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Secundum atrial septal defects: time to close them all?
  1. Andrew Sharp,
  2. Iqbal Malik
  1. 1
    Imperial College Healthcare NHS Trust, London, UK
  1. Dr I Malik, Imperial College Healthcare NHS Trust, St Mary’s Campus, Waller Department of Cardiology, Praed Street, London W2 1NY, UK; i.malik{at}imperial.ac.uk

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Catheter-based closure is now considered the first-line treatment strategy for secundum atrial septal defects (ASD). Although in some cases, surgery remains the only option (eg, for those with an insufficient rim to secure a device, or those with coincidental anomalous pulmonary venous return), a percutaneous approach is suitable for the vast majority of patients with secundum ASD. As skill and experience grow, defects as large as 40 mm in size have been successfully closed in this manner.

In the days when repairing any ASD required a thoracotomy, cardiopulmonary bypass and 4 days or more in hospital, the benefits from treatment had to markedly overcome the deleterious effects of surgery, including the effects on the right ventricle of opening the pericardium and going on bypass. With less invasive treatments available, the question to be asked is—just because we can, should we be closing them all? The evidence seems to be clear for symptomatic patients with large shunts, but what of those with no symptoms, or in those with established pulmonary arterial hypertension (PAH)?

TRANSCATHETER CLOSURE OF SECUNDUM ASD: THE RISKS

Transcatheter closure of an ASD is not a procedure without risk. Two large published series from the early days of catheter closure demonstrated complication rates from 4 to 8%.1 2 Other available datasets show a more realistic major complication rate of 1.6%3; however, this is still not a zero-risk procedure, and there is a steep learning curve for the operator.4 Complications include device embolisation, cardiac perforation, device thrombus, stroke, arrhythmia and serious vascular injury. These types of complication, together with device failure, may require conversion to open surgery either immediately, or at a later date.59 Recent data suggest that late valve problems may also occur.10 Suitability of the patient for at least 3 months of combined antiplatelet therapy must also …

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