The more presence of an asymptomatic ASD often does not necessitate repair. However, the development of significant hemodynamic changes becomes an indication for closure. Some patients, who have developed either advanced pulmonary hypertension or poor right ventricular dysfunction, become dependent upon the defect as a “pressure release”, and thus, have a relative contraindication to defect closure. Significant left to right atrial shunting can cause right heart enlargement, which is diagnosed most often by echocardiography. The extent of shunting is determined by the ratio of the mean pulmonary artery to mean systemic flow ratio (Qp:Qs) and when this ratio is at or above a 1.5, this is an indication for closure.

There are several effective methods to close ASDs, but each depends upon the appropriate anatomy. Today, atrial septal defect closure can be done by: a catheter-delivered closure device, a traditional open-heart direct closure, or a robot-assisted endoscopic repair. Depending on the septal defect size, open and endoscopic repairs can be done using either a primary suture closure or a patch technique. The goal of ASD closure is to improve functional status, increase exercise capacity, and improve long-term survival by preventing irreversible right heart failure and pulmonary hypertension. Favorable candidates for a percutaneous ASD closure must have an adequate tissue rim and/or a small to moderate defect size (<35-mm). Contiguous cardiac structures must be considered, as percutaneous closure devices act as a plug, extending beyond defect edges. Furthermore, implanted devices can become a nidus for thrombus formation, erode through the septum, or close the defect inadequately. Surgical repair assures the best closure in the presence of complex defect anatomy.

Most studies that utilized robot-assisted surgical systems for ASD closure have been in patients with secundum-type ASDs (18–80 years old) and with a mean pulmonary to mean systemic flow ratio of (Qp:Qs) ≥ 1.5 or in those with a patent foramen ovale and a documented neurologic event. ASD patients with extensive anomalies associated with primum or sinus venosus defects should be operated upon using either direct vision minimally invasive techniques or through a sternotomy. Operative selection excludes patients with a recent myocardial infarction, other cardiac lesions requiring intervention (either valvular or coronary artery disease), a left ventricular ejection fraction of <30 %, anomalous pulmonary venous return, a prior right thoracotomy or mediastinal radiation, and/or significant medical comorbidities (hepatic failure, dialysis–dependent renal failure, untreated cerebrovascular disease, uncontrolled diabetes, connective tissue disorders or severe bleeding disorders), morbid obesity, and/or pregnancy). Finally, patients must have adequate size and non-atherosclerotic femoral vessels to allow safe cannulation for peripheral cardiopulmonary bypass, and they must be able to tolerate single lung ventilation. Axillary artery cannulation is an alternative strategy when femoral vessels either are diseased or too small.