Q: Closure of atrial septal defect (ASD) is indicated in all of the following except?

A) Shunt causing right ventricular volume overload 
B) evidence of paradoxical emboli
C) Arrhythmias
D) Severe irreversible pulmonary hypertension 
E) Orthodeoxia-platypnea


Answer: ASD closure is indicated or at least suggested in most of the cases except severe irreversible pulmonary hypertension or Eisenmenger syndrome. Patients with severe irreversible pulmonary hypertension (defined as Pulmonary Vascular Resistance more than two-third of systemic vascular resistance) should not undergo ASD closure. This is for two reasons. First, these patients usually have lower life expectancy and risk of procedure may supercede benefit of closure. Second, maintenance of interatrial communication provides a mechanism to maintain cardiac output though at the expense of desaturation but in acceptable or rather advantageous way.


 Reference: 

 Baumgartner H, Bonhoeffer P, De Groot NM, et al. ESC Guidelines for the management of grown-up congenital heart disease (new version 2010). Eur Heart J 2010; 31:2915.