Atrial septal defect surgery

Atrial septal defect surgery: what it is and why a hole in the heart is closed

An atrial septal defect (ASD) is a hole in the wall, the septum, that separates the two upper chambers of the heart. Because pressure is higher on the left, some oxygen-rich blood flows through the hole into the right side and back to the lungs. Over many years this extra flow can enlarge the right side of the heart, raise pressure in the lung vessels and lead to breathlessness, tiredness, palpitations and atrial fibrillation. Atrial septal defect surgery closes the hole, either with a device passed through a vein or with a patch stitched in during open-heart surgery. Cardiology and cardiac surgery units in Turkey perform both, as part of the wider field of cardiology treatments in Turkey.

This guide explains which defects need closing, which method is used for which type, what it costs compared with the UK, US and Germany, how the hospital stay and recovery go and how to judge a heart team. It is information for adults; children with an ASD are managed by paediatric cardiology teams, and the decisions differ.

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Which type of atrial septal defect do you have?

The type decides the treatment. An echocardiogram, usually with a transoesophageal probe, shows where the hole is and how much rim of tissue surrounds it.

• Secundum ASD is the commonest type, in the middle of the septum. Many can be closed with a device.
• Primum ASD lies low in the septum and is often linked to a cleft in the mitral valve; it needs surgery.
• Sinus venosus defect lies near where the great veins enter the heart and is often linked to misplaced lung veins; it needs surgery.
• Coronary sinus defect is rare and also needs surgical repair.

A patent foramen ovale (PFO) is a different, smaller flap-like opening that many people have. It is not usually closed unless there has been a stroke with no other cause, so a PFO and an ASD should not be confused.

Does an ASD always need closing? What the evidence says

No. Small defects that cause no enlargement of the right heart and no symptoms are often watched with regular scans. Guidelines from cardiology societies in Europe and the United States advise closing a defect when there is a significant left-to-right shunt with enlargement of the right heart, or symptoms, and when lung pressures are not too high. Closure improves breathlessness and exercise capacity and stops the right heart enlarging; starting earlier gives fuller recovery of heart size, though adults of all ages can benefit. It does not cancel every risk: people who already had atrial fibrillation may still have it afterwards, and if lung pressures are severely raised, closure can be harmful, which is why an expert assessment is essential. A reliable clinic will review your echocardiogram and say honestly whether closing is advised.

How is an ASD closed: device or open surgery?

Device closure through a catheter

Under general anaesthesia or sedation, a cardiologist passes a catheter through a vein in the groin to the heart, using X-ray and ultrasound for guidance. A folding double-disc device is pushed across the hole and opened, so that one disc sits on each side of the septum and plugs it. There is no cut in the chest, the procedure takes about one to two hours and the hospital stay is short. It is possible only for suitable secundum defects with enough tissue rim, and the size must fit the device.

Surgical closure

A cardiac surgeon opens the right atrium and closes the hole directly with stitches or with a patch of the patient's own pericardium or synthetic material. The heart is stopped for a short time and the circulation is taken over by a heart-lung machine. The usual approach is through a breastbone incision; in selected patients smaller cuts at the side of the chest, or robotic assistance, are used. Surgery is required for primum, sinus venosus and coronary sinus defects, for large secundum defects with a weak rim, and when another heart operation is needed at the same time.

Atrial septal defect surgery cost in Turkey compared with the UK, US and Germany

The figures below are approximate ranges, not hospital quotes. The price depends on the type of closure, the device, the length of intensive care and ward stay, additional procedures and the hospital's category. Each hospital confirms its price in a written quote.

Device closure usually sits towards the lower part of the Turkish range and open surgery towards the upper part. A package normally includes the pre-operative tests, the procedure, anaesthetist and perfusion team, the intensive-care and ward stay, the device or patch, medication and transfers. Ask what happens to the price if the cardiologist starts with a device and finds that surgery is needed.

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Device closure or surgery: how do they compare?

Both closure methods are well established, and the question of which to use is mainly decided by the anatomy shown on the scan. Heart surgery is a major undertaking, but ASD repair is among the lower-risk open-heart operations. If you are comparing it with other cardiac procedures, such as replacement of the aortic valve, note that those address a different problem and usually involve a longer recovery.

Who is a good candidate, and who is not?

Closure is generally advised for people with a significant shunt and a dilated right heart, or symptoms such as breathlessness and palpitations, with lung pressures that are normal or only moderately raised. It is not advised, and may be dangerous, when severe pulmonary hypertension has led to a reversal of flow (Eisenmenger syndrome). Pregnancy planning, a history of stroke or a heart rhythm disorder affect timing and method, so share them with the team. The cardiologist will want your echocardiogram, ECG and any previous reports before agreeing to treat you.

Hospital stay and recovery after ASD closure

After device closure most patients stay one to three nights and walk the next day. Groin bruising is common, and normal activity resumes within about a week, although you are asked to avoid heavy lifting and contact sports for a few weeks and to take antiplatelet medication such as aspirin, often for six months. Antibiotic cover for dental work is advised for a time after device or patch placement.

After open surgery expect about one night in intensive care and five to seven days in hospital in total. The breastbone needs about six weeks to heal, during which you avoid lifting, pushing and driving; desk work is often possible after four to six weeks, and full activity after two to three months. Fatigue and chest wall soreness are common. Follow-up echocardiograms at one month, six months and then periodically confirm that the closure is complete.

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How long should you stay in Turkey?

For device closure plan about five to seven nights, including tests before the procedure, the hospital stay and a check-up before the flight. For open surgery plan about ten to fourteen nights, so the team can confirm that the wound, rhythm and fluid balance are stable. Air travel is usually allowed once the cardiologist has cleared you, normally about one to two weeks after surgery for device closure and longer after open surgery. Bring your earlier scans, ECGs and medication list, and arrange a cardiology review at home. Vascular problems such as varicose veins are a separate matter; for those see sclerotherapy of varicose veins.

Risks and complications of ASD closure

Any heart procedure carries risk. After device closure the recognised problems are groin bleeding or bruising, abnormal heart rhythms, device movement, a small residual leak, rarely a clot or erosion of heart tissue, and allergy to the metal, nickel in the device. After surgery the risks include bleeding, infection of the wound, fluid around the heart or lungs, rhythm disturbances in the early weeks, stroke and the general risks of anaesthesia and a heart-lung machine. Risk is generally low in people without other heart or lung disease. The British Heart Foundation, the NHS and the American Heart Association all emphasise assessment by a congenital heart specialist. Report chest pain, fever, breathlessness, fainting or a fast irregular heartbeat promptly.

How to choose a cardiac team and hospital, and red flags

Look for a hospital with a cardiology and cardiovascular surgery department, a catheter laboratory, a heart-lung machine, intensive care and a team that treats congenital heart conditions in adults. Ask for a written plan before you pay a deposit. Red flags include a quote without seeing your echocardiogram, a promise of a method before assessment, no named surgeon or cardiologist, and no plan for follow-up at home. Read how our process works and request a written plan through our free quote page.

Questions to ask the clinic:

• Is my defect suitable for a device, and what will you do if it is not?
• Are lung pressures measured before closure?
• How many ASD closures does the team perform each year?
• How many nights in intensive care and on the ward, and what does the price include?
• Who reviews my echocardiogram after I fly home?

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Conditions treated with Atrial Septal Defect Surgery

Hospitals with Cardiac Surgery in Turkey

Academic Hospital

Üsküdar, Istanbul

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Lokman Hekim Istanbul Hospital

Pendik, Istanbul

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