Percutaneous Closure of Atrial Septal Defects With Bidirectional or Right-to-Left Shunts

Atrial septal defect (ASD) closure in patients with bidirectional or right-to-left shunts presents significant challenges regarding indications, procedure, and follow-up.

We conducted a retrospective study on 47 patients undergoing percutaneous ASD closure with right-to-left or bidirectional shunts, analyzing clinical features, procedural details, and outcomes.

Median age was 10.2 years (IQR: 6.2-14.1), and weight was 30.9 kg (20.8-50.4). Desaturation (89.4%) was the main indication, with bidirectional (48.9%) or fixed right-to-left shunts (40.4%). Eight patients (16%) were NYHA class III-IV. Diagnoses included pulmonary hypertension (12.8%), restrictive RV physiology (44%), RV outflow tract obstruction (27.7%), tricuspid regurgitation streaming (6.4%), and elevated RA pressure due to tricuspid valve stenosis (8.5%). Median NT-pro-BNP was 1155 pg/mL (827-1692). ASD size on TOE was 11 mm (7.2-14.7); balloon sizing and occlusion were used in 25.5% and 12.8%, respectively. RA and RV pressures remained stable post-closure. First-attempt closure succeeded in 81.1%, mostly with the Amplatzer Septal Occluder (65.9%), oversized by 4 mm. Three early deaths (6.4%) were recorded: 2 with RV failure and Potts shunt in pulmonary hypertension and one from device embolization causing a major stroke. Median hospital stay was 2 days. Over a median 4.7 years follow-up (1.86-10.6), RV function was normal in 83.7%. Reintervention rates were 4.5% (percutaneous) and 11.3% (surgical). One late death and one transplantation occurred.

Percutaneous closure of atrial septal defects offers favorable outcomes even in high-risk patients, despite inherent concerns. Careful patient selection and tailored procedural strategies are essential for optimizing results in this population at risk.