ASD and VSD Closure, Antalya | Prof. Dr. Umuttan Doğan

Closing a hole in the heart means sealing an abnormal opening between its chambers with a device brought in on a catheter. It goes in through the vein in the groin; the chest is not opened and the heart is not stopped. There are two main kinds of hole: an ASD between the atria and a VSD between the ventricles. Not every hole can be closed this way, though. Suitability depends on the type of hole, where it is, and whether there is enough tissue around it.

What Does a Hole in the Heart Mean?

The heart has four chambers. The right side sends used blood returning from the body to the lungs; the left side sends fresh blood from the lungs out to the body. The two sides are separated by a wall.

If an opening is left in that wall from birth, blood mixes between the two sides. Because the pressure is higher on the left, fresh blood crosses to the right and an extra load falls on the lungs.

ASD (Atrial Septal Defect)

This is an opening in the wall between the atria. It is one of the commonest congenital heart defects seen in adults.

The difference in pressure there is low, so the flow across is slow. An ASD can therefore stay quiet for years and is often found in adulthood.

VSD (Ventricular Septal Defect)

This is an opening in the wall between the ventricles. The difference in pressure there is much higher, so a VSD usually shows itself in childhood and is picked up early.

A good proportion of small VSDs close by themselves during childhood. Those that reach adulthood call for an assessment of their own.

What Symptoms Do Adults Have?

Many people with an ASD have no symptoms at all into their thirties. The heart compensates for the load for a long time.

Breathlessness, on exertion at first and then with lighter activity
Tiring easily, with less capacity for exertion
Palpitations; rhythm disorders such as atrial fibrillation often go with an ASD
Swelling in the legs
Frequent chest infections
An unexplained stroke at a young age; a clot crossing through the hole can reach the brain

A murmur heard on examination, or an echocardiogram done for another reason, can be the first step towards the diagnosis.

How Is It Diagnosed?

Echocardiography: it shows the hole, its size and which way the blood is crossing. Whether the right-sided chambers have enlarged is assessed here.
An echo from the gullet: it shows exactly where the hole is, how big it is and the state of the tissue around it. Where a procedure is being planned, this is required.
ECG and rhythm assessment: whether a rhythm disorder is present as well.
Cardiac catheterisation: where needed, the pressure in the lung arteries is measured. In some patients this measurement decides the matter.

When Does a Hole Need Closing?

A hole on its own is not a reason to operate. Small openings that put no load on the heart may simply be followed.

Closure is considered in these situations:

Enlargement of the right-sided chambers; this is the most important measure
Symptoms such as breathlessness and limited exertion
A marked increase in the blood flow going to the lungs
A history of stroke thought to be due to a clot crossing through the hole
Recurring rhythm disorders

Can Every Hole Be Closed by Catheter?

No. This is the most important information on the page, and it is not explained well enough in most other sources.

The Question of Type in an ASD

A hole in the wall between the atria can sit in different places, and each position counts as a different type. Closure by catheter is possible only in a secundum ASD.

In primum, sinus venosus and coronary sinus defects, the structure of the wall does not suit a device holding on to it. Those types need surgical closure.

Only an echocardiogram can establish that distinction. The question “I have a hole in my heart, can it be closed without surgery?” cannot be answered without seeing the test.

Whether the Rims Are Adequate

The device used has two discs, which sit on either side of the hole. For a disc to rest properly there has to be enough sound tissue around the hole. That border is called the rim.

If one of the rims is thin or missing, the device will not sit securely, and surgery is considered. A hole that is very large can lead to the same conclusion.

When Closure Is Not Possible

One situation matters particularly: severely raised pressure in the lung arteries.

Where a hole has been open for many years, lasting changes can develop in the lung blood vessels and the pressure rises. Once it passes a certain level, the direction of flow reverses. Beyond that point, closing the hole brings no benefit and can be harmful, because the hole is now acting as a way of relieving pressure.

The pressure in the lungs therefore has to be assessed before the procedure. This is why finding a hole early and dealing with it in good time matters.

Other situations where it is not suitable:

ASD types other than secundum
Defects with inadequate rims, or that are very large
Other heart problems that have to be dealt with in the same session
An active infection

How Is an ASD Closure Carried Out?

The procedure goes in through the vein in the groin; no artery is entered.

Measuring. The true diameter of the hole is measured during the procedure and the size of device is chosen accordingly.
Placing the device. The folded double-disc device is advanced through a delivery sheath. The disc in the left atrium is opened first and rests against the wall; then the disc in the right atrium is opened. The hole is left between the two.
Confirming. Before the device is released, imaging checks that it is sitting securely and that no flow is left crossing. If it is not right, the device can be taken back and repositioned.

Imaging guidance throughout is essential. Either an echo from the gullet or intracardiac echocardiography is used for it. With the second, the probe is placed inside the heart, so a general anaesthetic may not be needed.

Closing a VSD: Why Is It Harder?

A VSD can be closed by catheter, but the choice of patients is far narrower than for an ASD. There are three reasons.

The difference in pressure is high. The device has to withstand the strong pressure between the ventricles.
The conduction pathways are close by. The heart’s electrical conduction system runs through a particular part of the wall. If the device presses on that area, a conduction problem can develop and a permanent pacemaker may be needed. This risk is discussed in detail beforehand.
Proximity to the aortic valve. Where the hole sits close to the aortic valve, the device may affect how that valve works.

