• Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA, del Nido P, Fasules JW, Graham TP, Hijazi ZM, Hunt SA, King ME, Landzberg MJ, Miner PD, Radford MJ, Walsh EP, Webb GD, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Antman EM, Buller CD, Creager MA, Ettinger SM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura RA, Page RL, Riegel B, Tarkington LG, Yancy CW. Atrial septal defect. In: ACC/AHA 2008 guidelines for the management of adults with congenital heart disease. J Am Coll Cardiol 2008;52(23):e173-78.

This is the current release of the guideline.

The guidelines will be reviewed annually by the American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Practice Guidelines and considered current unless they are updated, revised, or withdrawn from distribution.

• Adult congenital heart disease
• Atrial septal defect

Diagnosis
Evaluation
Management
Risk Assessment
Treatment

Cardiology
Family Practice
Internal Medicine
Radiology
Thoracic Surgery

Health Care Providers
Physicians

• To assist healthcare providers in clinical decision making by describing a range of generally acceptable approaches for diagnosis, management, and prevention of specific diseases or conditions associated with adult congenital heart disease (ACHD)
• To define practices that meet the needs of most patients in most circumstances
• To support the practicing cardiologist in the care of ACHD patients by providing a consensus document that outlines the most important diagnostic and management strategies and indicates when referral to a highly specialized center is appropriate

Adults with congenital heart disease and suspected or confirmed atrial septal defects

Evaluation of the Unoperated Patient

1. Clinical examination for signs of atrial septal defect (ASD)
2. Imaging studies (e.g., electrocardiogram, chest x-ray, echocardiography, magnetic resonance imaging)
3. Maximal exercise testing
4. Cardiac catheterization

Management Strategies

Medical Therapy

1. Cardioversion after appropriate anticoagulation
2. Rate control and anticoagulation

Interventional and Surgical Therapy

1. Percutaneous or surgical closure of the ASD
2. Concomitant maze procedure for intermittent or chronic atrial tachyarrhythmias in adults

Postintervention Follow-Up

1. Evaluation for postpericardiotomy syndrome with tamponade
2. Annual clinical follow-up in defined patient subgroups
3. Evaluation for possible device migration, erosion, or other complications

Reproduction

Discouragement of pregnancy in patients with ASD and severe pulmonary artery hypertension (PAH) (Eisenmenger syndrome)

• Utility of diagnostic tests
• Rate of false-positive and false-negative diagnoses
• Mortality
• Complications of surgery
• Pregnancy-related maternal and fetal mortality

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Unlike other American College of Cardiology/American Heart Association (ACC/AHA) practice guidelines; there is not a large body of peer-reviewed published evidence to support most recommendations, which will be clearly indicated in the text. An extensive literature survey was conducted that led to the incorporation of 647 references. Searches were limited to studies, reviews, and other evidence conducted in human subjects and published in English. Key search words included but were not limited to adult congenital heart disease (ACHD), atrial septal defect, arterial switch operation, bradycardia, cardiac catheterization, cardiac reoperation, coarctation, coronary artery abnormalities, cyanotic congenital heart disease, Doppler-echocardiography, d-transposition of the great arteries, Ebstein's anomaly, Eisenmenger physiology, familial, heart defect, medical therapy, patent ductus arteriosus, physical activity, pregnancy, psychosocial, pulmonary arterial hypertension, right heart obstruction, supravalvular pulmonary stenosis, surgical therapy, tachyarrhythmia, tachycardia, tetralogy of Fallot, transplantation, tricuspid atresia, and Wolff-Parkinson-White. Additionally, the writing committee reviewed documents related to the subject matter previously published by the ACC and AHA. References selected and published in this document are representative and not all-inclusive.

