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Zimmermann et al. Vessel Plus 2019;3:31 I http://dx.doi.org/10.20517/2574-1209.2019.010 Page 3 of 18

Figure 1. ASD locations. ASD: atrial septal defects

[13]
wellness sonograms . Furthermore, studies show referral to specialty services occurs at an earlier age
if subtle findings are detected on physical examination despite lack of symptoms. One such single center
[14]
retrospective study indicated the median age of diagnosis was 5 months of age . Areas of increasing
interest in pediatric management include predictors of spontaneous ASD closure. Many predictors of
spontaneous closure have been proposed; the longest held predictor appears to be size of the ASD at
time of detection with small defects (3-5 mm) having up to 87% closure rates and large defects (> 8 mm)
conferring much lower closure rates (0%-8%) [14-16] . Others suggest the use of patient age at time of detection
[17]
or normal weight gain after detection as clinical predictors for spontaneous ASD closure .

Adult populations with ASDs are typically asymptomatic with great variability in the onset of symptoms.
More common symptoms appear to be early onset atrial flutter or atrial fibrillation due to atrial stretch, and
[18]
less commonly decompensated right heart failure in patients under 40 years of age . The natural history
[19]
and subsequent prognosis were reported by Campbell with progressive worsening mortality approaching
90% by the 6th decade in patients with uncorrected defects.

Untreated atrial septal defect in the elderly
Elderly patients with hemodynamically significant defects more frequently encounter complications with
long-term adverse consequences such atrial arrhythmia, pulmonary hypertension, and atrioventricular
[20]
valvular insufficiencies related to chronic ventricular volume overload . These patients have comparatively
higher prevalence of co-morbid diseases including diabetes mellitus, stroke, systemic hypertension, chronic
lung diseases atherosclerosis and coronary heart diseases [21-23] . Longstanding left to right shunt at the atrial
level further results in a progressive atrial stretch and right ventricular dilatation which in turn eventually
[24]
leads to tricuspid insufficiency . The left heart may also be influenced by way of increased atrial pressure,
[6]
chronic volume under load, and co-morbid diseases like systemic hypertension or coronary heart disease .
Furthermore, chronic LV unloading due to the left to right shunt, and diastolic compression of left ventricle