[Atrial septal defects: problems in adults]

The clinical features of atrial septal defects in adults have changed due to the generalisation of surgery of the anomaly in childhood and the widespread use of transoesophageal echocardiography. Rare complications, such as paradoxical embolism or cerebral abscess, can now be more reliably attributed. Pulmonary hypertension, a feared traditional complication, is better understood: the severe form with right-to-left shunting (Eisen-menger's syndrome) occurs rarely in young adults, with a probable genetic predisposition; the less severe form, with persistence of a large left-to-right shunt is observed more often in adults over 50 years of age, and closure of the atrial septal defect remains beneficial over a long period of time. It has now been shown that this repair, even when performed late, improves symptoms but with less effect on atrial arrhythmias. Percutaneous closure is the treatment of choice and surgery is only considered after failure of endocavitary closure. The indication for closure of small atrial septal defects remains the subject of controversy.