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Surgical and percutaneous closure of atrial septal defects in adults

Surgical and percutaneous closure of atrial septal defects in adults
Literature review current through: Jan 2024.
This topic last updated: Dec 20, 2023.

INTRODUCTION — Atrial septal defect (ASD) is the most common congenital lesion in adults after bicuspid aortic valve. Although patients with this defect are often asymptomatic until adulthood, potential complications of an untreated ASD include atrial arrhythmias, paradoxical embolization, cerebral abscess, right ventricular failure, and pulmonary hypertension that can become irreversible and lead to right-to-left shunting (Eisenmenger syndrome).

This topic will review surgical and percutaneous closure of ASDs in adults.

Indications for ASD closure, medical management, pathophysiology, anatomy, natural history, and clinical features of ASDs in adults, the identification and assessment of ASDs, and issues related to ASDs in children are discussed separately. (See "Management of atrial septal defects in adults" and "Isolated atrial septal defects (ASDs) in children: Management and outcome" and "Clinical manifestations and diagnosis of atrial septal defects in adults" and "Isolated atrial septal defects (ASDs) in children: Classification, clinical features, and diagnosis".)

PREPROCEDURAL ASSESSMENT — Preprocedural assessment in patients with indications for ASD closure includes review of the transthoracic echocardiogram (TTE). Some patients require additional testing such as transesophageal echocardiogram (TEE), cardiovascular computerized tomography (CT), or cardiovascular magnetic resonance (CMR) imaging to confirm the diagnosis and identify or exclude associated defects prior to surgical or percutaneous closure. In patients with pulmonary hypertension, cardiac catheterization is recommended to determine the best management strategy.

Conditions that are likely to require surgical correction should be identified prior to intervention:

Primum ASD, sinus venosus ASDs, and coronary sinus defects generally require surgical closure.

Primum ASD is usually accompanied by a cleft mitral valve. A cleft mitral leaflet should be repaired at the time of ASD closure, even if associated mitral regurgitation is not severe, to avoid the need for another operation since mitral regurgitation usually progresses. Primum ASDs may also be associated with tricuspid valve abnormalities, left ventricular (LV) outflow tract obstruction, ventricular septal defects, and are part of a spectrum of defects involving the atrioventricular septum (atrioventricular septal defect). (See "Clinical manifestations and diagnosis of ventricular septal defect in adults", section on 'Anatomic types'.)

Superior sinus venosus ASDs are usually associated with one or more anomalous right-sided pulmonary veins. Sinus venosus ASDs and the associated anomalous veins are often missed on standard TTE. Agitated saline contrast administered during a TTE and injected into an upper extremity should demonstrate prompt filling of the left heart chambers with bubbles in the presence of a superior sinus venosus atrial septal defect. (See "Contrast echocardiography: Clinical applications", section on 'Shunt detection'.)

Additional imaging by TEE, CT, or CMR should be performed to identify the anomalous pulmonary vein anatomy. However, these types of ASDs and anomalous pulmonary veins can be missed even with advanced imaging techniques. These defects should be sought in patients with right heart enlargement. Our practice is to delineate the anatomy, including all of the anomalous pulmonary veins, with CT or CMR before the patient goes to the operating room for surgical intervention.

Coronary sinus defects (also known as "unroofed coronary sinus") are often missed despite echocardiography. They are often associated with persistent left superior vena cava (SVC) and may accompany other congenital anomalies including ostium primum or secundum ASDs. Observation of agitated saline in the left atrium initially, rather than the right atrium, after injection into a left-sided arm vein suggests the presence of a coronary sinus defect and left SVC. (See "Contrast echocardiography: Clinical applications", section on 'Persistent left SVC'.)

Multiple ASDs may be present (eg, concurrent secundum and primum ASDs). Some patients with multiple small secundum ASDs are amenable to percutaneous closure; others require surgical closure.

Some patients with ASDs have concomitant valve disease (in addition to cleft mitral valve with primum ASD as discussed above). Moderate or more tricuspid regurgitation may persist after ASD closure in the adult. When there is moderate or more tricuspid regurgitation, we favor surgery for both ASD closure and tricuspid repair [1]. (See "Management and prognosis of tricuspid regurgitation".)

CHOICE OF CLOSURE PROCEDURE

Options for closure based upon type of ASD

Secundum ASDs – Percutaneous transcatheter device closure is an excellent alternative to surgical repair for most patients with secundum ASDs. Surgical closure is recommended for patients with secundum ASD requiring closure when percutaneous repair is not feasible or appropriate [1]. Anatomic requirements for percutaneous closure are discussed below. A secundum ASD with a large atrial septal aneurysm or a multifenestrated atrial septum requires careful evaluation to determine whether percutaneous device closure will provide effective closure of the atrial shunt [1]. (See 'Anatomic requirements' below and 'Procedure in the presence of atrial septal aneurysm' below.)

Primum ASDs – Surgical repair of ostium primum defects is the preferred approach, as they are not generally amenable to percutaneous device closure [1].

Sinus venosus defect – Sinus venosus defects may be closed surgically or by percutaneous transcatheter custom-made covered stents. Short-term outcomes of percutaneous closure have been published [2-4].

Coronary sinus defect – Given the proximity of the coronary sinus ostium to the inferior atrial free wall and the association between coronary sinus defect and a persistent left-sided SVC, device closure is not recommended. Cases of "reroofing" of the coronary sinus using a covered stent have been reported [5,6]. However, surgical repair remains the generally recommended treatment.