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Applying Classification of Recommendations and Level of Evidence

		SIZE OF TREATMENT EFFECT
		CLASS I Benefit >>> Risk Procedure/Treatment SHOULD be performed/administered	CLASS IIa Benefit >> Risk Additional studies with focused objectives needed IT IS REASONABLE to perform procedure/administer treatment	CLASS IIb Benefit > Risk Additional studies with broad objectives needed; additional registry data would be helpful Procedure/Treatment MAY BE CONSIDERED	CLASS III Risk > Benefit Procedure/Treatment should NOT be performed/administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFUL
Estimate of Certainty (Precision) of Treatment Effect	LEVEL A Multiple population evaluated* Data derived from multiple randomized clinical trials or meta-analyses	Recommendation that procedure or treatment is useful/effective Sufficient evidence from multiple randomized trials or meta-analyses	Recommendation in favor of treatment of procedure being useful/effective Some conflicting evidence from multiple randomized trials or meta-analyses	Recommendation's usefulness/efficacy less well established Greater conflicting evidence from multiple randomized trials or meta-analyses	Recommendation that procedure or treatment is not useful/effective and may be harmful Sufficient evidence from multiple randomized trials or meta-analyses
	LEVEL B Limited population evaluated* Data derived from a single randomized clinical trial or nonrandomized studies	Recommendation that procedure or treatment is useful/effective Evidence from single randomized trial or nonrandomized studies	Recommendation in favor of treatment of procedure being useful/effective Some conflicting evidence from single randomized trial or nonrandomized studies	Recommendation's usefulness/efficacy less well established Greater conflicting evidence from single randomized trial or nonrandomized studies	Recommendation that procedure or treatment is not useful/effective and may be harmful Evidence from single randomized trial or nonrandomized studies
	LEVEL C Very limited population evaluated* Only consensus opinion of experts, case studies or standard of care.	Recommendation that procedure or treatment is useful/effective Only expert opinion, case studies, or standard-of-care	Recommendation in favor of treatment of procedure being useful/effective Only diverging expert opinion, case studies, or standard-of-care	Recommendation's usefulness/efficacy less well established Only diverging expert opinion, case studies, or standard-of-care	Recommendation that procedure or treatment is not useful/effective and may be harmful Only expert opinion, case studies, or standard-of-care

*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as gender, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Even though randomized trials are not available, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.

Note: In 2003, the American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Practice Guidelines developed a list of suggested phrases to use when writing recommendations. All guideline recommendations have been written in full sentences that express a complete thought, such that a recommendation, even if separated and presented apart from the rest of the document (including headings above sets of recommendations), would still convey the full intent of the recommendation. It is hoped that this will increase readers' comprehension of the guidelines and will allow queries at the individual recommendation level. (See Table 1 in the original guideline document for a list of suggested phrases for writing recommendations.)

Systematic Review

The committee reviewed and ranked evidence supporting current recommendations with the weight of evidence ranked as Level A if the data were derived from multiple randomized clinical trials involving a large number of individuals. The committee ranked available evidence as Level B when data were derived from a limited number of trials involving a comparatively small number of patients or from well-designed data analyses of nonrandomized studies or observational data registries. Evidence was ranked as Level C when the consensus of experts was the primary source of the recommendation. In the narrative portions of these guidelines, evidence is generally presented in chronological order of development. Studies are identified as observational, randomized, prospective, or retrospective. The committee emphasizes that for certain conditions for which no other therapy is available, the indications are based on expert consensus and years of clinical experience and are thus well supported, even though the evidence was ranked as Level C. An analogous example is the use of penicillin in pneumococcal pneumonia where there are no randomized trials and only clinical experience. When indications at Level C are supported by historical clinical data, appropriate references (e.g., case reports and clinical reviews) are cited if available. When Level C indications are based strictly on committee consensus, no references are cited. The final recommendations for indications for a diagnostic procedure, a particular therapy, or an intervention in adult congenital heart disease (ACHD) patients summarize both clinical evidence and expert opinion. The schema for classification of recommendations and level of evidence illustrates how the grading system provides an estimate of the size of treatment effect and an estimate of the certainty of the treatment effect (see "Rating Scheme for the Strength of the Evidence" above).

Expert Consensus

The American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Practice Guidelines was formed to create clinical practice guidelines for select cardiovascular conditions with important implications for public health. This guideline writing committee was assembled to adjudicate the evidence and construct recommendations regarding the diagnosis and treatment of adult congenital heart disease (ACHD). Writing committee members were selected with attention to ACHD subspecialties, broad geographic representation, and involvement in academic medicine and clinical practice. The writing committee included representatives of the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.

