How do you manage this patient?

Medical management

• should include treatment of possible complications:– Respiratory tract infections– Arrhythmias, atrial fibrillation, supraventricular

tachycardia– Pulmonary hypertension, coronary artery disease,

heart failure– Infective endocarditis

Harrison’s Principles of Internal Medicine 17th ed.

Surgical management

• Operative repair – definitive management• with a patch of pericardium OR• prosthetic material OR• percutaneous transcatheter device closure

should be advised for all patients with uncomplicated secundum atrial septal defects with significant left-to-right shunting

Harrison’s Principles of Internal Medicine 17th ed.

IndicationsThe mere presence of an ASD may warrant intervention especially if there is

a significant shunt (> 2:1) • symptomatic• pulmonary hypertension is present [pulmonary artery pressure (PAP) >

2/3 systemic arterial blood pressure (SABP) or• pulmonary arteriolar resistance > 2/3 systemic arteriolar resistance• net left-to-right shunt (Qp:Qs) of at least 1.5:1• RA or RV enlargement – radiographic, cardiac catheterization• or there is evidence of pulmonary artery reactivity when challenged with

a pulmonary vasodilator (e.g. oxygen, nitric oxide and/or prostaglandins)• or lung biopsy evidence shows that pulmonary arterial changes are

potentially reversible

Schwartz ‘s Principles of Surgery, 9th ed.http://www.achd-library.com/index.html

Device closure may now be offered as an alternative to surgical closure to patients with secundum ASD of up to 36-38 mm in diameter

Surgical closure may also be offered, and may be especially attractive should the patient prefer the surgical approach, or especially if atrial arrhythmia surgery (atrial maze procedure for atrial fibrillation and radiofrequency or cryoablation for atrial flutter) may be offered concurrently

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The following ASD patients require periodic follow up by an ACHD cardiologist

• Those repaired as adults• Elevated pulmonary artery pressures at the time of repair• Atrial arrhythmias pre- or post-operatively• Ventricular dysfunction pre-operatively• Co-existing heart disease (e.g. coronary artery disease, valvular

heart disease, hypertension) • Those with device closure need follow-up in specialized centers

with serial ECGs and echocardiograms to determine the late outcomes of these new techniques

• Endocarditis prophylaxis and aspirin are recommended for 6 months following device closure

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