Percutaneous versus surgical closure for secundum ASD — Observational studies comparing surgical and percutaneous transcatheter closure of secundum ASD suggest that mortality rates are similar. The rate of procedural success is comparable or slightly higher with surgery, while the rate of early complications is lower and length of hospital stay is shorter with the percutaneous approach. Differing types of complications occur following the two procedures, as illustrated by the following studies.

A systematic review compared short-term (follow-up generally less than 12 to 18 months) outcomes following surgical and percutaneous closure of secundum ASD in 13 observational studies with a total of 3082 patients [7]:

One death occurred in the surgical group of 1270 patients (mortality rate 0.08 percent) and none in the 1812 patients in the percutaneous group.

Total early complication rates were higher in the surgical group than in the percutaneous group (for total complications: 31 versus 6.6 percent; adjusted odds ratio [OR] 5.4, 95% CI 2.96-9.84).

Major early complication rates were also higher in the surgical group (6.8 versus 1.9 percent; adjusted OR for major complications was 3.81, 95% CI 2.7-5.36). The types of major complications differed in the two groups:

The most common major early complication in the surgical group was bleeding requiring blood transfusion, which occurred in 94 patients (7 percent). Redo surgery was performed in nine surgical patients (five for patch dehiscence and four for major bleeding). Severe heart failure was seen in one patient and two had severe neurologic sequelae.

The most frequent major early complication in the percutaneous group was device embolization or malposition needing surgery or further transcatheter therapy, which occurred in 30 patients (1.6 percent). Perforation of the heart due to erosion by the device was reported in three subjects. Significant pericardial effusion requiring surgical drainage occurred in two patients. Four patients underwent vascular surgery due to a femoral venous or arterial injury. Blood transfusion was performed in three patients.

Length of hospital stay was 2.6 days longer for patients treated surgically compared with those who underwent device closure.

A later retrospective population-based cohort study evaluated short-term (one-year) and long-term (five-year) outcomes after surgical (n = 383) and percutaneous (n = 335) ASD closure in adults in Québec [8]:

There were no statistically significant differences in mortality rates following surgical and percutaneous ASD closure at 30 days (1 versus 0.3 percent), one year (3.2 versus 0.8 percent), and five years (6.3 versus 5.3 percent) follow-up. However, percutaneous closure was associated with lower long-term mortality when evaluated using Kaplan-Meier curves, log-rank statistics, and adjusted hazard ratio.

The five-year reintervention rate was higher in patients with percutaneous ASD closure (7.9 versus 0.3 percent with surgical closure), with the majority of reinterventions occurring during the first year.

Short-term rates of mortality and the need for subsequent procedures (redo surgery or rescue procedures for failed device placement) were evaluated in a study using the US Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database for adverse events for Amplatzer septal occluder devices and the Society of Thoracic Surgery database for ASD closures [9]. Overall mortality rate was similar in the surgical and device closure groups (0.13 versus 0.09 percent). Rescue operation for device adverse events (0.83 percent) was 2.1 times more likely than reoperation for surgical closure (0.39 percent). However, this study was subject to a number of statistical and methodological limitations, including reliance upon databases that did not capture all adverse events, use of an estimate of total number of device closures, and inclusion of patent foramen ovale closures in the device closure group.

Procedure in the presence of atrial septal aneurysm — An atrial septal aneurysm (ASA) is defined as redundant and mobile interatrial septal tissue in the region of the fossa ovalis with phasic excursion of at least 10 mm during the cardiorespiratory cycle. ASA is commonly associated with patent foramen ovale or one or more ASDs [10]. The prevalence, clinical manifestations of ASA, and treatment to prevent stroke are discussed separately. (See "Atrial septal abnormalities (PFO, ASD, and ASA) and risk of cerebral emboli in adults", section on 'ASA' and "Stroke associated with patent foramen ovale (PFO): Evaluation".)

A perforated aneurysm may be associated with a significant left-to-right shunt and present with clinical and hemodynamic features of an ASD. Perforated aneurysms can be closed surgically or percutaneously, depending upon their morphology. In a retrospective review of 50 patients, perforated aneurysms were classified as follows [10]:

Type A - aneurysm with persistent foramen ovale

Type B - aneurysm with single ASD

Type C - aneurysm with two perforations

Type D - aneurysm with multiple perforations

Thirty-two had systemic thromboembolism or transient ischemic attacks, eight presented with dyspnea on exertion, and 10 were asymptomatic but had significant left-to-right shunt and right ventricular volume overload. Transcatheter device closure using an Amplatzer Septal Occluder or CardioSEAL device (no longer available) was possible in all 18 patients with a type A aneurysm. In the nine patients with a type B aneurysm, five had successful device closure, while four required surgery. Device closure was achieved in all 10 patients with a type C aneurysm, but four had a residual shunt. All 13 patients with a type D aneurysm underwent surgery.

SURGICAL CLOSURE

Technique

Overview — The traditional surgical approach for ASD repair has been a median sternotomy, with minimally invasive, including robotic, approaches evolving over time [11]. (See 'Minimally invasive surgery' below.)

Pericardial or Dacron patch closure is generally the surgical treatment of choice for secundum, primum, and sinus venosus ASD repair. Primary closure of the defect (suture closure) is generally not recommended [11] except for very small defects. Some surgeons advocate cannulation of the SVC rather than the right atrium to reduce the incidence of postoperative arrhythmias [12]. (See "Management and outcome of atrioventricular (AV) canal defects".)

A coronary sinus defect without a left SVC may be closed by direct suture closure or closure of the mouth of the coronary sinus. In the presence of a left SVC, creation of an intra-atrial baffle is typically indicated to direct the systemic venous return from the SVC to the right atrium [13].

