# Atrial Septal Defect

Evaluate ASD by anatomic subtype, right-heart volume loading, shunt magnitude, and pulmonary vascular status. Close hemodynamically consequential defects before irreversible pulmonary vascular disease, selecting transcatheter closure only for suitable secundum anatomy and surgery for primum, most sinus venosus, coronary sinus, or associated lesions.

**Clinical question:** How should clinicians evaluate ASD anatomy and hemodynamics, determine closure candidacy, and select transcatheter versus surgical repair?

Updated: 2026-09-15T22:37:17.293014+00:00

## What matters in practice
- Treat ASD as an anatomic and hemodynamic diagnosis: right atrial/right ventricular enlargement and a net left-to-right shunt identify clinically consequential disease even when the adult is minimally symptomatic. [6][8]
- An ASD with pulmonary hypertension requires invasive assessment of pulmonary vascular resistance before closure; persistent high resistance or Eisenmenger physiology can make closure poorly tolerated or contraindicated. [1][7][19]
- Percutaneous closure is principally for suitably rimmed secundum ASD; primum, sinus venosus, and coronary sinus defects usually require surgical repair, particularly when anomalous pulmonary venous return or another lesion needs correction. [4][7][24]
- For primum, sinus venosus, or coronary sinus defects with functional limitation, right-heart enlargement, and Qp:Qs at least 1.5:1, surgical repair is recommended when systolic pulmonary artery pressure is below 50% of systemic pressure and pulmonary vascular resistance is below one third of systemic vascular resistance. [5]

## Identify patients in whom closure may be unsafe

Pulmonary vascular disease and right-to-left shunting change the closure decision before device planning.

In an unrepaired ASD with suspected pulmonary hypertension, cyanosis, exertional desaturation, right-to-left or bidirectional shunting, or right-heart failure, determine whether the defect remains a net left-to-right volume lesion versus an advanced pulmonary vascular lesion. Unrepaired ASD can progress to right ventricular volume overload, right-heart failure, elevated pulmonary vascular resistance, atrial arrhythmias, systemic embolism, and, in a minority, pulmonary arterial hypertension with right-to-left shunting. [7][8]

Obtain hemodynamic assessment when pulmonary hypertension is present or suspected and closure is under consideration. The preclosure question is whether pulmonary vascular resistance is sufficiently responsive and whether a net left-to-right shunt persists; high pulmonary vascular resistance may make corrective closure intolerable, whereas a Qp:Qs greater than 1.5:1 with only modest resistance elevation is comparatively reassuring in reported experience. [1][9][19]

Do not proceed directly to conventional closure in Eisenmenger physiology or clinically important atrial-level right-to-left shunting. Reported exclusion criteria for device closure include pulmonary vascular resistance above 7 Wood units and right-to-left atrial shunting with peripheral arterial saturation below 94%. [7]
- Escalate to an adult congenital heart disease and pulmonary hypertension team when pulmonary hypertension, resting or exertional cyanosis, bidirectional shunting, or ventricular decompensation is present; the decision may require medical pulmonary vascular management and consideration of a fenestrated rather than complete repair. [1][5][19]
- Defer elective device closure in sepsis, serious infection within 1 month, intracardiac thrombus, unstable angina, recent myocardial infarction, or decompensated heart failure; these are reported procedural contraindications or exclusion conditions. [7]

*Hemodynamic findings that direct ASD closure decisions. [1][5][7][19]*

| Finding | Interpretation | Next action |
| --- | --- | --- |
| Right-heart enlargement with net left-to-right shunt | Hemodynamically consequential ASD; closure prevents ongoing right-sided volume load. [6][8] | Define anatomy and assess suitability for percutaneous versus surgical closure. [7][24] |
| Qp:Qs ≥1.5:1 with primum, sinus venosus, or coronary sinus ASD; systolic PA pressure <50% systemic; PVR <one third systemic vascular resistance | Meets guideline conditions supporting surgical repair when there is impaired functional capacity and right atrial and/or RV enlargement. [5] | Refer for surgical repair unless comorbidity precludes intervention. [5] |
| Pulmonary hypertension with high or uncertain PVR | Closure can precipitate intolerance if pulmonary vascular disease is advanced. [1][19] | Perform invasive hemodynamic assessment and evaluate pulmonary vascular responsiveness before deciding on closure. [1][9] |
| Right-to-left shunt with saturation <94% or PVR >7 Wood units | Reported contraindication/exclusion profile for transcatheter ASD closure. [7] | Avoid routine device closure; manage through specialized ACHD and pulmonary hypertension evaluation. [7] |

## Define ASD subtype before choosing a closure strategy

Anatomic misclassification can send a patient to the wrong intervention.

