Atrial Septal Defect Closure

Introduction to Complications

Vascular injury, including pulmonary vein avulsion and aortic laceration, is a rare but serious potential complication of atrial septal defect (ASD) closure procedures, particularly during surgical repair or catheter-based interventions 1
Pulmonary vein injury and inferior vena cava tears can occur during balloon atrial septostomy procedures and catheter manipulation, respectively 1

Elderly patients (>60 years) have a higher major complication rate (23%) for surgical ASD closure compared to younger populations 2
Sinus venosus defects have a higher risk due to their location near the superior vena cava and right pulmonary veins 2
Patients with elevated pulmonary pressures and advanced age have increased surgical risk and higher complication rates with both surgical and device closure 2, 3

Biplane fluoroscopy is essential during septostomy to confirm position before manipulation 1
All CHD interventions should be performed in centers with experience, ideally with multiple operators, and a multidisciplinary conference should be held to weigh the pros and cons of medical, interventional, and surgical approaches 2
Minimally invasive approaches, such as ministernotomy and thoracoscopic approaches, may reduce risk for secundum ASDs too large for device closure 2
The American College of Cardiology recommends closure of an ASD either percutaneously or surgically for right atrial and RV enlargement with or without symptoms, with percutaneous closure preferred for secundum ASDs with suitable anatomy and surgical repair required for other ASD types 4, 5

Closure is indicated for patients with a net left-to-right shunt (Qp:Qs) of ≥1.5:1 without cyanosis at rest or during exercise, as recommended by the American College of Cardiology 5
Closure is also indicated for patients with a net left-to-right shunt (Qp:Qs) of ≥1.5:1 with PA systolic pressure ≥50% of systemic pressure and/or pulmonary vascular resistance >1/3 systemic resistance, and for patients with net right-to-left shunt 5
Paradoxical embolism, documented orthodeoxia-platypnea, and sinus venosus, coronary sinus, or primum ASDs are indications for ASD closure, with Class IIa and Class I recommendations, respectively 4, 6, 5
Concomitant tricuspid valve repair/replacement is an indication for ASD closure, with a Class IIa recommendation 4, 6
Patients with mild to moderate pulmonary arterial hypertension (PAH) may be considered for ASD closure, with pulmonary artery pressure less than two-thirds systemic levels and PVR less than two-thirds systemic vascular resistance, which is a Class IIb recommendation 4, 6, 5
Patients with severe irreversible PAH are contraindicated for ASD closure if there is no evidence of left-to-right shunt, which is a Class III recommendation 4, 6, 5

Imaging confirmation of ASD is required, demonstrating shunting across the defect and evidence of RV volume overload, as recommended by the American Heart Association 4
Transthoracic echocardiography is the first-line assessment of defect size, location, and right heart enlargement, according to the American College of Cardiology 5
Transesophageal echocardiography provides better visualization of the atrial septum and pulmonary venous connections, as recommended by the American College of Cardiology 5
Pulse oximetry is useful for assessing shunt direction at rest and with exercise, according to the American College of Cardiology 5
Cardiac magnetic resonance (CMR) or cardiac computed tomography (CCT) is used to delineate pulmonary venous connections 5

The American College of Cardiology recommends percutaneous transcatheter device closure for secundum ASDs with suitable anatomy, defects with adequate rims for device anchoring, and defects typically <38mm in diameter 5
Surgical repair is required for sinus venosus, coronary sinus, or primum ASDs, large secundum ASDs (>38mm), defects with deficient rims, and when concomitant tricuspid valve repair is needed 6, 5
The Amplatzer device is a self-expanding nitinol mesh occluder used for transcatheter closure of various cardiac defects, including atrial septal defects, ventricular septal defects, and patent ductus arteriosus, with high technical success rates and low complication profiles, as recommended by the American Heart Association and American College of Cardiology 1, 7

Annual clinical follow-up is recommended for patients with persistent/residual pulmonary arterial hypertension, atrial arrhythmias, RV or LV dysfunction, or coexisting valvular or cardiac lesions 4, 6
Echocardiogram is recommended every 2-3 years to assess RV size and function and pulmonary pressure in patients with small unclosed ASDs, as recommended by the American Heart Association 4
Evaluation for device complications is recommended at 3 months to 1 year after closure and periodically thereafter 4
Potential complications of percutaneous transcatheter device closure include device thrombosis, cardiac erosion, atrial arrhythmias, nickel allergy, conduction abnormalities, and device endocarditis 6
Potential complications of surgical repair include postpericardiotomy syndrome, atrial arrhythmias, superior vena cava stenosis, and pulmonary vein stenosis 6

Early closure (before age 25) is associated with better outcomes and normal life expectancy, although this is not directly cited from a specific guideline society, it is mentioned in the context of the American College of Cardiology 8
Closure in adults still improves morbidity and survival but may be associated with new or recurrent atrial arrhythmias, as reported by the American College of Cardiology 8
Pooled analysis shows improvement in functional status and right ventricular size/function after ASD closure 8
Early closure (before age 25) is associated with better outcomes and lower incidence of arrhythmias 9
Closure in adults still improves morbidity and survival but may be associated with new or recurrent atrial tachyarrhythmias 9