STRUCTURAL CLOSURE

Indications and
Evaluation for
ASD Closure
Performing detailed hemodynamic evaluation of secundum atrial septal defects
using current imaging modalities and closure devices.
BY YOLANDEE BELL-CHEDDAR, MD, AND ZAHID AMIN, MD, FAAP, FSCAI, FACC

trial septal defect (ASD) is one of the most com-

A mon types of congenital heart defects.1 It

accounts for 6% to 10% of all cardiac anomalies
and occurs in one of every 1,500 live births. An
ASD is a communication between right and left atria. There
are several types of interatrial communications. The most
common communication is the patent foramen ovale
(PFO). This defect exists in utero and seals off after birth,
although the time of sealing of this defect is variable. The
PFO is not a true opening in the atrial septum; rather, it is a
slit or flap-like separation between the septum primum and
secundum. As the left atrial pressure increases after birth,
the opening closes because of the apposition of the septum
primum to the septum secundum.
A small, probe patent opening may remain despite excel-
lent apposition, which is termed as PFO. A PFO may
become a true opening if left or right atrial enlargement
occurs and if the overlapping of the septum primum to the
septum secundum disappears. Regardless, the location and
the type of opening tend to solve the enigma of whether Figure 1. The anatomy of the atrial septum. The flap-type
the defect is a PFO or a true ASD. Figure 1 shows the anato- opening is the PFO. LA, left atrium; RA, right atrium.
my of the atrial septum with the flap-like septum primum.
If there is a true deficiency of the septum primum that atrial communications that are not amenable to device clo-
results in communication between the two atria, it is called sure, and hence a thorough knowledge of these defects is
secundum ASD. The size of the defect is primarily based on needed in order to rule them out before embarking on
the extent of septum primum deficiency. The septum intervention. These defects include sinus venosus ASD, pri-
secundum is always present in these patients, although it mum or partial AV canal ASD, and coronary sinus ASD.
could be deficient in some areas. When deficiency of the Sinus venosus ASD is located close to the SVC or the IVC
secundum is present, the defect can be very large and tech- and is commonly associated with partial anomalous pul-
nically difficult to close. The septum secundum constitutes monary venous return. This defect is not amenable to
the atrial septal rims. The aortic, superior, superior vena cava device closure. Primum or partial AV canal ASD is located
(SVC), posterior, inferior vena cava (IVC), and atrioventricu- very close to the mitral and tricuspid valves and therefore is
lar (AV) valve rims all compose the septum secundum.1 also not amenable to device closure. In addition, primum
Figure 2 shows a depiction of the atrial septal rims. ASD is associated with a cleft in the anterior mitral valve
In addition to secundum ASD, there are other types of leaflet. Coronary sinus ASD is not a defect in the atrial sep-

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 STRUCTURAL CLOSURE

CONTRAINDICATIONS TO ASD CLOSURE

• Aortic rim absence or severe deficiency confirmed in
multiple TEE views. Absence of rims documented in
multiple views of 30º, 40º, 50º+.
• IVC rim absence or severe deficiency (Figure 3).
• Pulmonary vascular resistance > 15 Woods units is an
absolute contraindication.
• Coronary sinus rim absence with evidence of coronary
sinus impingement by the device in the catheterization
laboratory.
• Mitral valve impingement by the device with evidence of
new-onset or increasing mitral insufficiency. Try a smaller
device, if feasible.
• Development of AV block after device deployment.

