At what age is closure typically considered for a neonate with an atrial septal defect (ASD)?

Timing of ASD Closure in Neonates

Most neonates with isolated atrial septal defects do not require closure during the neonatal period or infancy, with elective closure typically performed between ages 2-5 years when the child is symptomatic with right ventricular volume overload. However, symptomatic neonates and infants with specific high-risk features require earlier intervention, sometimes within the first year of life.

Standard Timing for Asymptomatic 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
• The traditional approach delays closure until ages 4-5 years for isolated secundum ASDs in asymptomatic children 2
• Device closure can be successfully performed in children as young as 2 years of age, though a weight of 15 kg offers technical advantages 3

Indications for Early Closure in Neonates and Infants

Early surgical closure within the first 1-2 years of life is indicated when neonates or infants are symptomatic despite the general preference to wait 2, 4. Specific indications include:

Respiratory Compromise

• Tachydyspnea, recurrent respiratory infections, or signs of pulmonary hyperperfusion 2
• Ventilator dependence (4 of 8 ventilator-dependent patients were weaned within 1 month post-closure) 4
• Underlying pulmonary abnormalities, particularly bronchopulmonary dysplasia or chronic lung disease 2, 4

Hemodynamic Instability

• Heart failure requiring medical management 2
• Pulmonary hypertension (resolution occurred in 7 of 7 assessable patients post-closure) 4
• Failure to thrive or inability to maintain growth percentile 2, 4

High-Risk Comorbidities

• Prematurity with chronic lung disease (OR = 2.4 for early closure) 5
• Chromosomal abnormalities (OR = 3.4 for closure ≤2 years) 5
• Additional congenital heart defects (OR = 2.6 for early closure) 5
• Congenital diaphragmatic hernia or other conditions compromising respiratory function 2

Contraindications to Closure

• Small ASDs (<5 mm diameter) without RV volume overload and no other risk factors should not be closed 3
• Patients with Eisenmenger physiology or severe irreversible pulmonary arterial hypertension without left-to-right shunt must not undergo closure 3, 1
• Advanced pulmonary vascular obstructive disease is an absolute contraindication 3

Surgical vs. Device Closure Considerations

Device Closure Feasibility

• Device closure is the preferred method for secundum ASDs when anatomically suitable 1
• In infants and toddlers, an ASD size-to-patient weight ratio <1.2 predicts successful percutaneous closure (hazard ratio 9.5) 6
• Absolute patient weight or age alone does not independently predict procedural success 6

Surgical Closure Requirements

• Sinus venosus, coronary sinus, and primum ASDs require surgical closure and cannot be closed percutaneously 3, 1
• Neonates and infants typically require surgical rather than device closure due to size constraints 2, 7

Outcomes of Early Closure

• Clinical improvement occurs in 84% of symptomatic patients under 2 years after closure 4
• Respiratory status improves in 77.3% of those with respiratory symptoms 4
• Normal growth resumes in 62.5% of patients with failure to thrive 4
• Pulmonary hypertension resolves in the majority of cases (11 of 13 children in one series) 2
• Surgical complications are uncommon, with no early or late deaths in multiple series 2, 7

Critical Pitfalls to Avoid

• Do not delay closure in symptomatic infants waiting for the "ideal" age of 4-5 years, as even minor left-to-right shunts are poorly tolerated when lungs are compromised 2
• Do not assume all neonatal ASDs require immediate closure—most isolated ASDs can be managed expectantly unless specific high-risk features are present 2, 5
• Do not overlook the development of irreversible pulmonary vascular changes by delaying closure in infants with pulmonary hypertension 2
• Do not attempt device closure in non-secundum ASDs (primum, sinus venosus, coronary sinus defects) as these require surgical repair 3
• Do not proceed with closure in patients with established Eisenmenger physiology, as this worsens outcomes 3, 1