Atrial Septal Defect Closure Guidelines

Primary Indications for Closure

The American College of Cardiology recommends closure of an atrial septal defect (ASD) in adults with isolated secundum ASD who have impaired functional capacity, right atrial and/or RV enlargement, Qp:Qs ≥1.5:1, no cyanosis, PA systolic pressure <50% of systemic pressure, and PVR <1/3 systemic vascular resistance, with the goal of reducing RV volume and improving exercise tolerance 1, 2, 3
The American College of Cardiology suggests that closure is reasonable in asymptomatic adults with secundum ASD when right atrial and RV enlargement is present, Qp:Qs ≥1.5:1, and same hemodynamic criteria apply (PA pressure <50% systemic, PVR <1/3 systemic) 1, 2, 4

The American College of Cardiology recommends considering closure when Qp:Qs ≥1.5:1, PA systolic pressure 50-67% of systemic, and PVR 1/3 to 2/3 of systemic resistance, requiring careful evaluation by pulmonary hypertension specialists 1, 2, 4
The American College of Cardiology advises against closing the ASD when PA systolic pressure >2/3 systemic, PVR >2/3 systemic resistance, or net right-to-left shunt (Eisenmenger physiology) 1, 2, 4, 5, 6

The American Heart Association suggests not closing defects <5 mm without RV volume overload, as they do not impact natural history, unless paradoxical embolism is present 5, 6
The American College of Cardiology recommends surgical closure during another cardiac procedure if Qp:Qs ≥1.5:1 and RV enlargement are present, even if the ASD was not the primary indication for surgery 1, 2, 4

The American College of Cardiology warns against assuming small shunts are benign in older adults, as acquired conditions can increase left-to-right shunting over time, making previously insignificant ASDs hemodynamically relevant 5, 6
The American College of Cardiology emphasizes the importance of excluding severe PAH before closure, as this is the most critical assessment, and closure with established severe pulmonary vascular disease causes acute RV failure and death 1, 2, 4

The American Heart Association recommends ASD closure in adults with right atrial and right ventricular enlargement, with or without symptoms, to prevent premature mortality and progressive morbidity 7, 8, 9
Closure is indicated when right atrial and/or RV enlargement is present, typically with Qp:Qs ≥1.5:1, even in asymptomatic patients, as symptoms lag behind objective cardiopulmonary dysfunction 7
Sinus venosus, coronary sinus, and primum ASDs must be repaired surgically rather than percutaneously, and surgeons with training and expertise in congenital heart disease should perform these operations 7, 8, 9

The American College of Cardiology recommends closure when paradoxical embolism has occurred, after excluding other embolic sources, and in cases of orthodeoxia-platypnea syndrome 7, 8, 9
Tricuspid valve pathology is a reasonable indication for surgical closure, and concomitant tricuspid valve repair/replacement is a valid reason for closure 7, 8, 9

Closure may be considered in borderline pulmonary hypertension cases, where PA systolic pressure is 50-67% of systemic pressure AND/OR PVR is 1/3 to 2/3 of systemic resistance, with a net left-to-right shunt and evidence of pulmonary vascular reactivity 7, 8, 9
Test occlusion or vasodilator responsiveness testing may guide decision-making in these cases 7, 8, 9

The American Heart Association contraindicates closure in cases of severe irreversible pulmonary arterial hypertension with no evidence of left-to-right shunt (Eisenmenger physiology) 7, 8, 9

Small ASDs without hemodynamic significance should be monitored with echocardiography every 2-3 years to assess RV size, function, and pulmonary pressure 7, 8, 9