Writing committees are specifically charged to perform a formal literature review, weigh the strength of evidence for or against particular treatments or procedures, and include estimates of expected health outcomes where data exist. Patient-specific modifiers, comorbidities, and issues of patient preference that might influence the choice of tests or therapies are considered, as well as the frequency of follow-up and cost-effectiveness. When available, information from studies on cost is considered, but data on efficacy and clinical outcomes constitute the primary basis for recommendations in these guidelines.

See "Rating Scheme for the Strength of the Evidence" field, above.

A formal cost analysis was not performed and published cost analyses were not reviewed.

External Peer Review
Internal Peer Review

This document was reviewed by 3 external reviewers nominated from both the American College of Cardiology (ACC) and the American Heart Association (AHA), as well as reviewers from the American Society of Echocardiography, Canadian Cardiovascular Society, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, and Society of Thoracic Surgeons, and 20 individual content reviewers which included reviewers from the ACC Congenital Heart Disease and Pediatric Cardiology Committee and the AHA Congenital Cardiac Defects Committee. All reviewer relationships with industry information were collected and distributed to the writing committee and are published in the original guideline document (see the "Conflicts of Interest/Financial Disclosures" field in this document).

This document was approved for publication by the governing bodies of the American College of Cardiology Foundation (ACCF) and the AHA and endorsed by the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.

The American College of Cardiology/American Heart Association (ACC/AHA) classification of the recommendations for patient evaluation and treatment (classes I-III) and the levels of evidence (A-C) are defined at the end of the "Major Recommendations" field.

Recommendations for Evaluation of the Unoperated Patient

Class I

1. Atrial septal defect (ASD) should be diagnosed by imaging techniques with demonstration of shunting across the defect and evidence of right ventricular (RV) volume overload and any associated anomalies. (Level of Evidence: C)
2. Patients with unexplained RV volume overload should be referred to an adult congenital heart disease (ACHD) center for further diagnostic studies to rule out obscure ASD, partial anomalous venous connection, or coronary sinoseptal defect. (Level of Evidence: C)

Class IIa

1. Maximal exercise testing can be useful to document exercise capacity in patients with symptoms that are discrepant with clinical findings or to document changes in oxygen saturation in patients with mild or moderate pulmonary arterial hypertension (PAH). (Level of Evidence: C)
2. Cardiac catheterization can be useful to rule out concomitant coronary artery disease in patients at risk because of age or other factors. (Level of Evidence: B)

Class III

1. In younger patients with uncomplicated ASD for whom imaging results are adequate, diagnostic cardiac catheterization is not indicated. (Level of Evidence: B)
2. Maximal exercise testing is not recommended in ASD with severe PAH. (Level of Evidence: B)

Management Strategies

Recommendations for Medical Therapy

Class I

1. Cardioversion after appropriate anticoagulation is recommended to attempt restoration of the sinus rhythm if atrial fibrillation occurs. (Level of Evidence: A)
2. Rate control and anticoagulation are recommended if sinus rhythm cannot be maintained by medical or interventional means. (Level of Evidence: A)

Recommendations for Interventional and Surgical Therapy

Class I

1. Closure of an ASD either percutaneously or surgically is indicated for right atrial and RV enlargement with or without symptoms. (Level of Evidence: B)
2. A sinus venosus, coronary sinus, or primum ASD should be repaired surgically rather than by percutaneous closure. (Level of Evidence: B)
3. Surgeons with training and expertise in CHD should perform operations for various ASD closures. (Level of Evidence: C)

Class IIa

1. Surgical closure of secundum ASD is reasonable when concomitant surgical repair/replacement of a tricuspid valve is considered or when the anatomy of the defect precludes the use of a percutaneous device. (Level of Evidence: C)
2. Closure of an ASD, either percutaneously or surgically, is reasonable in the presence of:
   1. Paradoxical embolism. (Level of Evidence: C)
   2. Documented orthodeoxia-platypnea. (Level of Evidence: B)