Start with transthoracic echocardiography to establish right-sided chamber size, shunt direction, and apparent septal anatomy. A subcostal approach is particularly useful when the ultrasound beam is perpendicular to the atrial septum; however, transthoracic imaging can be suboptimal in older patients and may miss sinus venosus anatomy. [18][9]

Use transesophageal echocardiography when transthoracic imaging does not confidently define the defect, rim adequacy, or pulmonary venous anatomy. TEE better visualizes the interatrial septum and is particularly important for suspected sinus venosus defect, for which transthoracic imaging has limited yield because the lesion is far-field; TEE should also establish right-sided anomalous pulmonary venous connections and confirm normal left-sided pulmonary venous connections. [9][18]

Classify the lesion before referral: secundum defects occur in the fossa ovalis and account for about 80% of isolated ASDs; primum defects account for approximately 15% and are part of the atrioventricular septal defect spectrum; superior and inferior sinus venosus defects are less common and are associated especially with partial anomalous pulmonary venous return; unroofed coronary sinus is rare. [8][24]
- A suspected primum ASD should trigger assessment of mitral valve function and evaluation within the partial atrioventricular septal defect framework; primum anatomy is not suitable for device closure. [4][8]
- A suspected superior sinus venosus defect requires deliberate assessment for anomalous pulmonary venous return; the surgical technique differs from that for secundum ASD, making definitive anatomic confirmation essential. [9][24]
- Use color-flow and saline contrast imaging to characterize shunt direction when bidirectional flow is suspected. [9]

*ASD subtype determines associated-lesion assessment and closure route. [4][7][8][24]*

| Subtype | High-value anatomic issue | Usual closure approach |
| --- | --- | --- |
| Secundum ASD | Fossa ovalis location; define defect size and septal rims for device anchoring. [7][24] | Transcatheter device closure is preferred when anatomy is feasible; surgery is used for large defects, inadequate rims, or associated lesions requiring repair. [1][24] |
| Primum ASD | Partial atrioventricular septal defect anatomy and potential mitral valve dysfunction. [4][8] | Surgical repair; not suitable for device closure. [4][7] |
| Sinus venosus ASD | Confirm anomalous pulmonary venous return, especially on the right side; TEE may be needed after nondiagnostic TTE. [9][24] | Historically surgical repair; covered-stent transcatheter intervention has emerged for selected sinus venosus defects. [24] |
| Coronary sinus ASD | Unroofed coronary sinus anatomy. [8] | Surgical closure. [7] |

## Close defects producing right-heart volume overload

Symptoms are not required when objective right-heart enlargement establishes physiologic consequence.

In adults with secundum ASD, right atrial and right ventricular enlargement supports surgical or percutaneous closure with or without symptoms. This strategy is intended to reduce late morbidity from ongoing right-sided volume overload and is supported by consensus recommendations in adults with right-heart enlargement. [6][8]

For primum, sinus venosus, and coronary sinus defects, surgical repair is recommended when impaired functional capacity, right atrial and/or right ventricular enlargement, and a physiologically important net left-to-right shunt such as Qp:Qs at least 1.5:1 are present, provided there is no resting or exertional cyanosis, systolic pulmonary artery pressure is less than 50% of systemic pressure, and pulmonary vascular resistance is less than one third of systemic vascular resistance. [5]

