ASD Diameter Indexed to Total Septal Length Outperforms Expert Opinion in Predicting Future Candidacy for...

Percutaneous device closure is an attractive alternative to surgical closure of secundum atrial septal defects (ASDs) for those with suitable anatomy and size. Early surgery (< 2 years of age) allows for a more feasible "mini sternotomy" technique, while device closure is more commonly performed at an older age. Thus, the ability to predict future device-closure candidacy before 2 years of age is needed. Secundum ASD closures after 3 years of age from 2012 to 2023 at a single center were reviewed (n = 54). "Early" echocardiograms (obtained at 12-24 months of age) and "pre-intervention" echocardiograms (the last echo obtained prior to closure and after 36 months of age) for each patient were independently reviewed by echocardiographers who performed standardized measurements. The catheterization team reviewed the same echocardiograms and made recommendations on device closure candidacy. Reviewers were blinded to the paired echocardiograms and eventual interventions. There was moderate agreement in perceived device candidacy by catheterization team consensus between early and pre-intervention echocardiogram (Cohen's Kappa = 0.56, p < 0.001). In a multivariable model, the ratio of maximum ASD diameter indexed to total septal length (ASD/TSL) between 1 and 2 years of age was strongly predictive of eventual perceived candidacy for device closure (Area Under the Curve = 0.92, sensitivity 89%, specificity 89% at the optimal threshold of 0.46) outperforming expert consensus (sensitivity 81%, specificity of 77%). Patients with ASD/TSL < 0.46 on early echocardiograms are likely to be considered device candidates later in life.