Atrial Septal Defect (ASD) Surgery​ - Types, Benefits & Procedure

Atrial septal defect surgery can be performed using various techniques, depending on the type, size, location of the defect, and patient-specific factors. The primary goal of all approaches is to achieve permanent anatomical closure of the defect, thereby preventing long-term cardiac complications. The following are the types of ASD closure in adults:

• Transcatheter ASD closure (device-based)
• ASD open heart surgery
• Primary closure
• Patch closure
  
  

Transcatheter ASD closure (device-based)

This is a minimally invasive ASD closure where a self-expanding occluder device is delivered to the heart through a catheter inserted via the femoral vein, under echocardiographic and fluoroscopic guidance. Types of ASD closure devices include the Amplatzer Septal Occluder, Gore Cardioform Septal Occluder, and Amplatzer Cribriform device for multifenestrated defects.

This technique is most suitable for secundum-type ASDs with adequate surrounding septal rims (generally ≥5 mm) to ensure device stability. It is not recommended for primum or sinus venosus ASDs. In appropriately selected patients, transcatheter ASD closure has procedural success rates exceeding 95% and is associated with shorter hospital stay and faster recovery.

ASD open heart surgery

Surgical closure by open-heart surgery is a major form of ASD closure surgery in which the chest is opened, and the heart is repaired under cardiopulmonary bypass. This method is suitable for all types of ASDs, including primum ASD, sinus venosus ASD, large secundum ASD, and ASDs associated with other cardiac anomalies. This approach includes:

Primary closure: In this ASD closure is performed during open-heart surgery, where the defect is closed by directly suturing its edges. This technique is best suited for small ASDs, most commonly small secundum ASD or small primum ASD, provided there is sufficient septal tissue to allow tension-free closure. 

Patch closure: In this type of ASD closure, surgery is used for large ASDs with inadequate septal margins. It is especially suitable for large secundum ASD, primum ASD, and sinus venosus ASD. In this method, a patch made from pericardium or synthetic material is sewn over the defect to ensure complete closure without tension.

ASD closure indications

Atrial septal defect (ASD) closure is advised when the defect produces a significant hemodynamic burden or leads to clinical complications. The main clinical indications of ASD closure include:

• Primary surgical indications
• Hemodynamically significant shunt
• Right heart volume overload
• Symptoms attributable to ASD
• Recurrent respiratory tract infections
• Pulmonary hypertension with reversible pulmonary vascular resistance
• Additional indications
• Paradoxical embolism
• Atrial arrhythmias
• Prior to planned pregnancy in women with significant shunt
• Concomitant with other cardiac surgery
  
  

Primary surgical indications

Hemodynamically significant shunt

In an atrial septal defect, extra blood flows through a hole between the upper chambers of the heart. This makes the heart and lungs work harder than normal. Over time, this extra workload can damage the heart and lungs. Closing the hole stops this abnormal blood flow and protects the heart from long-term problems.

Right heart volume overload

Because of the extra blood passing through the hole, the right side of the heart has to handle more blood than normal. This causes the heart to stretch and enlarge. If left untreated, this can weaken the heart. Closing the ASD allows the heart to return toward normal size and function.

Symptoms attributable to ASD

Some people with ASD feel short of breath, get tired easily, or cannot exercise as much as others. These symptoms happen because the heart is not pumping blood efficiently. Closing the hole often improves energy levels, breathing, and overall quality of life.

Recurrent respiratory tract infections

In children, extra blood flow to the lungs can cause congestion, making them more prone to frequent chest infections. Closing the ASD reduces lung congestion, helps prevent repeated infections, and supports healthy growth and development.

Pulmonary hypertension with reversible pulmonary vascular resistance

Over time, extra blood flow can raise the pressure in the lung blood vessels. If this pressure rise is still reversible, closing the ASD can lower lung pressure and prevent permanent lung damage. 

Additional indications

Paradoxical embolism 

Sometimes, a blood clot that forms in the veins can pass through the hole in the heart and travel to the brain or other organs instead of going to the lungs. This can cause a stroke or sudden blockage of blood flow. Closing the ASD removes this pathway, preventing clots from crossing to the left side of the heart and greatly reducing the risk of future strokes.