Anomalous pulmonary venous drainage (expected to be present with sinus venosus ASD) should be repaired by baffling the anomalous veins to the SVC as part of a Warden procedure or directly into the left atrium. In patients with sinus venosus ASD with anomalous pulmonary venous drainage entering the mid- or upper SVC, the Warden procedure is used. This procedure involves anastomosis of the cephalic SVC to the right atrial appendage, and the caudal SVC, which includes the anomalous pulmonary veins, is baffled to the left atrium [1,14]. (See "Partial anomalous pulmonary venous return", section on 'Management'.)

Comprehensive preoperative delineation of associated lesions such as tricuspid or mitral valve regurgitation and the presence, number and course of the anomalous pulmonary veins is important to plan the operation. This is generally performed using a combination of echocardiography and cross-sectional imaging. Intraoperative TEE is routinely used to identify any additional defects, the adequacy of repair, and residual flow across the surgical site (movie 1). TEE is used to evaluate patients following repair including the atrial septum, redirected pulmonary veins, and valves. Tension from repair on the valvular annulus can distort the geometry of leaflet coaptation.

Minimally invasive surgery — Minimally invasive approaches include right parasternal or upper hemisternotomy [15], a right submammary [11,16], limited median sternotomy [11,16], a mini-median or transxiphoid sternotomy in children and young adults [11,17], a right axillary approach [18,19], and a totally thoracoscopic approach with or without the use of a robotic system [20]. An anterolateral approach is generally not used in prepubescent girls to avoid possible damage to the breast bud [11]. Published series report good cosmetic results with these approaches with low risks of conversion to a more invasive approach or inadequate repair.

Perioperative management — There are a number of postoperative considerations in patients undergoing ASD repair.

Beta blockers may be helpful for patients with postoperative atrial fibrillation (AF) and atrial flutter. The evidence for this recommendation comes from data in patients undergoing other types of cardiac surgery. The benefit is seen when therapy is begun prior to or immediately after surgery and is independent of the agent or dose used. The optimal duration of therapy is uncertain, but beta blockers are often continued until the first postoperative visit. (See "Atrial fibrillation and flutter after cardiac surgery", section on 'Prevention of atrial fibrillation and complications'.)

We favor anticoagulation for several months after surgery in adults undergoing ASD closure because of concern about postoperative AF and the small chance that thrombus can attach to the atrial septal patch. Long-term periodic follow-up is indicated because of the late occurrence of AF, atrial flutter, and stroke, particularly in adults over age 40 [21,22]. Patients with preoperative atrial tachyarrhythmias are at particular risk.

Some patients require permanent pacemaker placement early postoperatively to treat sinus node dysfunction or atrioventricular (AV) conduction block after surgical ASD closure. Surgery can damage the AV node or its blood supply. In addition, there may be a small increase in the lifetime risk of developing sinus and AV nodal dysfunction following surgical ASD closure.

Outcomes of surgical closure

General — The effect of surgical ASD repair is influenced by the type of ASD, the patient's age, the size of the defect, the size and function of the right ventricle, the presence of comorbidities, including pulmonary hypertension, and the experience of the surgeon. As noted above, complications after surgical ASD closure include bleeding requiring blood transfusion, infection, stroke, atrial arrhythmias, pericardial effusion or pericarditis, and, rarely, incomplete repair, incorrect patch placement directing the inferior vena cava to the left atria, or patch dehiscence requiring reoperation. (See 'Percutaneous versus surgical closure for secundum ASD' above.)

Secundum ASD — Most of the data on outcomes following ASD repair are for secundum ASDs, as these account for approximately 70 percent of ASDs.

Without pulmonary hypertension — Surgical closure in appropriate candidates <25 years old with secundum ASD without pulmonary hypertension or significant comorbidity is associated with low operative mortality (<1 percent) and normal life expectancy [7,23-27]. These outcomes are improved compared with those for patients with ASD receiving medical therapy. (See "Management of atrial septal defects in adults" and "Clinical manifestations and diagnosis of atrial septal defects in adults", section on 'Natural history'.)

With pulmonary hypertension — The outcomes in such patients were evaluated in a large retrospective study in which 6 percent of 702 patients with an isolated ASD (secundum or sinus venosus type) had pulmonary hypertension (pulmonary vascular resistance [PVR] of 7 Wood units (WU) x m2 or greater by catheterization) [28]. Among these 40 patients (mean age 46 years, 34 [85 percent] of whom were women), 26 underwent surgery and 14 were treated medically with the following outcomes:

The patients with severe pulmonary hypertension (PVR of 15 WU x m2 or greater) did poorly: At a mean follow-up of 12 years, all four surgically treated patients died; six of nine medically treated patients died; and the remaining three patients had progression of symptoms.

In patients with less severe pulmonary hypertension (PVR <15 WU x m2), survival after surgery was better (19 of 22).

However, this series was published in 1987, well before therapies for pulmonary hypertension were available or routinely used in this population. Improvements in the medical therapy for pulmonary vascular disease allow for preclosure and postclosure treatment of pulmonary hypertension in select patients. This approach is complex and requires input from adult congenital heart disease and pulmonary hypertension experts. (See "Pulmonary hypertension in adults with congenital heart disease: General management and prognosis".)

Effect of age — Younger patients (less than 25 years old) have better long-term outcomes following surgical ASD closure than older patients [23], but both younger and older patients (over 40 years old) with appropriate indications benefit from ASD closure [21,25,29].

