In an otherwise healthy adolescent or adult with a secundum atrial septal defect ≤38 mm and rim tissue ≥5 mm, is percutaneous device closure indicated, and what are the procedural steps, antiplatelet regimen, activity restrictions, and follow‑up schedule?

Percutaneous Device Closure for Secundum ASD ≤38 mm

For an otherwise healthy adolescent or adult with a secundum ASD ≤38 mm and adequate rim tissue ≥5 mm, percutaneous device closure is the preferred first-line treatment when hemodynamic criteria are met (Qp:Qs ≥1.5:1 with RV enlargement, PA systolic pressure <50% systemic, and PVR <1/3 systemic resistance). 1, 2

Indications for Device Closure

Proceed with device closure when ALL of the following are present:

• Right atrial and right ventricular enlargement (with or without symptoms) 1, 2
• Qp:Qs ratio ≥1.5:1 with evidence of RV volume overload 1, 2
• PA systolic pressure <50% of systemic pressure 2, 3
• Pulmonary vascular resistance <1/3 systemic resistance (<5 Wood units) 2
• Net left-to-right shunt present 2

Critical point: Do not delay closure based on absence of symptoms—symptoms lag behind objective cardiopulmonary dysfunction, and untreated ASDs carry 25% mortality before age 27 and 90% mortality by age 60. 1, 2

Anatomic Suitability Criteria

Your patient meets device closure criteria with:

• Secundum ASD with stretched diameter <38 mm 4, 1
• Adequate rim ≥5 mm in most locations (smaller rim acceptable toward aorta) 1, 2
• Weight ≥15 kg provides technical advantages 4

Device options in the United States:

• AMPLATZER septal occluder: Suitable for defects up to 38 mm diameter, composed of nitinol wire mesh with Dacron fabric, easily repositionable before release 4
• HELEX septal occluder: Suitable for small-to-moderate defects (≤18 mm), made of nitinol with expanded polytetrafluoroethylene, repositionable even after release 4

Procedural Steps

Pre-procedure imaging:

• Transesophageal echocardiography (TEE) or intracardiac echo to assess defect size, rim adequacy, and guide device deployment 4

Catheterization procedure:

• Measure hemodynamics (Qp:Qs, PA pressures, PVR) to confirm closure indications 5
• Size the defect using balloon sizing technique (stretched diameter) 5
• Deploy device under echo guidance with assessment of position and stability 4, 2
• Confirm no residual shunt or minimal residual shunt before release 5
• Mean procedure time approximately 44 minutes, fluoroscopy time 13 minutes 5

Expected immediate results: Complete closure at end of procedure in 75% of patients, with minimal shunting in most remaining cases. 5

Antiplatelet Regimen

While the provided guidelines do not specify exact antiplatelet protocols, standard practice based on device thrombosis risk includes:

• Dual antiplatelet therapy (aspirin plus clopidogrel) for 3-6 months post-procedure 6
• Aspirin continuation for 6-12 months total 6
• Endocarditis prophylaxis for 6 months post-device placement 6

Activity Restrictions

Post-procedure limitations:

• Avoid strenuous physical activity for 4-6 weeks to allow device endothelialization 6
• No contact sports during initial healing period 6
• Gradual return to full activity as tolerated after initial restriction period 6

Follow-Up Schedule

Immediate post-procedure:

• Monitor for postpericardiotomy syndrome symptoms (fever, fatigue, vomiting, chest pain, abdominal pain) 1, 2
• Perform immediate echocardiography if these symptoms develop to assess for tamponade 1, 3

Scheduled follow-up:

• Echocardiography at 3 months to assess device position/stability, residual shunting, pericardial effusion, and RV function 2, 3
• Annual follow-up if PAH, atrial arrhythmias, or ventricular dysfunction persist 3
• Long-term monitoring for rare delayed complications including device erosion, thrombosis, and arrhythmias 6

Complications and Risk Profile

Major complications (1.6% with AMPLATZER device): 4

• Device embolism requiring surgical removal (most serious immediate risk)
• Cardiac erosion/perforation leading to tamponade and potential death
• Cardiac arrhythmia requiring major treatment
• Cerebral embolism with neurologic sequelae
• Atrioventricular block

Minor complications (6.1%): 4

• Transient arrhythmias (most common)
• Thrombus formation
• Transient ischemic attack
• Wire-frame fracture (5-7% with HELEX device, usually without clinical sequelae) 4

Overall serious complication rate ≤1% with current devices, with no mortality in major series. 2, 3

Expected Outcomes

Functional improvement:

• Improvement in NYHA functional class in nearly all patients 2, 5
• Reduction in RV systolic pressure, volumes, and dimensions 1, 2
• Improved exercise tolerance 2, 5

Best outcomes achieved with repair before age 25 years; surgery after this age shows reduced survival compared to age-matched controls. 1, 2

Absolute Contraindications

Do NOT proceed with closure if:

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

If PA systolic pressure is ≥50% systemic OR PVR >1/3 systemic resistance but net left-to-right shunt still present, evaluation by pulmonary hypertension experts is mandatory before proceeding. 2

Key Clinical Pitfalls

Avoid these common errors:

• Delaying closure in asymptomatic patients—closure is indicated for RV enlargement regardless of symptoms 1, 2
• Using device closure for non-secundum defects (sinus venosus, primum, coronary sinus)—these require surgical repair 2
• Attempting device closure with inadequate rim or defects >38 mm—higher failure and complication rates 7, 8
• Missing postpericardiotomy syndrome—maintain high suspicion for tamponade in first weeks post-procedure 1, 2