Right Heart Catheterization for ASD Secundum with Shortness of Breath

Indications and Contraindications

The American College of Cardiology recommends that diagnostic right heart catheterization is not routinely indicated for patients with confirmed ASD secundum by TEE with bubble study, provided the noninvasive imaging adequately assessed pulmonary artery pressures, shunt magnitude, and right ventricular enlargement, representing a Class III recommendation (not indicated) 1
The American College of Cardiology states that for most younger patients with straightforward ASD secundum, where TEE has clearly demonstrated the defect morphology, right ventricular volume overload, adequate estimation of pulmonary pressures, and shunt magnitude, proceed directly to closure planning without diagnostic catheterization, representing a Class III recommendation (not indicated) 1
Diagnostic right heart catheterization is required before closure decisions in patients with elevated or uncertain pulmonary artery pressures, if noninvasive imaging suggests PA systolic pressure ≥50% of systemic pressure or pulmonary vascular resistance >1/3 systemic resistance, as recommended by the American College of Cardiology 2
The American College of Cardiology recommends that adults over 40 years old with ASD secundum should undergo diagnostic right heart catheterization due to the frequent presence of acquired left ventricular diastolic dysfunction that can paradoxically worsen after ASD closure 1

The American College of Cardiology recommends closure (Class I) when PA systolic pressure is <50% of systemic pressure, pulmonary vascular resistance is <1/3 systemic resistance, and right atrial and/or RV enlargement is present, with no cyanosis at rest or exercise 2
The American College of Cardiology recommends that closure should not be performed (Class III) when PA systolic pressure is >2/3 systemic or pulmonary vascular resistance is >2/3 systemic 2

The American College of Cardiology states that for a symptomatic patient with shortness of breath and confirmed ASD secundum by TEE, diagnostic right heart catheterization should be performed if PA pressure appears elevated on echo (>50% systemic), the patient is >40 years old, or echo data is unclear 1
The American College of Cardiology recommends that if the patient is young, echo shows clear RV enlargement, PA pressures appear normal (<50% systemic), and Qp:Qs ≥1.5, diagnostic catheterization can be skipped and closure planning can proceed 1