The effect of age on outcomes after surgical ASD repair was illustrated by a report of 123 patients of all ages who underwent surgery at Mayo Clinic for secundum or sinus venosus ASD between 1956 and 1960 and were followed for at least 27 years [23]. The 27-year survival rates for patients in the younger two quartiles at the time of surgery (≤11 years and 12 to 24 years) were not different from age-matched controls (97 and 93 percent). In contrast, 27-year survival was significantly less than controls for patients in the third quartile (25 to 41 years; 84 versus 91 percent) or fourth quartile (>41 years; 40 versus 59 percent).

A study of 281 patients who underwent surgical ASD repair investigated risk factors for a complicated postoperative course [30]. Older age at operation and a longer extracorporeal circulation time were independent risk factors for postoperative use of inotropic support. Preoperative atrial fibrillation and a larger ASD were independent risk factors for a prolonged intensive care unit stay.

Sinus venosus ASD — The surgical outcome of patients with a sinus venosus ASD is similar to that of patients with other types of isolated ASD when operations are performed by experienced congenital heart surgeons [31]. Surgical closure in appropriate candidates <25 years old with sinus venosus ASD without pulmonary hypertension or significant comorbidity is associated with low postoperative mortality (<1 percent) and normal life expectancy [23,24,31]. However, sinus venosus ASD is frequently accompanied by partial anomalous pulmonary venous drainage that should be corrected at the time of defect repair; the operation should be performed by an experienced congenital heart surgeon. Potential complications following sinus venosus ASD closure with baffling of anomalous pulmonary venous connection are baffle leak, SVC stenosis, pulmonary vein stenosis, and sinus node dysfunction. (See 'Technique' above.)

Short- and long-term outcomes were described in a report of 115 patients with sinus venosus ASD, 97 percent with anomalous pulmonary venous connection [31]. One hundred and eight had complete follow-up at a mean of 12 years. The following findings were noted:

The early mortality rate was 0.9 percent with the one early death occurring in a 76-year-old woman with preoperative New York Heart Association (NYHA) class IV symptoms.

Symptomatic improvement occurred in 77 percent, while deterioration occurred in 16 percent. Clinical improvement was more common with older age at surgery.

No patient required reoperation.

Sinus node dysfunction and/or a permanent pacemaker were noted in 6 percent and AF in 14 percent. Older age at repair was predictive of postoperative AF.

Patient survival was similar to that in an age- and sex-matched normal population.

A possible difference in natural history between sinus venosus ASD and secundum ASD was suggested in a report of 169 patients: 31 had a sinus venosus ASD and 138 had a secundum ASD [32]. The ratios of pulmonary to systemic blood flow (Qp/Qs) were 2.5 and 2.7, respectively. Patients with a sinus venosus ASD were more likely to have pulmonary hypertension (26 versus 9 percent) and elevated PVR (16 versus 4 percent). In addition, elevated PVR occurred at a younger age in those with a sinus venosus ASD. The overall shunt size in sinus venosus ASD with associated anomalous pulmonary venous connection is larger than most other ASDs.

These observations suggest that patients with sinus venosus ASDs should have closure and pulmonary vein redirection at the time that the diagnosis is made, and they should be monitored for arrhythmias and the development of pulmonary hypertension after closure.

As mentioned above, successful percutaneous transcatheter intervention of superior sinus venosus ASD has been reported. (See 'Options for closure based upon type of ASD' above.)

Primum ASD — Primum ASDs are typically larger than ostium secundum ASDs. However, the long-term outcomes for both groups of patients appear to be similar when adjusted for defect size. Surgery generally involves repair of the cleft mitral valve, and should be performed by an experienced congenital heart surgeon. A good outcome after surgery was illustrated in a review of 33 adults with ostium primum defects who underwent surgical closure at a mean age of 42 [33]. After a mean follow-up of 5.3 years, 85 percent were alive, asymptomatic, and in NYHA functional class I (table 1). All deaths occurred late after surgery, and none appeared related to the ASD or its repair. The presence of increasing age, symptoms, atrial arrhythmias, mitral regurgitation, or moderately elevated PVR did not predict mortality or surgical complications.

Coronary sinus defect — Coronary sinus defects are often missed and limited data are available on the outcomes of repair. (See 'Preprocedural assessment' above.)

In a series 25 patients with coronary sinus defect, 23 underwent surgical repair with death occurring in one patient due to complications unrelated to the repair. At median 85-month follow-up in the early survivors, there was one death in a patient with complex congenital cardiac disease after a third reoperation [13].

PERCUTANEOUS CLOSURE OF SECUNDUM ASD

Devices — Percutaneous device closure is an alternative to surgical closure in patients with secundum ASDs who have appropriate anatomic characteristics. Three devices have both US Food and Drug Administration approval and CE-mark and are commercially available in the United States and Europe for percutaneous ASD closure [34,35]: the Amplatzer Septal Occluder (figure 1 and movie 2), the Gore CARDIOFORM Septal Occluder (picture 1), and the Gore CARDIOFORM ASD Occluder. The Occlutech ASD Occluder, the Ceraflex ASD Occluder, and the Nit-Occlud ASD-R have received CE-mark and are in clinical use in Europe [36,37].

Of note, the Gore CARDIOFORM Septal Occluder does not have self-centering properties, which limits its use for larger defects and it is used mostly for patent foramen ovale closure. However, in selected patients with centrally located ASDs or multiperforated atrial septum, the CARDIOFORM Septal Occluder is a valid alternative device with less foreign material and excellent occlusion properties.

The self-centering Gore CARDIOFORM ASD occluder has been introduced, expanding the catheter interventional treatment possibilities for patients with large ASDs and deficient aortic rims [38-40].

