Percutaneous Closure of Atrial Septal Defects With Bidirectional or Right‐to‐Left Shunts

Introduction Atrial septal defect (ASD) closure in patients with bidirectional or right‐to‐left shunts presents significant challenges regarding indications, procedure, and follow‐up. Methods We conducted a retrospective study on 47 patients undergoing percutaneous ASD closure with right‐to‐left or bidirectional shunts, analyzing clinical features, procedural details, and outcomes. Results Median age was 10.2 years (IQR: 6.2–14.1), and weight was 30.9 kg (20.8–50.4). Desaturation (89.4%) was the main indication, with bidirectional (48.9%) or fixed right‐to‐left shunts (40.4%). Eight patients (16%) were NYHA class III–IV. Diagnoses included pulmonary hypertension (12.8%), restrictive RV physiology (44%), RV outflow tract obstruction (27.7%), tricuspid regurgitation streaming (6.4%), and elevated RA pressure due to tricuspid valve stenosis (8.5%). Median NT‐pro‐BNP was 1155 pg/mL (827–1692). ASD size on TOE was 11 mm (7.2–14.7); balloon sizing and occlusion were used in 25.5% and 12.8%, respectively. RA and RV pressures remained stable post‐closure. First‐attempt closure succeeded in 81.1%, mostly with the Amplatzer Septal Occluder (65.9%), oversized by 4 mm. Three early deaths (6.4%) were recorded: 2 with RV failure and Potts shunt in pulmonary hypertension and one from device embolization causing a major stroke. Median hospital stay was 2 days. Over a median 4.7 years follow‐up (1.86–10.6), RV function was normal in 83.7%. Reintervention rates were 4.5% (percutaneous) and 11.3% (surgical). One late death and one transplantation occurred. Conclusions Percutaneous closure of atrial septal defects offers favorable outcomes even in high‐risk patients, despite inherent concerns. Careful patient selection and tailored procedural strategies are essential for optimizing results in this population at risk.