Figure 2. Classification of atrial septal rims. Reprinted with Although criteria for closure are met on one level, there may
permission from Amin Z. Catheter Cardiovasc Interv be concurrent data that preclude closure of such defects.
2006;68:778–787.1 Naturally, if the defect is larger than 40 mm, it cannot be
closed with a device because there is no device available
tum; rather, it is a defect in the roof of the coronary sinus that can close defects of such size. Similarly, if a patient has a
that leads to communication between left and right atrium concomitant cardiac lesion that requires surgery, the ASD
through the coronary sinus. Again, ideally this defect is not defect can best be closed at the time of surgery. ASD closure
suited for device closure because of the risk of occluding the is contraindicated in patients with irreversible pulmonary
coronary sinus. hypertension. ASD in such patients acts as a “pop-off”
The subsequent discussion will focus on secundum ASD mechanism, and closure can be detrimental when the right
closure, as these are the only defects (barring PFO) that are heart cannot be decompressed during times of pulmonary
amenable to device closure. hypertensive crisis. We recommend that these patients
undergo cardiac catheterization for calculation of pul-
INDICATIONS FOR ASD CLOSURE monary vascular resistance.
The indications for closure of secundum ASD have been If the pulmonary vascular resistance (PVR) is < 7 Woods
clearly outlined in the 2008 American College of units, then the defect can be closed in the same setting.
Cardiology/American Heart Association guidelines that Pulmonary vascular obstructive disease is rare before 30
were published in the Journal of the American College of years of age and is more common in women. One may con-
Cardiology (Table 1).2 sider using a fenestrated device if there are concerns for ele-
The indications for closure in the pediatric and the adult vated pulmonary artery pressures because the fenestration
population are essentially the same. In pediatric patients, can act as a pop-off when right ventricular pressures are
however, primary attention is directed to symptomatology high.3 There are some data showing that this may be effica-
of recurrent respiratory tract infection and failure to thrive. cious in the short term.4 Some patients may require antipul-
In adults, respiratory symptoms such as shortness of breath monary hypertensive therapy and oxygen at night for a few
tend to occur after the age of 40 years. months after closure. If the PVR is > 7 Woods units, it is best
The indications for ASD closure are based on the type of not to close the ASD. There are data available that suggest
defect and the devices available to treat the defect. At the that closure may be performed in patients with PVR as high
current time, there are two devices that have been as 10 Woods units because symptoms of pulmonary hyper-
approved for device closure by the US Food and Drug tension regress after closure.5
Administration. The Amplatzer septal occluder (St. Jude We believe that ASD closure should be withheld if PVR is
Medical, Inc., St. Paul, MN) can close defects up to 40 mm, > 10 Woods units. We recommend that the patient be
and the Helex septal occluder (Gore & Associates, Flagstaff, started on antipulmonary hypertensive medical therapy,
AZ) can close defects up to 17 mm in diameter. with the help of a pulmonologist, for at least 6 months.
It should be noted that having knowledge of the indica- After this time, the patient should undergo recatheteriza-
tions for device closure is not sufficient to close an ASD. tion to assess PVR and the degree of left-to-right shunt. If

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TABLE 1. INDICATIONS FOR ASD CLOSURE FROM THE AMERICAN COLLEGE

OF CARDIOLOGY/AMERICAN HEART ASSOCIATION GUIDELINES
Indications for Closure of ASD Indication Class

· Right atrial and right ventricular enlargement by echocardiography with or without symptoms. Class I
· ASD minimum diameter should be > 5 mm and < 40 mm on echocardiography.
· Adequate rims of tissue (> 5 mm) from the defect to surrounding structures such as the coronary sinus,
SVC, IVC, and AV valves, as well as the pulmonary veins.

· Presence of an ASD with documented or verified paradoxical embolization and/or documented Class IIa
orthodeoxia-platypnea.

· Net left-to-right shunting, pulmonary artery pressures less than two-thirds systemic levels, pulmonary vas- Class IIb
cular resistance less than two-thirds systemic vascular resistance, when either is responsive to pulmonary
vasodilators, or test occlusion of the defect is successful.