The CARDIOFORM devices are characterized by a relatively stiff delivery mechanism, so the angulation of the device can change notably after device release. The original delivery system of the Amplatzer ASD occluder was relatively stiff as well. The improved Amplatzer Trevisio delivery system has a soft distal delivery cable that allows for better device alignment to the interatrial septum [41].

The Occlutech and Ceraflex occluders have even more flexible delivery mechanisms, which enable optimal septal alignment prior to device release. The device remains in its final configuration and does not change its angulation at release. An additional advantage of the flexible properties of the Occlutech and Ceraflex occluders is that the left atrial disc has less of a tendency to slip along the aortic root into the right atrium during device placement, and hence, fewer adjunctive procedures (eg, device deployment with an additional balloon) are needed [42].

A few other devices that had been approved and were previously used for ASD closure are no longer available, including the CardioSEAL Septal Occlusion System, the STARFlex device (a next-generation version of the CardioSEAL device), and the Gore HELEX (a predecessor of the CARDIOFORM device).

The following discussion will review the efficacy and complications associated with percutaneous device closure of secundum ASD.

Contraindications and cautions

Pulmonary hypertension — As noted above, severe fixed pulmonary hypertension is considered a contraindication to ASD closure. However, advances in the medical management of patients with pulmonary vascular disease, together with the development of novel percutaneous closure techniques, may make ASD closure feasible in this setting. It has been suggested that patients with a net left-to-right shunt, a pulmonary vascular resistance (PVR) less than 800 to 960 dyn-s/cm5 (10 to 12 Wood units [WU]), and a resting systemic arterial oxygen saturation ≥90 percent might benefit from ASD closure [43]. (See "Pulmonary hypertension in adults with congenital heart disease: General management and prognosis".)

The potential efficacy of percutaneous closure was demonstrated in a report of 29 patients with a secundum ASD and a baseline peak pulmonary artery pressure >40 mmHg (mean 65 mmHg) in whom an Amplatzer device was implanted [44]. Complete ASD occlusion was achieved in 28 patients (97 percent). Immediately after the procedure, the mean peak pulmonary artery pressure decreased to 54 mmHg; at a mean of 21 months, it decreased further to 31 mmHg. There were no procedural complications. Functional status was improved after the procedure and was maintained at a mean of 21 months. Six of 12 patients who had AF at baseline recovered sinus rhythm by discharge.

Diastolic dysfunction — Unrecognized LV diastolic dysfunction may be present in older patients with ASDs. The presence of the left-to-right shunt at the atrial level may function to "offload" the stiff LV in these patients. One series demonstrated that temporary test occlusion of the ASD with a soft balloon catheter in adult patients may help identify individuals whose left heart filling pressures will worsen if device closure is performed [45]. Although this finding is not necessarily a contraindication to device closure, balloon test occlusion may provide useful information for evaluating older patients for ASD closure.

In patients with suspected pulmonary hypertension, defined as a mean pulmonary arterial pressure ≥20 mmHg, the hemodynamics need to be assessed prior to ASD closure to determine the relative contribution of elevated PVR (precapillary pulmonary hypertension) versus elevated left atrial pressure (postcapillary pulmonary hypertension). Isolated precapillary pulmonary arterial hypertension (PAH) is present if the left atrial or wedge pressure is ≤15 mmHg and the PVR is ≥2 WU. In isolated postcapillary pulmonary hypertension, the left atrial or wedge pressure is ≥15 mmHg and PVR is lower than 2 WU. In most older adults with ASD and PAH, a combination of both is present [46].

In patients with PVR >4 WU, pulmonary vasoreactivity testing should be performed. In patients with postcapillary pulmonary hypertension, a balloon test occlusion of the ASD should be performed assessing the left atrial pressure or the LV end-diastolic pressures (LVEDP). A rise of the LVEDP to >20 mmHg or a pressure increase >10 mmHg indicates severe diastolic LV dysfunction with the risk of postclosure pulmonary edema. In these patients, the ASD closure procedure may be abandoned or a fenestrated ASD occluder may be chosen.

Anatomic requirements — Percutaneous device closure is generally applicable only to secundum ASDs [1]. Primum and coronary sinus defects are not often amenable to percutaneous repair, although cases of percutaneous repair of these defects have been reported [2-5,47].

The ideal lesion for percutaneous closure is a secundum defect ≤38 mm in diameter with a rim of tissue around the defect of at least 5 mm to prevent obstruction of the coronary sinus, right pulmonary veins, venae cavae, or atrioventricular valves. The presence of a "retroaortic" superior-anterior atrial septal rim is favorable for device closure, but septal deficiency in this region is common and not necessarily a contraindication to percutaneous closure. Retroaortic rim deficiency has been associated with risk of erosion, as discussed below. (See 'Erosion' below.)

Approximately one-half to two-thirds of secundum ASDs in adults meet these criteria [48,49]. While smaller defects are often more amenable to device closure, larger defects can also be closed percutaneously. The Amplatzer device is available in sizes ranging from 4 to 38 mm, reflecting the diameter of the central device of the waist and generally correlating with the size of the ASD to be closed. By comparison, the CARDIOFORM septal device comes in only three sizes (20, 25, and 30 mm), reflecting the diameter of the device disk at full deployment. It can be used to close defects up to approximately 18 mm in diameter. The self-centering Gore CARDIOFORM ASD occluder is available in five sizes (27 to 48 mm disk diameter) and even large ASDs (up to 35 mm) with deficient aortic rims may be treated successfully with this double-disk device. Closure of multiple ASDs has been performed using one or more closure devices, including use of an Amplatzer multifenestrated "cribriform" septal occluder device or one or more CARDIOFORM device [50-53].

