Management of Residual Left-to-Right Shunt After ASD Device Closure

Initial Assessment and Conservative Management

The American College of Cardiology recommends determining the hemodynamic significance of the residual shunt by evaluating right ventricular size and function, pulmonary artery pressure, shunt magnitude, and tricuspid regurgitation severity 1, 2
Transthoracic echocardiography is the primary imaging modality, with transesophageal echocardiography used if transthoracic windows are inadequate, as recommended by the American College of Cardiology 1, 4
If the right ventricle is normal in size and function, no medical therapy is required, and repeat echocardiography every 2-3 years is recommended to monitor RV size, function, and pulmonary pressures, according to the American Heart Association 1, 2
Monitoring for symptoms, including arrhythmias and paradoxical embolic events, is essential, as suggested by the European Society of Cardiology 1, 2, 5

Closure of the residual shunt is indicated if right atrial and/or RV enlargement develops, which is a primary Class I indication, as stated by the American College of Cardiology 1, 2, 5, 6
Reintervention is also considered if paradoxical embolism occurs, or if symptomatic deterioration is observed, according to the European Heart Journal 6, 7

The American College of Cardiology recommends being aware of potential late device complications, including device erosion, thrombus formation, and late arrhythmias, such as atrial fibrillation or flutter 4, 7, 9
If atrial fibrillation or flutter occurs, cardioversion after appropriate anticoagulation, rate control, and anticoagulation are recommended, as suggested by the American Heart Association 1, 2
Consideration of radiofrequency ablation for recurrent intra-atrial reentrant tachycardia or atrial flutter is also recommended, according to the European Heart Journal 7

If RV enlargement develops, percutaneous device closure is preferred if anatomically feasible, while surgical closure is required if device anatomy is unsuitable, as stated by the American College of Cardiology 3, 6, 8
Hemodynamic assessment with cardiac catheterization may be necessary if pulmonary hypertension is suspected, according to the Journal of the American College of Cardiology 4, 9