Atrial arrhythmias

Long-standing ASD can stretch the upper chambers of the heart, which may lead to irregular heartbeats. These rhythm problems can cause palpitations, dizziness, fatigue, or even increase the risk of stroke.

Prior to planned pregnancy in women with large shunt

Pregnancy puts extra strain on the heart because blood volume grows dramatically. If a woman has a severe ASD, the additional workload might cause shortness of breath, arrhythmias, or cardiac failure during pregnancy. Closure ensures the heart's safety and also reduces risks to both the mother and the baby.

Concomitant with other cardiac surgery

If a person is already undergoing surgery for another heart problem, leaving an ASD open can allow ongoing strain on the heart. Since the chest is already open, it is safer to close the ASD at the same time.

Contraindications for ASD closure

In some clinical conditions, closing the defect may have little effect and may potentially exacerbate the patient's health by causing abrupt heart failure, worsening pulmonary hypertension, or increasing perioperative mortality. Therefore, identifying contraindications is important to ensure that ASD closure is performed only when the expected benefits clearly outweigh the risks.
Below are the contraindications of ASD heart surgery:

Absolute contraindications

• Eisenmenger syndrome
• Severe irreversible pulmonary arterial hypertension (PAH)
• Pulmonary vascular resistance above operable limits

Relative contraindications

• Hemodynamically insignificant ASD
• Severe left ventricular diastolic dysfunction
• Advanced age with long-standing ASD
• Active infection
• Severe comorbid illness with prohibitive surgical risk

Absolute contraindications

Eisenmenger syndrome

This represents an advanced stage of pulmonary vascular disease in which long-standing left-to-right shunting has led to chronic pulmonary hypertension and reversal or bidirectional shunt flow. In this situation, the ASD functions as a pressure-relief pathway for the right heart. Closing it can precipitate acute right ventricular failure, severe hypoxemia, and sudden death.

Severe irreversible pulmonary arterial hypertension (PAH)

When pulmonary arterial hypertension becomes irreversible, the right ventricle is unable to handle the sudden increase in pressure that follows ASD closure. Removing the shunt worsens right ventricular overload and can precipitate rapid right heart failure. 

Pulmonary vascular resistance above operable limits

When pulmonary vascular resistance is above operable limits, the pulmonary circulation cannot accommodate normal cardiac output after defect closure. In this case, removing the shunt increases pressure and workload on the right ventricle, significantly raising perioperative mortality and the risk of progressive right heart failure, which makes surgery unsafe.

Relative contraindications

Hemodynamically insignificant ASD

A small ASD that does not cause abnormal blood flow, right heart enlargement, or symptoms does not place stress on the heart or lungs. Closing such a defect provides no clinical benefit while exposing the patient to surgical risks. Therefore, surgery is unnecessary and contraindicated in these cases.

Severe left ventricular diastolic dysfunction

This is a contraindication because the ASD may act as a “pop-off” valve, which allows blood to move from the left atrium to the right atrium and prevents excessive rises in left-sided filling pressures. Closure in such patients can cause abrupt elevation of left atrial and pulmonary venous pressures.

Advanced age with long-standing ASD

Elderly patients with untreated ASD have irreversible heart and lung changes. In these cases, closure may not improve symptoms or survival and may increase perioperative risk.

Active infection

Cardiac surgery performed during active infection increases the risk of infectious complications, including sepsis and surgical site infection. ASD repair needs to be deferred until the infection is fully treated, making this a temporary contraindication.

Severe comorbid illness with prohibitive surgical risk

Patients with serious coexisting diseases like advanced lung disease, renal failure, malignancy, or severe frailty may not tolerate surgery safely. In these patients, the overall risk of surgery outweighs the potential benefits, making surgical intervention contraindicated.

