Transcatheter ASD Closure in a Bidirectional Cardiopulmonary Diagnostic Blind Spot: When Dyspnea Does Not Fit.

backgroundDyspnea in adults with secundum atrial septal defect (ASD) is often attributed to shunt physiology, whereas coexisting airway disease may remain unrecognized. Conversely, clinically significant ASD may be overlooked in patients presenting with predominant respiratory symptoms, creating a bidirectional cardiopulmonary diagnostic blind spot. CASE SUMMARY: We retrospectively identified 8 adults (median age 55.5 years; 5 women) with secundum ASD (15-30 mm) and clinically significant airway disease through bidirectional cardiology-pulmonology referral (6 cardiology-to-pulmonology; 2 pulmonology-to-cardiology). Airway physiology was obstructive in 6, restrictive in 1, and mixed in 1, with bronchodilator reversibility in 5. Integrated cardiopulmonary evaluation and respiratory optimization improved symptom attribution and guided individualized management. Seven patients underwent transcatheter ASD closure (median device size, 38 mm), including fenestrated closure in 2 after balloon occlusion testing identified impaired left ventricular compliance; 1 deferred closure after symptomatic improvement with respiratory therapy alone. No procedural complications occurred, and 1 noncardiac death occurred 5 years after intervention. TAKE-HOME MESSAGES: Dyspnea in adults with ASD may reflect combined cardiac and airway disease. Disproportionate symptoms should prompt integrated cardiopulmonary evaluation. Accurate symptom attribution underpins respiratory optimization and individualized ASD closure.