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Device closure has become the first choice for secundum defect closure, when feasible, based on the morphology (includes stretched diameter <_38 mm and sufficient rim of 5 mm except towards the aorta). This is the case in 80% of patients. Although it cannot be assumed to be zero, several recent studies have reported no mortality. Serious complications have been observed in <_1% of patients.148,149

Atrial tachyarrhythmias occurring early after intervention are mostly transient. Erosion of the atrial wall, anterior mitral leaflet, or the aorta, as well as thromboembolic events, appear to be very rare.150,151 Antiplatelet therapy is required for at least 6 months (aspirin 75 mg o.d. minimum). Potential incidence of late arrhythmias or adverse events still requires investigation. Studies comparing surgery and catheter intervention have reported similar success rates and mortality, but morbidity was lower and hospital stays shorter with catheter intervention while reintervention rate was slightly higher.148,152 Outcome is best with repair at age <25 years.144,145 ASD closure after the age of 40 years appears not to affect the frequency of arrhythmia development during follow-up.146,153 However, the patient’s morbidity benefits from closure at any age (exercise capacity, shortness of breath, right heart failure), particularly when it can be done by catheter intervention.146,153 In patients with impaired LV function (systolic and diastolic), ASD closure may worsen heart failure. These patients must be carefully evaluated and may require pre-interventional testing (balloon occlusion with reassessment of haemodynamics) to decide between complete, fenestrated, or no closure, considering that an increase in filling pressure due to ASD closure may worsen symptoms and outcome.154 Patients with PH must be evaluated with particular care. Calculation of PVR is mandatory. In patients with PVR <5 WU, ASD closure has been shown to be safe and associated with a decrease in PAP and improvement of symptoms.60,153,155 However, even in this group, the extent of improvement decreases with increasing PAP. Patients with PVR >_5 WU are unlikely to improve60 and likely to have an even worse outcome with complete ASD closure.48,156 Vasoreactivity testing is not recommended when making the decision whether to close an ASD in patients with PVR >_5 WU. It appears safer to treat PAH, re-evaluate haemodynamics during follow-up, and consider fenestrated closure only when PVR falls below 5 WU in the presence of significant LR shunt. If this is not the case, ASD closure should be avoided. In patients with atrial flutter/AF, cryo- or radiofrequency ablation (modified maze procedure) should be considered at the time of surgery. Device closure may restrict access to the LA for later EP interventions. In patients of advanced age with ASDs not suitable for device closure, individual surgical risk due to comorbidities must be carefully weighed against the potential benefits of ASD closure.

4.1.5 Specific aspects of isolated anomalous pulmonary venous connections Anomalous pulmonary venous connections do not only occur in association with ASD (typically in sinus venous defects) but can also be isolated. This results in volume overload of the right heart, with a physiological effect similar to that of an ASD, but when isolated, differs in that there is no potential for RL shunting, and the magnitude of the LR shunt is not exacerbated by the development of acquired left heart disease. Most common is the connection of the right upper pulmonary vein to the SVC. Other abnormal connections include right pulmonary vein(s) to the IVC (‘scimitar vein’, which may be associated with sequestration of the right lower lobe), left upper

Recommendations for intervention in atrial septal defect (native and residual)

Recommendations Classa Levelb

In patients with evidence of RV volume overloadc and no PAH (no non-invasive signs of PAP elevation or invasive confirmation of PVR <3 WU in case of such signs) or LV disease, ASD closure is recommended regardless of symptoms.146,147 I B Device closure is recommended as the method of choice for secundum ASD closure when technically suitable. I C In elderly patients not suitable for device closure, it is recommended to carefully weigh the surgical risk against the potential benefit of ASD closure. I C In patients with non-invasive signs of PAP elevation, invasive measurement of PVR is mandatory. I C In patients with LV disease, it is recommended to perform balloon testing and carefully weigh the benefit of eliminating LR shunt against the potential negative impact of ASD closure on outcome due to an increase in filling pressure (taking closure, fenestrated closure, and no closure into consideration). I C In patients with suspicion of paradoxical embolism (exclusion of other causes), ASD closure should be considered regardless of size providing there is absence of PAH and LV disease. IIa C In patients with PVR 35 WU, ASD closure should be considered when significant LR shunt is present (Qp:Qs >1.5). IIa C In patients with PVR >_5 WU, fenestrated ASD closure may be considered when PVR falls below 5 WU after targeted PAH treatment and significant LR shunt is present (Qp:Qs >1.5). IIb C ASD closure is not recommended in patients with Eisenmenger physiology, patients with PAH and PVR >_5 WU despite targeted PAH treatment, or desaturation on exercise.d III C

ASD = atrial septal defect; LR = left-to-right; LV = left ventricle/ventricular; PAH = pulmonary arterial hypertension; PAP = pulmonary artery pressure; PVR = pulmonary vascular resistance; Qp:Qs = pulmonary to systemic flow ratio; RV = right ventricle/ventricular; WU = Wood units. aClass of recommendation. bLevel of evidence. cRV enlargement with increased stroke volume. dThere are limited data available for a precise cut-off, but by clinical experience, this would be given by a fall of arterial oxygen saturation <90%. Downloaded from academic.oup.com/eurheartj/article/42/6/563/5898606 by guest on 07 October 2026