Class IIb

1. Closure of an ASD, either percutaneously or surgically, may be considered in the presence of net left-to-right shunting, pulmonary artery pressure less than two thirds systemic levels, pulmonary vascular resistance (PVR) less than two thirds systemic vascular resistance, or when responsive to either pulmonary vasodilator therapy or test occlusion of the defect (patients should be treated in conjunction with providers who have expertise in the management of pulmonary hypertensive syndromes). (Level of Evidence: C)
2. Concomitant Maze procedure may be considered for intermittent or chronic atrial tachyarrhythmias in adults with ASDs. (Level of Evidence: C)

Class III

1. Patients with severe irreversible PAH and no evidence of a left-to-right shunt should not undergo ASD closure. (Level of Evidence: B)

Recommendations for Postintervention Follow-Up

Class I

1. Early postoperative symptoms of undue fever, fatigue, vomiting, chest pain, or abdominal pain may represent postpericardiotomy syndrome with tamponade and should prompt immediate evaluation with echocardiography. (Level of Evidence: C)
2. Annual clinical follow-up is recommended for patients postoperatively if their ASD was repaired as an adult and the following conditions persist or develop:
   1. PAH. (Level of Evidence: C)
   2. Atrial arrhythmias. (Level of Evidence: C)
   3. RV or LV dysfunction. (Level of Evidence: C)
   4. Coexisting valvular or other cardiac lesions. (Level of Evidence: C)
3. Evaluation for possible device migration, erosion, or other complications is recommended for patients 3 months to 1 year after device closure and periodically thereafter. (Level of Evidence: C)
4. Device erosion, which may present with chest pain or syncope, should warrant urgent evaluation. (Level of Evidence: C)

Recommendations for Reproduction

Class III

1. Pregnancy in patients with ASD and severe PAH (Eisenmenger syndrome) is not recommended owing to excessive maternal and fetal mortality and should be strongly discouraged. (Level of Evidence: A)

Definitions:

Applying Classification of Recommendations and Level of Evidence

		SIZE OF TREATMENT EFFECT
		CLASS I Benefit >>> Risk Procedure/Treatment SHOULD be performed/administered	CLASS IIa Benefit >> Risk Additional studies with focused objectives needed IT IS REASONABLE to perform procedure/administer treatment	CLASS IIb Benefit > Risk Additional studies with broad objectives needed; additional registry data would be helpful Procedure/Treatment MAY BE CONSIDERED	CLASS III Risk > Benefit Procedure/Treatment should NOT be performed/administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFUL
Estimate of Certainty (Precision) of Treatment Effect	LEVEL A Multiple population evaluated* Data derived from multiple randomized clinical trials or meta-analyses	Recommendation that procedure or treatment is useful/effective Sufficient evidence from multiple randomized trials or meta-analyses	Recommendation in favor of treatment of procedure being useful/effective Some conflicting evidence from multiple randomized trials or meta-analyses	Recommendation's usefulness/efficacy less well established Greater conflicting evidence from multiple randomized trials or meta-analyses	Recommendation that procedure or treatment is not useful/effective and may be harmful Sufficient evidence from multiple randomized trials or meta-analyses
	LEVEL B Limited population evaluated* Data derived from a single randomized clinical trial or nonrandomized studies	Recommendation that procedure or treatment is useful/effective Evidence from single randomized trial or nonrandomized studies	Recommendation in favor of treatment of procedure being useful/effective Some conflicting evidence from single randomized trial or nonrandomized studies	Recommendation's usefulness/efficacy less well established Greater conflicting evidence from single randomized trial or nonrandomized studies	Recommendation that procedure or treatment is not useful/effective and may be harmful Evidence from single randomized trial or nonrandomized studies
	LEVEL C Very limited population evaluated* Only consensus opinion of experts, case studies or standard of care.	Recommendation that procedure or treatment is useful/effective Only expert opinion, case studies, or standard-of-care	Recommendation in favor of treatment of procedure being useful/effective Only diverging expert opinion, case studies, or standard-of-care	Recommendation's usefulness/efficacy less well established Only diverging expert opinion, case studies, or standard-of-care	Recommendation that procedure or treatment is not useful/effective and may be harmful Only expert opinion, case studies, or standard-of-care

*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as gender, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Even though randomized trials are not available, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.

