Congenital ASD/VSD · Device Closure vs Surgery

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

🎓 Want to practice? Do a case challenge with this pathway → (get a case, choose management step by step, scored).

Full pathway

1. [Decision] Defect type + hemodynamics
   ASD or VSD? Significant shunt? Eisenmenger?
   • ASD: hemodynamically significant (right heart dilation, Qp:Qs >1.5), no severe pulmonary hypertension → Significant ASD · choose modality
   • VSD: significant left-to-right shunt (LV volume overload, Qp:Qs >1.5-2)/recurrent endocarditis/with AR → Significant VSD → mainly surgery
   • Established Eisenmenger (reversed shunt/severe irreversible pulmonary hypertension) → Eisenmenger → closure contraindicated
   • Small defect, hemodynamically insignificant → Small defect → observe
2. [End] Small defect → observe
   Small defect, no right heart dilation/asymptomatic → observe and follow up; most small muscular VSDs close spontaneously and small ASDs need no intervention.
3. [Decision] Significant ASD · choose modality
   ASD anatomic type?
   • Secundum type, adequate rims, suitable size → device closure → Secundum → device closure
   • Primum/sinus venosus type/inadequate rims/too large → surgical repair → Primum/sinus venosus → surgical repair
4. [End] Secundum → device closure
   Secundum ASD, adequate rims, suitable size → transcatheter device closure (minimally invasive, faster recovery).
5. [End] Primum/sinus venosus → surgical repair
   Primum/sinus venosus type/inadequate rims/too large → surgical repair (direct suture/patch); sinus venosus type often has partial anomalous pulmonary venous drainage requiring concurrent correction.
6. [End] Significant VSD → mainly surgery
   Significant VSD → mainly surgical patch repair; selected perimembranous/muscular with suitable anatomy may have device closure; with aortic valve prolapse/AR or doubly committed subarterial type → favor surgery.
7. [End] Eisenmenger → closure contraindicated
   Eisenmenger (severe irreversible pulmonary hypertension, reversed shunt) → closure/repair contraindicated; pulmonary hypertension targeted therapy + symptomatic care, evaluate for heart-lung transplant.

Source guidelines & references

• Adult congenital heart disease management (ESC 2020/AHA-ACC 2018; ASD/VSD device vs surgery)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

Other pathways