Closing the defect through surgery corrects the underlying problem rather than just treating symptoms. By restoring normal blood flow, ASD closure allows the heart and lungs to recover, prevents future complications, and significantly improves both daily functioning and long-term health outcomes. Below are some of the advantages of an atrial septal defect surgery:

• Improved heart function
• Reduced risk of serious complications
• Alleviation of symptoms
• Improvement of exercise capacity 
• Improved life expectancy
• Resolves or reduces pulmonary hypertension
• Faster recovery and less pain with transcatheter closure compared to open surgery
  
  

Improved heart function

Closing an atrial septal defect can stop abnormal blood flow between the upper chambers of the heart. This reduces the extra workload on the right side of the heart, allowing it to function more efficiently. Over time, the enlarged heart chambers can return to their normal size, which improves overall heart performance.

Reduced risk of serious complications

An untreated ASD increases the risk of serious problems such as heart rhythm disturbances, stroke from blood clots, heart failure, and progressive lung disease. ASD closure removes the cause of these complications, which significantly lowers the risk of life-threatening events.

Alleviation of symptoms

Many patients with ASD generally report symptoms like shortness of breath, fatigue, palpitations, and decreased activity ability. Following surgery, blood circulation improves, oxygen supply increases, and symptoms frequently subside or go entirely.

Improvement of exercise capacity

Atrial septal defect surgery can help restore normal blood flow, alleviate right heart and pulmonary overload, and increase oxygen supply during exercise. As a result, patients have better exercise tolerance, less dyspnea and fatigue, and improved overall functional ability.

Improved life expectancy

By preventing long-term heart and lung damage, ASD closure helps patients live longer and healthier lives. Early correction, especially before permanent complications develop, greatly improves survival and long-term outcomes.

Resolves or reduces pulmonary hypertension

In patients with flow-related pulmonary hypertension, closing the ASD may reduce excess blood flow to the lungs. This can lower lung pressures, slow disease progression, and prevent irreversible damage to pulmonary blood vessels when performed at the appropriate time.

Faster recovery and less pain with transcatheter closure compared to open surgery

ASD closure catheterization avoids open-heart surgery. This approach results in smaller incisions, less pain, shorter hospital stays, rapid recovery, and faster return to normal activities, while providing the same long-term benefits as surgery.

Atrial septal defect closure may be performed either by transcatheter device closure (catheter-based) or by surgical ASD closure (open or minimally invasive surgery).

The steps vary depending on the approach.

Before ASD surgery

• Medical evaluation: To confirm the patient's fitness for atrial septal defect surgery, the cardiology team carries out a detailed preoperative evaluation. This includes a detailed clinical evaluation, and a review of cardiac procedures like ECG and echocardiography is used to determine the type, size, and location of the ASD, the direction and magnitude of the shunt, and right ventricular hypertrophy. Other diagnostic tests like chest X-ray, cardiac MRI, CT scan, or cardiac catheterisation are also performed.
• Assessment of procedure suitability: The cardiology team evaluates the patient to determine whether device closure or open surgical repair is appropriate.
• Pre-Anaesthesia Check-up: An anaesthesiologist evaluates the patient to ensure safe administration of general or local anaesthesia. Blood tests, kidney function tests, and infection screening are reviewed at this stage.
• Medication Review and Adjustments: Patients are advised to continue or stop certain medications before the procedure. Blood thinners, certain heart drugs, or herbal supplements may need temporary discontinuation.
• Informed Consent and Counselling: The cardiologist explains the procedure, benefits, possible risks, alternatives, and recovery expectations. Written informed consent is obtained after addressing the patient's and family's concerns.
  
  

