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The atrial septal defect: do we know everything?, ESC and the Association for European Paediatric Cardiology

ESC Congress Report

  • ASD is neither a pediatric nor an adult problem but a congenital lesion and lifelong disease with age-specific features.
  • ASD secundum type is the most common  intraatrial communication located in the fossa ovalis.
  • ASD is a low pressure shunt lesion and elevated pulmonary pressure  is not due to high resitance and does not necessarily mean pulmonary vascular disease.
  • ASD should be closed irrespective of age, transcatheter technique is first choice.

View the Slides from this session in ESC Congress 365

The session was focussed mainly on the secundum type ASD in respect to its clinical features and impact on the treatment, whatever technique used, with clear preference of transcatheter closure. The other intraatrial communications were also mentioned with their anatomical specification and best imaging technique.

As first speaker of the session Eero Jokinen (Helsinki,Finland) showed the differences in prevalence and clinical presentation of patients with an ASD in the pediatric and adult age group. He discussed the potential of spontanous closure of  >80% when the diameter is <6mm. Due to the low pressure – high flow nature of the lesion, the risk of developing pulmonary hypertension is low, <5% before the age of 20.
This increases after the age of 40 to 50%, but still with low resistance. Patients can be symptom-free through their sixties, before showing dyspnea and dysrhythmia. Closure is possible in about two-thirds of patients interventionally and will improve exercise capacity even in these, and PA-pressure will decrease in almost all.

Jan Marek (London, GB) first described the different types of intratarial communications of which the defects in the fossa ovale are about 75% and defined the surrounding structures and their importance for interventional closure. The most suitable imaging technique is still echocardiography: 2-dimensional and colour  doppler transthoracic echo for patient selection being precise in predicting success in > 90%, transesophageal approach during the procedure and 3-dimensional as advanced tool in selected cases. MRI is usefull in defining the more complex other locations and venous connections whereas CT might only be of use in defining pulmonary venous return.

Helmut Baumgartner (Münster, Germany) dealt with the elderly patient group, which proved to be somehow difficult to define due to a great variety in age distribution in the available studies. Overall it was shown that all patients >40 years old do benefit from closure, irrespective of which technique was used. There are even more surgical data for older patients. Age does matter for the significance of a positive outcome but even in the group >60 years the RV-size decreased significantly but PAP did not come down to normal. Persistance of atrial fibrillation is unlikely to be affected, whereas improvement of  paroxysmal arrhythmia is likely untill 55 years. If transcatheter closure is not possible surgery must be judged individually with respect to the comorbidity.

Markus Schwerzmann (Bern, Switzerland) demonstrated the difficulties in defining patients with elevated pulmonary pressure still eligible for closure. In congenital heart disease high pulmonary pressure does not necessarily go along with elevated pulmonary resistance or pulmonary vascular disease, and there is no technique to clearly prove the grade of PVD. The reported prevalence in ASD is 6-23%. With 2 cases he demonstrated the need for an intense work up to rule out other causes using also current medication and repeated hemodynamics. A cut-off point seems to be a PVR >8 WU and Qp::Qs:<1,5:1. With these numbers it is most likely that PVD is unchageable and closure is even harmful, whereas PVR <7 WU before closure showed positive outcome.




The atrial septal defect: do we know everything?, ESC and the Association for European Paediatric Cardiology

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.