ACHD indicates adult congenital heart disease; ASD, atrial septal defect; PAH, pulmonary artery hypertension; PASP, pulmonary artery systolic pressure; PDE-5, phosphodiesterase type-5 inhibitors; PH, pulmonary hypertension; and Qp:Qs, pulmonary systemic blood flow ratio. CLINICAL STATEMENTS AND GUIDELINES capacity but, in patients with normal functional capacity, the long-term benefit of ASD closure is Pending further study, it is reasonable to close an ASD that is hemodynami- cally important in the absence of significant PAH. Older adults should be evaluated for left atrial hypertension resulting from diastolic dysfunction that may cause symptoms simulating those from an ASD alone, in whom ASD closure could result in clinical worsening because of further increase in left atrial pressure because the relatively restric- tive and higher pressure left atrium can no longer decompress into the lower pressure right atrium. Concomitant tricuspid annuloplasty can be of benefit in patients with moderate or more TR, as the additional volume load may adversely affect RV remodeling. 7. If surgical treatment is necessary for other con- genital or acquired cardiac conditions and the patient has a secundum ASD, it is reasonable to perform ASD closure at the time of surgery. When there is moderate or greater TR, tricuspid valve repair may improve RV remodeling. 8. To evaluate the patient with PAH and ASD, ensure the shunt remains left to right despite elevated pulmonary vascular resistance and/or pulmonary pressure and that pulmonary pressure and PVR are accurately measured. In this circumstance, data derived from invasive hemodynamic assess- ment are important in clarifying the appropriate course of action. The exclusion of patients with severe PAH from ASD closure may eventually be obviated by PA vasodilator and remodeling therapy with prostaglandins, endothelin blockers, and PDE-5 inhibitors. 