Echocardiographic monitoring — The use of TEE or intracardiac echocardiography (ICE) can facilitate the deployment of percutaneous ASD closure devices. Measurement of the size and location of the ASD by TEE can help select the appropriate device. In addition, TEE and ICE can be used to guide the procedure in real time, an approach that may eliminate the need for fluoroscopy [54-60]. Two- and three-dimensional (3D) TEE is particularly helpful when multiple devices are inserted to close multiple ASDs [51]. TEE or ICE during the procedure can also determine whether disruption of systemic or pulmonary venous inflow or valve function occurs with device placement.

ICE has some advantages compared with TEE. It does not require endotracheal intubation or general anesthesia [57,60], it permits continuous monitoring during the procedure, and it may shorten the duration of the procedure [60].

In one series, 94 patients underwent ICE during percutaneous closure of an ASD or patent foramen ovale (PFO) [56]. All devices were deployed successfully. During the procedure, ICE identified a previously unrecognized anatomical diagnosis in 32 patients (an additional ASD or PFO, a redundant atrial septum, or an atrial septal aneurysm). Procedural complications occurred in four patients: atrial fibrillation (AF) in three and supraventricular tachycardia in one. Two of the arrhythmias resolved spontaneously and two required cardioversion with no recurrence.

3D echocardiography enables direct and complete visualization of the ASD, so that the area of the defect can be estimated and the anatomy of the entire interatrial septum can be defined. This 3D information facilitates optimal deployment and positioning of all types of interatrial closure devices.

Clinical series suggest that percutaneous ASD closure can be safely and effectively performed using only echocardiographic guidance without fluoroscopy [55,61].

Outcomes of percutaneous closure — Observational studies of percutaneous closure have generally reported efficacy rates similar to surgical closure with shorter hospital stays and lower rates of complications [7,50,62-68]. Defect closure is associated with a reduction in left atrial volume and improvements in right and LV function [69] and functional capacity even in adults who were asymptomatic at baseline [70]. (See 'Percutaneous versus surgical closure for secundum ASD' above.)

Complications — Complications associated with transcatheter closure of a secundum ASD include device embolization or malposition, access site complications, atrial arrhythmias, atrioventricular conduction block (often transient), erosion/perforation, and sudden death (in at least some cases related to erosion) [7,62,63,71-74].

Early — The type and frequency of early complications were evaluated in a report of 417 patients (mean age 27 years) who underwent secundum ASD closure with the AMPLATZER or CardioSEAL/STARFlex device [63]. Thirty-four patients (8.6 percent) experienced a complication during hospitalization:

Device embolization or malposition requiring surgery in 2.4 percent and managed percutaneously in 1 percent.

AF or supraventricular tachycardia in 2.4 percent.

Other complications (heart block, pericardial effusion, thrombus formation on the left atrial portion of the device, iliac vein dissection, groin hematoma) in 2.2 percent.

A similar rate of early complications (11.5 percent) and no mortality were reported in a multi-center study of 688 patients undergoing ASD closure with the Amplatzer, CardioSEAL/STARflex, or HELEX septal occluder [74]. Device embolization occurred in 1.4 percent of patients with 0.4 percent of cases requiring surgical device removal. In contrast, in another series of 124 patients, 6.5 percent required surgery for device malposition or embolization [72].

Embolized Amplatzer ASD occluders may be removed relatively safely by snaring the detachment hub and withdrawing through an adequately sized sheath. The Occlutech and Ceraflex occluders, especially the larger sizes, are more difficult to be removed since a snare may slip off the detachment hub. The additional use of a dedicated bioptome can be very helpful in these rare cases [75].

Transient atrioventricular block has been described with a frequency ranging from 1 to 6 percent [62,66]. Atrioventricular block may be more common with larger devices and smaller patients. This problem appears to resolve or improve spontaneously in most cases.

Thrombus formation — Antiplatelet therapy (aspirin and clopidogrel) is given for at least six months to all patients receiving a percutaneous closure device to protect against thrombus formation [67,68,76]. Thrombus formation can occur in the left and/or right atrium [67]. Anticoagulation is used in patients with ASD closure devices who have another indication for anticoagulation therapy, such as AF.

The frequency with which thrombus formation occurs was evaluated in a review of 407 consecutive patients with an ASD and 593 consecutive patients with a PFO who were treated with a variety of devices [67]. The following findings were noted:

Thrombus on the device was detected by TEE at four weeks in 14 patients (1.4 percent) and at six months in six patients (0.6 percent). The overall rate of thrombus formation was 1.2 percent in patients with an ASD and 2.5 percent in patients with a PFO.

After the investigators discontinued use of heparin therapy after implantation, thrombus occurred in only 1 of 183 patients (0.5 percent) treated with aspirin and clopidogrel.

Thrombus formation was significantly more common with the CardioSEAL and STARFlex devices than with the Amplatzer device (5.9 versus 0 percent). An intermediate rate of 3.6 percent was noted with the Atrial-Septal-Defect-Occlusion-System (ASDOS) device.

The thrombus resolved in 17 of 20 patients after anticoagulation with heparin and/or warfarin; in the remaining three patients, the thrombus was removed surgically. Four of the 20 patients suffered embolic events (strokes in three and a transient ischemic attack in one).

Left atrial thrombus formation with transient ischemic attacks has been described as late as three years after implantation [77].

