Dear Richard,
Without evaluating Jamie, I cannot say for sure if he needs to have this defect closed specfically, or not. I can say that a 4x5 mm defect MAY be large enough to cause enough cardiac recirculation to cause some symptoms. As well, with Trisomy-21, he is absolutely at greater risk of pulmonary hypertension, or irreversible high blood pressure across the lungs, so we do tend to take a more aggressive stance toward closing defects like this. It is interesting that he doesn't have any right ventricular enlargement. And, it is often difficult with these kids to ascertain the reason of exercise intolerance, sleepiness, etc. He could be obstructing his airway, snoring, and having sleep apnea, which is a common finding in these kids. That said, unrepaired moderate and large ASDs can lead to pulmonary hypertension. If he meets criteria for placement of an Amplatzer device by transcatheter means, he should actually do well with it; the success rate for this is quite good, and the long term outcomes are excellent, as well. You may want to consider a true second opinion, to include an evaluation, and not just this advice, however.
Dear Jeffrey
thank you so much for taking time to reply. I think I will get a second opinion in our local children's hospital.
Thanks again,
Richard/Zurich, Switzerland