criteria are met, then the defect can be closed in the same EVALUATION FOR ASD CLOSURE
setting. In general, ASD closure is recommended in all symp- The first ASD closure via transcatheter approach was per-
tomatic and asymptomatic patients with PVR < 10 Woods formed in 1976.6 After a hiatus of several years, the closure
units. However, it is absolutely contraindicated in patients process restarted in the late 1980s and has significantly pro-
with PVR of 15 Woods unit or more. Patients with PVR gressed during the last 12 years.
between 10 and 15 should have aggressive antipulmonary A physical examination of a patient with ASD usually
hypertensive treatment and evaluation before exploring reveals subtle findings, and hence the diagnosis may be
ASD closure. missed. Echocardiographic evaluation can confirm the diag-
Patients with evidence of left ventricular dysfunction, nosis. Echocardiography is not only important for the diag-
whether diastolic or systolic, represent a group that is at nosis but is crucial in determining suitability for device clo-
increased risk. These patients with ASD are generally older sure. In addition, it is the primary modality on which the
than 60 years and have a history of congestive cardiac fail- interventionist depends during the closure procedure. The
ure. The left ventricle is less compliant than the right ventri- determination can be made whether a particular ASD is
cle in these patients. The ASD tends to act as a pop-off for suitable for transcatheter closure—not just from a typologi-
the left ventricle (as opposed to the right ventricle in cal perspective but also for size determination and the ade-
patients with pulmonary hypertension), leading to compen- quacy of rims for device placement. For the Amplatzer
satory fluid retention. Closure of the ASD may therefore device, the rims should be 5 mm or larger (excluding the
result in acute left heart failure and pulmonary congestion. aortic rim), as suggested by the manufacturer in the instruc-
During the cardiac catheterization procedure, evaluation of tions-for-use pamphlet. If 5 mm is considered to be an ade-
left atrial pressures or pulmonary capillary wedge pressures quate rim size, then aortic rim deficiency will be common
after temporarily occluding the defect is very helpful. because more than 40% of patients with ASD have an aortic
A significant increase in left atrial pressure and a drop rim that is < 5 mm.7 Therefore, aortic rim deficiency is not a
in cardiac output is a clear indication that the patient will generalized contraindication to device closure. The aortic
require aggressive diuresis and anti-heart failure medica- rim, however, is the most important rim when it comes to
tions. After ASD closure, it is also recommended to leave device-related complications such as erosion.8 Aortic rim
a catheter in the pulmonary artery to measure pul- deficiency in multiple transesophageal echocardiography
monary artery pressures overnight in these patients for (TEE) views should be considered a contraindication to
optimal pressure measurement. Sometimes, it is best to device closure.
optimize these patients with anti-heart failure medica- The Amplatzer septal occluder is a self-centering device,
tions and diuretics before device closure. These patients and its size is determined by its waist. The left disc is 6 mm
have been found to do very well at subsequent device larger than the waist for devices up to 10 mm, 7 mm larger
closure. The Contraindications to ASD Closure sidebar sum- for devices up to 32 mm, and 8 mm larger for devices up to
marizes what we believe to be the major contraindications 40 mm. The right atrial disc is 4 mm larger than the waist for
to device placement in secundum ASD. devices up to 10 mm and 5 mm larger for all other sizes.

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 STRUCTURAL CLOSURE

A B venous drainage delineation becomes increasingly difficult

in adults who generally have poor acoustic windows. TEE
has been used to successfully guide transcatheter closure of
secundum ASD and PFO.9,10 Intracardiac echocardiography
(ICE) can provide very similar information as TEE. It has
replaced the use of TEE during ASD closure in some centers
and is thought to be superior to TEE by some.11 However, at
this time, TEE remains the gold standard for ASD closure.
The drawbacks of ICE are the requirement for skilled
expertise, difficult learning curve, placement of an 8- to 11-F
C D venous line, the wide curve of the ICE catheter (which is
more suitable for adults), the inability to obtain a four-
chamber view (the ICE catheter sits in one of the four cham-
bers), and the added cost incurred by using the disposable
ICE catheters. The advantage of ICE is the ability to clearly
delineate IVC and superior rims.
Correct sizing of the device is crucial. It is strongly recom-
mended to measure the defect in three views if using TEE
and two views if using ICE (a four-chamber view is not
Figure 3. Intracardiac echocardiogram showing nearly obtainable by ICE). The ASD should be measured in four-
absent IVC rim in a patient with a large ASD. Caval (A) and chamber, short-axis, and bicaval views with TEE as outlined
short-axis (B) aortic views without color. Caval (C) and short- in Figures 4 and 5. With the use of ICE (Figure 6), short-axis
axis (D) aortic views with color. aortic and bicaval views are similar to the TEE views. A third
view by ICE is called the atrial view, which shows the superi-
Because the right atrial disc of the Amplatzer septal or rim (the rim between the aortic and the SVC rims) can
occluder device is 5 mm larger than the waist, it was be seen while rotating the probe from bicaval to short-axis
thought that atrial septal rims that are 5 mm in length view. Every effort should be made to ensure that there is no
should be adequate. However, there is no scientific study obstruction to surrounding structures such as AV valves,
supporting 5-mm rim adequacy. the right upper pulmonary vein, and coronary sinus after
If one were to use the Helex device, there are no known placement of the device.
criteria for atrial rim deficiency. The Helex is a non–self-cen- Once the patient is in the cardiac catheterization labora-
tering device. The nominal diameter of the device has to be tory, a complete right heart catheterization should be per-
twice the size of the balloon-stretched diameter of the ASD. formed on all patients. An arterial line is not typically need-
It should be determined whether there is a single defect ed. The catheter can be advanced into the left ventricle
or whether the atrial septum is fenestrated. In cases of mul- through the ASD for saturations and systemic pressures.
tiple defects, it is important to assess the septum separating Pulmonary vascular resistance is calculated if the pulmonary
the defects because the distance between the defects deter- artery pressures are high. If the patient has pulmonary
mines whether the patient will require more than one hypertension, right heart catheterization is performed on
device. Transthoracic echocardiography in the pediatric age room air and with consecutive administration of 100% oxy-
group is a useful tool prior to performing cardiac catheteri- gen, which may be followed by the addition of nitric oxide.
zation. The true delineation of the anatomy of the atrial sep- Some institutions use adenosine to determine reversibility
tum, its relationship to nearby structures, and pulmonary of increased pulmonary vascular resistance.12
A B C D E
A B C D E

