Is cardiac catheterization of the left and right heart indicated for a patient with confirmed ASD (Atrial Septal Defect) secundum diagnosed via TEE (Transesophageal Echocardiography) with bubble study, presenting with shortness of breath?

Cardiac Catheterization for Confirmed ASD Secundum

Diagnostic cardiac catheterization is NOT routinely indicated for this patient with confirmed ASD secundum by TEE, provided the noninvasive imaging adequately estimates pulmonary artery pressures and shunt magnitude. 1

When Catheterization is NOT Needed

• In younger patients with uncomplicated ASD secundum where imaging results are adequate, diagnostic cardiac catheterization is not indicated (Class III recommendation). 1

• If your TEE with bubble study has already provided:

  • Clear defect size and morphology 1
  • Evidence of right ventricular volume overload 1
  • Adequate estimation of pulmonary artery pressures 1
  • Assessment of shunt magnitude (Qp:Qs ratio) 1

Then proceed directly to closure planning without diagnostic catheterization. 1

When Catheterization IS Indicated

Diagnostic catheterization becomes necessary in specific clinical scenarios: 1

• Discrepant or inconclusive noninvasive imaging data - when TEE findings don't match clinical presentation or when pulmonary artery pressure estimates are uncertain 1

• Suspected pulmonary arterial hypertension (PAH) - when you need detailed hemodynamics to determine if the patient has elevated pulmonary vascular resistance that would contraindicate closure 1

• Older adults (>40 years) - to evaluate for left atrial hypertension from diastolic dysfunction, which could worsen after ASD closure when the left atrium loses its "pop-off" into the right atrium 1

• Risk factors for coronary artery disease - catheterization can be useful to rule out concomitant coronary disease in at-risk patients (Class IIa recommendation) 1

Critical Decision Points for Your Patient

For this symptomatic patient with shortness of breath, focus on these key questions before deciding on catheterization: 1

1. Does the TEE clearly show right ventricular volume overload? If yes, and pulmonary pressures appear normal or mildly elevated, proceed to closure without catheterization. 1

2. Are pulmonary artery pressures elevated on echo? If PASP >50 mmHg or there's clinical concern for PAH, catheterization is necessary to measure pulmonary vascular resistance and determine operability. 1

3. Is the patient older (>40 years)? Consider catheterization to assess left ventricular end-diastolic pressure and exclude diastolic dysfunction that could cause clinical worsening post-closure. 1

4. Is there exercise-induced desaturation? This suggests either PAH with shunt reversal or abnormal RV compliance - both require invasive hemodynamic assessment, potentially with exercise catheterization. 1

Catheterization at Time of Transcatheter Closure

If planning percutaneous device closure, cardiac catheterization will be performed at the time of the procedure itself - this is standard practice for device deployment, balloon sizing, and hemodynamic confirmation. 1

This is distinct from a separate diagnostic catheterization beforehand. 1

Common Pitfalls to Avoid

• Don't order routine diagnostic catheterization reflexively - the 2018 ACC/AHA guidelines explicitly state this is not indicated when noninvasive imaging is adequate (Class III). 1

• Don't miss pulmonary hypertension - if resting oxygen saturation is >90% but drops to <90% with exercise, this may indicate elevated pulmonary vascular resistance requiring catheterization before closure. 1

• Don't ignore age-related considerations - adults over 40 with ASD often have acquired left ventricular diastolic dysfunction that can cause paradoxical worsening after closure; catheterization helps identify these patients. 1

• Don't confuse diagnostic catheterization with procedural catheterization - transcatheter closure always involves catheterization for device deployment, but this doesn't mean a separate diagnostic study is needed beforehand. 1