Note: In 2003, the American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Practice Guidelines developed a list of suggested phrases to use when writing recommendations. All guideline recommendations have been written in full sentences that express a complete thought, such that a recommendation, even if separated and presented apart from the rest of the document (including headings above sets of recommendations), would still convey the full intent of the recommendation. It is hoped that this will increase readers' comprehension of the guidelines and will allow queries at the individual recommendation level. (See Table 1 in the original guideline document for a list of suggested phrases for writing recommendations.)

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Appropriate management of patients with atrial septal defect

• False-positive or false-negative diagnosis of atrial septal defect
• Complications of surgical and catheter interventions for atrial septal defect (refer to Table 10 in the original guideline document)

Pregnancy in patients with atrial septal defect (ASD) and severe pulmonary arterial hypertension (PAH) (Eisenmenger syndrome) is contraindicated owing to excessive maternal and fetal mortality and should be strongly discouraged

• These practice guidelines are intended to assist healthcare providers in clinical decision making by describing a range of generally acceptable approaches for diagnosis, management, and prevention of specific diseases or conditions. Clinicians should consider the quality and availability of expertise in the area where care is provided. These guidelines attempt to define practices that meet the needs of most patients in most circumstances. The recommendations reflect a consensus of expert opinion after a thorough review of the available current scientific evidence and are intended to improve patient care.
• Patient adherence to prescribed and agreed upon medical regimens and lifestyles is an important aspect of treatment. Prescribed courses of treatment in accordance with these recommendations are only effective if they are followed. Because lack of patient understanding and adherence may adversely affect outcomes, physicians and other healthcare providers should make every effort to engage the patient's active participation in prescribed medical regimens and lifestyles.
• If these guidelines are used as the basis for regulatory or payer decisions, the goal is quality of care and serving the patient's best interest. The ultimate judgment regarding care of a particular patient must be made by the healthcare provider and the patient in light of all of the circumstances presented by that patient. There are circumstances in which deviations from these guidelines are appropriate.

An implementation strategy was not provided.

Getting Better
Living with Illness

Effectiveness

• Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA, del Nido P, Fasules JW, Graham TP, Hijazi ZM, Hunt SA, King ME, Landzberg MJ, Miner PD, Radford MJ, Walsh EP, Webb GD, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Antman EM, Buller CD, Creager MA, Ettinger SM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura RA, Page RL, Riegel B, Tarkington LG, Yancy CW. Atrial septal defect. In: ACC/AHA 2008 guidelines for the management of adults with congenital heart disease. J Am Coll Cardiol 2008;52(23):e173-78.

Not applicable: The guideline was not adapted from another source.

2008

American College of Cardiology Foundation - Medical Specialty Society
American Heart Association - Professional Association

The American College of Cardiology Foundation and the American Heart Association. No outside funding accepted.

American College of Cardiology/American Heart Association Task Force on Practice Guidelines

Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease

Task Force Members: Sidney C. Smith, Jr, MD, FACC, FAHA, Chair; Alice K. Jacobs, MD, FACC, FAHA, Vice-Chair; Cynthia D. Adams, RSN, PhD, FAHA#; Jeffrey L. Anderson, MD, FACC, FAHA#; Elliott M. Antman, MD, FACC, FAHA**; Christopher E. Buller, MD, FACC; Mark A. Creager, MD, FACC, FAHA; Steven M. Ettinger, MD, FACC; Jonathan L. Halperin, MD, FACC, FAHA#; Sharon A. Hunt, MD, FACC, FAHA#; Harlan M. Krumholz, MD, FACC, FAHA; Frederick G. Kushner, MD, FACC, FAHA; Bruce W. Lytle, MD, FACC, FAHA#; Rick A. Nishimura, MD, FACC, FAHA; Richard L. Page, MD, FACC, FAHA; Barbara Riegel, DNSc, RN, FAHA#; Lynn G. Tarkington, RN; Clyde W. Yancy, MD, FACC, FAHA

