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ASD Closure with Pulmonary Hypertension — EECC MCQ

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HardCongenital Heart Disease (Adult)ASD Closure with Pulmonary HypertensionEECC

A 55-year-old woman with a large ASD and mild PAH (mPAP 28 mmHg, PVR 2.8 WU) is assessed for closure. During balloon test occlusion of the ASD, her PA pressure rises to 38 mmHg and she develops breathlessness. What does this indicate?

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Reveal the answer and explanation

Correct answer: C — The ASD may be acting as a pressure relief valve for the RV; closure could worsen pulmonary hypertension and RV failure — further assessment including exercise haemodynamics is needed before deciding on closure

In patients with an ASD and elevated PVR, temporary balloon occlusion testing during cardiac catheterisation helps predict the haemodynamic consequences of ASD closure. A significant rise in PA pressure and/or fall in cardiac output during balloon occlusion suggests that the ASD is functioning as a 'pop-off' valve, allowing left-to-right shunting that decompresses the RV. Closing the ASD in this scenario could cause acute RV failure and worsening PH. The 2020 ESC ACHD Guidelines recommend careful haemodynamic assessment including exercise haemodynamics in borderline cases. PVR >5 WU or net right-to-left shunting are generally contraindications to closure. For borderline cases (PVR 2.3-5 WU), treat-and-close strategies (PAH-specific therapy to reduce PVR, followed by reassessment) may be considered.

Reference: ESC (2020): ACHD Guidelines