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Challenges in the care of adult patients with congenital heart defects
  1. Gary D Webb
  1. Correspondence to:
    Professor Gary D Webb, Toronto Congenital Cardiac Centre for Adults, Toronto General Hospital, Peter Munk Cardiac Centre, Ground Floor, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada;gary.webb{at}

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This article will endeavour to accomplish four things: to point out some of the more common challenges in the assessment and management of adult patients with congenital heart defects (CHD); to review in general which adult patients with CHD do not need to be seen in specialised adult CHD centres; to review which patients should be seen in such specialised centres; and to review the resources which should thereby be available to them in the expert centres.


Atrial septal defects

Even the humble atrial septal defect (ASD) has its complexities. First, not all ASDs need to be closed. As a rule, an ASD worth closing should be at least 10 mm in diameter and be associated with clear right ventricular dilation.

There is a consensus view that all ASDs meeting these criteria should be closed unless there are reasons not to do so.1 Moreover, the ASD should be closed when diagnosed, and preferably before the age of 25 years if the goal of treatment is to avoid premature mortality and morbidity.2

The dilemma as to whether to recommend ASD closure in the asymptomatic patient has eased greatly now that device closure of ASDs can be done so successfully and easily. That said, one needs to have access to a skilled interventionalist and modern devices to make this promise relevant.

Estimation of the size, the number, and type(s) of atrial defects can be difficult at times. While transthoracic echocardiography (TTE) will usually confirm the diagnosis of an ASD, it will seldom identify whether multiple ASDs are present, an issue that must be evaluated by transoesophageal echocardiography (TOE) before considering device closure of the defect. Anomalous pulmonary venous drainage (APVD) must also be excluded before proceeding to device closure.

While most isolated ASDs are of the secundum type, it is important to recognise …

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