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PubMed This is a summary of 21 peer-reviewed journal articles Updated
Cardiology

Treating the Connection: Observation, Devices, and Surgery

At a Glance

Treatment for an interatrial communication like an ASD or PFO depends on the hole's size and symptoms. Small holes often just need observation, while larger or symptomatic defects are treated with minimally invasive device closure or open heart surgery. Asymptomatic PFOs typically require no treatment.

Choosing a treatment path for an interatrial communication involves balancing the current strain on the heart with the long-term risks of stroke or heart failure. In many cases, the “standard of care” is dictated by the specific type of hole, its size, and whether it has already caused a complication [1][2].

The Decision Tree

While every patient is unique, doctors generally follow a structured approach to determine the next steps.

1. The Small ASD: “Wait and See”

If an Atrial Septal Defect (ASD) is small (often defined as less than 6mm) and the right side of the heart is a normal size, the standard of care is often observation [3][4].

  • The Goal: To see if the hole closes on its own (common in infants) or stays small enough that it never strains the heart [4][1].
  • The Follow-up: Periodic echocardiograms to ensure the right ventricle isn’t starting to stretch or enlarge [5].

2. The Significant Secundum ASD: Device Closure

When a secundum ASD is “clinically significant”—meaning it has caused the right side of the heart to enlarge or has a shunt ratio (Qp:Qs) greater than 1.5:1—the standard of care is closure [5][6].

  • Standard Method: Transcatheter Device Closure. A cardiologist threads a thin tube through a vein in the leg to place a permanent “plug” in the hole [7][8].
  • What to Expect: This is typically performed under mild sedation or general anesthesia. It takes a few hours, and patients usually stay overnight in the hospital for observation before going home the next day.
  • Benefits: It is less invasive than surgery, has a shorter recovery time, and carries a lower risk of complications like bleeding or infection [8][9].

3. The Complex ASD: Surgical Repair

Certain types of holes, such as Sinus Venosus or Primum ASDs, cannot be safely “plugged” with a catheter because they lack a surrounding rim of tissue to hold the device in place [10][11].

  • Standard Method: Open Heart Surgery. A surgeon uses a patch (made of your own tissue or medical-grade material) to seal the hole [12].
  • When it’s needed: This is required for complex anatomy, very large holes, or when the hole is associated with other heart issues that need direct repair [13][12].

4. The PFO: No Treatment, Medication, or Closure

The management of a Patent Foramen Ovale (PFO) is highly specific to the patient’s symptoms.

  • Asymptomatic PFO (No Treatment Needed): If a PFO is found incidentally and you have never had a stroke or TIA, no medical therapy is required. Taking daily blood thinners like aspirin is not recommended for an asymptomatic PFO, as it introduces unnecessary bleeding risks without clinical benefit [14].
  • Medical Management: For patients who have had a cryptogenic stroke (a stroke with no other clear cause) but are not candidates for closure (or opt out), doctors will prescribe blood thinners or antiplatelet drugs (like aspirin) to prevent clots [15][16].
  • PFO Closure: This is recommended for younger patients (typically under age 60) who have had a cryptogenic stroke and have high-risk PFO features, like a large shunt or an atrial septal aneurysm [15][14]. For these patients, closing the flap with a device prevents a second stroke more effectively than medication alone [7][17]. Note: If a stroke patient is over 60, the decision for closure is highly individualized based on overall health and other risk factors. Furthermore, doctors do not recommend closing a PFO solely for migraines.

Risks and Safety

While both device closure and surgery are highly successful, they carry different risks:

  • Device Risks: Rare complications include erosion (the device rubbing against the heart wall) or the device moving out of place (embolization) [12][18]. There is also a small risk of developing a temporary heart rhythm issue called atrial fibrillation shortly after the procedure [19].
  • Surgical Risks: These include standard surgical risks like infection, bleeding, or a longer recovery time [9].
  • Perioperative Concerns: If you have an uncorrected PFO and need surgery for something else (like a knee replacement), tell your surgical team. While the overall risk is low, there is a small potential for a “paradoxical stroke” during the recovery period after non-cardiac surgeries [20][21].

Return to the Home Page

Common questions in this guide

When does a small atrial septal defect (ASD) need to be treated?
Small ASDs, typically those measuring less than 6mm, often only require observation. Your doctor will monitor the defect with periodic echocardiograms to ensure the right side of the heart is not enlarging or becoming strained over time.
What is the standard treatment for a secundum ASD?
The standard of care for a significant secundum ASD is transcatheter device closure. A cardiologist places a permanent plug in the hole using a thin tube inserted through a vein in the leg, which avoids the need for open heart surgery.
Why might an ASD require open heart surgery instead of a catheter device?
Complex holes like sinus venosus or primum ASDs lack a surrounding rim of healthy tissue to hold a catheter plug in place safely. These specific defects require open heart surgery so a surgeon can securely seal the hole with a patch.
Do I need treatment for a PFO if I have no symptoms?
If a PFO is found incidentally and you have never had a stroke or mini-stroke (TIA), no medical treatment is needed. Taking daily blood thinners like aspirin is not recommended for an asymptomatic PFO because it introduces unnecessary bleeding risks.
What are the risks associated with device closure for an ASD or PFO?
While highly successful, rare risks of device closure include the device moving out of place or rubbing against the heart wall (cardiac erosion). There is also a small risk of developing a temporary heart rhythm issue like atrial fibrillation shortly after the procedure.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.Is this defect suitable for a catheter-based device closure, or are the anatomy and rims complex enough to require surgery?
  2. 2.If we choose observation, how often do we need repeat imaging to check for right heart enlargement?
  3. 3.For a PFO: What is my 'RoPE' score, and how does it help predict if my stroke was caused by the heart flap?
  4. 4.What are the specific risks of 'cardiac erosion' with the current device options, and how common is it?
  5. 5.How long will I be in the hospital for a catheter closure procedure, and what type of anesthesia is used?

Questions For You

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References

References (21)
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    Transcatheter closure of atrial septal defect: principles and available devices.

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This page provides educational information on ASD and PFO treatment options. Always consult your cardiologist to determine the best treatment plan for your specific heart anatomy and medical history.

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