What is the management strategy for a 54-year-old female with an ostium secundum (Atrial Septal Defect) of 2.8cm, left to right shunt, deficient aortic margin, and thin posterior margin, and is surgery required?

Management of 2.8cm Ostium Secundum ASD with Deficient Aortic and Posterior Rims in a 54-Year-Old Female

This patient requires closure of the ASD, but the deficient aortic margin and thin posterior rim make surgical repair the definitive treatment rather than transcatheter device closure. 1

Initial Hemodynamic Assessment Required

Before proceeding with any intervention, you must establish:

• Pulmonary artery systolic pressure (must be <50% of systemic pressure for Class I indication, or <2/3 systemic for any consideration of closure) 1
• Pulmonary vascular resistance (must be <1/3 systemic resistance for Class I indication, or <2/3 systemic for any consideration) 1
• Qp:Qs ratio (should be ≥1.5:1 to confirm hemodynamically significant shunt) 1, 2
• Right ventricular and right atrial size (enlargement confirms hemodynamic significance) 1, 2
• Presence or absence of cyanosis at rest and during exercise using pulse oximetry 1

Cardiac catheterization is reasonable to assess these parameters definitively, particularly given her age and potential for pulmonary hypertension 1

Why Surgical Closure is Indicated Over Transcatheter Approach

The deficient aortic margin and thin posterior rim are anatomic contraindications to percutaneous device closure. 3, 4

• Deficient posterior rim is a major predictor of device closure failure, with high rates of device embolization and misalignment 3
• Absent or deficient aortic rim creates instability for device placement and increases erosion risk 3
• At 2.8cm (28mm), the defect size itself is within the range for device closure, but the rim deficiencies override this consideration 1, 3
• Transcatheter closure requires adequate rims for device stability—your patient lacks this critical anatomic requirement 3, 4

Surgical Management Strategy

Surgical patch closure via sternotomy is the definitive treatment. 1, 2

The procedure should include:

• Patch closure of the secundum ASD using either pericardial or synthetic patch material 1
• Intraoperative assessment of pulmonary venous connections using transesophageal echocardiography or direct visualization 1
• Evaluation for concomitant tricuspid valve pathology that may require repair 1
• Surgery must be performed by a surgeon with expertise in adult congenital heart disease 2, 5

At age 54, surgical outcomes remain excellent with equivalent long-term survival to younger patients, though complication rates (pneumothorax, heart failure, pneumonia) are slightly higher 5, 6

Absolute Contraindications to Closure (Must Rule Out)

Do not proceed with closure if any of the following are present: 1, 2

• PA systolic pressure >2/3 systemic pressure 1
• Pulmonary vascular resistance >2/3 systemic resistance 1
• Net right-to-left shunt (Eisenmenger physiology) 1, 2
• Severe irreversible pulmonary arterial hypertension with no left-to-right shunt 2, 5

This is fatal if missed—always exclude severe PAH before proceeding. 2

Post-Operative Management and Surveillance

Following surgical repair, monitor for:

• Atrial arrhythmias (atrial fibrillation/flutter), which require anticoagulation and rhythm control 2, 7
• Residual shunt via transthoracic echocardiography at 1 month, 3-6 months, and 1 year 5, 7
• Right ventricular size and function normalization on serial echocardiography 5, 7
• Paradoxical embolic events if any residual shunt persists 7

Critical Pitfalls to Avoid

• Do not attempt transcatheter closure in the presence of deficient aortic and posterior rims—this leads to device embolization, erosion, and procedural failure 3, 4
• Do not assume the defect is benign because the patient may be asymptomatic—acquired conditions in older adults increase left-to-right shunting over time, making previously compensated ASDs hemodynamically significant 2
• Do not proceed without hemodynamic assessment—unrecognized severe PAH makes closure fatal 2, 5
• Do not underestimate arrhythmia risk—older patients have higher rates of postoperative atrial fibrillation requiring long-term management 5, 7