Sudden death — Sudden death has rarely been reported following percutaneous device implantation [63,73], though the risk of sudden death may be largely related to associated conditions rather than device implantation. The frequency with which this might occur was addressed in a review of three databases involving 777 patients who received a device for an ASD or ventricular septal defect [73]. At a median follow-up of 25 months, sudden death occurred in nine patients (1.2 percent); three had undergone device closure of an ASD alone. Patients who experienced sudden death were more likely to have had multiple devices inserted and to have a history of serious tachyarrhythmias, severe valve regurgitation, one or more cardiac surgeries, pulmonary hypertension, and ventricular dysfunction. Since these conditions may be associated with risk of sudden death, the relationship between the risk of sudden death and device insertion is uncertain. As discussed below, erosion is a potential cause of sudden death after Amplatzer septal occluder (ASO) implantation.

Erosion — An uncommon early or late and potentially catastrophic complication following implantation of certain percutaneous ASD closure devices is erosion with perforation of one or both atria and/or the aorta [9,78-81].

This complication has been reported mainly with the ASO device. In an analysis using the US Food and Drug Administration Manufacturer and User facility Device Experience (MAUDE) database, erosion was estimated to occur in 0.1 to 0.3 percent of ASO implants (eg, an estimate of 51 in 18,333 implants) [9,78,82]. Erosion has not been reported with the Gore HELEX or CARDIOFORM devices.

Symptoms and signs of erosion include chest pain, shortness of breath, syncope, pericardial effusion, cardiac tamponade, hemodynamic compromise, and sudden cardiac death [79,83]. Of 100 documented and nine suspected cases of erosion in a later MAUDE database analysis, 80 devices were explanted and there were 13 deaths [79,83]. Although most cases present within hours, days, or months following implantation, some cases present years later [79].

Given the risk of erosion, all patients with an ASO device should receive follow-up, with closer monitoring of patients with any of the above potential risk factors or the presence of even a very small pericardial effusion [80].

Although risk factors for erosion have been proposed [80], a review found that there are neither conclusive data nor consensus about the causes of erosion by the ASO [79]. As an example, an expert panel and experienced operators have offered differing opinions regarding the role of oversizing or undersizing in the development of erosions [84]. Proposed potential risk factors include protrusion of the device into the atrial wall or aorta, device-oversizing (ie, ASO >1.5 times the native diameter of the ASD), splaying or flaring of the device around the aortic root after implantation, presence of a condition predisposing to aortic dilation (eg, bicuspid aortic valve), rotation or translation of the device relative to the heart after implantation (which may cause cutting of the atrial free wall), absent or deficient aortic or superior rim, "malaligned septum" (aorta not centered in relation to the septum), and thicker device profile at the time of deployment [79,80,84,85]. A later case control study of 125 erosions reported to St. Jude Medical (the original manufacturer of the ASO) reported relative risk factors for device erosion [86]. Deficiency of the retroaortic rim (<5 mm) was significantly more common among patients who experienced an erosion (94 versus 24 percent in the nonerosion cohort, odds ratio [OR] 45). A balloon-sized defect diameter >5 mm larger than the static diameter was also associated with risk of erosion (OR 5.4). Larger device size relative to patient weight was also associated with an increased incidence of erosion. This study was limited by incomplete echocardiographic data for both the erosion and control cohorts.

In patients with deficient aortic rims, the Gore CARDIOFORM ASD occluder may be a good alternative to a double-disk metal occluder since it is softer. However, long-term data are not available. Wire fracture occurred in a relatively large percentage (36 percent) at the six-month follow-up in patients treated with the self-centering Gore CARDIOFORM ASD occluder. In affected patients, it was without clinical sequelae, residual shunt, or device instability [38]. More and longer follow-up information is necessary to understand the clinical importance of this relatively frequent complication.

Postclosure migraines — Some patients may experience new or increased migraine headaches within the first few months after ASD device closure [87]. The precise cause is unknown, but the addition of clopidogrel therapy to the postclosure antiplatelet regimen has been shown to be beneficial [88]. In a randomized trial, migraine attacks spontaneously improved or resolved within 6 to 12 months after ASD closure in most patients with or without treatment with clopidogrel during the first three months [89].

EFFECT OF DEFECT CLOSURE ON RISK OF ATRIAL ARRHYTHMIAS — Atrial arrhythmias, primarily atrial fibrillation and atrial flutter, occur in approximately 20 percent of adult patients with an ASD and are often the presenting symptom [21,22,25,90]. The risk of these arrhythmias increases with patient age (especially over age 40) and with higher pulmonary artery pressures [22,90]. In a report of 211 adults, for example, the incidence of AF or atrial flutter prior to surgery was 1 percent for those aged 18 to 40, 30 percent for those aged 40 to 60, and 80 percent in those over the age of 60 [90].

Observational data suggest that ASD closure may reduce but does not eliminate the risk of atrial tachyarrhythmias. The effect of surgical or percutaneous defect closure on the prevalence of atrial arrhythmias was evaluated by a systematic review, including 26 studies in which a total of 1841 patients (with median or mean age at least 18 years prior to intervention) underwent surgical closure and 945 patients underwent percutaneous closure [91]. Meta-analysis demonstrated a reduction in the prevalence of atrial tachyarrhythmias after ASD closure (odds ratio [OR] = 0.66, 95% CI 0.57-0.77). This effect was found after both surgical closure (OR = 0.72, 95% CI 0.60-0.87) and percutaneous closure (OR = 0.49, 95% CI 0.32-0.76). A significant decline in atrial tachyarrhythmias was seen both at <30 days and midterm (30 days to five years) follow-up. Limitations of the analysis include differences in methods for monitoring arrhythmias before and after closure in most of the studies.