VSDs that sit in the muscular part of the wall, with suitable rims and of moderate size, are therefore better suited to closure by catheter. In other situations surgery is considered.

Catheter or Surgery?

Both are in use, and neither is automatically the alternative to the other. The choice depends largely on the hole itself.

Closure by catheter: comes to the fore in a secundum ASD where the rims are adequate and the hole is a suitable size. The chest is not opened, recovery is short, and there is no incision on the arm or the chest.
Surgical closure: needed in types other than secundum, where the rims are inadequate, or where the hole is very large. Surgery is also preferred where another heart problem has to be corrected in the same session. The hole is closed with stitches or with a patch.

Your age, your symptoms, the pressure in your lungs and your other conditions all come into the decision. In complicated cases this assessment is made through a process in which cardiology and cardiac surgery give their views together.

One thing should be said plainly: the catheter method is not always the better option. A device forced into an anatomy that does not suit it causes more trouble than a well-performed operation. The hole decides the method, not preference.

How Do You Prepare?

The imaging is completed: an echo from the gullet establishes the type of hole, its size and its rims.
Your list of medicines: bring everything you take, with the doses. Your doctor decides how blood thinners are managed.
Dental check: because a permanent device is being placed in the heart, untreated dental infections are dealt with first. This step is often skipped.
Any history of allergy: say if you have a known sensitivity to contrast dye or to any metal.
Pregnancy: always say if you are pregnant or might be; X-rays are used during the procedure.

At the consultation beforehand the expected benefit, the possible risks and the alternatives are explained, and your written consent is taken.

How Long Does It Take, and When Do You Go Home?

An ASD closure usually takes around an hour. The structure of the hole, the choice of device and the imaging method can change that.

The choice of anaesthetic follows the imaging. If an echo from the gullet is to be used, the probe has to be swallowed and you have to stay still, so a general anaesthetic is given. If the imaging is done from inside the heart, local anaesthetic with light sedation may be enough.

Afterwards, pressure is applied at the access site in the groin and bed rest is advised for a period. Your rhythm and the position of the device are checked. Discharge is usually planned for the following day; the exact time depends on your situation.

A return to ordinary life comes quickly. For heavy exertion and contact sports, follow the period your doctor sets.

What Are the Possible Risks?

Bruising, bleeding or injury to the vessel at the access site
The device moving from its position; rare, and it may need to be retrieved
A small amount of flow left at the edge of the device; it usually lessens over time and is followed
Rhythm disorders; watched for particularly in VSD procedures, because of how close the conduction pathways are
Fluid collecting in the sac around the heart; rare, and drained if needed
Infection of the device; this is the reason for the dental and infection checks beforehand

The risks are weighed against the benefit expected from the procedure and discussed in detail for your own situation beforehand.

Afterwards: What Happens to the Device?

This section covers what patients most want to know and are told least about.

The device stays in the heart permanently; it does not need removing. In the early period its metal surface is in contact with the blood. Over the months the heart’s own inner lining grows over it and the device becomes part of the tissue.

Because of that process:

Blood-thinning treatment is given in the first months to prevent clot forming. Your doctor decides how long; do not stop it on your own.
During the same period, preventive antibiotics may be advised before dental treatment and some other procedures.
Echocardiography at set intervals checks the position of the device and whether the flow has closed off.
Activity is increased in stages.

If you notice a fever, palpitations, worsening breathlessness or swelling at the access site, see your doctor without waiting.

Closing a Hole in the Heart in Antalya

Prof. Dr. Umuttan Doğan is a cardiologist working in the interventional treatment of heart defects and in heart valve disease. ASD and VSD closure procedures are carried out in the catheter laboratory at Antalya American Hospital.

If your echocardiogram has shown a hole in the heart, you can be seen at the clinic in Konyaaltı with the results you already have. For the other procedures see the heart valve treatments page. You will find his background and contact details on their own pages.

Frequently Asked Questions

Does a hole in the heart always need closing?

No. Small holes that put no load on the heart may simply be followed. The most important measure in the decision is whether the right-sided chambers have enlarged. Your symptoms, the blood flow going to the lungs and your rhythm are weighed together.

Does the device stay in the heart for life?

Yes, it is permanent and does not need removing. Over the months the heart’s own inner lining grows over it and the device becomes one with the tissue. This is why blood-thinning treatment and precautions against infection are advised in the early period.

Will I be on medication permanently afterwards?

Usually not. A blood thinner is given in the first months to prevent clot forming. Your doctor decides how long for. If you have a separate condition such as atrial fibrillation, its treatment follows its own rules.

Can a hole in the heart close by itself?

A good proportion of small VSDs can close by themselves during childhood. With an ASD, a hole that has reached adulthood generally does not close by itself and calls for assessment.

Are an ASD and a PFO the same thing?

No. A PFO is a flap-like passage that everyone has before birth and that normally seals after it; in some people it does not seal completely. An ASD is a genuine absence of tissue in the wall. The two are assessed differently and the grounds for closing them differ.

The information on this page is for general guidance and does not replace a consultation. Decisions about diagnosis and treatment are made by your doctor after assessing your own situation.