Committee Members: Carole A. Warnes, MD, FRCP, FACC, FAHA, Co-Chair; Roberta G. Williams, MD, MACC, FAHA, Co-Chair; Thomas M. Bashore, MD, FACC; John S. Child, MD, FACC, FAHA; Heidi M. Connolly, MD, FACC; Joseph A. Dearani, MD, FACC*; Pedro del Nido, MD; James W. Fasules, MD, FACC; Thomas P. Graham, Jr, MD, FACC†; Ziyad M. Hijazi, MBBS, MPH, FACC, FSCAI‡; Sharon A. Hunt, MD, FACC, FAHA; Mary Etta King, MD, FACC, FASE§; Michael J. Landzberg, MD, FACC; Pamela D. Miner, RN, MN, NP; Martha J. Radford, MD, FACC; Edward P. Walsh, MD, FACC||; Gary D. Webb, MD, FACC¶

*Society of Thoracic Surgeons representative.

†International Society for Adult Congenital Heart Disease representative.

‡Society for Cardiovascular Angiography and Interventions representative.

§American Society of Echocardiography representative.

||Heart Rhythm Society representative.

¶Canadian Cardiovascular Society representative.

#Former Task Force member during this writing effort.

**Immediate past chair.

The American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Practice Guidelines makes every effort to avoid actual, potential, or perceived conflicts of interest that might arise as a result of industry relationships or personal interests among the writing committee. Specifically, all members of the writing committee, as well as peer reviewers of the document, are asked to disclose all such relationships that might be perceived as real or potential conflicts of interest. Writing committee members are also strongly encouraged to declare previous relationships with industry that might be perceived as relevant to guideline development. If a writing committee member develops a new relationship with industry during their tenure, they are required to notify guideline staff in writing. These statements are reviewed by the parent task force, reported orally to all members at each meeting of the writing committee, and updated and reviewed by the writing committee as changes occur.

Author Relationships With Industry and Other Entities–ACC/AHA 2008 Guidelines for the Management of Adults With Congenital Heart Disease

Committee Member	Research Grant	Speakers' Bureau	Stock Ownership	Board of Directors	Consultant/Advisory Member
Dr. Carole A. Warnes (Co-Chair)	None	None	None	None	None
Dr. Roberta G. Williams (Co-Chair)	None	None	None	None	None
Dr. Thomas M. Bashore	None	None	None	None	None
Dr. John S. Child	None	None	None	None	None
Dr. Heidi M. Connolly	None	None	None	None	None
Dr. Joseph A. Dearani	None	None	None	None	None
Dr. Pedro del Nido	None	None	None	None	None
Dr. James W. Fasules	None	None	None	None	None
Dr. Thomas P. Graham, Jr	None	None	None	None	None
Dr. Ziyad M. Hijazi	None	None	None	None	AGA Medical
Dr. Sharon A. Hunt	None	None	None	None	None
Dr. Mary Etta King	None	None	None	None	None
Dr. Michael J. Landzberg	Actelion AGA Medical Myogen NMT Medical Pfizer	None	None	None	None
Dr. Pamela D. Miner	None	None	None	None	None
Dr. Martha J. Radford	None	None	None	None	None
Dr. Edward P. Walsh	None	None	None	None	None
Dr. Gary D. Webb	None	None	None	None	None

This table represents the relevant relationships of committee members with industry and other entities that were reported orally at the initial writing committee meeting and updated in conjunction with all meetings and conference calls of the writing committee during the document development process. It does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of 5% or more of the voting stock or share of the business entity, or ownership of $10,000 or more of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person's gross income for the previous year. A relationship is considered to be modest if it is less than significant under the preceding definition. Relationships in this table are modest unless otherwise noted.

See Appendix 2 in the original guideline document for peer reviewer relationships with industry.

American Society of Echocardiography - Professional Association
Heart Rhythm Society - Professional Association
International Society for Adult Congenital Heart Disease - Disease Specific Society
Society for Cardiovascular Angiography and Interventions - Medical Specialty Society
Society of Thoracic Surgeons - Medical Specialty Society

This is the current release of the guideline.

The guidelines will be reviewed annually by the American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Practice Guidelines and considered current unless they are updated, revised, or withdrawn from distribution.

None available

This NGC summary was completed by ECRI Institute on September 17, 2009.