During ASD surgery

• Administration of Anaesthesia and Monitoring: Patient is taken to the operating room, where identity and safety protocols are verified, and general anaesthesia is administered. An anaesthesia team monitors heart rhythm, blood pressure, oxygen levels, and body temperature. Sterile preparation and draping of the chest are performed.
• Surgical Access to the Heart: The surgeon accesses the heart through open-heart or minimally invasive approaches, depending on patient factors.
• Initiation of Cardiopulmonary Bypass: The surgeon connects the cardiopulmonary bypass (heart-lung) machine, which temporarily takes over circulation and oxygenation.
• Cardiac Arrest and Exposure of the Defect: The surgeon now administers cardioplegia solution to stop the heart. 
• Closure of the Atrial Septal Defect: During surgical ASD repair, if the defect is small, it may be closed directly using sutures. For larger defects or those with inadequate septal tissue, a patch made from the patient’s own pericardium or a biocompatible synthetic material is used.
• Transcatheter ASD Closure (MICS ASD closure): This is a catheter-based procedure and does not involve open-heart surgery, cardiopulmonary bypass, or cardiac arrest. An interventional cardiologist passes a catheter through a vein to the heart, and a closure device is deployed across the defect to seal it without open surgery. The device stays in place permanently and is gradually covered by heart tissue. 
• ASD closure open-heart surgery procedure: During open-heart surgery, the surgeon repairs the hole in the heart. If the defect is small, it can be closed directly with stitches. If the defect is larger, the surgeon uses a patch made from the patient’s own pericardium or a safe synthetic material to close it. The repair is done carefully to preserve valve function and normal heart conduction.
• Restoration of Heart Function: Surgeon removes air from the heart chambers to prevent embolism. The heart is gradually restarted, and the normal rhythm is restored.
• Weaning Off Cardiopulmonary Bypass: Once stable heart function is confirmed, the patient is slowly disconnected from the bypass machine. Blood pressure, oxygenation, and cardiac performance are closely assessed.
• Closure of the Chest: After the heart repair is complete, the surgeon places temporary wires and drainage tubes. The chest is closed with surgical wires.
  
  

After ASD surgery

• Immediate ICU Monitoring: After surgery, the patient is moved to the cardiac intensive care unit (ICU) for close monitoring. The medical team continuously checks the heart rhythm, blood pressure, oxygen levels, and urine output to ensure the heart and body are functioning well. A breathing machine is used to support breathing and is removed once the patient can breathe. 
• Pain Control and Supportive Care: Pain after surgery is controlled with appropriate medications to keep the patient comfortable. Chest tubes help drain any extra fluid from around the heart and lungs, and temporary pacing wires may be used if there are any changes in heart rhythm.
• Gradual Recovery and Mobilisation: As the heart and lungs recover and become more stable, the patient is encouraged to sit up, start walking, and slowly return to light activities. This helps to minimise complications like lung infections and blood clots.
• Medication and Infection Prevention: The doctor prescribes medications to prevent infection, alleviate pain, and support normal heart rhythm and function. 
• Follow-up and Long-term Care: An echocardiogram is performed to confirm successful closure of the defect. These regular follow-up visits are essential to monitor heart function and rhythm over the long term.
  

ASD closure is generally considered a safe and effective procedure with an excellent success rate. However, like any heart procedure or surgery, it may be associated with certain risks and complications. These can occur during the procedure, shortly after treatment, or rarely in the long term. The common ASD closure surgery complications are:

• Bleeding 
• Infection of the wound, bloodstream, or heart lining 
• Pain and inflammation around the chest incision or groin site
• Arrhythmias 
• Stroke or systemic embolism
• Pulmonary hypertension-related complications
  
  

Bleeding: Incisions made during open surgical repair might result in significant blood loss, requiring transfusions, whereas transcatheter procedures may cause hematoma or bleeding at femoral vein/artery puncture sites.

Infection of the wound, bloodstream, or heart lining: Infections may develop at the surgical incision or catheter entry site. Uncommonly, bacteria can enter the bloodstream, resulting to bacteraemia or infective endocarditis.

Pain and inflammation around the chest incision or groin site: Tissue trauma from an incision, muscle retraction, or vascular puncture can leads to local inflammation and post-operative pain.

Arrhythmias: Disturbances in atrial tissue or conduction pathways during closure can lead to rhythm issues. These sudden changes in atrial pressures after the atrial closure may also temporarily change the heart's electrical stability.

Stroke or systemic embolism: Any air bubbles, blood clots, or debris may enter the circulation during or shortly after the procedure, potentially travelling to the brain or other organs. Device-based closure carries less risk of thrombus formation.

Pulmonary hypertension-related complications: In patients with long-standing ASD and elevated pulmonary pressures, sudden closure can lead to acute right-heart strain or pulmonary vascular instability, especially if pulmonary hypertension is advanced or irreversible.

ASD closure recovery depends on the method used weather catheter-based device closure or surgical closure.

