Medical Care
Small-to-moderate–sized ostium secundum atrial septal defects diagnosed in the infant demonstrate significant likelihood of either spontaneous closure or reduction in size to the point that medical intervention no longer is indicated. Such patients should be followed until age 3-4 years before considering either device use or surgical closure. [5, 19]
No medications are required, except bacterial endocarditis prophylaxis for 6 months following either device or patch closure.
Consultations
Patients should be evaluated by a pediatric cardiologist. Patients with defects considered appropriate for transcatheter device closure should be evaluated by an interventional pediatric cardiologist experienced in the procedure. If surgery is contemplated, the patient should be evaluated by a cardiovascular surgeon experienced in surgery of congenital heart defects. Ideally, decisions regarding therapy should result from simultaneous evaluation of patient data at a group meeting that includes all of these physicians.
Transfer
Evaluation and treatment should be carried out at a center specializing in congenital heart disease.
Diet and activity
No special diet is required.
No activity restrictions are required except for a few weeks following either device closure or heart surgery.
Surgical Care
Minimally invasive cardiac surgery
Minimally invasive cardiac surgery techniques allow closure without the use of blood or blood products in appropriately sized patients. [20, 21, 22]
The skin incision is short because complete vertical division of the sternum is not necessary.
If the defect is moderate in size and oval in shape, direct suture closure may be appropriate. Larger or rounder defects require patch closure. The patch can be fashioned from the patient's pericardium or made from Dacron.
Results of surgery are excellent; a 100% closure rate should be achieved. Risk of mortality does not exceed that of general anesthesia. [23, 24]
Inpatient hospital stay averages 2-3 days. Perform postoperative echocardiography to confirm closure.
Postoperative care includes bacterial endocarditis precautions for 6 months if a patch was placed.
Cardiac catheter intervention
Catheter intervention may be indicated.
Transcatheter device closure of secundum atrial septal defect now represents a standard of care for this abnormality. [25] Experience at centers throughout the world is extensive; the success rate has been high, and the risk of complications has been low. [26, 27, 28, 29, 30, 31, 32, 33] Indication for closure in the pediatric age range is a shunt of sufficient size to be clinically apparent. Most cardiologists use the criterion of right ventricular volume overloading on echocardiographic evaluation. The reason for closure is to prevent development of complications (eg, atrial dysrhythmia, right heart dysfunction) that may appear in the adult. Small defects in children that are detectable only by echocardiography do not require closure.
In adult patients who experience a suspected thrombotic stroke and who manifest a patent foramen ovale (15-20% of all adults demonstrate a patent foramen ovale on echocardiography), concern arises that the stroke may have been caused by a paradoxical embolus. [34] In these patients, device closure of the communication is often recommended and accomplished. Studies remain controversial regarding the appropriateness of this treatment.
Transcatheter device occlusion of a secundum atrial septal defect should be accomplished only by physicians properly trained and experienced in the procedure. Proper sizing of the defect and anatomic evaluation to assure reliable seating of the device is essential.
The device is placed in the atrial septum via a catheter introduced into a femoral vein. Most operators advise monitoring the procedure with transesophageal or intracardiac echocardiography. Multiple studies indicate a high degree of success, with complete closure rates only slightly less than those obtained by surgery.
Studies comparing device closure with surgery establish that hospital stay is shorter in patients undergoing device closure. Total costs of the two techniques do not significantly differ, apparently because of the cost of the device. [35]
Complications of device occlusion include hemorrhage, vascular disruption, pain, nausea and vomiting, and arterial or venous obstruction from thrombosis or spasm. Other complications include rupture of blood vessel, tachyarrhythmias, bradyarrhythmias, and vascular occlusion. Embolization of the device during placement rarely occurs but can result in emergency surgery for removal. The most common complication is incomplete closure of the defect. [36] Erosion of aorta and migration of the device was observed during follow-up in 0.1% (1 in 1000) Amplatzer device implantations. [37, 38] Initial review of the data suggested that use of over-sized devices is associated with aortic erosion and that device size greater than 1.5 times the echo diameter of the ASD should not be used in the occlusion of the defect. [37, 38] A more recent analysis indicated additional factors such as deficient aortic or superior vena caval rims, large balloon size of the ASD, large Amplatzer device and others may also be associated with aortic erosion. [39]
Long-Term Monitoring
If the immediate postoperative echocardiography confirms complete closure, a follow-up visit one year following closure is adequate to evaluate possible long-term complications (rare). Patients who undergo closure of a large defect late in childhood (when >8 y) should be advised to continue infrequent cardiology evaluations with electrocardiographic studies approximately every 5 years to monitor for the possible occurrence of a dysrhythmia. [40]
Patients who undergo device closure of a secundum atrial septal defect should continue cardiology evaluations until long-term published studies establish the absence of late complications.
