

• Open heart surgery:
  • Higher risk of complications, such as infection, bleeding, and adverse reactions to anesthesia 2
  • Longer recovery time and hospital stay 2
• Cath lab procedure with device placement:
  • Risk of device erosion, embolization, and stroke, although rare 3, 4
  • Risk of new-onset atrial arrhythmia and residual shunt, although the difference between devices is not significant 4
  • Need for anticoagulation therapy and follow-up echocardiograms for approximately 6 months 2

Device-Related Risks

The risks associated with specific devices used in cath lab procedures are:

• Amplatzer Septal Occluder:
  • Risk of device embolization and erosion, although rare 5
  • High occlusion rate, with total occlusion rates of 92.5% and 98.9% at one and three months, respectively 5
• Occlutech Figulla Flex II:
  • Similar efficacy and safety profile compared to Amplatzer Septal Occluder, with no significant difference in procedural complications or efficacy 4
• Gore Cardioform atrial septal occluder:
  • New device with a learning curve for deployment, but technical aspects can be employed to close challenging ostium secundum atrial septal defects 6

Considerations for ASD Closure

When considering ASD closure, it is essential to:

• Evaluate the size, position, and morphology of the ASD using transesophageal echocardiography 5
• Choose the appropriate device based on the stretched diameter of the ASD and the patient's anatomy 5
• Carefully select cases and assess the risks and benefits of each procedure 2, 3