What is the management approach for a patient with an atrial septal defect (ASD)?

Management of Atrial Septal Defects

Closure is recommended for any ASD causing right atrial and right ventricular enlargement (Qp:Qs ≥1.5:1), regardless of symptoms, to prevent long-term mortality and morbidity, with percutaneous device closure preferred for anatomically suitable secundum defects. 1

Indications for ASD Closure

All ASDs with hemodynamic significance require closure to improve survival and prevent complications. The key criteria include:

• Right ventricular volume overload with Qp:Qs ratio ≥1.5:1 is the primary indication for closure, as unoperated ASDs result in 25% mortality before age 27 and 90% mortality by age 60 1
• Right atrial and right ventricular enlargement on echocardiography, even in asymptomatic patients, warrants intervention 1
• Closure improves mortality, functional status (NYHA class), and reduces RV systolic pressure, volumes, and dimensions 2, 1
• Early closure before age 25 years yields the best long-term outcomes with lower incidence of atrial arrhythmias compared to later repair 2
• Even closure later in adult life improves morbidity and survival, though it carries higher risk of new (7%) or recurrent (60%) atrial tachycardia 2

Treatment Algorithm by ASD Subtype

Secundum ASD (Percutaneous Approach Preferred)

Transcatheter device closure is the first-line treatment for secundum ASDs when anatomically suitable:

• Anatomic criteria for device closure: stretched diameter <38 mm with adequate rim ≥5 mm in most locations 1
• FDA-approved devices include Amplatzer Septal Occluder (most commonly used), Gore HELEX (for small-to-medium defects), and Amplatzer Cribriform device (for fenestrated ASDs) 3
• Transcatheter closure is as effective as surgery but with shorter hospital stay, no sternotomy, lower cost, and faster recovery 3, 4

Surgical Closure Indications

Surgery is required when:

• Secundum ASD anatomy is unsuitable for device closure (inadequate rims, excessive size) 1, 3
• Concomitant tricuspid valve repair/replacement is needed 1
• Another cardiac procedure is being performed and Qp:Qs ≥1.5:1 with RV enlargement exists 1
• Non-secundum defects (ostium primum, sinus venosus, coronary sinus defects) are present, as these require surgical correction 3, 5

Absolute Contraindications to Closure

Do not close ASDs in the following scenarios:

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

Management of ASD with Arrhythmias

An integrated approach addressing both hemodynamic and arrhythmic issues is essential:

• Assessment of hemodynamic abnormalities for potential structural repair is recommended as part of arrhythmia therapy 2
• Patients with unoperated significant ASD and arrhythmias should undergo both ablation of atrial tachycardia AND closure of the ASD 2
• Catheter ablation of atrial arrhythmias associated with ASD repair has acute success rates of 93-100% 2
• The choice between catheter versus surgical closure combined with arrhythmia intervention depends on anatomic features of the ASD 2
• Surgical closure of large ASDs combined with arrhythmia surgery can be safely performed, with 6.5% AF occurrence during 2-year follow-up 2
• Anticoagulation is recommended for all adult congenital heart disease patients with AF/atrial flutter and intracardiac repair to prevent ischemic stroke, regardless of other thromboembolic risk factors 2

Timing Considerations

Age-specific management strategies:

• In asymptomatic pediatric patients, closure is typically performed at 4-5 years of age 3
• Medium-sized ASDs (Qp/Qs 1.5-2.0) in children warrant re-evaluation before adulthood, as Qp/Qs and RV volume increase with age 6
• Adult patients should undergo closure at time of presentation, as current evidence supports intervention even in older adults 3, 7
• Closure before age 40 years (particularly in patients with atrial septal defect and risk of atrial flutter) may decrease the risk of developing atrial arrhythmias 2

Post-Closure Monitoring

Essential follow-up includes:

• Monitor for postpericardiotomy syndrome symptoms: fever, fatigue, vomiting, chest pain, or abdominal pain 1
• Perform immediate echocardiography if these symptoms develop to assess for tamponade 1
• Watch for new or recurrent atrial arrhythmias, particularly in patients closed after age 25 years 2
• Continue cardiac follow-up in specialized adult congenital heart disease centers for long-term complications including arrhythmias, thromboembolism, and right heart failure 7

Critical Pitfalls to Avoid

• Do not perform ablation alone without addressing hemodynamic issues, as this allows significant hemodynamic problems to progress and deteriorate 2
• Do not assume small or "medium-sized" defects are benign in children, as hemodynamic significance increases with age 6
• Do not close ASDs in patients with established Eisenmenger physiology, as this worsens outcomes 1
• In patients with stroke after PFO closure, recognize increased AF risk but do not perform PFO closure for AF-related stroke prevention 2