Optimal treatment choices for adult atrial septal defects: the role of appropriate risk stratification.

INTRODUCTION

Adult atrial septal defect (ASD) is no longer regarded as a benign congenital lesion, as long-term follow-up studies have demonstrated substantial risks of atrial arrhythmias, heart failure (HF), pulmonary hypertension (PH), and excess mortality. Optimal treatment selection in adults therefore requires risk stratification beyond defect size and shunt magnitude alone. Importantly, adult ASD management increasingly demands a physiology-driven and patient-centered approach rather than a purely anatomical paradigm.

AREAS COVERED: This narrative expert review summarizes contemporary evidence on treatment strategies for adult ASD, focusing on surgical and transcatheter closure and the role of individualized risk stratification. A structured literature search was performed using PubMed and Embase databases, covering studies published up to 2024, including observational cohorts, registry data, and guideline documents addressing long-term outcomes, timing of intervention, and predictors of adverse events in adult ASD populations.

EXPERT OPINION: Risk-based decision-making should be central to adult ASD management, integrating age, atrial arrhythmia burden, right ventricular (RV) remodeling, pulmonary vascular disease, and comorbidities This review translates existing evidence into a practical decision-oriented framework. Future strategies should move away from a 'one-size-fits-all' closure approach toward personalized treatment pathways within specialized adult congenital heart disease (ACHD) programs.