Indications and Timing of Intervention for Common Congenital Heart Diseases (ASD)

Indications and Timing of Intervention for Common Congenital Heart Diseases

Atrial Septal Defect (ASD)

Diagnostic work-up:

Physical examination, ECG, X-ray chest, echocardiography, and cardiac catheterization (may need in select cases).

Types of Atrial septal defect:

Ostium secundum (~75%);

Ostium primum (15%-20%);

Sinus venosus (5%-10%); and

Coronary sinus (<1%). 

Patent foramen ovale:

Small defect in fossa ovalis region with a flap with no evidence of right heart volume overload. Diagnosed on echocardiography, is a normal finding in newborns. 

Indication for closure:

ASD with left-to-right shunt associated with evidence of right ventricular volume overload without evidence of irreversible pulmonary vascular disease.

Indications for ASD closure remain the same irrespective of the method of closure.

Contraindications for closure:

Severe pulmonary arterial hypertension or irreversible pulmonary vascular disease. 

Ideal Age of Closure Asymptomatic child:

2-4 years. For sinus venosus defect surgery may be delayed to 4-5 years.

Symptomatic ASD: Rarely seen in infants. Present with congestive heart failure, pulmonary arterial hypertension. Early closure is recommended after ruling out associated lesions such as left ventricular inflow obstruction, aortopulmonary window, total anomalous pulmonary venous drainage, etc.

If presenting beyond ideal age: Elective closure irrespective of age as long as there is left-to-right shunt with right heart volume overload and pulmonary vascular resistance is within operable range.

Method of Closure:

Surgical: Established mode.

Device: For secundum ASDs with adequate rims and weight of child >15kg.

Recommendations for Follow-up:

Follow-up after surgical closure: Clinical and echo in the first year only. No further follow-up required if no residual disease, no pulmonary hypertension or arrhythmia.

Patient/guardians should be explained about reporting to hospital in case of any cardiac symptoms, or symptoms suggestive of arrhythmias.

Follow-up after device closure:

(a) Anti-platelet agents for total duration of 6 months

(b) Echocardiography: - At discharge, 1 month, 6 months, 1 year, then every 3-5 years.

Infective endocarditis prophylaxis: It is recommended for 6 months after device or surgical closure. However, all patients are advised to maintain good oro-dental hygiene after this period also.