Recovery after catheter-based ASD closure

• Immediate recovery: Recovery after catheter-based ASD closure is usually fast, with a hospital stay of 24–48 hours. Mild groin discomfort, fatigue, or headache may occur for a few days.
• Short-term recovery: Normal daily activities are typically resumed within one week, while strenuous exercise is avoided for about 4–6 weeks. Antiplatelet therapy needs to be continued for several months.
• Long-term outcome: Patients show normalisation of right heart size and significant improvement in exercise tolerance over time.
  
  

Recovery after surgical ASD closure (open-heart repair)

• Immediate recovery: Hospital stays typically last 5–7 days and include a short period of ICU monitoring. Pain at the chest incision, temporary fatigue, and reduced stamina are common in the early postoperative period.
• Short-term recovery: During the first few weeks, patients gradually regain strength. Most are able to return to routine daily activities within 6–8 weeks as pain decreases and stamina improves.
• Long-term outcome: Complete recovery usually occurs over 2–3 months. Long-term outcomes are excellent, with low recurrence rates, marked symptom reduction, and very good survival once cardiac remodelling has taken place.
  

What questions can patients ask the healthcare team about atrial septal defect surgery?

• How long will the procedure take?
• What type of anaesthesia will be used?
• What are the possible risks or complications of ASD closure?
• Will closing the ASD improve my symptoms and quality of life?
• How long will I stay in the ICU and hospital?
• When can I return to normal activities, work, or school?
• Will I have pain after surgery, and how will it be managed?
• What medications will I need after surgery, and for how long?

Difference between ASD and VSD closure

Who is suitable for catheter-based ASD closure?

Catheter-based(transcatheter) ASD closure is suitable for patients with a secundum-type atrial septal defect located in the central part of the heart wall and with firm surrounding tissue to support a closure device. The defect size need to be within a safe range for device placement. Patients without other major heart defects and with normal lung blood pressure are ideal candidates. This method avoids open surgery and allows faster recovery in selected individuals.

What is ASD closure surgery?

ASD closure surgery is a medical procedure used to close an abnormal opening in the wall between the two upper chambers of the heart, called an atrial septal defect. The closure can be done using open-heart surgery or, more commonly, through a minimally invasive catheter-based device procedure. Closing the defect can help to prevent abnormal blood flow between heart chambers, reduce strain on the heart and lungs, and help prevent complications such as heart failure, abnormal heart rhythms, and stroke later in life.

Is ASD closure painful?

ASD closure surgery is generally not painful during the procedure because it is performed under anaesthesia. After catheter-based closure, discomfort is usually mild and limited to the groin area, where the tube was inserted. After surgical closure, some chest pain is expected for a few days, but is well controlled with pain medicines. Most patients experience manageable pain and recover comfortably with standard postoperative care and monitoring.

What medications are needed after ASD closure?

Following ASD closure, medications are frequently administered to avoid blood clots as the heart repairs. These often contain low-dose blood thinners for several months. Some patients may also receive short-term antibiotics around certain procedures to reduce infection risk. Analgesic medicines are given if needed. These medicines support safe healing of the closure site and reduce complications when taken as suggested by the treating cardiologist.

What is the success rate of ASD closure surgery?

Atrial septal defect closure surgery has a very high success rate when performed in appropriate patients, with successful defect closure in 95–98% of cases. Most patients experience complete sealing of the hole, improvement in heart size, and better exercise capacity. Serious complications and death are rare. However, the long-term outcomes are excellent with most individuals living a normal life after the surgery.

How many days in ICU after open-heart surgery?

After open-heart surgery, most adult patients stay in the intensive care unit (ICU) for almost 1 to 3 days. This period allows close monitoring of heart rhythm, blood pressure, breathing, and wound healing. Many patients are moved out of the ICU within 24 hours if recovery is stable. A longer ICU stay may be needed if there are complications, advanced age, or other medical conditions.

Does ASD repair improve quality of life?

Yes, atrial septal defect repair significantly improves quality of life by restoring normal heart function, reducing symptoms like fatigue and shortness of breath, and preventing long-term complications such as pulmonary hypertension and heart failure. Both surgical and transcatheter (device) closures show excellent long-term results, with patients often returning to normal, active lives within weeks.

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