Figure 4. Use of TEE for defect evaluation and device closure. ASD in short-axis aortic view (A). ASD in four-chamber view (B).
ASD with color flow in bicaval view (C). Short-axis aortic view after Amplatzer device placement (D). Bicaval view after
Amplatzer device placement (E).

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 STRUCTURAL CLOSURE

A B C

Figure 5. TEE standard views for evaluation of atrial septum. This patient has a PFO. Four-chamber view (A). Short-axis aortic
view (B). Bicaval view (C). The white arrow points toward the PFO type opening.

A B the defects are closed, an improved understanding of the

available devices and their limitations, and with echocardio-
graphic expertise of the interventionist. ■

Yolandee Bell-Cheddar, MD, is a third-year cardiology fellow

at the Rush Center for Congenital and Structural Heart
Disease, RUSH University Medical Center in Chicago, Illinois.
She has disclosed that she holds no financial interest related to
this article.
C D Zahid Amin, MD, FAAP, FSCAI, FACC, is Professor and
Director of Cardiac Hybrid Suites at Rush University Medical
Center in Chicago, Illinois. He has disclosed that he is a paid
consultant for St. Jude Medical, and that he receives
grant/research funding from Gore. Dr. Amin may be reached
at (312) 942-7496; zahid_amin@rush.edu.
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2006;68:778-787.
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the management of adults with congenital heart disease. A report of the American College of
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This patient has a tunnel type PFO. Caval view with and with- Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in
Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International
out color (A,B). Short-axis view with and without color (C,D). Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and
RA, right atrium; LA, left atrium. White arrow points toward Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2008;52:e1-121.
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the PFO opening. The measurement in A is the length of the septal defects. Catheter Cardiovasc Interv. 2002;57:246-251.
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PFO tunnel. patients with pulmonary hypertension and/or right heart failure. J Interv Cardiol. 2008;21:44-49.
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CONCLUSION 1987;76:1037-1042.
Device closure is one the most common procedures per- 6. King TD, Thompson SL, Steiner C, et al. Secundum atrial septal defect: nonoperative closure dur-
ing cardiac catheterization. JAMA. 1976;235:2506-2509.
formed in cardiac catheterization laboratories. The morbidi- 7. Podnar T, Martanovic P, Gavora P, et al. Morphological variations of secundum-type atrial septal
ty and mortality rates associated with this procedure should defects: feasibility for percutaneous closure using Amplatzer septal occluders. Catheter Cardiovasc
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be as low as possible, because technically, it is a simple pro- 8. Amin Z, Hijazi ZM, Bass JL, et al. Erosion of Amplatzer septal occluder devices after closure of
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2004;63:496-502.
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transesophageal echocardiography remains the gold standard. Pediatr Cardiol. 2005;26:128-134.
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brought down to a minimum with detailed and complete transcatheter closure of atrial septal defect. Am J Cardiology. 1990;66:207-213.
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52 I CARDIAC INTERVENTIONS TODAY I SEPTEMBER/OCTOBER 2011