The risk of AF after ASD closure is presumably primarily related to preexisting and irreversible factors, such as incomplete atrial remodeling, that predispose to the arrhythmia. Surgical techniques, such the Maze procedure performed at the time of surgical ASD closure, decrease the long-term incidence of AF in selected patients [90,92,93]. This procedure involves the placement of incisions or cryolesions in the atria to interrupt the macroreentrant circuits that sustain atrial flutter and AF (see "Atrial fibrillation: Surgical ablation"). The use of radiofrequency ablation to create endocardial lesions is also effective in preventing recurrences of AF, although data are limited in the patients with ASD [94]. (See "Atrial fibrillation: Catheter ablation".)

FOLLOW-UP AFTER CLOSURE

General measures — Transthoracic echocardiography (TTE) should be performed following surgical or percutaneous closure to evaluate the adequacy of the repair and document the expected postoperative decreases in right atrial and right ventricular size and pulmonary pressures following successful repair (movie 1). TTEs should also be used to exclude postprocedure pericardial effusion/tamponade.

Antiplatelet therapy (aspirin and clopidogrel) is given for at least six months to protect against thrombus formation in all patients receiving a percutaneous closure device [67,68,76]. Likewise, antimicrobial prophylaxis for the prevention of bacterial endocarditis should be provided if a relevant procedure (likely to cause bacteremia with a microorganism that has the potential ability to cause endocarditis) is performed during at least the first six months after surgical or device closure of an ASD. (See "Prevention of endocarditis: Antibiotic prophylaxis and other measures".)

Patients with repaired ASD are at risk of developing long-term sequelae such as atrial arrhythmias and sinus node or atrioventricular node dysfunction requiring pacemaker placement. Patients who develop atrial fibrillation should receive antithrombotic therapy as indicated to prevent thromboembolism. (See "Atrial fibrillation in adults: Use of oral anticoagulants".)

Patients with an implanted Amplatzer Septal Occluder, particularly those with potential risk factors, should receive education and prompt attention for development of signs of symptoms of erosion. (See 'Erosion' above.)

Participation in sports — The recommendations for athletics in patients with a closed ASD are as follows [95]:

Three to six months after the operation or intervention, patients can participate in all sports unless one or more of the following is present: evidence of pulmonary hypertension, symptomatic atrial or ventricular tachyarrhythmias or second- or third-degree heart block, and evidence of myocardial dysfunction.

Patients with any of these abnormalities should have an exercise evaluation and an individualized exercise prescription with respect to competitive sports. After such an evaluation, athletes can participate in all sports, assuming pulmonary hypertension, right heart dysfunction, and arrhythmias are absent [95,96].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Congenital heart disease in adults".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Atrial septal defects in adults (The Basics)")

SUMMARY AND RECOMMENDATIONS

Preprocedural assessment – Preprocedural assessment in patients with indications for atrial septal defect (ASD) closure includes review of the transthoracic echocardiogram (TTE; and other imaging such as transesophageal echocardiogram [TEE], cardiovascular magnetic resonance [CMR] imaging, or computerized tomography [CT], as needed) to confirm the diagnosis and identify or exclude associated defects prior to surgical or percutaneous closure; associated defects may help determine the most appropriate closure technique. (See 'Preprocedural assessment' above.)

Percutaneous closure – Percutaneous device closure is an alternative to surgical closure in patients with secundum ASDs that have appropriate anatomic characteristics. Catheter interventions for superior sinus venosus defect have been reported; thus, percutaneous intervention is an alternative to surgical therapy in select patients with sinus venosus defect. (See 'Options for closure based upon type of ASD' above and 'Anatomic requirements' above.)

Surgical closure – Surgery is required for closure of primum ASDs and coronary sinus defects. (See 'Options for closure based upon type of ASD' above.)

Outcomes – Mortality rates are similar with surgical and percutaneous ASD closure, the rate of procedural success is comparable or slightly better with surgery, and the rate of early complications and length of hospital stay are reduced with the percutaneous approach. (See 'Percutaneous versus surgical closure for secundum ASD' above.)

Percutaneous closure outcomes – Complications of percutaneous ASD closure include device embolization or malposition, device erosion, wire fracture, atrial arrhythmias, and access site complications. Complications of surgical ASD closure include bleeding, infection, stroke, and atrial arrhythmias. (See 'Percutaneous versus surgical closure for secundum ASD' above and 'Outcomes of surgical closure' above.)

-An uncommon early or late and potentially catastrophic complication following Amplatzer septal occluder implantation is erosion with perforation of one or both atria and/or the aorta. (See 'Erosion' above.)

Surgical closure outcomes – Surgical closure in appropriate candidates <25 years old with ostium secundum ASD without pulmonary hypertension or significant comorbidity is associated with low postoperative mortality (<1 percent) and normal life expectancy. (See 'Without pulmonary hypertension' above.)

Effect of age – Patients under and over 40 years old with appropriate indications benefit from ASD closure. Younger patients (<40 years) have better long-term outcomes following surgical ASD closure than older patients [23]. (See 'Effect of age' above.)

Risk of atrial arrhythmias – Observational data suggest that ASD closure may reduce but does not eliminate the risk of atrial tachyarrhythmias, so other treatments, such as the Maze procedure performed at the time of ASD closure, may be helpful in selected patients. (See 'Effect of defect closure on risk of atrial arrhythmias' above.)

Postprocedural assessment – TTE should be performed following surgical or percutaneous closure to evaluate the adequacy of the repair, and to document the expected postoperative decreases in right heart chamber size and pulmonary pressures. (See 'General measures' above.)

Role of antiplatelet therapy – Antiplatelet therapy (aspirin and clopidogrel) is given for at least six months to protect against thrombus formation in all patients receiving a percutaneous closure device. (See 'General measures' above.)

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Topic 95760 Version 17.0

References

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