There are few topics in adult congenital heart disease as persistently debated as the management of atrial septal defects (ASDs). The paper by Jemielity and colleagues in this issue ofHeart reactivates these fires.1Their retrospective study includes 88 largely symptomatic patients who received surgical closure of secundum and sinus venosus ASDs. Their age range at surgery was 40–62 years, with a mean of 46 years. They were followed for 1–17 years, mean 6.9 years. There was only one operative death. Functional class improved strikingly from 62% in New York Heart Association (NYHA) functional class III and IV preoperatively to 82% in NYHA class I and II postoperatively. Pulmonary vascularity improved on x ray, and right ventricular size diminished as assessed by echocardiography. Atrial flutter and fibrillation continued to be troublesome. This study adds additional evidence to the proposition that closure of secundum and sinus venosus ASDs benefits many or most symptomatic patients over age 40 years.

The “Canadian recommendations” state that the mere presence of a “significant ASD” (one associated with right ventricular volume overload, attributable exercise limitation, atrial arrhythmias, and/or late right heart failure) “warrants intervention”.2

As Ward described in 1993, the clinical trials on this issue and on which we base our management decisions are generally of poor quality by modern standards.3 More recent publications have not changed our dilemma. The available data do not have enough scientific merit to enable me or anyone else to …