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Zimmermann et al. Vessel Plus 2019;3:31 I http://dx.doi.org/10.20517/2574-1209.2019.010 Page 13 of 18

concept of device-in-device salvage involves deploying a second device through residual defects the first
device did not completely close, in order to provide an adequate seal zone the first device did not provide.
These early reports may eventually become the foundational principals for guidelines to prevent conversion
to open surgery, but no definitive conclusions can be drawn with such limited data. Likewise, residual
shunts following surgical repair of ASDs may be of great interest in the case of secundum ASDs.

GENE THRAPY, TISSUE ENGINEERING, AND STEM CELL THERAPY FOR ASD
The goals of treatment in congenital cardiac malformations are ever shifting. Seventy-five years ago,
researchers and clinicians sought to find appropriate screening criteria where risk factors for ASDs were
poorly understood. With the advent of better screening methods and guidelines, the difficult decision of
who should undergo surgery or medical management then became the diagnostic dilemma. With newer,
safer, conventional and endovascular procedures well established, the next logical progression in the field
is primary prevention of the disease process. Several reports proposing genes associated with ASD that
may inform progress toward potential targets for gene therapy in genetically linked variants of ASD [140-142] .
Furthermore, elucidating the temporal and spatial relationships among terminally differentiating cells
during cardiogenesis may provide further insight into the precise moment in congenital defects begin [143,144] .

Until primary prevention with gene therapy is technically feasible, other interventions may be on the
horizon. Tissue compatibility of ASD closure devices remains an area of interest for researchers and
clinicians alike. Biocompatible and bioabsorbable based devices are currently under investigation [145] . Those
at the beginning of their surgical career may see 3D printed custom devices or bio inspired devices in the
form of surgical glue or gels that can be deployed endovascularly emerge within their career [54,146-148] .

DECLARATIONS
Acknowledgments
Marguerite Zimmermann, MSN was responsible for creating the artwork contained in this article.

Authors’ contributions
Made substantial contributions with initial draft, subsequent revisions, and approved final draft:
Zimmermann E, Hussain H, Avgerinos D
Made substantial contributions with subsequent revisions and approval of final draft:
Worku B, Dougenis D

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.

Consent for publication
Not applicable.

Copyright
© The Author(s) 2019.