Clinical Practice Algorithm For the Follow-up of Unrepaired and Repaired Secundum Atrial Septal Defects

Quick Takes

  • This clinical practice algorithm for management of secundum atrial septal defects may be used as a decision support tool by clinicians.
  • Patients with incidentally diagnosed patent foramen ovale may often be discharged from cardiology care.
  • Most patients with unrepaired and repaired secundum atrial septal defects do not require annual visits and testing (though for the majority, periodic follow-up every few years is recommended).

Congenital heart disease (CHD) is one of the most common birth defects, present in approximately 1% of live births.1,2 Mildly complex lesions, including atrial septal defects (ASDs), ventricular septal defects, pulmonary stenosis, and patent ductus arteriosus comprise a significant percentage of these defects and require follow-up over time. There continues to be a significant lack of evidence-based guidelines to help cardiologists determine the frequency of follow-up and repeat testing in patients with CHD. Thus, there remains a wide variation in clinical practice even for the management of common types of CHD.

The goal of the CHD Clinical Practice Algorithms is to provide cardiologists and other providers who care for patients with CHD a decision support tool for mildly complex lesions both prior to or following catheterization or surgical-based interventions. These algorithms will help bridge the current knowledge gap that exists due to a lack of evidence-based guidelines and universal standard of care for CHD. These clinical practice algorithms are not intended to replace the independent medical or professional judgement of health care providers, which may vary from an individual case-by-case basis. Ultimately, the implementation of these clinical practice algorithms is aimed towards improvement in quality of care by reducing practice variation and promoting appropriate utilization of diagnostic testing and directed therapies leading to improved resource utilization. These guidelines are meant to be living documents that may be amended over time as evidence-based practice shifts.

Methods: Algorithm Development
The initial CHD Clinical Practice Algorithm for Patent Foramen Ovale and Secundum ASDs was derived by the Quality Working Group of the American College of Cardiology (ACC) Adult Congenital and Pediatric Cardiology (ACPC) member section. This is a multidisciplinary group of experienced pediatric and adult congenital cardiologists from diverse training and practice backgrounds. A quality-driven approach was used to translate the current evidence into best practice recommendations. Rigorous quality improvement methodology was used, including appropriate pre-work to identify desired outcomes, process measures, potential unintended consequences, and required stakeholders.3,4,5 The algorithm is evidence-based with lesion-specific references as outlined.6,7,8 Existing guidelines were utilized when applicable.9,10,11 The included secundum ASD clinical practice algorithm was subsequently peer reviewed.

Future Directions
The goal of the ACC ACPC Quality Working Group is to develop similar clinical practice algorithms for additional common and mildly complex CHD lesions including ventricular septal defects, isolated pulmonary stenosis, patent ductus arteriosus, and coarctation of aorta. As the group looks to expand its scope, additional multidisciplinary teams have been assembled from various practice background across the United States. A similar quality-driven process will be followed by each team, with the goal of developing additional high quality and easy to use algorithms.

Once these practice algorithms are available for wide-spread use, individual physicians and centers can use them to create their own internal quality improvement initiatives. It is this institutional-level use that will have the most impact on standardizing pediatric cardiology and adult CHD practice and improving quality outcomes and resource utilization. We anticipate that quality improvement projects that include Maintenance of Certification (MOC) part IV credit will stem from this work.


  1. Hoffman JIE, Kaplan S. The incidence of congenital heart disease. J Am Coll Cardiol 2002;39:1890-1900.
  2. Reller MD, Strickland MJ, Riehle-Colarusso T, Mahle WT, Correa A. Prevalence of congenital heart defects in Atlanta, 1998-2005. J Pediatr 2008;153:807-13.
  3. Langley G, Moen R, Nolan K, Nolan T, Norman C, Provost L, eds. The Improvement Guide. 2nd ed. San Francisco: Jossey-Bass; 2009.
  4. Anderson J, Verghese G, Lihn S, et al. Quality Improvement in Congenital Heart Disease. In: Wernovsky G, Anderson RH, Kumar K, Mussatto KA, Redington AN, Tweddell JS, Tretter JT, eds. Anderson's Pediatric Cardiology. 4th ed. Elsevier, 2019:1505-1518.
  5. Friedman KG, Rathod RH, Farias M, et al. Resource utilization after introduction of a standardized clinical assessment and management plan. Congenit Heart Dis 2010;5:374-81.
  6. Jalal Z, Hascoët S, Gronier C, et al. Long-term outcomes after percutaneous closure of ostium secundum atrial septal defect in the young: a nationwide cohort study. JACC Cardiovasc Interv 2018;11:795-804.
  7. Ziebell DS, Ghaleb S, Anderson J, Statile CJ. Resource utilization in pediatric patients with secundum atrial septal defects. Cardiol Young 2020;30:383-87.
  8. Alnasser S, Lee D, Austin PC, et al. Long term outcomes among adults post transcatheter atrial septal defect closure: systematic review and meta-analysis. Int J Cardiol 2018;270:126-32.
  9. Stout KK, Daniels CJ, Aboulhosn JA, et al. 2018 AHA/ACC guideline for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2019;73:1494-1563.
  10. ACC/AHA/ASE/HRS/ISACHD/SCAI/SCCT/SCMR/SOPE 2020 appropriate use criteria for multimodality imaging during the follow-up care of patients with congenital heart disease: a report of the American College of Cardiology Solution Set Oversight Committee and Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Pediatric Echocardiography. J Am Coll Cardiol 2020;75:657-703.
  11. Baumgartner H, De Backer J, Babu-Narayan SV, et al. 2020 ESC guidelines for the management of adult congenital heart disease: the task force for the management of adult congenital heart disease. Eur Heart J 2021;42:563-645.

Clinical Topics: Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and CHD and Pediatrics, Cardiac Surgery and VHD, Congenital Heart Disease, CHD and Pediatrics and Quality Improvement

Keywords: Aortic Coarctation, Ductus Arteriosus, Patent, Foramen Ovale, Patent, Process Assessment, Health Care, Quality Improvement, Standard of Care, Heart Defects, Congenital, Heart Septal Defects, Ventricular, Pulmonary Valve Stenosis, Algorithms, Evidence-Based Practice, Patient Care Team, Diagnostic Techniques and Procedures, Catheterization, Certification

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