Use surgery rather than attempting a marginal device procedure when the defect is large, adequate rims are absent, or another congenital lesion requires operative correction. This is especially relevant for primum and most sinus venosus defects, including those with partial anomalous pulmonary venous drainage. [1][7]
- Choose transcatheter closure for a secundum defect only after imaging confirms a secure device landing zone; inadequate rims increase the likelihood that surgery is the safer definitive option. [1][7]
- For unrepaired superior sinus venosus ASD, transcatheter closure may be a reasonable alternative to surgery when technically feasible, with the aim of reducing operative morbidity. [5]
- If ASD closure is indicated in pulmonary arterial hypertension, consider fenestrated repair rather than complete closure in selected patients; guideline language supports this as a consideration to improve functional class and clinical outcomes. [5]

*Practical selection of ASD closure route. [1][4][5][7][24]*

| Clinical-anatomic setting | Preferred strategy | Reason to avoid routine device closure |
| --- | --- | --- |
| Hemodynamically consequential secundum ASD with suitable rims | Percutaneous device closure. [24] | Choose surgery if the defect is large, rims are inadequate, or associated lesions need repair. [1][7] |
| Primum ASD | Surgical repair. [4][7] | Primum anatomy is not suitable for device closure and may involve mitral valve dysfunction. [4] |
| Sinus venosus ASD with anomalous pulmonary venous return | Surgical repair is the established approach; selected superior lesions may undergo technically feasible transcatheter closure. [5][24] | Pulmonary venous anatomy requires correction and must be fully defined. [9][24] |
| ASD with advanced pulmonary vascular disease or right-to-left shunting | Specialized individualized assessment; fenestrated repair may be considered only when closure remains indicated. [5] | Complete closure may not be tolerated when PVR remains high or Eisenmenger physiology is present. [1][7] |

## Monitor residual hemodynamic and rhythm risk after repair

Closure corrects the shunt but does not erase preexisting arrhythmia or pulmonary vascular risk.

After closure, reassess right-sided chamber remodeling, residual shunt, pulmonary pressure, and symptoms with echocardiography directed by the anatomy and preintervention physiology. Patients closed later in life have an increased frequency of atrial arrhythmia, so new palpitations, decline in exercise tolerance, or embolic events should trigger rhythm evaluation rather than attribution to a repaired defect alone. [8]

Maintain adult congenital heart disease involvement for patients with complex anatomy, prior pulmonary hypertension, residual lesions, or arrhythmias. Contemporary multisociety guidance emphasizes routine care at ACHD centers in collaboration with ACHD cardiologists and multidisciplinary management for more complex cases. [5]

Do not extrapolate uncomplicated repaired secundum-ASD follow-up to primum, sinus venosus, or coronary sinus defects. The ACC secundum-ASD follow-up algorithm specifically excludes those lesions because they are associated with more complex anatomy; follow-up should instead account for repaired atrioventricular valve disease, pulmonary venous repair, pulmonary vascular disease, and arrhythmia burden as applicable. [21][23]
- Re-evaluate pulmonary vascular status if pulmonary hypertension persists or progresses despite early symptomatic improvement after closure; adverse outcomes have been reported in patients with elevated PVR despite initial improvement. [19]
- In repaired sinus venosus ASD, ensure follow-up includes the consequence of the pulmonary venous abnormality that required anatomic correction. [9][24]

*Features requiring more intensive post-repair surveillance. [5][8][19][21][23]*

| Feature | Why it matters | Follow-up focus |
| --- | --- | --- |
| Closure later in adulthood | Atrial arrhythmia occurs more frequently in patients closed later in life. [8] | Investigate symptomatic rhythm disturbance and maintain congenital-cardiology follow-up. [5][8] |
| Preclosure pulmonary hypertension or elevated PVR | Early clinical improvement does not exclude progressive pulmonary hypertension. [19] | Reassess pulmonary hemodynamics and manage with ACHD/pulmonary hypertension expertise. [5][19] |
| Primum, sinus venosus, or coronary sinus anatomy | These lesions have associated structural complexity beyond isolated secundum ASD. [8][21] | Use lesion-specific ACHD surveillance rather than an isolated secundum-ASD pathway. [21][23] |

## References
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## Editorial note

Prepared from cited clinical literature using Astra's research workflow. Verify recommendations against current guidance and patient-specific factors.