From the Guidelines
Atrial septal defect (ASD) treatment should prioritize catheter-based closure using an occluder device or surgical repair to prevent complications like heart failure, pulmonary hypertension, and arrhythmias, as recommended by the 2018 AHA/ACC guideline for the management of adults with congenital heart disease 1.
Overview of Atrial Septal Defect
Atrial septal defect (ASD) is a congenital heart defect characterized by a hole in the wall (septum) between the heart's upper chambers (atria), allowing oxygen-rich blood from the left atrium to mix with oxygen-poor blood in the right atrium, causing increased blood flow to the lungs. Small ASDs may not require treatment and can close on their own, particularly in children. However, larger defects typically need intervention to prevent complications.
Treatment Options
Treatment options include:
- Catheter-based closure using an occluder device, which is minimally invasive and preferred when anatomically suitable
- Surgical repair for larger defects or those with complex anatomy After repair, patients generally have excellent outcomes with normal life expectancy. Regular follow-up with a cardiologist is important, particularly for adults who had repairs later in life. Antibiotic prophylaxis for dental procedures is typically recommended for six months after device closure or surgery. Physical activity restrictions are usually minimal after complete recovery, though competitive athletes should consult with their cardiologist.
Importance of Early Intervention
Early natural history studies of unoperated large ASDs have indicated a risk of severe pulmonary hypertension with significant morbidity and mortality 1. Nearly 25% of patients with unoperated ASDs died just before their 27th year and 90% by their 60th birthday. Even patients with surgically repaired ASD may have reduced survival when compared with an age- and sex-matched control population when surgery is performed after age 25 years.
Recent Guidelines and Recommendations
The 2018 AHA/ACC guideline for the management of adults with congenital heart disease recommends surgical or percutaneous ASD closure in adults with right heart enlargement, with or without symptoms 1. A systematic review and meta-analysis of the literature showed a protective effect of ASD closure on New York Heart Association functional class and on right ventricular systolic pressure, volumes, and dimensions 1. However, the overall body of evidence was limited to observational cohort studies, and the quality of evidence was further diminished by the lack of well-defined clinical outcomes.
Conclusion and Recommendation
In summary, ASD treatment should prioritize catheter-based closure or surgical repair to prevent complications and improve outcomes, as supported by the 2018 AHA/ACC guideline and recent systematic reviews and meta-analyses 1.
From the Research
Atrial Septal Defect Overview
- Atrial septal defects (ASDs) are a common form of congenital heart disease (CHD) that can be treated with either surgical or transcatheter closure 2, 3.
- The indication for closure of ASDs is typically the presence of right ventricular volume overload, and closure is usually recommended at the time of presentation, even in asymptomatic patients 3, 4.
Treatment Options
- Transcatheter closure of ASDs has been shown to be as effective as surgical closure, with benefits including decreased hospital stay, avoidance of a sternotomy, lower cost, and more rapid recovery 2, 3, 4.
- Surgical closure is still recommended for more complex cases, such as those with large defects or other cardiac anomalies 2, 3.
- Several FDA-approved devices are available for percutaneous closure, including the Amplatzer Septal Occluder, Amplatzer Cribriform device, and Gore HELEX device 3.
Outcomes and Complications
- Studies have shown that transcatheter closure of ASDs is safe and effective, with minimal complications, even in patients over 40 years of age 4, 5.
- Long-term outcomes have shown that transcatheter closure is associated with a higher reintervention rate, but similar mortality rates compared to surgical closure 5.
- Complications of ASD closure, including device migration, atrial arrhythmias, and hematoma, are rare but can occur 4.
Current Practice
- Current practice recommends transcatheter closure of ASDs in most patients with appropriately selected secundum ASDs 6.
- Early diagnosis and treatment of ASDs is crucial to prevent long-term complications, such as pulmonary artery hypertension, atrial dysrhythmias, and right and left ventricular dysfunction 6.